D028 – CPE Task 1: Clinical Practice Experience Details

Grace J.
January 2, 2026January 2, 2026
D028, MSN, Western Governors University

Student Name

Western Governors University

D028 Advanced Health Assessment for Patients and Populations

Prof. Name

Date

MSN Core Word E-Portfolio Template

Instructions for Course Completion

To fulfill the course requirements, students are required to complete the Clinical Practice Experience (CPE) Record. This record includes specific deliverables necessary for assessment, which can be found under “Supporting Documents” in the Assessment Task Overview.

Students should integrate all required deliverables, such as reflective writings, within this e-portfolio template for each phase of the course. Documents previously created can be inserted into the Word document by following these steps:

Click the location where the content will be placed.
Go to Insert > Object and click the arrow.
Select Text from File.
Choose the desired file and double-click it.
Repeat this process to add additional documents as needed.

D028 CPE Schedule Table

Below is a suggested timeline for completing the course assignments. Students are encouraged to copy this table into their e-portfolio and fill it out accordingly.

Required CPE Activities (Deliverables)	Estimated Time	Anticipated Completion Date
1a. CPE schedule table	20 minutes	September 6, 2024
1b. Discussion of CMS HRRP	1 hour	September 6, 2024
1c. Discussion of selected patient:		September 6, 2024
– One Social Determinant of Health (SDOH) affecting the patient
– One intervention to prevent readmission related to SDOH	2 hours
2a. Evidence-based practices to reduce hospital readmission		September 7, 2024
– Identify one practice to prevent readmission for the patient	30 minutes
2b. Public health intervention for the patient at each practice level	1 hour	September 7, 2024
3a. Discuss five standards of Transitions of Care	1.5 hours	September 7, 2024
3b. Develop communication plan (Standard 5) for patient	1.5 hours	September 7, 2024
3c. GoReact Video and Peer Responses	1 hour	September 7, 2024
3d. Reflection Summary	45 minutes	September 7, 2024

What Is the Hospital Readmissions Reduction Program (HRRP)?

The Hospital Readmissions Reduction Program (HRRP), initiated by the Centers for Medicare & Medicaid Services (CMS), is designed to reduce hospital readmissions for specific conditions and surgeries after patient discharge. These conditions include acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, coronary artery bypass graft (CABG) surgery, and elective total hip or knee arthroplasty (THA/TKA) (CMS, n.d.).

CMS provides confidential annual Hospital-Specific Reports (HSRs) to healthcare providers, which advanced practice nurses (APNs) use to identify areas for improvement. These reports guide the tailoring of interventions to improve care coordination, communication, and implementation of evidence-based strategies aimed at minimizing readmissions. These efforts contribute to better patient outcomes and cost reductions within healthcare systems.

Patient Case Scenario

The patient is a 55-year-old Hispanic male who suffered a myocardial infarction (MI) following symptoms of chest tightness, nausea, and shortness of breath experienced during gardening. His medical history is significant for hypertension, obesity, and hyperlipidemia. Family history includes a father who died from an MI at age 62, and a mother with Type II diabetes, hypertension, and osteoporosis.

His lifestyle involves frequent dining out (6-8 times per week) at restaurants, cafeterias, or fast food establishments, daily consumption of coffee and soda, and social drinking of 2-4 beers on weekends, 3-4 times per month. His physical activity is limited to a 15-20 minute walk once weekly. He last visited his primary care provider seven months ago.

What Are Social Determinants of Health (SDOH) and How Do They Affect the Patient?

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age, all of which significantly impact health outcomes (Social Determinants of Health, n.d.). In this patient’s case, the most relevant SDOH category is the neighborhood and built environment, which affects his access to safe, affordable, and nutritious food options (Healthy People 2030, n.d.).

His reliance on dining out, especially fast food, highlights a need for interventions that improve access to healthier food choices within his community.

Intervention
A practical approach is to arrange regular consultations with a dietary coach or nutritionist. This professional can collaborate with the patient to develop heart-healthy meal plans that emphasize portion control and incorporate practical dining-out options suited to his community. Engaging the patient actively in meal planning is vital to lowering the risk of hospital readmission.

What Evidence-Based Practices Can Reduce Hospital Readmission?

For patients recovering from myocardial infarction, maintaining health and preventing readmissions is crucial. Cardiac rehabilitation (CR) is an evidence-based practice proven to reduce morbidity and mortality by combining endurance training, dietary education, and lifestyle modifications (Grochulska, Glowinski, & Bryndal, 2021).

CR programs provide supervised exercise counseling, stress management techniques, and education on heart-healthy living. Applying CR to the patient’s recovery supports habit change and reduces the risk of recurrent cardiac events (American Heart Association [AHA], 2024).

What Public Health Interventions Can Support the Patient?

Public health interventions for this patient should occur across multiple levels: individual, community, and systemic.

Level	Intervention
Individual	Assist the patient with scheduling regular follow-ups with the primary care provider, medication adherence support, and referrals to cardiac rehabilitation programs.
Community	Promote involvement in heart health education outreach programs, enabling the patient to share experiences, disseminate prevention information, and participate in workshops or media campaigns.
System	Advocate for policies that enforce standardized discharge protocols for MI patients, including scheduled follow-ups, CR referrals, and comprehensive medication plans.

What Are the Five Standards of Transitions of Care?

The American Case Management Association (ACMA) has established five key standards to ensure effective patient transitions and reduce hospital readmissions (ACMA, 2023):

Standard	Description
1	Identify patients at risk for poor transitions and apply targeted interventions.
2	Conduct comprehensive transition assessments for patients at high risk.
3	Ensure medication reconciliation occurs at every care transition, including prescribed and OTC drugs.
4	Develop ongoing care management plans with input from patients and caregivers, shared among providers.
5	Communicate essential care transition information promptly to stakeholders such as caregivers, providers, payers, and care managers.

How Should Care Transitions Be Communicated to Stakeholders?

Effective communication during care transitions is essential to prevent readmissions and support patient recovery. For the 55-year-old MI patient, the primary stakeholders include:

Primary Care Provider (PCP): Receives updates on hospital discharge, procedural details (e.g., angioplasty), medication regimens, and follow-up plans to manage ongoing care.
Cardiologist: Needs information on patient recovery, rehabilitation plans, and treatment adjustments.
Cardiac Rehabilitation Team: Should be promptly informed to initiate customized exercise and education programs and provide progress reports to the healthcare team and patient.

Reflection

During my nursing career in the emergency department, the prevailing mindset was often to quickly assess and discharge patients, summarized as “treat them and street them.” This assignment challenged me to reconsider this approach by exploring the complex dynamics of care continuity after hospital discharge.

Using a hypothetical MI patient, I analyzed how medical history, social determinants, and lifestyle factors collectively influence health outcomes. This process reinforced the necessity of integrating social and clinical data to design individualized care plans that effectively reduce readmission risks.

Studying the Transitions of Care Standards illuminated the structured processes necessary for smooth care transitions, medication safety, and stakeholder engagement. Furthermore, learning about the HRRP deepened my understanding of systemic efforts to enhance healthcare quality.

As an advanced practice nurse, I now recognize the critical role I will play in discharge planning, patient education, care coordination, and follow-up to promote successful patient recovery post-discharge.

References

American Case Management Association. (2023). Transitions of care standards [PDF]. https://transitionsofcare.org/wp-content/uploads/2023/06/ACMA-Transitions-of-Care-Standards_Final_06132023.pdf

American Heart Association. (2024, April 24). What is cardiac rehabilitation? Cardiac Rehab. https://www.heart.org/en/health-topics/cardiac-rehab/what-is-cardiac-rehabilitation

Centers for Medicare & Medicaid Services. (n.d.). Hospital readmissions reduction program (HRRP). https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp