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NURS FPX 6030 Assessment 6 Final Project Submission

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    NURS FPX 6030 Assessment 6 Final Project Submission

    Student Name

    Capella University

    NURS-FPX 6030 MSN Practicum and Capstone

    Prof. Name


    Final Project Submission


    The objective of the capstone project was to improve patient understanding of post-discharge regimens, diminish hospital readmissions, and enhance patient satisfaction following cardiac catheterization. This was achieved through a tailored educational program and the integration of telehealth services. The initiative aimed to address knowledge gaps and continuity of care for post-cardiac catheterization patients, ensuring well-informed individuals with sustained post-discharge support. The approach included individualized discharge education and the incorporation of multimodal education delivery, utilizing audiovisual, remote monitoring devices, and communication tools. Two key findings emphasized the transformative role of nurses as knowledge brokers and the positive correlation between patient education and reduced hospital readmissions, offering potential cost savings for healthcare institutions.


    The capstone project addressed the high 30-day hospital readmission rates among Coronary Artery Disease (CAD) patients discharged after cardiac catheterization at Manatee Memorial Hospital in Bradenton, Florida. The emphasis was on enhancing post-discharge patient education, incorporating individualized discharge education, and telehealth services to reduce readmissions. The intervention plan focused on transformational leadership, adherence to regulatory guidelines (HIPAA and HRRP), and a 12 to 18-month implementation timeline.

    Problem Statement

    The need statement addressed the impact of a comprehensive and personalized post-discharge education program compared to basic discharge instructions on 30-day hospital readmission rates and patient outcomes. Citing a study by Madan et al. (2019), the urgency to minimize readmission rates for PCI patients was highlighted.

    Population and Setting

    The target population was patients discharged after cardiac catheterization at Manatee Memorial Hospital. The tailored approach aimed to reduce complications, readmission rates, and improve patient satisfaction within a culturally diverse population.

    Intervention Overview

    Two central interventions were proposed: tailored discharge education and telehealth services. The Plan-Do-Check-Act (PDCA) cycle guided the development of an individualized post-cardiac catheterization education program. The components included medication management, lifestyle modification guidance, symptom recognition education, and early follow-up appointments.

    Comparison of Approaches

    Inter-professional collaboration was emphasized for comprehensive care. Customized education plans were compared with alternative approaches, such as standardized education plans and group education sessions led by inter-professional teams.

    Initial Outcome Draft

    The goal was to reduce 30-day readmission rates by 20%, increase medication adherence by 15%, achieve a 30% increase in follow-up appointments, and a 25% increase in prompt symptom reporting.

    Time Estimate

    The estimated timeframe for developing and implementing the education program was approximately 12 months, divided into planning, platform development, pilot testing, and full-scale implementation phases.

    Literature Review

    The review highlighted the effectiveness of tailored post-procedure patient education, emphasizing individual health literacy and cultural background. Current telehealth policies and remote monitoring tools were identified as valuable for continuous, tailored patient support.

    Interventional Plan

    The intervention plan focused on comprehensive and individualized discharge education, including customized educational programs and telehealth services. Cultural needs and characteristics, along with theoretical foundations like Dorothea Orem’s Self-Care Theory, were considered.

    Stakeholders, Policy, and Regulations

    Stakeholders included patients, healthcare professionals, administrators, and external entities like insurance providers. Policies such as HIPAA and HRRP were relevant, ensuring patient privacy, data security, and adherence to regulatory guidelines.

    Ethical and Legal Implications

    Ethical implications included balancing autonomy and beneficence, while legal considerations involved adherence to HIPAA regulations during telehealth services.

    Implementation Plan

    Leadership strategies, management strategies, and nursing practices focused on transformational leadership, interdisciplinary training, project planning, and patient-centered care.

    Implications of Change to Improve Outcomes and Cost-effectiveness

    Anticipated changes included improved patient satisfaction, reduced readmission rates, and efficient care coordination, leading to cost savings for healthcare institutions.

    Delivery and Technology

    A combination of in-person and digital delivery methods, including traditional methods, augmented reality (AR), virtual reality (VR), digital resources, virtual platforms, personalized apps, and wearable devices, were considered for comprehensive education.

    Current and Emerging Technological Options

    Current technologies like PowerPoint presentations and interactive videos were contrasted with emerging options like AR, VR, personalized apps, and wearable devices, acknowledging potential challenges.

    Stakeholders, Policy, and Regulations

    Stakeholders, including patients, healthcare professionals, administrators, and external entities, were identified, along with the impact of policies such as HRRP and HIPAA on the implementation plan.

    Ethical and Legal Implications

    In our intervention plan, the ethical consideration revolves around the tension between autonomy and beneficence. Balancing patients’ right to care based on their preferences requires navigating the ethical dilemma of respecting autonomy while fulfilling the healthcare provider’s duty to act in the patient’s best interest. Addressing this ethical concern involves implementing customized educational plans that adhere to the moral principle of informed decision-making.

    This approach allows healthcare providers to provide comprehensive information on risks and benefits, respecting patients’ choices in their healthcare decisions. On the legal front, organizations must be mindful of the Health Insurance Portability and Accountability Act (HIPAA), particularly regarding patient privacy and data security when implementing telehealth services (Rahim & Alshahrani, 2023). Compliance with HIPAA policies, stringent data protection security measures, patient information disclosure practices, and authorized data access become imperative for organizations to avoid legal issues.

    Implementation Plan

    Management and Leadership

    For our intervention centered on comprehensive and personalized discharge education, effective coordination across disciplines is crucial, necessitating leadership, management, and nursing practices.

    Leadership Strategies:

    Adopting a transformational leadership style, characterized by a clear vision and goals, is vital for successful intervention implementation. Clearly defining project goals ensures a shared direction for the interprofessional team, enhancing their understanding of the initiative’s value and objectives. Interdisciplinary training is another effective leadership strategy to foster understanding among team members about their respective roles, promoting empathy, and facilitating collaboration through regular meetings (Mistretta et al., 2023).

    Management Strategies:

    Project planning and execution serve as management strategies to establish well-defined milestones and deadlines, ensuring that the interprofessional team stays on track and works towards long-term goals. Feedback and monitoring mechanisms enhance interdisciplinary collaboration, providing a platform for team members to contribute insights, monitor performance, and collectively strive towards shared goals (Mistretta et al., 2023).

    Nursing Practices:

    Embracing patient-centered care, tailored to individual patient needs, is crucial for customizing our intervention of comprehensive discharge education. This approach improves patient adherence and enhances care coordination among the healthcare team. Additionally, incorporating digital health literacy among nurses enables effective communication through virtual platforms. Interprofessional collaboration with technological experts ensures a seamless telehealth experience for both providers and patients (Mistretta et al., 2023). While these strategies and nursing practices contribute to project success and interprofessional collaboration, addressing conflicting perspectives on limited resources, resistance to change, interprofessional dynamics, and regulatory barriers is essential.

    Implications of Change to Improve Outcomes and Cost-effectiveness

    The proposed strategies aim to create a shared direction in the care setting, aligning the efforts of the interprofessional team to enhance communication, strength, and coordination. This is anticipated to successfully implement comprehensive discharge education plans for post-cardiac catheterization patients. The changes are expected to provide patient-centered discharge education, increasing personalized attention, trust in providers, and satisfaction related to healthcare, positively impacting healthcare quality (Madan et al., 2019).

    Seamless transitions from inpatient to residential settings, facilitated by telehealth services, empower patients to self-manage and adhere to care plans. Efficient and well-coordinated care, enabled by remote monitoring and early interventions, is anticipated to mitigate unnecessary expenditures for complications and hospital readmissions. The financial resources saved can be redirected to necessary adjustments for improving the quality of care and patient outcomes. However, potential knowledge gaps and uncertainties, such as resistance to change, leadership changes, regulatory modifications, and organizational policy amendments, may necessitate strategic adjustments leading to unexpected outcomes.

    Delivery and Technology

    A combination of in-person and digital delivery methods is deemed appropriate for implementing personalized discharge education plans and telehealth services.

    Traditional methods include one-on-one consultations, group sessions, and hands-on training, fostering direct patient-provider connections, peer support, and practical demonstrations (Liu et al., 2022). Digital methods involve providing resources through virtual telehealth platforms and enhancing accessibility of healthcare information for patients. This approach overcomes geographical barriers and promotes patient engagement in the healthcare process (Liu et al., 2022). Current and Emerging Technological Options

    Current technologies, such as PowerPoint presentations and interactive videos, enhance engagement and understanding of complex medical concepts. Emerging augmented reality (AR) and virtual reality (VR) tools can further enhance patient visualization of discharge instructions related to post-cardiac surgeries (Jung et al., 2022). Dissemination of digital resources through videos, interactive courses, and downloadable materials provides convenient guides for patients. Personalized apps and wearable devices constitute emerging technologies that deliver customized health information, promoting continuous engagement and self-management.

    While existing video conferencing and messaging facilitate patient-provider interactions, emerging remote monitoring devices and AI-driven chatbots collect real-time data for data-driven interventions (Jung et al., 2022). Addressing knowledge gaps and uncertainties involves considering patient readiness for technology adoption, evaluating the effectiveness of these technologies, overcoming resource constraints, and addressing accessibility challenges.

    Stakeholders, Policy, and Regulations

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

    External stakeholders, including insurance providers and regulatory bodies, impact reimbursements and uphold legal and ethical standards. Healthcare regulations like Medicare’s Hospital Readmission Reduction Program (HRRP) and the Health Insurance Portability and Accountability Act (HIPAA) play a vital role in the intervention plan. HRRP focuses on reducing readmission rates through across-the-board discharge planning, while HIPAA emphasizes patient privacy and confidentiality during telehealth interactions (CMS, 2023; Rahim & Alshahrani, 2023). Stakeholders and regulations directly influence successful implementation, necessitating adequate support, funding, and collaboration.

    Existing and New Policies

    Existing policies, such as telehealth reimbursement policies, ensure healthcare workers receive compensation for telehealth services, increasing accessibility for patients (, 2023). 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 planning could be established. Policies like the Affordable Care Act (ACA) targeting health disparities can provide funding and resources for underserved communities’ access to telehealth services and digital educational resources (CMS, 2023).


    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 educational program and integrating telehealth services. The targeted outcomes are enhanced patient comprehension, reduced hospital readmissions, and heightened patient satisfaction (King-Dailey et al., 2022). 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 standard discharge instructions facilitates a comparative study. Data collection includes patient feedback forms, hospital readmission records, Electronic

    Health Records (EHRs), and dedicated patient portals for real-time tracking. Specialized software tools analyze quantitative and qualitative metrics for a comprehensive evaluation.



    Nurses emerge as transformative leaders, particularly when innovation and change are 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 education. This proactive shift strengthens interprofessional dynamics, necessitating collaboration from diverse healthcare professionals. Beyond immediate patient-nurse interactions, the intervention enhances trust and reputation for healthcare institutions. 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.

    Future Steps

    To enhance the intervention’s impact, future steps involve nuanced personalization of educational content, incorporating Augmented and Virtual Reality (AR/VR) systems for immersive patient education, and adopting the Chronic Care Model (CCM) for proactive health systems. Integrating advanced AI-driven patient monitoring systems can predict potential 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 provided invaluable lessons for future leadership roles. The transferable framework from the project can be integrated across various facets of patient care, ensuring consistent 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 and addressing knowledge gaps are essential for successful leadership in healthcare.


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