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Assessment 6: Final Project Submission

Student Name

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Capella University

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NURS-FPX 6030 MSN Practicum and Capstone

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MAR 24, 2024
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Final Project Submission
Abstract m
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The aim of the culmination project was to enhance patient comprehension of
post-discharge routines, decrease hospital readmissions, and elevate patient
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satisfaction subsequent to cardiac catheterization. This was accomplished through a

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personalized educational initiative and the integration of telehealth services. The

endeavor sought to tackle knowledge deficiencies and continuity of care for post-cardiac
catheterization patients, ensuring well-informed individuals with ongoing post-discharge
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assistance. The strategy encompassed individualized discharge instruction and the

integration of multimodal education delivery, employing audiovisual aids, remote
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monitoring devices, and communication platforms. Two pivotal findings underscored the
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transformative function of nurses as information facilitators and the favorable

association between patient education and diminished hospital readmissions,
presenting potential cost reductions for healthcare establishments.
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Introduction
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The culmination project addressed the elevated 30-day hospital readmission rates
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among Coronary Artery Disease (CAD) patients discharged subsequent to cardiac

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catheterization at Manatee Memorial Hospital in Bradenton, Florida. The focus was on
amplifying post-discharge patient education, integrating individualized discharge
instruction, and telehealth services to curtail readmissions. The intervention plan
prioritized transformational leadership, compliance with regulatory directives (HIPAA
and HRRP), and a 12 to 18-month implementation schedule.

Problem Statement

The necessity statement tackled the effect of a comprehensive and tailored

post-discharge education scheme compared to basic discharge guidance on 30-day
hospital readmission rates and patient outcomes. Referencing a study by Madan et al.
(2019), the urgency to minimize readmission rates for PCI patients was underscored.

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Population and Setting

The target demographic comprised patients discharged subsequent to cardiac

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catheterization at Manatee Memorial Hospital. The personalized approach aimed to
diminish complications, readmission rates, and boost patient satisfaction within a

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culturally diverse populace.

Intervention Overview
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Two central interventions were suggested: customized discharge education and
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telehealth services. The Plan-Do-Check-Act (PDCA) cycle steered the formulation of an
individualized post-cardiac catheterization education scheme. The components
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encompassed medication management, guidance on lifestyle modifications, education

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on symptom recognition, and early follow-up appointments.

Comparison of Approaches
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Inter-professional collaboration was stressed for comprehensive care. Tailored

education plans were juxtaposed with alternate methods such as standardized
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education schemes and group education sessions conducted by inter-professional

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teams.

Initial Outcome Draft

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The objective was to diminish 30-day readmission rates by 20%, enhance medication
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adherence by 15%, achieve a 30% increase in follow-up appointments, and a 25% rise
in timely symptom reporting.
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Time Estimate

The approximate timeframe for devising and executing the education program was
around 12 months, divided into planning, platform development, pilot testing, and
full-scale implementation phases.

Literature Review

The review underscored the efficacy of tailored post-procedure patient education,

emphasizing individual health literacy and cultural context. Contemporary telehealth
policies and remote monitoring tools were recognized as valuable for sustained, tailored
patient support.

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Interventional Plan

The intervention plan zeroed in on comprehensive and individualized discharge

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education, encompassing tailored educational schemes and telehealth services.
Cultural requisites and attributes, alongside theoretical underpinnings like Dorothea

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Orem’s Self-Care Theory, were taken into account.

Stakeholders, Policy, and Regulations

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Stakeholders encompassed patients, healthcare practitioners, administrators, and
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external entities like insurance providers. Policies such as HIPAA and HRRP were
pertinent, ensuring patient confidentiality, data security, and adherence to regulatory
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directives.
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Ethical and Legal Implications

Ethical implications encompassed balancing autonomy and beneficence, while legal

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considerations entailed compliance with HIPAA regulations during telehealth services.

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Implementation Plan
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Leadership strategies, management strategies, and nursing practices focused on

transformational leadership, interdisciplinary training, project planning, and
patient-centered care.
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Implications of Change to Improve Outcomes and Cost-effectiveness

Projected changes encompassed enhanced patient satisfaction, reduced readmission

rates, and streamlined care coordination, culminating in cost savings for healthcare
establishments.

Delivery and Technology

A blend of in-person and digital delivery methods, including conventional methods,

augmented reality (AR), virtual reality (VR), digital resources, virtual platforms,
personalized apps, and wearable devices, were contemplated for comprehensive
education.

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Current and Emerging Technological Options

Current technologies like PowerPoint presentations and interactive videos were

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compared with emerging options like AR, VR, personalized apps, and wearable
devices, acknowledging potential challenges.

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Stakeholders, Policy, and Regulations

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Critical stakeholders in the intervention plan for comprehensive discharge education
encompassed patients, caregivers, healthcare professionals, administrators, managers,
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IT professionals, insurance providers, and regulatory bodies. Ensuring patient needs
are met enhances engagement, satisfaction, and adherence to care plans.
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Collaboration and care coordination from healthcare professionals, along with support
from administrators, managers, and IT professionals, are crucial for resource allocation,
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budget management, and technological support.

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Existing and New Policies

Existing policies, such as telehealth reimbursement policies, ensure healthcare workers

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receive compensation for telehealth services, increasing accessibility for patients.

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Standardizing digital health educational material is crucial for accurate and reliable
information circulation. Policies encouraging collaborative care, interdisciplinary
teamwork, and involving various healthcare disciplines in patient education and care
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planning could be established. Policies like the Affordable Care Act (ACA) targeting
health disparities can provide funding and resources for underserved communities’
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access to telehealth services and digital educational resources.

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Timeline

The proposed timeline for implementing the comprehensive discharge education plan,
including customized education plans and telehealth services, spans 12-18 months.
Factors influencing the timeline include patient-specific needs, resource availability,
stakeholder commitment, patient readiness for change, and technological infrastructure
availability. Uncertain situations, such as stakeholder buy-in, resource availability,
patient input, staff training, and compliance with regulations, may require adjustments to
the timeline.

Evaluation Plan

The intervention plan combines two primary strategies: developing a tailored

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educational program and integrating telehealth services. The targeted outcomes are
enhanced patient comprehension, reduced hospital readmissions, and heightened

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patient satisfaction. Evaluation begins with a pre-intervention assessment using detailed
questionnaires to gauge baseline patient understanding. Follow-ups at 1-month,
3-month, and 6-month intervals measure lasting effects. A control group receiving

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standard discharge instructions facilitates a comparative study. Data collection includes
patient feedback forms, hospital readmission records, Electronic Health Records

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(EHRs), and dedicated patient portals for real-time tracking. Specialized software tools
analyze quantitative and qualitative metrics for a comprehensive evaluation.
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Discussion
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Nurses emerge as transformative leaders, particularly when innovation and change are
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at play. The intervention, focusing on tailored educational strategies, amplifies the

nurse’s role in translating complex medical directives into layperson’s terms. Nurses
become vital knowledge brokers, actively leading a shift towards bespoke patient
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education. This proactive shift strengthens interprofessional dynamics, necessitating

collaboration from diverse healthcare professionals. Beyond immediate patient-nurse
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interactions, the intervention enhances trust and reputation for healthcare institutions.
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For post-cardiac cath patients, the intervention equips them with a robust understanding
of their recuperation, empowering them for optimal long-term health. Challenges include
robust training for nurses and consistent delivery of quality education.
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Future Steps
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To enhance the intervention’s impact, future steps involve nuanced personalization of

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educational content, incorporating Augmented and Virtual Reality (AR/VR) systems for
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immersive patient education, and adopting the Chronic Care Model (CCM) for proactive
health systems. Integrating advanced AI-driven patient monitoring systems can predict
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issues for early interventions. Challenges include technology readiness, effectiveness,

resource constraints, and patient adaptation.

Reflection on Leading Change and Improvement

Engaging with the capstone project has profoundly impacted my ability to lead change,
emphasizing the critical nature of individualized patient care. It has enhanced my
confidence and capability in spearheading change-driven tasks, guiding teams, and
ensuring patient-centric decision-making. The project’s challenges and successes have

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provided invaluable lessons for future leadership roles. The transferable framework from
the project can be integrated across various facets of patient care, ensuring consistent

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quality improvement. The project’s universal relevance lies in its foundational elements,
contributing to improvements across different care settings and contexts. The focus on
customized care remains central to impactful interventions. Remaining a lifelong learner

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and addressing knowledge gaps are essential for successful leadership in healthcare.

References
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● Bolton, C., Vikram Kandhari, & Coolican, M. (2021). Medical optimization of the
patient prior to surgery. Springer, 241–252.
https://doi.org/10.1007/978-3-030-81553-0_24
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● Chen, A., Ayub, M. H., Mishuris, R. G., Rodriguez, J. A., Gwynn, K., Lo, M. C.,
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Noronha, C., Henry, T. L., Jones, D., Lee, W. W., Varma, M., Cuevas, E.,
Onumah, C., Gupta, R., Goodson, J., Lu, A. D., Syed, Q., Suen, L. W., Heiman,
E., … Schmidt, S. (2023). Telehealth policy, practice, and education: A position
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statement of the society of general internal medicine. Journal of General Internal

Medicine, 1–8. https://doi.org/10.1007/s11606-023-08190-8
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● CMS. (2023). Hospital readmissions reduction program (HRRP).

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https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientp
ps/readmissions-reduction-program
● Jung, C., Wolff, G., Wernly, B., Bruno, R. R., Franz, M., Schulze, P. C., Silva, J.
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N. A., Silva, J. R., Bhatt, D. L., & Kelm, M. (2022). Virtual and augmented reality
in cardiovascular care. JACC: Cardiovascular Imaging, 15(3), 519–532.
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https://doi.org/10.1016/j.jcmg.2021.08.017
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● King-Dailey, K., Frazier, S., Bressler, S., & King-Wilson, J. (2022). The role of
nurse practitioners in the management of heart failure patients and programs.
Current Cardiology Reports, 24(12), 1945–1956.
https://doi.org/10.1007/s11886-022-01796-0

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