Heart Failure Discharge Plan

Capella University

Leadership and Management

Assignment 3

Heart Failure Discharge Plan

The leadership team has asked that a nurse-run outpatient heart failure clinic be initiated in order to reduce the readmission rates of heart failure patients being discharged from the hospital. This clinic is being put in place to ensure that patients are receiving adequate discharge teaching before going home. The clinic will serve as a central location that the patients will visit for education and resources once leaving their areas within the facility and prior to being discharged. The clinics goals are to have ninety percent of patient enrollment, one hundred percent patient compliance with education, and a readmission rate decrease by five percent over the next year. Meeting the above stated goals, or continuously moving in a positive direction of the goals, will predict the success of the program.

Care Plan

The discharge education plan will discuss how the patient can monitor their daily progress and activities and available resources. The care plan will also cover education for self-care, prevention, and lifestyle changes needed going forward. It will also discuss any cultural or social accommodations, current heart failure guidelines and standards, follow up recommendations, and procedures or tools to measure effectiveness of the clinics program. All information will be covered in person in detail with the patients.

The clinic should have several different ways of delivering this information to the patient along with face to face. The staff should ask the patient the best way they learn and use that method in conjunction with the face to face education. These methods can be charts and pictures, demonstrations, hands on learning tools, audio versions to follow along in a book or handout, or even online learning with interactive options. There must also be a language line or video interpreter available as well. Once the patient has finished each section of the educational area, they will be required to answer questions or do a teach back method to check for understanding.

The heart failure clinic will be nurse-run, but also consist of many different team members who will be involved. While there are many people within this interprofessional team, continuity of care, education, and communication is of the upmost importance for the patient’s outcomes and management. The transition for these patients from admission to the hospital to outpatient can be overwhelming and a vulnerable time. Therefore, it requires a large number of people working together to meet the patients needs. This team can consist of many disciplines including, but not limited to: heart failure clinic nurse, primary care physician, cardiologist, case manager, family members, palliative care team, spiritual/cultural support, pharmacist, dietician and social worker.