Proposed Solution, Implementation, and Evaluation Research

Implementation Plan
Your Name
November 7, 2016
Your Institution of Affiliation
Proposed Solution
Congestive Heart Failure (CHF) is a lethal disease mostly predominant among people older than 65 years of age. The proposed solution is to follow a disease management (DM) program that is multidisciplinary in nature for individuals that are at significant risk of worsening their health condition given that this kind of illness needs constant monitoring and guidance on what to eat, proper exercise, continuous treatment and factors that need to be avoided in order for hospital readmission to be prevented. A multidisciplinary approach program will be followed for the reduction of risk for patients to be hospitalized again. The disease management (DM) program of Hines and Randall (2010) will be followed. These include the ideal transition to the home environment for a patient which will be assessed first. Following from this, it is important that providers focus and increase their participation in "assessment, identification of needs post-discharge, and the discharge planning" (Hines et al.,2010). Enhanced teaching and learning for the family and caregivers which include written, verbal and visual methods to understand the care requirements thoroughly. There is also a great need for the guarantee of communication among the patient and its family to the caregiver to understand the patient’s needs and care plan. Lastly, a multidisciplinary approach to post-discharge care with a focus on the patient and family members which can reduce mortality, costs, and admissions that include different individuals with specializations on this kind of disease, such as nurses, cardiologists and a primary care provider (Ibid). These proposals are of most importance in decreasing the risk of readmission and further complication of the patient’s current condition considering its gravity and delicateness.
Proposed Solution
Congestive Heart Failure (CHF) is a lethal disease mostly predominant among people older than 65 years of age. The proposed solution is to follow a disease management (DM) program that is multidisciplinary in nature for individuals that are at significant risk of worsening their health condition given that this kind of illness needs constant monitoring and guidance on what to eat, proper exercise, continuous treatment and factors that need to be avoided in order for hospital readmission to be prevented. A multidisciplinary approach program will be followed for the reduction of risk for patients to be hospitalized again. The disease management (DM) program of Hines and Randall (2010) will be followed. These include the ideal transition to the home environment for a patient which will be assessed first. Following from this, it is important that providers focus and increase their participation in "assessment, identification of needs post-discharge, and the discharge planning" (Hines et al.,2010). Enhanced teaching and learning for the family and caregivers which include written, verbal and visual methods to understand the care requirements thoroughly. There is also a great need for the guarantee of communication among the patient and its family to the caregiver to understand the patient’s needs and care plan. Lastly, a multidisciplinary approach to post-discharge care with a focus on the patient and family members which can reduce mortality, costs, and admissions that include different individuals with specializations on this kind of disease, such as nurses, cardiologists and a primary care provider (Ibid). These proposals are of most importance in decreasing the risk of readmission and further complication of the patient’s current condition considering its gravity and delicateness.
Implementation Plan
Methods in Obtaining Support and Approval
It is vital in implementing the solution that the support and approval of proper specialists and consultants. In obtaining support and approval one must identify first the relevant stakeholders. This is in order to make sure or guarantee the outcome of the proposed solution and in order for the stakeholders to be informed about the case. It is necessary to get the approval of the stakeholders, in this case, the participation of (1) cardiologists (2) nurses (3) physicians and a (4) telephone nurse which has specialization in handling heart failure treatment during and after hospitalization. In order to obtain support, filing a feasibility form and getting signatures from the stakeholders is necessary. It is important also to clarify the commitment of stakeholder because the level of engagement will vary among the stakeholders, and level of involvement should be specified from the start.
Description of current problem requiring change
The current problem that is prevalent in the management of patients is that they unable to comprehend with the given instructions after hospitalization. It is challenging to an extent due to the inability of patients to comply with the given directions. There is a high tendency among Congestive Heart Failure (CHF) patients not to adhere to the given medication as well as a minimal evidence-based intervention within this group to enhance adherence among patients. Patients must not assume a passive role in their plan of care if an exacerbation and an improvement of the quality of life are to be guaranteed (Hong et.al, 2004). It is, therefore, essential to provide a new strategy in order to reduce the risk of procurement and to avoid hospitalization again by devising a new disease management plan.
Explanation of proposed solution
The proposed solution of a just transition to a home care needs necessary requirements for a successful treatment and care for the patient. First is that the patient needs to be assessed during admission and should be continued beyond the hospital. It is also important that cooperation and inclusion of all care providers (hospitals, clinics, etc.) should be present in utilizing assessment findings to implement a plan of attention. It should also focus on the addition of evaluation on inpatient nurses, home health nurses, Heart Failure Clinic nurses which will play an integral part in communication and coordination across care settings. Second is the enhanced teaching and education for caregivers to identify the stakeholders which include the family and other caregivers. This process should include verbal, written and visual learning tools to understand the care requirements when the patient is discharged fully. Next is the importance of communication among the patient, his/her family members, and caregivers. The handoff communication is essential to ensure that the patient and caregivers in the next setting understand the patient's history and care plan (Hines et al., 2010). To implement a more efficient and better quality care, the patient's functional status, medical history, baseline information, learning needs, care plans, and services during the time when he/she was admitted is also important (Hines et al., 2010).
Also, understanding the medication needs and ensuring its availability post-discharge. For high-risk patients (those who have been admitted twice in the last year for HF, have continued learning needs, and little confidence that self-care can be successfully carried out) in person follow-up (e.g., physician home visit) should occur within 48 hours. Patients of moderate risk (patients who have been admitted once in the past year, and have a family confidence to provide self-care successfully) should have phone call follow up within 48 hours, and a physician office visit with the primary care provider within five days (Nielsen et al., 2008). La...