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Assessment 6: Final Project Submission

Student Name

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Capella University

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Course Name

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Prof Name
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Mar 08, 2024
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Final Project Submission

Abstract

The capstone project expected to improve patient perception of post-release regimens,

decrease emergency clinic readmissions, and increase patient fulfillment after heart
catheterization through a custom-made instructive program and the reconciliation of
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telehealth administrations. The drive tended to an information hole and coherence of
care for post-cardiovascular catheterization patients, giving individualized release
instruction and using multimodal schooling conveyance. Two key discoveries featured
the extraordinary job of attendants as information intermediaries and the relationship
between's very much informed patients and diminished medical clinic readmissions,
recommending expected cost investment funds for medical care foundations.

Introduction

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This capstone project tends to the high 30-day clinic readmission rates among Coronary
Vein Illness (computer aided design) patients released after heart catheterization at

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Manatee Commemoration Emergency clinic in Bradenton, Florida. The emphasis is on
improving post-release patient instruction to accomplish improved results. The

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intercession plan incorporates thorough and individualized release schooling,
enveloping tweaked instructive projects and telehealth administrations. The execution

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includes groundbreaking authority, clear objective setting, patient-focused care, and

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adherence to administrative rules. The task's objective course of events is 12 to year
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Problem Statement
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Need Statement
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The undertaking plans to look at the effect of a far reaching and customized
post-release training program with fundamental release directions on 30-day medical
clinic readmission rates and patient results for computer aided design patients released
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from Manatee Remembrance Clinic after heart catheterization.

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Population and Setting

The objective populace is post-heart catheterization patients at Manatee Dedication

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Emergency clinic, at an increased gamble of difficulties post-release. The customized

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approach looks to work on quiet fulfillment and decrease readmission rates here.

Intervention Overview

Two mediations are proposed: customized release instruction and telehealth

administrations. The Arrangement Do-Check-Act (PDCA) cycle directs the
advancement of an individualized post-heart catheterization training program. Between
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proficient coordinated effort and elective methodologies, for example, normalized
schooling plans or gathering meetings, are thought of.

Initial Outcome Draft

The goal is to reduce 30-day readmission rates by 20%, increase medication adherence
by 15%, raise follow-up appointment attendance by 30%, and prompt symptom
reporting by 25%.

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Time Estimate

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The estimated timeframe for program development and implementation is
approximately 12 months, including planning, platform development, pilot testing, and

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full-scale implementation.

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Literature Review

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The literature supports the effectiveness of comprehensive education for post-cardiac
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catheterization patients, emphasizing personalized interventions and the role of
telehealth in continuous support and reduced readmission rates.
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Interventional Plan
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Intervention Plan Components

The plan includes customized educational programs and telehealth services.

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Customized educational plans involve patient assessments, profiling, and tailored

discharge instructions. Telehealth services use audiovisual and remote monitoring
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devices for post-discharge education and monitoring.

Cultural Needs and Characteristics

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Considering the diverse population in Bradenton, Florida, the intervention plan focuses
on cultural competence, respecting language preferences, cultural beliefs, and health
practices. Customized communication strategies aim to engage patients effectively.

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Theoretical Foundations

Dorothea Orem's Self-Care Theory guides the intervention plan, emphasizing patient
engagement in managing their health. Motivational interviewing addresses patients'
readiness for change, and telehealth services align with Orem's theory, supported by
literature indicating positive outcomes.

Conclusion

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The project aims to bridge the knowledge gap in post-cardiac catheterization care,
emphasizing personalized education and telehealth services. The theoretical foundation

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and literature review support the comprehensive intervention plan, tailored to the
cultural needs of the diverse population in Bradenton, Florida.

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Stakeholders, Policy, and Regulations

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Patients and their caregivers are pivotal stakeholders in our intervention strategy for

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comprehensive discharge education. Addressing patient needs is crucial for boosting
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their engagement, satisfaction, and adherence to care plans, ultimately leading to
desired outcomes in our intervention plan, such as reduced readmission rates and
improved health results. In addition to patients, healthcare professionals support our
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educational intervention through collaboration and care coordination. Administrators,
managers, and IT professionals are vital for managing human, financial, and
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technological resources, assisting in resource allocation, budget management, and

technological support throughout the planning and implementation phases.
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External stakeholders, including insurance providers and regulatory bodies, play

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essential roles in providing reimbursements and maintaining legal and ethical

standards. Healthcare regulations such as Medicare’s Hospital Readmission Reduction
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Program (HRRP) and the Health Insurance Portability and Accountability Act (HIPAA)
are relevant to our intervention plan. The HRRP penalizes hospitals with
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higher-than-expected readmission rates for chronic health conditions, focusing on

comprehensive discharge planning to reduce readmission rates (CMS, 2023). Similarly,
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our program's policy emphasizes comprehensive discharge education to achieve

reduced readmission rates, enhanced patient education, improved outcomes, and
heightened healthcare quality.

The HIPAA Act, which underscores the protection of patients’ privacy during telehealth
interactions (Rahim & Alshahrani, 2023), is especially pertinent to our plan, which
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involves using digital resources and educational virtual platforms. Safeguarding patient
information's security and confidentiality is fundamental to complying with HIPAA
guidelines. This analysis assumes that stakeholders and regulations directly impact the
plan’s successful implementation, emphasizing the need for adequate support, funding,
and collaboration from internal and external stakeholders. Regulatory compliance is
essential to maintaining ethical and legal care standards for patient satisfaction.

Existing and New Policies

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Existing reimbursement policies can ensure healthcare workers receive compensation
for telehealth services (Telehealth.HHS.gov, 2023). If such policies are not available in a

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state, they can be developed to incentivize providers to offer telehealth services,
ultimately increasing healthcare accessibility for patients. Standardizing digital health
educational materials is equally important to ensure accurate and reliable information is

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disseminated to patients. Policies promoting collaborative care, interdisciplinary

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teamwork, and the involvement of various healthcare disciplines in patient education
and care planning could be established. Policies like the Affordable Care Act (ACA) can

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target health disparities within a state, providing funding and resources to underserved
communities for access to telehealth services and digital educational resources (CMS,
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2023).
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Timeline

The proposed timeline for implementing our comprehensive discharge education plan’s
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two-pronged approach, involving customized education plans and telehealth services,

depends on factors such as patient-specific needs, resource availability, stakeholder
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commitment, patients’ readiness for change, and technological infrastructure availability.

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However, a reasonable implementation timeframe is set at 12-18 months, considering

the time-consuming processes of resource allocation, developing telehealth and digital
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platforms, and staff training.

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However, various uncertainties may necessitate extending the timeframe. These factors
include the need for stakeholder buy-in, as stakeholders play a crucial role in the plan’s
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successful implementation. It is essential to secure buy-in from all stakeholders,

including patients, healthcare providers, and hospital administrators. Adequate
resources, such as staff, technological materials, and finances, are crucial, and the
unavailability or scarcity of such resources may lead to delayed implementation. Other
significant factors include patients’ input, readiness for change, staff training, and
compliance with regulations and policies.

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Evaluation Plan

The intervention plan combines two primary strategies: developing a tailored

educational program and integrating telehealth services for patients discharged after
cardiac catheterization. The targeted outcomes of this intervention include enhanced
patient comprehension of their post-discharge regimen, reduced hospital readmissions,
and heightened patient satisfaction (King-Dailey et al., 2022). These outcomes are
central to the intervention's purpose, aiming to reduce post-discharge complications,
lower readmission rates, and improve patient adherence and understanding.

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The intervention promises benefits through these dual pathways, from patient health

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outcomes to systemic improvements in quality, safety, and care experience.
Personalized education bridges the knowledge gap, ensuring patients are well-prepared
for post-hospitalization care (Al-Noumani et al., 2023). Combining this with telehealth

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services provides continuity of care, promoting safety and a seamless healthcare

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experience, even from home. Challenges are anticipated, including the
resource-intensive nature of crafting tailored educational content and the potential for

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patients to become overly reliant on medical professionals for clarifications.
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Evaluation Plan and Assumptions
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The evaluation plan rests on two foundational assumptions. Firstly, individualized
discharge education and telehealth services will significantly improve patient
comprehension and adherence post-discharge. Secondly, a measurable reduction in
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readmissions will indicate the successful implementation of our intervention. The

strategy involves a comprehensive pre-intervention assessment using detailed
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questionnaires to gauge patients’ baseline understanding of discharge directives

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(King-Dailey et al., 2022). Follow-ups are scheduled at 1-month, 3-month, and 6-month
intervals, with data collection including patient feedback forms and hospital readmission
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records.
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Electronic Health Records (EHRs) will be used for real-time tracking of patient
readmissions, and dedicated patient portals will provide a two-way channel for
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disseminating tailored educational content and gathering feedback. Specialized

software tools for data analysis will process quantitative metrics and qualitative data to
thoroughly gauge the intervention’s impact on health promotion and education.

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Discussion

Advocacy

Nurses play a transformative role in the healthcare landscape, especially when

innovation and change are involved. With close patient interactions, nurses gain insights
into individual needs and identify areas for improvement. Our tailored educational
strategy for discharged cardiac catheterization patients enhances the nurse’s role as a
knowledge broker. Empowered by the intervention, nurses actively lead a shift towards

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bespoke patient education, ensuring complex medical directives are translated into
layperson’s terms for post-cardiac cath patients. This shift augments the quality and

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experience of care, guiding patients toward better health outcomes (Mistretta et al.,
2023).

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Nurses become change catalysts in healthcare settings when armed with appropriate
tools, actively spearheading a shift towards comprehensive patient education. The

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tailored educational content demands collaboration from diverse healthcare

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professionals, fostering a multidisciplinary approach to post-cardiac cath care. From an
economic perspective, a well-informed patient stands a reduced chance of hospital
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readmission, leading to substantial cost savings. Healthcare institutions pioneering
patient-centric approaches can expect enhanced trust and reputation. Specifically, for
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post-cardiac cath patients, this intervention equips them with a robust understanding of
their recuperation, empowering them to mitigate potential complications and ensure
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optimal long-term health (Madan et al., 2019). Challenges include the need for robust
nurse training and consistent delivery of quality education.
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Future Steps
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In healthcare interventions, there is a desire to enrich strategies further for better patient
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service. While robust, our intervention can be expanded for a more significant impact,
aligning with emerging technologies and care models. Educational content could benefit
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from more nuanced personalization, and the introduction of Augmented and Virtual
Reality (AR/VR) systems could make patient education more immersive. Such
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technologies can provide a three-dimensional, interactive space for patients to visualize

and understand their post-surgery care and potential complications (Jung et al., 2022).

The intervention can adopt the Chronic Care Model (CCM), emphasizing proactive
health systems and placing the patient at the center. This involves stronger relationships
and transparent communication between healthcare providers and patients, fostering

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involvement, information, and empowerment in the recovery process. Advanced
AI-driven patient

monitoring systems can be integrated for real-time tracking, predicting potential issues,
and enhancing patient safety. Immediate alerts can be sent to patients and healthcare
providers if deviations from the optimal recovery path are detected. The proposed
enhancements assume that technology will foster a more profound understanding and
commitment to post-discharge instructions, promising improved patient outcomes and
enhanced safety protocols (Jung et al., 2022).

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Reflection on Leading Change and Improvement

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Engaging with this capstone project has profoundly impacted my ability to lead change
in my current care setting and personal practice. It has revealed the critical nature of

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individualized patient care and how this approach can shape better health outcomes.
Managing a customized educational plan has enhanced my confidence and capability in

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spearheading change-driven tasks in the future. The project’s challenges and

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successes have taught me invaluable lessons I will carry into future leadership roles.
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My understanding of adaptive patient care, bolstered by this project, will be instrumental
in guiding teams, strategizing healthcare initiatives, and ensuring that the patient
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remains at the core of all decisions. My primary objective is to remain a lifelong learner,
constantly updating my knowledge base and skills. I also aim to bridge the gaps
identified during this project, especially in ensuring effective delivery and
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comprehension of patient education. Completing this project has provided a highly

transferable framework to my existing practice. The essence of the project, a bespoke
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patient-centric approach, can be integrated across various facets of patient care.

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The methodology of implementing a tailored educational plan, the feedback

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mechanisms, and the evaluation methods can all be adapted to different scenarios
within my current care setting, ensuring consistent quality improvement. While the
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project was designed for a specific purpose, its foundational elements have universal
relevance. Considering its application to other care settings and contexts, its principles
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can drive improvements across the board. Whether in outpatient care, specialized
clinics, or community health setups, the focus on customized care, informed by this
project, can be the cornerstone of impactful interventions. However, it is essential to
remain receptive to alternative perspectives and conflicting evidence, always ensuring
that the strategies adopted are grounded in evidence-based practices and cater to the
diverse needs of the patient population.

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