1. Discussion: Heart Failure Clinic Care Plan
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PAPERS ON Discussion: Heart Failure Clinic Care PlanAssessment
InstructionsPREPARATIONRefer to the Capella library and the Internet for supplemental
resources to help you complete this assessment.INSTRUCTIONSDeliverable: Develop an
evidence-based plan for health care delivery.Scenario:The hospital where you work has an
issue with increased readmissions within 30 days of discharge. After examining the core
measures, it was found that heart failure was the most common core measure disease
process experiencing the highest rate of readmissions. The leadership team has given your
team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of
this clinic is to ensure that discharge education is presented to the patient in an orderly,
consistent manner and complies with evidence-based practice protocols. Since these
patients may be discharged from a variety of areas in the facility, having the heart failure
clinic staff take ownership of the process will improve both consistency and compliance.
There are cardiologists that interact with the staff and patients, but the day-to-day
operations of the clinic are designed and supported by the nurses as they interact with
appropriate members of the other health care team disciplines promoting the best care for
the heart failure patients. Discussion: Heart Failure Clinic Care PlanAs a member of the
nurse team, you have been asked to develop one component of the clinic.The hospital
leadership established these objectives for the clinic services:Evaluate and maximize proper
medication therapy.Conduct regular diet, exercise, and stress management classes for the
patients.Monitor physiological indicators for the patients (lab work, weights, vital signs,
ECGs).Provide a case management system for patients in the program post-discharge.The
overall goals for the heart failure clinic are to:Enroll greater than 90 percent of the patients
with a primary or secondary diagnosis of HF prior to discharge.Facilitate discharge planning
to achieve 100 percent compliance with patient education prior to discharge (discharge
planning).Decrease readmission rates in this population by 5 percent over the next year.The
leadership team has asked you to provide them with an evidence-based plan for one of the
components of the clinic. You may use any combination of documents (for example, a
spreadsheet or a table) in addition to explanatory information to convey information clearly
and succinctly.Develop one: an Orientation Course Plan, a Discharge Education Plan, or a
Care Coordination Plan.An Orientation Course Plan:Develop an evidence-based plan for
health care delivery.Include a comprehensive schedule of topics, objectives, key points, and
patient resources for the orientation course.What are the components of an evidence-based

2. education plan?How will you know that patients will understand what to do?What
modalities will you use to deliver information?How will you adapt the plan to meet the
needs of patients from diverse cultural and language backgrounds?Identify specialized and
supplementary material needs.Apply professional and legal standards in support of a care
plan.Explain the alignment to the most recent Heart Failure Guidelines and specific
professional standards.Describe the accountability tools and procedures used to measure
effectiveness.How will you know if the patient education plan is successful?What are the
indicators of success or effectiveness?A Discharge Education Plan:Develop an evidence-
based plan for health care delivery.Develop a discharge plan with objectives and resources,
and tools for patients to monitor their progress.How will you know that patients
understand what to do?What modalities will you use to deliver information?How will you
adapt the plan to meet the needs of patients from diverse cultural and language
backgrounds?Apply professional and legal standards in support of a care plan.Explain the
alignment to the most recent Heart Failure Guidelines and specific professional
standards.Describe accountability tools and procedures used to measure effectiveness.How
will you know if the discharge plan is successful?What are the indicators of success or
effectiveness?Care Coordination Plan:Develop an evidence-based plan for health care
delivery.Develop a procedure for coordinating services.Consider the needs of “outliers.” For
example, someone with lung disease may need extra resources.Who should be on the
team?When would the team be activated?How would it be activated?What is the time frame
required to coordinate services?How would the intervention plan be monitored for
effectiveness?Apply professional standards in support of a care plan.Explain the alignment
to the most recent heart failure guidelines and specific professional standards.Describe
accountability tools and procedures used to measure effectiveness.How will you know if the
care coordination plan is successful?What are the indicators of success or
effectiveness?How will information be collected or communicated?ADDITIONAL
REQUIREMENTSWritten communication: Written communication should be free of errors
that detract from the overall message.APA formatting: Resources and in-text citations
should be formatted according to current APA style and formatting.Length: The report
should be 3-4 pages in content length, double-spaced.Font and font size: Times New Roman,
12 point.Number of resources: Support your plan with a minimum of three peer-reviewed
resources, in addition to professional standards.Library ResourcesCapella MultimediaClick
the links provided below to view the following multimedia pieces:Riverbend City: Insurance
Issues Mission | Transcript.Leadership Styles | Transcript.Leadership, Theories, Models, and
Styles | Transcript.The following resources are provided for you in the Capella University
Library and are linked directly in this course. These articles contain content relevant to the
topics and assessments that are the focus of this unit.Mensik, J. S. (2013). Nursing’s role and
staffing in accountable care. Nursing Economics, 31(5), 250–253.Ganz, F. D., Wagner, N., &
Toren, O. (2015). Nurse middle manager ethical dilemmas and moral distress. Nursing
Ethics, 22(1), 43–51.Ott, J., & Ross, C. (2014). The journey toward shared governance: The
lived experience of nurse managers and staff nurses. Journal of Nursing Management, 22(6),
761–768.Tait, G. R., Bates, J., LaDonna, K. A., Schulz, V. N., Strachan, P. H., McDougall, A., &
Lingard, L. (2015). Adaptive practices in heart failure care teams: Implications for patient-

3. centered care in the context of complexity. Journal of Multidisciplinary Healthcare, 8, 365–
376.Boyde, M., Song, S., Peters, R., Turner, C., Thompson, D. R., & Stewart, S. (2013). Pilot
testing of a self-care education intervention for patients with heart failure. European
Journal of Cardiovascular Nursing, 12(1), 39–46.Brennan, E. J. (2015). Heart failure care for
patients who do not speak English. British Journal of Nursing, 24(20), 1004–
1008.Coordinating the medical home for heart failure patients; transitioning to palliative
care: Adjusting locus of care and focusing on integrated medicine sheds light on best
practices and patient-centered care in heart failure clinics. (2010, September 15). PR
Newswire.Ivany, E., & While, A. (2013). Understanding the palliative care needs of heart
failure patients. British Journal of Community Nursing, 18(9), 441–445.Limpahan, L. P.,
Baier, R. R., Gravenstein, S., Liebmann, O., & Gardner, R. L. (2013). Closing the loop: Best
practices for cross-setting communication at ED discharge. American Journal of Emergency
Medicine, 31(9), 1297–1301.Lingle, C. L. (2013). Evidence based practice: Patient discharge
education barriers to patient education(Master’s thesis). Available from ProQuest
Dissertation Publishing. (UMI No. 1542582)Delaney, C., Apostolidis, B., Bartos, S., Morrison,
H., Smith, L., & Fortinsky, R. (2013). A randomized trial of telemonitoring and self-care
education in heart failure patients following home care discharge.Home Health Care
Management and Practice, 25(5), 187–195.Wolfson, B. J., & Campbell, R. (2014, February
9). With Medicare watching, hospitals make changes: Orange County medical centers put
new focus on discharge practices to reduce patient readmissions. Orange County
Register.Berry, L. L., Rock, B. L., Houskamp, B. S., Brueggeman, J., & Tucker, L. (2013). Care
coordination for patients with complex health profiles in inpatient and outpatient
settings. Mayo Clinic Proceedings, 88(2), 184–194.Veenstra, W., op den Buijs, J., Pauws, S.,
Westerterp, M., & Nagelsmit, M. (2015). Clinical effects of an optimised care program with
telehealth in heart failure patients in a community hospital in the Netherlands. Netherlands
Heart Journal, 23(6), 334–340.Aller, M., Vargas, I., Coderch, J., Calero, S., Cots, F., Abizanda,
M., … Vázquez, M. L. (2015). Development and testing of indicators to measure coordination
of clinical information and management across levels of care. BMC Health Services
Research, 15(323), 1–16.Course Library GuideA Capella University library guide has been
created specifically for your use in this course. You are encouraged to refer to the resources
in the BSN-FP4012 – Nursing Leadership and Management Library Guide to help direct your
research.Internet ResourcesNational Council of State Boards of Nursing (NCSBN). (n.d.).
Retrieved from https://www.ncsbn.org/index.htmAmerican Nurses Association (ANA).
(2015). Code of ethics for nurses. Retrieved
from http://www.nursingworld.org/MainMenuCategories/Eth…Bookstore ResourcesThe
resources listed below are relevant to the topics and assessments in this course. Unless
noted otherwise, these materials are available for purchase from the Capella University
Bookstore. When searching the bookstore, be sure to look for the Course ID with the
specific –FP (FlexPath) course designation.Kelly, P., & Tazbir, J. (2014). Essentials of nursing
leadership and management (3rd ed.). Clifton Park, NY: Delmar.Chapter 2.Chapters 11–
15.heart_failure_clinic_care_plan_scoring_guide.pdfleadership__theories__models_and_styles
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