NURS FPX 4905 Assessment 3: Improving Patient Education to Reduce Hospital Readmissions
Readmissions to hospitals continue to be a significant problem for patients, healthcare systems, and clinicians. In addition to raising expenses, they also contribute to patient discontent and worse health results. Chronic heart failure (CHF) stands out among the avoidable readmissions because it is one of the conditions that is most impacted by the standard of discharge education and treatment continuity. I understand from my practicum at a community-based acute care hospital that patients with congestive heart failure (CHF) are likely to be readmitted within 30 days of being discharged, frequently as a result of inadequate understanding of medication instructions, self-management strategies, and the significance of follow-up visits. Through improved patient education and support, the proposed capstone project plan is aimed at reducing hospital readmissions.
The suggested hypothesis in NURS FPX 4905 Assessment 3 is motivated by a practice gap to address the problem of patient education upon discharge, which is currently high. Standardizing patient education procedures at discharge and offering patient education at discharge to reduce readmission rates and boost patient self-efficacy are the goals of this evidence-based program.
The problem of high readmission rates
According to the history of my practicum site in NURS FPX 4905 Assessment 3, there haven’t been any internal quality improvement reports that sufficiently address the problem of high readmission rates among CHF patients. The average 30-day readmission rate over the past 12 months is around 24%, which is higher than the national average and subject to a hospital readmissions reduction program penalty. According to the hospital’s quality department’s root
In addition to limiting their fluid intake, patients say they are confused about how to weigh themselves every day, how to recognize when their symptoms are getting worse, and when to call for help. In a systematic review and meta-analysis published in 2023, Chartrand et al. showed that patient- and family-centered care transition treatments significantly improved the quality and safety of care for persons moving between healthcare settings.
Evidence-Based Framework and Implementation Plan
The importance of setting up nurse-led educational programs to reduce the readmission rates of heart failure patients is supported by a review of the literature. According to Coffey and colleagues, certain types of education interventions, such as those that use the teach-back method and follow-up phone calls, can reduce readmission by as much as 25%. Similarly, the American Heart Association emphasizes that specific instructions on how to take medication, monitor symptoms, diet, and fluid intake/output, along with patient-centered and culturally-competent education, are crucial activities that help patients feel more in control of their condition at home. According to data gathered nationwide, Jha et al. (2022) found that patients with heart failure and intact ejection fraction have a high rate of readmissions over the course of 30 days; therefore, discharge planning should target these patients to address the problem. Additionally, they showed that medication reconciliation and continuity of care are positively impacted by discharge planning with an interdisciplinary team of nurses, pharmacists, and case managers. This supports the idea that patient education improves outcomes and helps prevent needless hospital readmissions.
To promote a common sense of urgency and readiness to learn new methods, such understanding is essential. I will use the teach-back method to train nurses how to use the established discharge checklist in order to improve care transitions and patient education in light of the changes. According to Madanat et al. (2021), the characteristics that contribute to 30-day readmission in patients with congestive heart failure include demographics, comorbidities, and a lack of patient awareness and self-management. This not only makes it possible to accurately convey information to patients, but it also allows them to repeat it in their own words, which strengthens the accurate impression.
Stakeholder Engagement and Project Resources
The project’s main objectives in NURS FPX 4905 Assessment 3 are to create a straightforward and easy-to-use discharge education checklist for CHF patients, train nursing staff on how to use the checklist, and teach the back technique. The objectives also include introducing the new practice to a pilot group of ten patients over the course of four weeks, and assessing the project’s outcomes in terms of readmission rates and post-discharge follow-up calls. These goals and objectives are also in line with the hospital’s performance goals and the expectations of baccalaureate-prepared nurses to spearhead quality improvement projects
“The nursing staff are the most important characters since they will be in charge of educating patients and recording compliance in the electronic health record, both of which are vital in reducing hospital readmission rates. Social workers and case managers will offer supporting services that include scheduling follow-up appointments and connecting the patient with further community resources. Since polypharmacy is the kind of problem that older heart failure patients are likely to experience, the pharmacy staff will make sure the drug counseling is comprehensive and touches on any possible difficulties. The Committee on Quality Improvement Monitoring will be crucial to ensuring that the initiative stays compliant with institutional regulations and that data is routinely gathered to gauge its effectiveness. Responses from impacted patients and their family caregivers will also be taken seriously and used to guide future research, such as modifying the instructional materials’ content and delivery to make them more relevant and understandable.
Although there will be a small financial input for the project, some resources will be used to increase its chances of success. Nurse educators will create the training modules. On average, they will spend four hours creating the course materials and two hours conducting the staff nurse learning session. In addition to being produced in a suitable quantity, handouts and checklists will also be translated into some common languages and used in conjunction with the projected $100 cost of literacy and language hurdles. Together with the hospital’s IT team, minor changes will be made to the electronic health records system to prevent nurses from receiving reminders to complete and document the discharge planning workflow checklist. In addition to supporting
Evaluation, Barriers, and Dissemination
Within eight to ten weeks, the idea would be put into action. During the first week, checklists and patient-friendly educational materials will be created and aligned with the American Heart Association’s and other credible sources’ recommendations for best practices. The review of staff training will take place in the second week and will focus on both the technical parts of the procedures and the justification for implementing new processes in an effort to gain support. The nurses will apply the teach-back method and the standardized checklist to all eligible CHF patients who were discharged during the four weeks that follow the training. In order to evaluate the patients’ comprehension and adherence to the care plan, case managers will concurrently give them a call back within three days after their release. In a critical care context, Rizzuto et al. (2022) describe how to reduce the 30-day readmission rate of patients with heart failure by applying nurse-delivered education and discharge planning strategies. Next week, data analysis will compare readmission rates and patient comprehension to the pilot’s baseline numbers. Lastly, a summary of the findings will be sent to the nursing leadership and the Quality Improvement Committee, along with suggestions for hospital-wide adoption that will be involved in reducing hospital readmission.
Measures of the process and outcomes will be used to evaluate the project. The percentage of CHF discharges where the checklist was fully and accurately completed, or direct observation audits where the teach-back technique is always used, will serve as process measures. Patient comprehension, which will be assessed during follow-up conversations, and the 30-day readmission rate of this pilot group in comparison to the same unit’s history data are
There are a number of potential obstacles to this endeavor. One of the anticipated difficulties is that the nursing staff might feel that the checklist adds to their already heavy burden. In response, I will reiterate that the checklist was created to standardize and expedite the education process rather than to add to the workload. The training will concentrate on practical advice on how to incorporate it into the current discharge plans. The second obstacle that could prove to be troublesome is the staff’s resistance to change after they become accustomed to individualization. As a result, the process of improving patient education and other care outcomes might not go as planned.
I’ll make sure to find and contact nursing champions in a timely manner in order to lessen this. NURS FPX 4905 Assessment 3 places a strong emphasis on the improvement of new protocols, and these distinguished peers will be able to support the Mentor’s value in an informal manner. Furthermore, regardless of how well a staff member communicates, problems that influence patients, like insufficient health literacy or even a lack of proficiency in English, might affect comprehension. The preparation of instructional materials at the appropriate reading level and the use of translators and interpreters when necessary will help to overcome it.
Various methods will be used to promote the project’s results in order to maximize awareness and sustainability. Quality improvement staff, the unit’s staff nurses, and nursing leadership will all be invited to a staff meeting where the results and lessons gained will be discussed. The following is an outline of the conclusions drawn by Tian et al. (2024): Treatment for heart failure patients should involve nurse-led education, which improves the patients’ self-management and has a significant prognostic impact. A concise report with significant
Conclusion
To summarize NURS FPX 4905 Assessment 3, this capstone project plan has outlined a workable, evidence-based approach to resolving a pressing need that has a significant influence on both patient and hospital outcomes. To reduce this avoidable readmission, improve patient satisfaction, and establish a culture of continuous quality improvement, the project will ensure that the discharge education process for patients with chronic heart failure is more standardized, that nursing staff members have easy-to-use tools and training, and that patients are trained to become active participants in their own care. The project concept that has been suggested is feasible and aligns precisely with the BSN program’s aims and institutional priorities. By successfully implementing, evaluating, and assessing such an initiative, I can show that, as a nurse with a baccalaureate degree, I am capable of starting and fostering significant practice changes, such as improving patient education and advancing patient-centered care long after this practicum experience is over.
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
Marques, C. R. G., de Menezes, A. F., Ferrari, Y. A. C., Oliveira, A. S., Tavares, A. C. M., Barreto, A. S., Vieira, R. C. A., da Fonseca, C. D., & Santana-Santos, E. (2022). Educational nursing intervention in reducing hospital readmission and the mortality of patients with heart failure: A systematic review and meta-analysis. Journal of Cardiovascular Development and Disease, 9(12), 420. https://doi.org/10.3390/jcdd9120420
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
