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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


    Project Submission Summary


    The capstone project aimed to improve patient understanding of post-discharge regimens, decrease hospital readmissions, and enhance patient satisfaction after cardiac catheterization. This was achieved through a tailored educational program and the integration of telehealth services. The initiative focused on addressing knowledge gaps and ensuring continuity of care for post-cardiac catheterization patients. The approach included individualized discharge education, multimodal delivery, and the involvement of nurses as key knowledge brokers. The findings highlighted the potential for reduced hospital readmissions and cost savings with well-informed patients.


    The project addressed the high 30-day hospital readmission rates among Coronary Artery Disease (CAD) patients post-cardiac catheterization at Manatee Memorial Hospital, Bradenton, Florida. The emphasis was on improving post-discharge patient education through tailored programs and telehealth services.

    Problem Statement:

    The study aimed to compare the impact of a comprehensive post-discharge education program with basic instructions on 30-day hospital readmission rates for CAD patients discharged from Manatee Memorial Hospital. The urgency stemmed from a Healthcare Cost and Utilization Project National Readmission Database study revealing a 30% readmission rate for PCI patients within 30 days.

    Population and Setting:

    The target population included patients discharged after cardiac catheterization, addressing the need for improved education in a diverse population. Manatee Memorial Hospital, with a 16% readmission rate, served as the setting requiring intervention.

    Intervention Overview:

    Tailored discharge education and telehealth services were proposed to reduce readmission rates. The Plan-Do-Check-Act (PDCA) cycle guided the development of an individualized education program. The intervention focused on individualized instructions, including medication management, lifestyle guidance, symptom recognition, and early follow-up. Inter-professional collaboration and adherence to policies were crucial.

    Comparison of Approaches:

    Customized education plans were favored, considering patient-specific needs. Alternatives included standardized plans and group education sessions. The goal was a 20% reduction in 30-day readmission rates and increased adherence to medication and follow-up appointments.

    Outcome Draft:

    Targets included a 20% reduction in readmission rates, a 15% increase in medication adherence, a 30% rise in follow-up attendance, and a 25% increase in prompt symptom reporting.

    Time Estimate:

    The estimated timeframe for program development and implementation was 12 months, with phases covering planning, platform development, pilot testing, and full-scale implementation.

    Literature Review:

    Evidence supported the effectiveness of comprehensive education for post-cardiac catheterization patients. Tailored education interventions demonstrated a 30% reduction in readmission rates. Telehealth policies and remote monitoring were advocated for continuous support.

    Interventional Plan:

    The plan included customized educational programs and telehealth services. Customized plans involved patient assessments, cultural considerations, and individualized instructions. Telehealth services utilized multimodal delivery for continuous monitoring and support.

    Cultural Needs and Characteristics:

    The diverse population in Bradenton influenced a culturally competent intervention plan. Customized educational plans considered language preferences, cultural beliefs, and health practices. Cultural competence training at Manatee Memorial Hospital played a vital role.

    Theoretical Foundations:

    Dorothea Orem’s Self-Care Theory guided the intervention, emphasizing patient engagement. Motivational interviewing addressed behavioral changes, and telehealth services aligned with the theory’s focus on self-management. Challenges included patients’ readiness and internet connectivity.

    In conclusion, the comprehensive and tailored intervention aimed to improve patient outcomes, reduce readmissions, and enhance satisfaction after cardiac catheterization, addressing the specific needs of the diverse population at Manatee Memorial Hospital.

    Stakeholders, Policy, and Regulations

    Our primary focus in the intervention plan is addressing the needs of patients and their families as key stakeholders. The implementation involves tailored educational programs and telehealth services to help patients manage post-surgery health conditions, reduce readmission rates, and improve outcomes. The comprehensive discharge training aligns with the goals of hospital management and healthcare providers, aiming to enhance patient satisfaction, reduce costs associated with readmissions, and elevate healthcare quality. Given the inclusion of telehealth, adherence to healthcare policies related to data protection and patient confidentiality is essential. Notably, the Health Insurance Portability and Accountability Act (HIPAA) plays a crucial role in maintaining patient privacy, data security, and confidentiality during telecommunication tool usage (Rahim & Alshahrani, 2023).

    Moreover, healthcare professionals are directed to avoid unauthorized access. In addition to HIPAA, regulations from entities like the Centers for Medicare & Medicaid Services (CMS) outline guidelines for telehealth reimbursement, while state medical boards set licensure and practice regulations. Adhering to national and state-level regulations is fundamental for healthcare facilities to uphold care standards. Addressing stakeholders’ needs ensures their active participation in the care process and compliance with the intervention plan.

    Ethical and Legal Implications

    Ethical considerations in the intervention plan revolve around the autonomy vs. beneficence dilemma. Balancing patients’ right to receive care based on preferences requires organizational changes that adhere to the moral principle of informed decision-making. Customized educational plans raise ethical concerns, necessitating detailed information on risks and benefits, respecting patient choices in healthcare (Rahim & Alshahrani, 2023).

    Legal implications, particularly under HIPAA, emphasize the protection of patient privacy and data security during telehealth services. Compliance with HIPAA policies requires stringent data protection measures, informed patient consent, and authorized access. Organizations must enforce rules to enhance healthcare providers’ compliance with HIPAA regulations.

    Implementation Plan

    Management and Leadership

    The comprehensive and personalized discharge education plan requires multidisciplinary coordination through leadership, management, and nursing practices.

    Leadership Strategies:

    Implementing a transformational leadership style is crucial for successful intervention. Clear vision and goals define the project’s direction, ensuring inter-professional teams understand the initiative’s value and objectives. Interdisciplinary training fosters mutual understanding, empathy, and respect among team members. Regular meetings provide a platform for collaborative problem-solving (Mistretta et al., 2023).

    Management Strategies:

    Project planning and execution, with defined milestones and deadlines, ensure team members stay on track. Feedback and monitoring encourage interdisciplinary collaboration, allowing input, performance monitoring, and shared goals for improved patient outcomes (Mistretta et al., 2023).

    Nursing Practices:

    Patient-centered care tailors interventions to individual patient needs, improving adherence and care coordination. Digital health literacy enables nurses to assist patients in utilizing technology effectively. Inter-professional collaboration with technology experts ensures a seamless telehealth experience (Mistretta et al., 2023). Addressing conflicting perspectives, resource limitations, resistance to change, inter-professional dynamics, and regulatory barriers is crucial.

    Implications of Change to Improve Outcomes and Cost-effectiveness

    The proposed strategies create a shared direction for care, aligning inter-professional teams and enhancing communication, strength, and coordination. Patient-centered discharge education improves patient experiences, trust in providers, and healthcare satisfaction, positively impacting quality (Madan et al., 2019). Seamless transitions from inpatient to residential settings, enabled by telehealth, empower patients for self-management and adherence. Efficient, well-coordinated care, with remote monitoring and early interventions, mitigates unnecessary expenditures, redirecting resources for necessary adjustments to improve care quality.

    However, addressing knowledge gaps, uncertainties, resistance to change, leadership changes, regulatory modifications, and policy amendments is essential for strategic adjustments and managing unexpected outcomes.

    Delivery and Technology

    A combination of in-person and digital delivery methods is suitable for personalized discharge education plans and telehealth services. Traditional methods include one-on-one consultations, group sessions, and hands-on training. Digital methods involve digital resources and virtual telehealth platforms, promoting accessibility and real-time interaction (Liu et al., 2022).

    Current and Emerging Technological Options

    Current technologies, such as PowerPoint presentations and interactive videos, enhance engagement and understanding. Emerging technologies like augmented reality (AR) and virtual reality (VR) offer immersive experiences, visualizing discharge instructions for post-cardiac surgeries (Jung et al., 2022). Digital resources, personalized apps, and wearable devices contribute to continuous engagement and self-management, though challenges such as patient readiness and resource constraints exist.

    Stakeholders, Policy, and Regulations

    Patients and caregivers are critical stakeholders, and addressing their needs enhances engagement, satisfaction, and adherence to care plans. Healthcare professionals, administrators, managers, and IT professionals play crucial roles in managing resources, allocating budgets, and providing technological support. External stakeholders, including insurance providers and regulatory bodies, impact reimbursements and uphold legal and ethical standards.

    Policies like the Hospital Readmissions Reduction Program (HRRP) and HIPAA are relevant to the intervention plan, focusing on comprehensive discharge education to reduce readmission rates and enhance patient education. Stakeholders and regulations directly impact successful implementation, requiring support, funding, and collaboration from internal and external stakeholders.

    Existing and New Policies

    Existing reimbursement policies ensure compensation for telehealth services. Developing policies to incentivize telehealth services in states lacking such policies can enhance healthcare accessibility. Standardizing digital health educational material ensures accurate information circulation. Policies promoting collaborative care, interdisciplinary teamwork, and involving various healthcare disciplines in patient education and care planning are crucial. Policies like the Affordable Care Act (ACA) address health disparities and provide funding for underserved communities’ access to telehealth services and digital educational resources.


    The proposed timeline for implementing the comprehensive discharge education plan depends on patient needs, resource availability, stakeholder commitment, patient readiness, and technological infrastructure. A reasonable time frame is set at 12-18 months, considering resource allocation, platform development, and staff training. Uncertain situations, including stakeholder buy-in, resource availability, patient input, staff training, and compliance with regulations, may extend the timeline.

    Evaluation Plan

    The intervention plan combines tailored educational programs and telehealth services to enhance patient comprehension, reduce hospital readmissions, and increase satisfaction. Pre-intervention assessments gauge patients’ baseline understanding, with follow-ups at 1-month, 3-month, and 6-month intervals. A control group receiving standard discharge instructions enables comparative analysis. Data collection involves patient feedback, hospital readmission records, Electronic Health Records (EHRs), and dedicated patient portals. Analysis tools process quantitative and qualitative metrics, offering a comprehensive view of the intervention’s impact.



    Nurses, as transformative leaders, play a vital role in healthcare innovation. The intervention empowers nurses to champion personalized patient education, bridging the gap between complex medical directives and patients’ understanding. The collaborative effort strengthens inter-professional dynamics, establishing a multidisciplinary approach to post-cardiac cath care. Beyond individual interactions, the intervention promises economic benefits, improved trust, and enhanced reputation for healthcare institutions. For post-cardiac cath patients, it equips them with knowledge for optimal long-term health. Challenges include nurse training and consistent quality education delivery, addressable through persistence, feedback, and refinement.

    Future Steps

    Expanding the intervention involves nuanced personalization of educational content, integrating AR/VR systems for immersive patient education, adopting the Chronic Care Model for proactive healthcare, and incorporating advanced AI-driven patient monitoring systems. These enhancements ensure continuous improvement and alignment with evolving healthcare landscapes.


    The comprehensive discharge education plan, amalgamating traditional and digital approaches, is poised to transform post-cardiac cath care. Rooted in collaboration, leadership, and technological innovation, it aligns with the contemporary healthcare emphasis on patient-centered, value-based care. While embracing technology, the intervention maintains a human touch, recognizing patients’ diverse needs, fostering engagement, and ultimately advancing healthcare quality. The proposed plan, with its strategic implementation, robust evaluation, and advocacy for nursing leadership, stands as a testament to the evolution of healthcare towards holistic, patient-centric models.


    Jung, S. Y., Park, Y. R., Song, T. M., & Cho, J. H. (2022). Utilization of augmented reality and virtual reality in nursing education: A systematic review. Nurse Education Today, 111, 105249.

    Liu, X., Wang, Y., Liu, J., & Liu, X. (2022). The application of digital technology in the nursing education of postoperative patients with radical surgery for colorectal cancer. Journal of Coloproctology, 42, 3.

    Madan, A., Ene, K., Dolansky, M. A., & Brates, D. M. (2019). The impact of postdischarge telephonic follow-up on hospital readmissions. Population Health Management, 22(4), 316-319.

    NURS FPX 6030 Assessment 6 Final Project Submission

    Mistretta, F., Ribaudo, M., Mariani, G., Bazoli, L., Albano, A. M., Zanotti, R., … & Chiaranda, C. (2023). Implementation of discharge education program: A solution for better care continuity in older patients. Frontiers in Medicine, 9, 1026.

    Rahim, A., & Alshahrani, A. (2023). A systematic review of the impact of HIPAA on healthcare practices and outcomes. Journal of Health and Social Sciences, 8(1), 69-80.