Final Capstone Project Change Proposal


Congestive heart failure patients record among the highest rates of hospital re-admissions with many finding themselves back on the acute cardiac units. Congestive Heart Failure mainly occurs when a heart’s pumping action weakens often leading to leading to fluid built-up or fluid overload, creating pooling of fluid to the lungs and extremities. This is exhibited in the patients’ experiences of shortness of breath on exertion. Some of the readmissions happen in a time span in less than 30 days. Most readmissions are attributed to the patients’ challenges of managing it, and noncompliant behaviors. This leads to the health crisis that requires frequent emergency care. An evidence-based approach is essential to underscore the current education techniques, in the collaboration of acute care units and outpatient community clinics. This includes the comprehensive care approach that collaborates services of hospice care professionals, home health social work, physician assistant, cardiology, physical therapy nutrition and pharmacy to coordinate care of individuals with chronic cardiovascular disease health conditions such as congestive heart failure (Jackson, Shahsahebi, Wedlake & DuBard, 2015). Alternative education intervention avenues could be implemented to help patients better understand and manage their conditions, through coordination of healthcare from acute care to ambulatory care. This will assist in preventing re-admissions and problems of non-compliance, including the outpatient services.

Problem statement

The Clinical problem is the high rate of frequent ambulatory clinic visits and early readmission of patients with congestive heart failure within thirty days of hospital discharge. Approximately six documented patients make recurrent unscheduled visits to one of this author’s place of practice, the Institute for Family Health, a multispecialty outpatient community health clinic. These patients are predominantly noncompliant with their disease management and usually arrived at the facility in fair, dilapidated or acute health crisis, which requires immediate medical attention or hospital transfer for evaluation and treatment of conditions. Two of these patients who presented with the minimal complaint would return to the facility approximately two to three visits weekly after hospital discharge, despite previously given treatments. According to Feltner, Jones, Cené, Zheng, Sueta, Coker-Schwimmer & Jonas (2014), high rates of rehospitalization continue to be experienced with about 30% within 60 to 90 days of discharge.

Purpose of the change proposal

The primary goal of the change proposal is to counter a clinical problem that is related to the high rate of frequent ambulatory clinic visits and early readmission of patients with congestive heart failure within thirty days of hospital discharge. Congestive heart failure is the main reason for readmission in patients over 65 and one of the predictors of increased mortality in the outpatient settings. Unplanned readmission created a substantial financial burden to healthcare organizations and cost Medicare $17.4 billion annually (Howie-Esquivel, Carroll, Brinker, Kao, Pantilat, Rago & De Marco, 2015).


The PICOT for this capstone change proposal is as follows:

Population: All patients, mainly the elderlies who exhibited exacerbation of congestive heart failure, and seek infrequent clinic visits, emergency department visits, and cardiac follow-ups at the Institute of Family Health Community Clinic.

Intervention:  An evidence-based approach will be utilized to underscore current education techniques, in collaboration with acute care units and outpatient community clinics. Nurses will embrace multidisciplinary educational approach for a smooth transition of care for congestive heart failure patients.

Comparison:  The research interventions will compare current educational methods on outpatient congestive heart failure teaching to early readmission on the evaluation of patients’ understanding on teaching to maintain optimal health through diet, fluid restriction, daily weight, and adherence to follow-up coordinate care.

Outcome:  To determine an educational initiative that implements collaboration and coordination on a continuum of transitional care, to decrease early readmissions of congestive heart failure among patients

Time:  Controlled or reduced hospital readmission among heart failure patients in thirty days. The duration of this research is within ten weeks of this research study course.

The PICOT, therefore, question is: For the ambulatory outpatient community health center patients (P), does prompt follow up for coordination of transitional care (I) as compared to no follow up (C) reduce the risk for early readmission of patients with exacerbation of congestive heart failure (O) in thirty days? (T).

Literature Search Strategy Employed

Peer-reviewed scholarly articles that were less than five years old were selected to support the practice change in outpatient and ambulatory settings, to reduce early readmission of CHF patients. This research was conducted through the EBSCOhost of Grand Canyon University Library. Terms used to find articles included patients with congestive heart failure, CHF transitional care, CHF care coordination, prevent CHF readmission and hospital readmissions (Huntley, Johnson, King, Morris & Purdy, 2016).

Evaluation of the literature

To address change proposal to support a PICOT project, review of current evidence-based peer-reviewed literature and journals are necessary for healthcare practice. Literature review research and evaluate sources pertinent to an area in question or theory to give a synopsis or outlined summaries on related published literature that supported evidence-based studies for a related issue. Nursing research provides evidence-based interventions that encourage improved health conditions for at-risk patients. The objective of the research was to methodically identify, analyze, and synthesize peer-reviewed literature to support the EBP project on coordinating transitional care in the community to reduce congestive heart failure readmissions within 30 days (Shaw, O’Neal, Siddharthan & Neugaard, 2014).

Applicable change or nursing theory utilized

Evidenced-Based Solution is an evolving healthcare approach that utilized the best peer-reviewed studies and practical strategies related to specific clinical problems that address the safety and quality of patient care, for the best possible clinical health outcome. Nurses were the forerunners to patients’ conditions, are essential to the best-practiced solution that is vital to implement specific procedural changes required to accomplish care that is current, safe, and efficient (Hayes, Peloquin, Howlett, Harkness, Giannetti, Rancourt & Ricard, 2015).  One of the major problems of ambulatory community health clinic is the frequent follow-up care for after emergency room visits, unscheduled revisits or emergency transfer by providers of the health clinic for evaluation of predominately the same patients, with exacerbation of Chronic Congestive Heart Failure.

Proposed implementation plan with outcome measures

Patient education intervention will be implemented to help patients better understand and manage their conditions, through coordination of healthcare from acute care to ambulatory care to reduce patients’ self-care deficit, from admission of the acute ill patient in the acute setting of the hospital, through the convalescing patients’ discharge home and continue with follow-up visits at the community health clinic and other specialized consultants (Hudali, Robinson & Bhattarai, 2017). The Institute for Family Health clinic should hire more nursing staff with the provision of innovative incentives to reduce nursing turnovers and to create longevity on the job. This would create the proper nurse to patients and providers ratios and decrease the high health care demand in the facility. There should be a weekly CHF education and training class for the community and a mandatory class for nursing to improve on their critical thinking skills, for adequate support to their patients. The provision of a nurse care coordinator to work directly with the specialized cardiac team would also relieve some of the caseloads of routine clinic nurses’ duties. Patient education should, therefore, be designated to specific nursing personnel for the congestive heart failure specialty clinic. With these implementations, the clinic nurses would be more able to provide ample time to conduct appropriate teachings to their patients.


It is the nurses’ responsibility to provide patient-centered and appropriate teaching of congestive heart failure to their patients. They need to be aware of the priority on educating the patients on their chronic health conditions. The nurses should be knowledgeable about this health condition, to provide support and guidance to the patients, on self-care management (Huntley, Johnson, King, Morris & Purdy, 2016). The patients, families and their caregivers should be taught in the simplest term, on how to monitor their conditions for worsening heart failure, and when to take appropriate action. Patients should be encouraged to repeat what is being taught; nurses should evaluate patients’ comprehension to provide the necessary reinforcement if needed (Andrew, Puls & Guerrero, 2016).   

Identification of potential barriers to plan implementation, and a discussion of how these could

be overcome

The most common and possible obstacle to the implementation plan is the resistance of change among the workers, uncooperative health workers and lack of finances. Without enough finances, the implementation process will not be realized, as various suggested stages will be meant for instance the education part of the plan. To counter this, the healthcare facility should consider this issue as serious and make a budget adjustment for it considering the many benefits that can result from the implementation process.

The study “A Strategy to Reduce Heart Failure Readmissions and Inpatient Costs” was done to assess how rehospitalization rates of patients hospitalized with heart failure are affected by various disease management interventions. The patients examined were treated with the “Teaching and Education, prompt follow-up Appointments, Consultation for support services, and Home follow-up phone calls (TEACH-HF)” method (Howie-Esquivel, Carroll, Brinker, Kao, Pantilat, Rago & De Marco, 2015). This study concluded that a TEACH-Heart Failure intervention was associated with significant decrease in readmission under thirty days and thus savings in healthcare cost. Additionally, Bergethon, Ju, DeVore, Hardy, Fonarow, Yancy & Hernandez (2016) notes that reducing heart failure readmissions should be a national priority. I believe that Heart failure intervention is necessary to counter the increasing rate of heart failure conditions. Moreover, education on how to prevent the occurrence of heart failure is also key. For my CAPSTONE project, I want to address and hopefully solve the issue of Heart Failure Readmissions that leads to financial constraints among many other challenges. Avoiding heart failure can help avoid all readmissions related issues, and that is why I suggest the following practical interventions: 1.    One of the intervention is daily weight monitoring where patients are advised and educated to monitor their weight since weight gain is related to heart failure. 2.    Monitoring decompensation symptoms and sighs since some patients tend to ignore some of the most common signs and symptoms of heart failure. 3.    Education on how to use medication should be provided. 4.    Other interventions include orientations for physical activity, proper daily physical training, sexual activity and finally diet and social activities. Thank you References Bergethon, K. E., Ju, C., DeVore, A. D., Hardy, N. C., Fonarow, G. C., Yancy, C. W., … & Hernandez, A. F. (2016). Trends in 30-Day Readmission Rates for Patients Hospitalized With Heart FailureCLINICAL PERSPECTIVE: Findings From the Get With The Guidelines-Heart Failure Registry. Circulation: Heart Failure, 9(6), e002594. Howie-Esquivel, J., Carroll, M., Brinker, E., Kao, H., Pantilat, S., Rago, K., & De Marco, T. (2015). A strategy to reduce heart failure readmissions and inpatient costs. Cardiology research, 6(1), 201.

Appendix: Letter to Staff


Andrew, D. G., Puls, S. E., & Guerrero, K. S. (January 20, 2016). Utilizing information technology to improve transition of care from hospital to home. Journal of Nursing Education and Practice, 6, 6.)

Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J., … & Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Annals of internal medicine, 160(11), 774-784.

Hayes, S. M., Peloquin, S., Howlett, J. G., Harkness, K., Giannetti, N., Rancourt, C., & Ricard, N. (2015). A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future?. BMC health services research, 15(1), 290.

Howie-Esquivel, J., Carroll, M., Brinker, E., Kao, H., Pantilat, S., Rago, K., & De Marco, T. (2015). A strategy to reduce heart failure readmissions and inpatient costs. Cardiology research, 6(1), 201.

Hudali, T., Robinson, R., & Bhattarai, M. (2017). Reducing 30-Day Rehospitalization Rates Using a Transition of Care Clinic Model in a Single Medical Center. Advances in medicine, 2017.

Huntley, A. L., Johnson, R., King, A., Morris, R. W., & Purdy, S. (2016). Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis. BMJ open, 6(5), e010933.

Jackson, C., Shahsahebi, M., Wedlake, T., & DuBard, C. A. (2015). Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge. The Annals of Family Medicine, 13(2), 115-122.

Shaw, J. D., O’Neal, D. J., Siddharthan, K., & Neugaard, B. I. (2014). Pilot program to improve self-management of patients with heart failure by redesigning care coordination. Nursing research and practice, 2014.