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Capella 4900 Assessment 4

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    Capella 4900 Assessment 4

    Capella 4900 Assessment 4 Patient, Family, or Population Health Problem Solution

    Student Name

    Capella University

    NURS-FPX 4900 Capstone Project for Nursing

    Prof. Name


    Assessing the Problem; Patient, Family, or Population Health Problem Solution

    The focus of this assessment is Joey who was selected in assessment 1. He had been suffering from coronary heart disease. The major problems identified in Joey’s case were financial crisis and noncompliance with the medications. This led to numerous revisits to the hospital. Other problems he faced during his previous experience of hospital visits were limited resources and delayed treatment. The identification of these problems advocated the need for developing internvetions for him. Coronary heart disease is a common disease that requires extensive treatment and management. 

    This assessment discusses leadership and change management strategies utilized in this case. Moreover, some communication and collaboration strategies are also discussed. Some nursing standards and governmental policies are also shared which influencd the development of these strategies. Lastly, the integration of technologies, care coordination, and community resources are elaborated.

     Role of Leadership and Change Management in CHD Treatment and Management

    In every healthcare system, it is necessary to have some sort of leadership and change management according to the current circumstances, needs, and requirements of patients and their conditions. Nurses play an important role in performing leadership and change management for the better treatment and management of healthcare problems. Similarly, healthcare treatment and management in the case of CHD needs accurate leadership and change management. Nurses can be the best roles for performing this task. 

    Leadership strategies such as effective communication, identification of patients’ needs, and providing effective care through collaboration can address the CHD problem of Joey. These leadership strategies result in accurate treatment and provision of effective education to patients with chronic diseases like CHD (Lappalainen et al., 2019). Change management strategies are also effective in addressing any healthcare problem including CHD. These strategies include the identification of patients’ needs, transparent communication, providing effective training, collaboration with physicians and patients, and evaluating the impact of the provided care treatment plans. 

    These leadership and change management strategies had a profound impact on developing an intervention plan for Joey. These strategies paved the way by identifying the needs of Joey according to his disease condition and made changes quickly to intervention according to the current needs of Joey’s condition. The nursing ethics including autonomy, beneficence, justice, and non-maleficence were important in developing an intervention for Joey that regarded his human rights and decisions were based on his own will after adequate cooperation and communication (Haddad & Geiger, 2022).

    These nursing ethics were made sure to be maintained while developing an intervention for Joey considering his demands and needs and not forcing a certain treatment plan on him. This led to the creation of an intervention plan which was based on patient-centered care. As any forced treatment can never result in desired clinical outcome, it is necessary to keep these nursing ethical considerations which will eventually create patient-oriented and patient-satisfied intervention plan. 

    Communication and Collaboration Strategies to Improve Patient Outcomes  

    To require improved outcomes in CHD treatment and management, effective communication and collaboration strategies should be employed. The recovery and secondary prevention of CHD need proper information exchange among healthcare professionals and patients. This information exchange should be flexible and customized to individual patients including patient risk factor profiles, health needs, and personal conditions like socioeconomic status, gender, employment background, and locality-related information. One of the effective communication strategies is the Secondary Prevention for All in Need (SPAN) strategy (Zwack et al., 2023).

    It enables a standardized flexible methodology and consists of four basic components: assessment, information sharing, individualized risk factor management, and ongoing support with follow-up. This strategy helps generate effective communication through the collaborative work of nurses, clinicians, and patients. In the information-sharing step of this strategy, extensive education is provided to patients about their disease, symptoms, risk factors, and self-management strategies. This helps in improving the outcomes of the patients with CHD. Communication and collaboration strategies help in decision-making, goal-setting, optimization, and practicality. This also promotes patient-centered communication, which improves patient health outcomes (Zwack et al., 2023).

    There are numerous benefits of obtaining input from Joey and his family in this case, as his willpower of managing his CHD is the most important factor here. In our intervention plan of Orem’s Self-Management theory which is chosen for Joey considering his condition, Joey and his family need to equally participate in improving his condition. Input from the patients and their families will foster a shared-decision making environment, ultimately controlling the risk factors for the prevention of further health complications (Gok Metin et al., 2022).

    State Board Nursing Practice Standards/Governmental Policies on Proposed Intervention

    In the case of Joey, our aim is to enlighten him about the resources to be utilized in providing him care treatment in the cheapest way. This is accomplished by raising his knowledge about technologies useful in managing his condition and other governmental and state board nursing practice standards which help provide patients with enhanced access to health care services.  These policies are great to help in the development of an intervention for Joey as they provide various resources, funding, and insurance to health and healthcare services.

    The American Nurses Association provides nursing practice standards including assessing and diagnosing the problem, identification of outcomes, planning, implementation, and evaluation (American Nurses Association, 2015). These nursing practices are also utilized while developing the intervention plan for Joey on his condition CHD. First, his condition was assessed and diagnosed. Afterward, desired outcomes that need to be achieved were identified. On the basis of these desired outcomes, planning of intervention was done, and lastly needed the implementation of the proposed intervention and its evaluation.

    The Affordable Care Act which rejects the health insurers to charge extra from patients with CHD is great help in the development and running of this proposed intervention. The ACA enhances Joey’s access to healthcare services and facilities. This will enable Joey to take healthcare assistance anytime with no extra financial burden. ACA’s insurance expansion by Medicaid expansion further improves the healthcare treatment provision. This enhances the effectiveness of these policies on heart patients like Joey (Wolfe & Joynt Maddox, 2019).

    The HITECH Act promotes the use of healthcare information technologies such as telehealth, remote monitoring, SMS reminders, etc, which benefits the development of this proposed intervention. For example, one of the applications of HITECH is the use of mobile health for enhancing the physical activity in patients and preventing primary and secondary incidences of cardiovascular disease which has been proven to be effective. (Feldman et al., 2018). The ACA and HITECH Act guided me in developing an intervention for Joey by providing motivation to enhance the access to healthcare services to patients anytime through telehealth.

    Impact of Proposed Intervention on Quality of Care, Patient Safety, and Cost

    The proposed intervention of using self-management techniques with the help of educational programs by nurses has the potential to improve the quality of care, enhance patient safety, and reduce costs to both the system and the patient. By providing educational programs on self-management of chronic diseases like CHD, there will be less hospital readmission and revisit rates as the patient is managing his disease by himself through proper strategic ways. Risk factors of CHD will remain under control and the patient will feel better quality of health and care provided to him through telehealth and remote monitoring methodologies.

    This will ultimately enhance patient safety (Li et al., 2022; Säfström et al., 2023). When the readmission rate of patients to hospitals is reduced, the costs inflicted upon healthcare systems and the patient himself will be reduced (Säfström et al., 2023). There will be reduced chances of complications as well as severe procedures, which will further reduce the costs to the healthcare systems and patients. With enhanced quality of care provision, patient safety will also be improved.

    In our case, Joey will be able to have better quality care from nurses and physicians with collaborative treatment through a telehealth-based self-education program along with the continuation of pharmacotherapy. Moreover , this is further accompanied by remote monitoring of Joey’s adherence to his medication. All these interventions will enhance the quality of care, enhance patient safety, and reduce costs to Joey and the healthcare systems.

    Utilization of Technology, Care Coordination, and Community Resources in CHD

    Many healthcare systems have started employing the use of these healthcare information technologies (HITs). Some of these technologies that guided us in addressing the healthcare problem of Joey, were telehealth, remote monitoring of medication adherence, and a remote-based self-management education program. All these technologies are providing common benefits like better care provision through one-on-one online meeting sessions of healthcare professionals and patients, less rates of hospital readmissions, no fatigue to patients in traveling, enhanced safety, low-waiting times, etc. 

    Telehealth is the use of digital communication platforms for the purpose of care provided to patients who are staying at home. This technology has provided extra benefits to patients like Joey who do not have enough resources to make a visit to the hospital for every emergency and non-emergency checkup. Healthcare professionals can monitor the symptoms, and risk factors, and gather patient data through smartphone apps or web-based portals. This has improved the quality of care and patient safety as well. Telehealth is often liked by many patients including Joey who was happy to use this technology for treatment and management. As a chronic disease, patients like Joey do not have to commute for a long time as the treatment can be delivered to them with the help of telehealth (Black et al., 2023).

    Remote patient monitoring and more specifically remote monitoring of medication adherence is highly important in addressing CHD as it requires consistent and ongoing treatment with pharmacotherapy. This is also achieved by technology where both nurses and patients are together where patient sends medication compliance data to nurses and nurses are notified about it through beep or chime features (Al-Arkee et al., 2021). Moreover, Technology has also aided self-management education programs which can be conducted online and patients gain knowledge about lifestyle modifications and CHD management (Koson et al., 2022). Joey will get immense benefits through these technologies-based interventions as his proposed plan.

    Capella 4900 Assessment 4

    Healthcare provision is not up to the benchmark unless the element of care coordination is added to it. Care coordination is significant in addressing issues like CHD which demand the overall participation of healthcare professionals so that everyone is aware of the patient’s needs and appropriate treatment according to his needs, demands, and will is provided (Daumit et al., 2020). Community resources such as American Heart Association (AHA) and others have been valuable in addressing CHD as their credible and authentic knowledgeful guidelines resources are additional resources for communities to enhance awareness about CHD.

    Patients including Joey are often unaware of the community resources made for the betterment of these community individuals. Educating patients about these community resources is also an important parameter of providing quality care. The ANA provides resources to communities on CHD and how to manage and treat it from the perspective of community patients (Lawton et al., 2021).   


    In this assessment, an analysis of intervention for our patient Joey has been done. The proposed plan or intervention for Joey is a telehealth-based self-management education program and remote monitoring of medication adherence. We also analyzed the role of leadership and change management in improving CHD and the impact of governmental policies on CHD. The impact of technology, care coordination, and community resources was also investigated. Joey will acquire an improved quality of care, enhanced safety, and reduced costs as a result of this proposed intervention. 


    Al-Arkee, S., Mason, J., Lane, D. A., Fabritz, L., Chua, W., Haque, M. S., & Jalal, Z. (2021). Mobile apps to improve medication adherence in cardiovascular disease: Systematic review and meta-analysis. Journal of Medical Internet Research23(5), e24190.

    American Nurses Association. (2015). Nursing: Scope and standards of practice. Retrieved from. 

    Black, J. A., Lees, C., Chapman, N., Kelleher, L., Campbell, J. A., Otahal, P., Cheng, K., Marwick, T. H., & Sharman, J. E. (2023). Telehealth rapid access chest pain clinic: Initial experience during COVID-19 pandemic. Telemedicine and E-Health

    Daumit, G. L., Dalcin, A. T., Dickerson, F. B., Miller, E. R., Evins, A. E., Cather, C., Jerome, G. J., Young, D. R., Charleston, J. B., Gennusa, J. V., Goldsholl, S., Cook, C., Heller, A., McGinty, E. E., Crum, R. M., Appel, L. J., & Wang, N.-Y. (2020). Effect of a comprehensive cardiovascular risk reduction intervention in persons with serious mental illness: A randomized clinical trial. JAMA Network Open3(6), e207247.

    Feldman, D. I., Theodore Robison, W., Pacor, J. M., Caddell, L. C., Feldman, E. B., Deitz, R. L., Feldman, T., Martin, S. S., Nasir, K., & Blaha, M. J. (2018). Harnessing mHealth technologies to increase physical activity and prevent cardiovascular disease. Clinical Cardiology41(7), 985–991. 

    Gok Metin, Z., Izgu, N., Gulbahar Eren, M., & Eroglu, H. (2022). Theory‐based nursing interventions in adults with coronary heart disease: A systematic review and meta‐analysis of randomized controlled trials. Journal of Nursing Scholarship 

    Capella 4900 Assessment 4

    Haddad, L. M., & Geiger, R. A. (2022). Nursing ethical considerations. In StatPearls. StatPearls Publishing. 

    Koson, N., Srisuk, N., Rattanaprom, A., Thompson, D. R., & Ski, C. F. (2022). Psychometric evaluation of the Thai version of the self-care of coronary heart disease inventory version 3. European Journal of Cardiovascular Nursing 

    Lappalainen, M., Härkänen, M., & Kvist, T. (2019). The relationship between nurse manager’s transformational leadership style and medication safety. Scandinavian Journal of Caring Sciences34(2). 

    Lawton, J. S., Tamis-Holland, J. E., Bangalore, S., Bates, E. R., Beckie, T. M., Bischoff, J. M., Bittl, J. A., Cohen, M. G., DiMaio, J. M., Don, C. W., Fremes, S. E., Gaudino, M. F., Goldberger, Z. D., Grant, M. C., Jaswal, J. B., Kurlansky, P. A., Mehran, R., Metkus, T. S., Nnacheta, L. C., & Rao, S. V. (2021). 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. Journal of the American College of Cardiology79(2). 

    Li, X., Gao, Q., Sun, L., & Gao, W. (2021). Effect of self-control on health promotion behavior in patients with coronary heart disease: Mediating effect of ego-depletion. Psychology, Health and Medicine27(6), 1268–1276. 

    Li, Y., Gong, Y., Zheng, B., Fan, F., Yi, T., Zheng, Y., He, P., Fang, J., Jia, J., Zhu, Q., Jiang, J., & Huo, Y. (2022). Effects on adherence to a mobile app–based self-management digital therapeutics among patients with coronary heart disease: Pilot randomized controlled trial. JMIR MHealth and UHealth10(2), e32251. 

    Mohamed, H., & Soliman, M. (2022). Effect of telenursing -based self-management program on cardiac self-efficacy and heart health indexes among myocardial infarction patients. Original Article Egyptian Journal of Health Care13(1), 2022. 

    Capella 4900 Assessment 4

    Säfström, E., Årestedt, K., Liljeroos, M., Nordgren, L., Jaarsma, T., & Strömberg, A. (2023). Associations between continuity of care, perceived control and self‐care and their impact on health‐related quality of life and hospital readmission—A structural equation model. Journal of Advanced Nursing 

    Wolfe, J. D., & Joynt Maddox, K. E. (2019). Heart Failure and the Affordable care act. JACC: Heart Failure7(9), 737–745. 

    Zwack, C. C., Smith, C., Poulsen, V., Raffoul, N., & Redfern, J. (2023). Information needs and communication strategies for people with coronary heart disease: A scoping review. International Journal of Environmental Research and Public Health20(3), 1723.