Capella university
NURS FPX 4905 Assessment 3: Improving Patient Education to Reduce Hospital Readmissions
Hospital readmissions remain to be a major challenge to both patients, providers and health systems. Not only do they increase costs, but also, they are a source of patient dissatisfaction and poorer health outcomes. Among the preventable readmissions, one may distinguish chronic heart failure (CHF) as one of the conditions, which is predominantly affected by the quality of discharge instruction and continuity of care. In my practicum at a community-based acute care hospital, I recognize that patients with CHF are likely to be readmitted within thirty days of discharge, often due to ineffective knowledge of self-management techniques, medication instructions, and the importance of follow-up visits. The proposed capstone project plan is aimed at reducing hospital readmissions through improved patient education and support.
In NURS FPX 4905 Assessment 3, the proposed hypothesis is driven by a practice gap to address the issue of patient education at discharge as currently high. This is an evidence-based initiative aimed at standardizing patient education practices at discharge and provide patient education at discharge to drive down patient readmission rates and increase patient self-efficacy.
The problem of high readmission rates
In NURS FPX 4905 Assessment 3, the history of my practicum site is that there have not been any reports which adequately address the issue of high readmission rates within CHF patients provided through internal quality improvement reports. The average of the last year thirty-day readmission rate is around twenty-four percent, which goes beyond the national standard, and it is exposed to a hospital readmissions reduction program penalty. Discharge education had been a significant factor in this trend according to the root causes analyses
conducted by the quality department of the hospital, making it a key strategy for reducing readmissions in hospitals.
Patients claim they are puzzled on how to measure their weight on a daily basis, restricting fluids taken by the patient, and how they should know the worsening of their symptoms and when to call an ambulance. This is reported in a systematic review and meta-analysis by Chartrand et al. (2023), which demonstrated significant improvements in patient- and family-centered care transition interventions in terms of quality and safety of care in adults transferring between healthcare environments.
Evidence-Based Framework and Implementation Plan
Reviewing the literature available, the significance of organizing and nurse-led teaching programs in eliminating the readmission rates of patients with heart failure is justified. Coffey and colleagues found that education interventions with specific design (e.g., those incorporating the teach-back approach and employing follow-up phone calls) can lower readmission by up to a quarter. Similarly, the American Heart Association highlights that patient-centered and culturally-competent education, as well as specific instructions on how to take medication, how to monitor their symptoms, diet, and fluid intake/output are an important activity that helps patients feel more in control of their condition at home. Jha et al. (2022) retrieved countrywide information and identified the fact that patients with heart failure and preserved ejection fraction are characterized by a high number of readmissions during the 30-day period, and discharge planning should focus on these patients to solve the issue. Moreover, they demonstrated that discharge planning with an interdisciplinary team of nurses, pharmacists, and case managers positively impacts medication reconciliation and continuity of care, supporting the principle that patient education improves outcomes and helps eliminate unnecessary hospital readmissions.
The implementation of standardized CHF discharge education protocol will follow this solid body of evidence identified by the research presented in the field, which is emphasized in NURS FPX 4905 Assessment 3. I chose Change Management Model elaborated by Lewin to provide the change process with a firm structure; further, this model can be split into three phases: unfreezing, changing, and refreezing. The unfreezing aspect will be employed to engage the nursing employees and other interested stakeholders to present to them the latest readmission data and request them to visualize the direct correlation between improved education and reduced readmission. It is imperative to have such knowledge to foster a shared sense of urgency and willingness to acquire new practices. To reflect the changes, I will present the developed discharge checklist and teach nurses how to use it by employing the teach-back approach, thereby improving patient education and enhancing care transitions. Madanat et al. (2021) identified the presence of demographics, comorbidities and lack of patient knowledge and self-management as the factors leading to 30-day readmission in patients with congestive heart failure. This not only enables one to impart information to patients but even to accurately replay the same in their own words, and this reinforces the accurate perception. At the final phase of refreezing, the project is likely to introduce this new workflow into the daily routine, which is likely to be promoted by the continuous observance and re-enforcement by the unit leaders and quality improvement personnel.
Stakeholder Engagement and Project Resources
The most significant goals of the project in NURS FPX 4905 Assessment 3 would include the development of a direct and simplified checklist of discharge education that would be designed to use with CHF patients, training nursing staff on the usage of the checklist and teach-back method, introducing the new practice to a pilot group of ten patients over four weeks,
and evaluating the results of the project in terms of post-discharge follow-up calls and readmission rates. These objectives and aims are also aligned with the goals of the performance of the hospital and the expectations of the baccalaureate-prepared nurses to lead quality improvement initiatives using evidence-based practice. Close inclusion of all the stakeholders is one of the points in successful implementation. “The most valued characters are the nursing personnel, as they will be responsible for providing education and documenting compliance in the electronic health record, which plays a critical role in reducing readmissions in hospitals. Case managers and social workers will provide supportive services which will help to make follow-up appointments and refer the patient to other resources available within the community. The pharmacy team will ensure the medication counseling is thorough and touching on the potential issues that may be related to polypharmacy as this is the type of issue older heart failure patient are prone to have. A meta-analysis by Marques et al. (2022) showed the positive role of educational nursing interventions in the reduction of hospital readmission and mortality among patients with heart failure. Quality Improvement Committee Oversight will be important so that the project remains in tune with institutional regulation and the data would be collected regularly to measure the results. The response of the affected patients and their family caregivers will also be taken quite seriously and used to conduct further, i.e., tailoring the content of their educational material as well as the manner in which it should be conveyed in order to make it pertinent and easy to understand.
The financial aspect of the undertaking will be quite minimal; however, some resources shall be invested to enhance success of the project. The modules to be used in this training will be developed by nurse educators; and on average, the nurse educator will make use of four hours preparing the learning content and two hours to undertake the learning session with staff nurses.
Handouts and check lists will be printed on sufficient number of copies and in addition will be translated to some of the common languages and combined to serve a similar purpose to literacy and language barriers, which are estimated to cost a hundred dollars. Minor adjustments to the electronic health records system will be made with the information technology team in the hospital to block alerts to the nurses to fill and record the checklist in the discharge planning workflow. All these components tap into institutional resources that already exist, making the project highly achievable within the current allocation of budgetary resources and staffing complement, while supporting the goal of reducing hospital readmissions.
Evaluation, Barriers, and Dissemination
The project would be implemented within a period of eight to ten weeks. The first week will involve developing checklists and patient-friendly education materials, and to align them with the best practice suggestions made by reliable sources, such as the American Heart Association. Week two will be allocated to the evaluation of staff training, and it will not only revolve around the technical aspects of the processes, but also around the rationale behind new process implementation in a bid to win the buy-in. The pilot period will be four weeks immediately following the training; the nurses will incorporate the standardized checklist and the teach-back approach into all the eligible CHF patients that were discharged. Simultaneously, case managers will call back the patients within three days after their release with an aim of assessing how the patients understand and follow through with the care plan. Rizzuto et al. (2022) provide the method of implementing nurse-delivered education and discharge planning interventions to decrease the rate of 30-days readmission of patients with heart failure within a critical care setting. “Data will be analyzed next week with a comparison of readmission rates and patient understanding against the baseline figures in the pilot. Finally, the results will be summarized
and presented to the Quality Improvement Committee and nursing leadership, with recommendations for hospital-wide implementation aimed at reducing hospital readmissions.
Project evaluation will be done based on measures of the process and results. Measures of Process will be the percent of CHF discharges where the checklist was completed in full and documented or direct observation audit where teaching processes are always done using the teach-back technique. The outcome measures will include the patient comprehension which will be evaluated during the follow up calls and the thirty-day readmission rate of this pilot group against the historical data of the same unit. These will help in the quantitative and qualitative assessment of the effectiveness and long-term sustainability of the intervention.
There are various barriers that can come into play in this undertaking. Among the challenges which can be expected is the fact that the nursing personnel may perceive that the checklist adds to their current workload, which is heavy. To answer this, I will reemphasize the fact that the checklist was designed to streamline and standardize the education and not to create more work and training will focus on how to work with practical tips on how to integrate it into the existing discharge planning. The second barrier that may turn out to be problematic is the reluctance of the staff to change once they are used to individualization and therefore the process of improving patient education and other care outcomes may not play out as it should.
To mitigate this, I will make sure that I identify and engage nursing champions in good time. These esteemed peers will be in a position to advocate the utility of the
Mentor in an informal way and assist in the improvement of new protocols, which is highly emphasized in NURS FPX 4905 Assessment 3. Moreover, those issues affecting patients such as low literacy in health or even not being competent in English can hinder the process of understanding, no matter how good the staff member might communicate. To overcome it,
educational materials will be prepared at the proper reading level and, in case of need, translates and interpreters will be involved.
The outcomes of the project will be publicized in various ways so as to have maximum awareness and sustainability. The findings and lesson learned will be presented in a staff meeting where the nursing leadership, staff nurses of the unit, and quality improvement staff will be invited. The conclusions reached by Tian et al. (2024) can be outlined as follows: Patients with heart failure should be treated with the help of nurse-led education that has a huge prognostic effect and benefits the self-management of such patients. A brief report on meaningful of findings and recommendations will be submitted to the Quality Improvement Committee of the hospital where they can be considered and may be included in the hospital-wide policies about discharges. To implement the new standards, I will develop an easy-to-read educational handout that will describe the best practices in CHF discharge education and would be hung up in staff break areas and near nursing stations as a quick guide.
Conclusion
In summary of NURS FPX 4905 Assessment 3, this capstone project plan has described a feasible, evidence-based strategy to addressing a dire need with far-reaching impact to patient outcomes, as well as to that of the hospital. The project will accomplish this by ensuring that the discharge education process in patients with chronic heart failure is more standardized and that the nursing staff provides easy to use tools and training to the nursing staff and trains patients to become active participants in their own care in order to reduce this preventable readmission, increase patient satisfaction, and institute a culture of continuous quality improvement. The proposed design of the project can be accomplished within a reasonable number of resources, and it perfectly correlates with the institutional priorities and the outcomes of the BSN program.
Through the effective rollout, assessment, and evaluation of such an initiative, I can demonstrate my competence as a baccalaureate-prepared nurse to initiate and promote meaningful practice improvements, including improving patient education and advancing patient-centered care well beyond this practicum experience.
References
Chartrand, J., Shea, B., Hutton, B., Dingwall, O., Kakkar, A., Chartrand, M., Poulin, A., & Backman, C. (2023). Patient- and family-centered care transition interventions for adults: A systematic review and meta-analysis of RCTs. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 35(4), mzad102. https://doi.org/10.1093/intqhc/mzad102
Jha, A. K., Ojha, C. P., Krishnan, A. M., & Paul, T. K. (2022). Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database. World Journal of Cardiology, 14(9), 473–482. https://doi.org/10.4330/wjc.v14.i9.473
Madanat, L., Saleh, M., Maraskine, M., Halalau, A., & Bukovec, F. (2021). Congestive heart failure 30-day readmission: Descriptive study of demographics, co-morbidities, heart failure knowledge, and self-care. Cureus, 13(10), e18661. https://doi.org/10.7759/cureus.18661
Rizzuto, N., Charles, G., & Knobf, M. T. (2022). Decreasing 30-day readmission rates in patients with heart failure. Critical Care Nurse, 42(4), 13–19. https://doi.org/10.4037/ccn2022417
Tian, C., Zhang, J., Rong, J., Ma, W., & Yang, H. (2024). Impact of nurse-led education on the prognosis of heart failure patients: A systematic review and meta-analysis. International Nursing Review, 71(1), 180–188. https://doi.org/10.1111/inr.12852