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NURS FPX 6030 Assessment 6 Final Project Submission

Student Name

Capella University

NURS-FPX 6030 MSN Practicum and Capstone

Prof. Name

Date

Final Project Submission

Abstract

The capstone project aimed to improve patient understanding of post-discharge regimens, reduce hospital readmissions, and enhance patient satisfaction following cardiac catheterization by implementing a tailored educational program and integrating telehealth services. The initiative sought to address knowledge gaps and continuity of care for post-cardiac catheterization patients, ensuring they receive adequate information and support after discharge. The approach involved individualized discharge education and the use of multimodal education delivery, including audiovisual aids and remote monitoring devices, to disseminate information and address concerns. Key findings included the potential for nurses to act as key knowledge brokers, enhancing patient care, and the indication that well-informed patients have reduced readmission rates, potentially saving healthcare costs.

Introduction

This capstone project addresses the high 30-day hospital readmission rates among patients with Coronary Artery Disease (CAD) discharged after cardiac catheterization at Manatee Memorial Hospital in Bradenton, Florida. The focus is on enhancing post-discharge patient education to improve outcomes. The intervention plan aims to strengthen post-discharge outcomes through comprehensive and individualized discharge education, integrating telehealth services. This intervention is supported by evidence highlighting the effectiveness of tailored discharge education and modern telehealth technologies in improving postoperative outcomes and patient satisfaction.

Problem Statement

Need Statement

This study aims to compare the impact of implementing a comprehensive and personalized post-discharge education program versus providing basic discharge instructions on 30-day hospital readmission rates and patient outcomes among patients discharged from Manatee Memorial Hospital after cardiac catheterization. According to a study by Madan et al. (2019), 30 percent of patients discharged after percutaneous coronary intervention (PCI) were readmitted within 30 days, emphasizing the urgency to minimize readmission rates to improve health outcomes and reduce healthcare costs.

Population and Setting

The target population consists of patients discharged after cardiac catheterization, who are at increased risk of post-discharge complications. Addressing this population’s needs is crucial to reduce complications, decrease readmission rates, and improve patient satisfaction. The intervention is implemented at Manatee Memorial Hospital, where readmission rates among cardiac catheterization patients are significantly higher than the national average, indicating the need for comprehensive and personalized education.

Intervention Overview

The intervention comprises tailored discharge education and telehealth services to reduce readmission rates among cardiac catheterization patients. The Plan-Do-Check-Act (PDCA) cycle was applied to develop an individualized post-cardiac catheterization education program. This involved identifying factors contributing to readmissions, creating customized education programs, collecting feedback, and continuously monitoring outcomes. Challenges such as healthcare illiteracy and language barriers among Manatee County residents were considered during implementation.

Comparison of Approaches

Inter-professional collaboration is crucial for delivering comprehensive care to post-cardiac catheterization patients. While customized education plans are effective, alternative strategies such as standardized education plans and group education sessions led by inter-professional teams can also address patient needs.

Initial Outcome Draft

The goal is to reduce 30-day readmission rates by 20%, increase medication adherence by 15%, increase follow-up appointment attendance by 30%, and improve symptom reporting by 25% within 12 months.

Time Estimate

The estimated timeframe for developing and implementing the education program is approximately 12 months, including planning, platform development, pilot testing, full-scale implementation, and ongoing monitoring.

Literature Review

Comprehensive education post-cardiac catheterization has shown to reduce cardiac arrest incidents and improve medication adherence, leading to fewer readmissions. Tailored education interventions have been effective in reducing readmission rates, emphasizing the importance of personalized education. Telehealth policies support continuous education and care, benefiting remotely located patients and allowing for timely interventions, thereby reducing readmission rates.

Intervention Plan Components

The intervention plan for enhancing post-discharge outcomes revolves around delivering thorough and personalized discharge education. Two main components constitute this plan: customized educational programs and telehealth services.

Customized Educational Plans

The initial step involves patient assessments and profiling to gauge their health literacy levels, learning needs, preferences, and socio-cultural factors affecting their learning and self-management process. This tailored approach ensures patient-centered education, fostering better patient engagement and shared decision-making (Al-Noumani et al., 2023). Individualized discharge instructions are then crafted, considering cultural beliefs, language preferences, and health practices, encompassing procedural details, medication management, dietary, and physical activity advice. This component aims to empower patients in their healthcare journey, thereby reducing readmission rates (Chen et al., 2023).

Telehealth Services

Integrating telecommunication methods and digital health services facilitate effective discharge education and post-discharge adherence. Telehealth services, including remote monitoring and communication tools, enhance patient education and outcome measurement, improving patient experiences, cost-effectiveness, and healthcare equity (Chen et al., 2023). Multimodal education delivery through various technological tools ensures continuous monitoring and guidance for treatment adherence and self-management, ultimately reducing hospital visits and readmission rates.

Cultural Needs and Characteristics

The diverse patient population at Manatee Memorial Hospital underscores the need for culturally competent intervention plans. Tailoring educational plans to respect language preferences, cultural beliefs, and health practices ensures inclusivity and care effectiveness. Cultural competence training among healthcare professionals facilitates communication and enhances patient engagement.

Theoretical Foundations

Dorothea Orem’s Self-Care Theory is the primary theoretical framework guiding our intervention plan. This theory emphasizes patients’ active role in managing their health conditions, aligning with the goal of promoting patient engagement in their recovery through self-care practices. Research supports the effectiveness of this theory in improving patient outcomes, as evidenced by positive results in hypertensive patients following education on self-care (Labani, 2022). Thus, utilizing Orem’s theory, our intervention plan focuses on developing comprehensive discharge education, encompassing medication compliance and lifestyle modifications, tailored specifically for post-surgery patients.

However, a limitation of Orem’s theory is its assumption of patients’ motivation and ability to adhere to treatment plans, which may not always align with reality due to various socio-cultural and economic factors. Therefore, incorporating motivational interviewing (MI) as a strategy can address patients’ readiness for behavioral change and enhance treatment plan adherence. Although MI may be time-consuming, it proves valuable in evaluating patient readiness and addressing uncertainties in discharge education for post-cardiac catheterization patients.

Moreover, integrating telecommunication methods such as video conferencing and remote monitoring into our intervention plan supports continuity of care post-surgery. Telehealth services facilitate patient monitoring and self-management, ultimately improving patient outcomes (Chen et al., 2023). However, challenges such as internet connectivity may impede the effectiveness of telehealth interventions, highlighting the need for robust infrastructure to support such initiatives.

Stakeholders, Policy, and Regulations

Our intervention plan prioritizes patient and family needs as primary stakeholders, aiming to enhance patient engagement, reduce readmission rates, and improve outcomes. Additionally, hospital management and healthcare providers are stakeholders invested in augmenting patient satisfaction, minimizing costs associated with readmissions, and enhancing healthcare quality. Compliance with healthcare policies, particularly HIPAA, is crucial when implementing telehealth services to ensure patient privacy and data security (Rahim & Alshahrani, 2023).

Regulatory bodies like the Centers for Medicare & Medicaid Services (CMS) provide guidelines for telehealth reimbursement and licensure, shaping the landscape of telehealth implementation. Adherence to national and state-level regulations is imperative for maintaining care standards and ensuring stakeholder involvement in the care process.

Ethical and Legal Implications

Ethically, our intervention plan balances patient autonomy with beneficence, ensuring patients receive care aligned with their preferences while promoting their best interests. Customized educational plans uphold the principle of informed decision-making, empowering patients to actively participate in their healthcare journey. Legally, adherence to HIPAA regulations is essential to safeguard patient privacy and data security during telehealth interactions (Rahim & Alshahrani, 2023). Organizations must establish robust data protection measures and ensure compliance with HIPAA guidelines to mitigate legal risks.

Implementation Plan

Management and Leadership

Transformational leadership is instrumental in articulating clear goals and vision for the interventional plan, fostering interdisciplinary collaboration, and ensuring team understanding and commitment. Project planning and execution, coupled with feedback mechanisms, facilitate milestone achievement and performance monitoring, ensuring sustained success. Nursing practices emphasizing patient-centered care and digital health literacy enhance patient engagement and support seamless telehealth experiences (Mistretta et al., 2023).

Implications of Change to Improve Outcomes and Cost-effectiveness

Successful implementation of the intervention plan is expected to improve patient experiences, trust in providers, and healthcare quality. Telehealth services enable seamless transitions and early interventions, reducing unnecessary expenditures and enhancing cost-effectiveness. However, addressing challenges such as resistance to change and regulatory barriers is crucial for achieving desired outcomes.

Delivery and Technology

Combining in-person and digital delivery methods ensures effective implementation of personalized discharge education plans. Traditional methods facilitate direct patient-provider interaction, while digital platforms promote accessibility and real-time interaction, overcoming geographical barriers. Augmented reality (AR) and virtual reality (VR) tools offer immersive educational experiences, enhancing patient comprehension and engagement (Jung et al., 2022).

Stakeholders, Policy, and Regulations

Patients, healthcare professionals, administrators, and regulatory bodies are key stakeholders in our intervention plan. Compliance with existing policies such as telehealth reimbursement and HIPAA guidelines is essential for legal and ethical practice. Developing new policies to incentivize telehealth adoption and standardize digital health education materials can further support plan implementation and improve patient outcomes.

Timeline

A realistic timeline of 12-18 months is proposed for implementing the intervention plan, considering factors such as stakeholder buy-in, resource availability, and patient readiness. Addressing challenges such as limited resources and staff training is crucial for timely implementation and successful outcomes.

Evaluation Plan

The intervention plan integrates two primary strategies: the development of a tailored educational program and the integration of telehealth services for patients discharged after cardiac catheterization. The targeted outcomes of this intervention are threefold: improved patient comprehension of their post-discharge regimen, decreased hospital readmissions, and increased patient satisfaction (King-Dailey et al., 2022). These outcomes elucidate the fundamental purpose of our intervention. By enhancing patients’ understanding of their care regimen, we anticipate a decrease in post-discharge complications, thereby reducing the readmission rate.

This reduction not only signifies improved patient adherence and comprehension but also alleviates the financial and logistical burdens on the healthcare system. Elevating patient satisfaction, conversely, indicates our commitment to individualized care, ensuring that each patient’s unique needs and concerns are comprehensively addressed. The combined emphasis on tailored discharge education and telehealth services demonstrates our ambition to create a healthcare system where patients are empowered with knowledge and have sustained access to healthcare professionals even after discharge.

Furthermore, our intervention promises benefits through these dual pathways, from the patients’ health outcomes to systemic improvements. Our intervention establishes a solid framework for enhancing quality, safety, and the care experience. Personalized education is a cornerstone, bridging the knowledge gap and ensuring patients are well-prepared for post-hospitalization care (Al-Noumani et al., 2023). This, coupled with telehealth services, provides continuity of care, promoting safety and a more seamless healthcare experience, even from the comfort of one’s home. However, like all ambitious projects, challenges are anticipated. Crafting tailored educational content can be resource-intensive and might introduce variations due to differing expertise among healthcare professionals. Moreover, the high level of personalization could lead to patients becoming overly reliant on medical professionals for even minor clarifications.

Evaluation Plan and Assumptions

Our evaluation plan is based on two foundational assumptions to assess the effectiveness of our intervention. Firstly, individualized discharge education and telehealth services will significantly enhance patient comprehension and adherence post-discharge. Secondly, a measurable reduction in readmissions will indicate the successful implementation of our intervention. The strategy begins with a comprehensive pre-intervention assessment using detailed questionnaires to gauge patients’ baseline understanding of discharge directives (King-Dailey et al., 2022). This initial measure provides a reference for subsequent evaluations.

We will then assess the lasting effects of our intervention with follow-ups scheduled at 1-month, 3-month, and 6-month intervals. The intervention will initially target a select group, allowing us to maintain a control group that continues to receive standard discharge instructions. However, this method facilitates a comparative study, elucidating the advantages or potential shortcomings of our approach. For data collection, we will incorporate patient feedback forms to gain insights into their experiences and comprehension, alongside hospital readmission records as a direct metric of intervention outcomes.

To optimize data collection and monitoring, Electronic Health Records (EHRs) will be utilized for real-time tracking of patient readmissions. Furthermore, we will introduce dedicated patient portals, ensuring a two-way channel for disseminating tailored educational content and gathering feedback. We will employ specialized software tools for data analysis to ensure accuracy and depth. These tools will process quantitative metrics, such as readmission rates, and qualitative data, like patient feedback, to offer a comprehensive perspective. This blend of qualitative and quantitative analysis will enable us to thoroughly assess the intervention’s impact on health promotion and education.

Discussion

Advocacy

Nurses emerge as transformative leaders in the vast healthcare landscape, particularly when innovation and change are at play. With close patient interactions, nurses gain insights into individual needs and identify areas ripe for improvement. Our intervention—a tailored educational strategy for discharged cardiac catheterization patients—is poised to amplify the nurse’s role in this transformative journey. In a professional context, nurses are no longer confined to traditional caregiving; they evolve into vital knowledge brokers.

Moreover, empowered by the intervention, they actively spearhead a shift toward bespoke patient education, ensuring that complex medical directives are seamlessly translated into layperson’s terms for post-cardiac catheterization patients. This proactive shift enhances the quality and experience of care as nurses treat and educate, guiding patients toward better health outcomes.It is grounded in the belief that nurses can become formidable change catalysts in healthcare settings when armed with the appropriate tools (Mistretta et al., 2023). Beyond the immediate patient-nurse interaction, the ripples of this intervention enhance inter-professional dynamics.

NURS FPX 6030 Assessment 6 Final Project Submission

Tailoring educational content to each patient’s needs demands a symphony of inputs from diverse healthcare professionals, from doctors to therapists. Moreover, this necessitates and strengthens collaboration, ensuring comprehensive educational materials are tailored to each patient’s unique recovery journey. Such a collaborative endeavor accentuates the nursing profession’s pivotal role in patient education and establishes a cohesive, multidisciplinary approach to post-cardiac catheterization care. Zooming out to the broader healthcare paradigm, this intervention promises multifaceted benefits.

From an economic perspective, a well-informed and educated patient stands a reduced chance of hospital readmission, paving the way for substantial cost savings. Healthcare institutions that pioneer such patient-centric approaches can also expect enhanced trust and reputation among their patient base. Specifically, for our target demographic—post-cardiac catheterization patients—this intervention equips them with a robust understanding of their recuperation, empowering them to mitigate potential complications and ensure optimal long-term health (Madan et al., 2019).

However, embracing such a tailored educational paradigm is not without its challenges. It mandates robust training regimes for nurses, ensuring they are well-equipped to deliver personalized content. Consistently delivering quality education across diverse medical cases also remains an intricate task. However, with persistence, feedback, and continual refinement, we believe this intervention can herald a new era in patient care and education.

Future Steps

In healthcare interventions, we aspire to enrich our strategies further to better serve patients. While robust, our intervention for post-cardiac catheterization patients can be expanded upon for more significant impact and alignment with emerging technologies and care models. Expanding its reach and depth, the educational content could benefit from more nuanced personalization. Although our current model leverages telehealth services, introducing Augmented and Virtual Reality (AR/VR) systems can make patient education more immersive. This allows patients to visualize and understand their post-surgery care and potential complications in a three-dimensional, interactive space (Jung et al., 2022). Such an in-depth view can lead to better retention of information and a deeper understanding of their recovery journey.

Regarding care models, the Chronic Care Model (CCM) emphasizes the need for health systems to be proactive and prepared, placing the patient at the center. Our intervention can adopt this model by emphasizing stronger relationships and transparent communication between healthcare providers and patients. Doing so creates an environment where patients are more involved, informed, and empowered in their recovery process. Regular feedback sessions can be institutionalized, fostering a two-way communication channel. This ensures that the intervention remains dynamic and evolves based on real-world feedback.

NURS FPX 6030 Assessment 6 Final Project Submission

The intervention can integrate advanced AI-driven patient monitoring systems, continuing on the technological frontier beyond AR/VR. These systems can predict potential issues before they become severe, enhancing patient safety significantly. Moreover, immediate alerts can be sent to the patient and their healthcare provider if any deviations from the optimal recovery path are detected, allowing for early interventions and corrections. Firstly, there is an inherent belief that technology, especially AR/VR and AI-driven systems, will foster a more profound

understanding and commitment to post-discharge instructions. Secondly, a shift towards a more feedback-intensive, patient-centric approach, drawing inspiration from the Chronic Care Model, promises improved patient outcomes and enhanced safety protocols (Jung et al., 2022).

Reflection on Leading Change and Improvement

Engaging deeply with this capstone project has profoundly impacted my ability to lead change in my current care setting and personal practice. It has revealed the critical nature of individualized patient care and how this approach can shape better health outcomes. By introducing and managing a customized educational plan, I have realized the magnitude of responsibility leaders hold in championing such initiatives. Every step taken in this project has enhanced my confidence and capability in spearheading similar change-driven tasks in the future. The project’s challenges and successes have taught me invaluable lessons I will carry into future leadership roles.

My understanding of adaptive patient care, bolstered by this project, will be instrumental in guiding teams, strategizing healthcare initiatives, and ensuring that the patient remains at the core of all decisions. Also my primary objective is to remain a lifelong learner, constantly updating my knowledge base and skills. I also aim to bridge the gaps identified during this project, especially in ensuring effective delivery and comprehension of patient education. Completing this project has provided a highly transferable framework to my existing practice. The essence of the project, a bespoke patient-centric approach, can be integrated across various facets of patient care.

NURS FPX 6030 Assessment 6 Final Project Submission

The methodology of implementing a tailored educational plan, the feedback mechanisms, and the evaluation methods can all be adapted to different scenarios within my current care setting, ensuring consistent quality improvement. While the project was designed for a specific purpose, its foundational elements have universal relevance. Considering its application to other care settings and contexts, its principles can drive improvements across the board. Whether in outpatient care, specialized clinics, or community health setups, the focus on customized care, informed by this project, can be the cornerstone of impactful interventions. However, it is essential to remain receptive to alternative perspectives and conflicting evidence, always ensuring that the strategies adopted are grounded in evidence-based practices and cater to the diverse needs of the patient population.

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NURS FPX 6030 Assessment 6 Final Project Submission

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NURS FPX 6030 Assessment 6 Final Project Submission

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