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. By providing better patient education and assistance, the proposed capstone project plan seeks for 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 release 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 th
national average and subject for reducing readmissions in hospitals program penalty. According to the hospital’s quality department’s root causes analysis, discharge education played a major role in this trend, making it a crucial tactic for lowering readmission rates.
Patients say they are confused about how to weigh themselves every day, how to limit the amount of fluids they consume, and how to recognize when their symptoms are getting worse and when to contact for help. According to Chartrand et al.’s systematic review and meta-analysis from 2023, 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
This strong body of data, which is highlighted in NURS FPX 4905 Assessment 3, will be followed by the introduction of a standardized CHF discharge education program. To provide the change process a solid framework, I went with Lewin’s Change Management Model, which is divided into three stages: unfreezing, altering, and refreezing. In order to involve nursing staff and other interested parties, the unfreezing component will be used to show them the most recent readmission statistics and ask them to illustrate the clear link between better education and lower readmission rates. Such information is necessary to promote a common sense of urgency and readiness to learn new methods. In order to improving patient education and care transitions, I will use the teach-back approach to train nurses how to use the discharge checklist that I have prepared to reflect the improvements. 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. The project will probably incorporate this new workflow into the daily routine at the end of the refreezing phase, which will probably be encouraged by the unit leaders’ and quality improvement staff’s constant observing and re-enforcement.
Stakeholder Engagement and Project Resources
research, such as modifying the instructional materials’ content and delivery to make them more relevant and understandable.
Although there won’t be much money involved, certain resources will be used to increase the project’s chances of success. Nurse educators will create the modules that will be used in this training; on average, they will spend four hours creating the instruction and two hours conducting the staff nurse learning session. A sufficient number of copies of the handouts and check lists will be printed, and they will also be translated into some common languages and used in conjunction with the anticipated $100 cost of literacy and language hurdles. The hospital’s information technology team will make minor changes to the electronic health records system to prevent nurses from receiving notifications to complete and record the discharge planning process checklist. All of these elements support the objective of reducing hospital readmissions by utilizing institutional resources that are already in place, making the project extremely feasible given the current financial resource allocation and personnel complement.
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 evaluation 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
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 among the outcome measures. These will support the quantitative and qualitative evaluation of the intervention’s efficacy and long-term viability.
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 order to address this, I will reiterate that the checklist was created to standardize and expedite instruction rather than to add to the workload, and that training will concentrate on practical advice on how to incorporate it into the current discharge strategy. The second obstacle that could prove to be troublesome is the staff’s resistance to change after they become accustomed to individualization; as a
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 procedures, and these respected peers will be able to support the Mentor’s value in an informal manner. Furthermore, even if a staff person communicates well, problems that influence patients, like insufficient health literacy or even a lack of proficiency in English, can make it difficult for them to understand. To get around it, instructional materials will be developed at the appropriate reading level, and interpreters and translators will be available if necessary.
The project’s results will be disseminated in a variety of methods to maximize sustainability and awareness. The unit’s staff nurses, nursing leadership, and quality improvement personnel will all be invited to a staff meeting where the results and lessons gained will be discussed. The following summarizes the findings of Tian et al. (2024): Heart failure patients should receive treatment with nurse-led education, which improves their self-management and has a significant prognostic impact. The hospital’s Quality Improvement Committee will receive a concise report with significant findings and suggestions, which they can review and possibly include into the hospital’s discharge policy. The best practices in CHF discharge education will be covered in an easy-to-read educational handout that I will create and hang in staff break areas and close to nursing stations as a quick reference in order to implement the new standards.
Conclusion
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
