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.
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?
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