Overview Write a 3-4 page evidence-based health care delivery plan for one component of a heart failure clinic. Nursing within an organization is a critical component of health care delivery and is an essential ingredient in patient outcomes (Kelly & Tazbir, 2014). The concern for quality care that flows from evidence-based practice generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: •Competency 2: Explain the accountability of the nurse leader for decisions that affect health care delivery and patient outcomes. ◦Describe accountability tools and procedures used to measure effectiveness. •Competency 3: Apply management strategies and best practices for health care finance, human resources, and materials allocation decisions to improve health care delivery and patient outcomes. ◦Develop an evidence-based plan for health care delivery. •Competency 4: Apply professional standards of moral, ethical, and legal conduct in professional practice. ◦Apply professional and legal standards in support of a care plan. •Competency 5: Communicate in manner that is consistent with the expectations of a nursing professional. ◦Write content clearly and logically, with correct use of grammar, punctuation, and mechanics. ◦Correctly format citations and references using current APA style. Reference Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership and management (3rd ed.). Clifton Park, NY: Delmar. Context In an effort to improve the patients' health literacy concerning heart failure, it is important that the clinic staff and the hospital staff present a consistent, evidence-based message on self-care to these patients and their families in order to decrease acute exacerbation and re-admissions. Review current evidence for clinical practice guides or protocols when developing your patient teaching plans and materials. Consider the following: •What does the patient know about the disease process as a baseline? •What does the patient need to do understand as far as the best self-care processes? •Can the patient identify proper medication compliance? •Is there a financial issue that affects compliance? •Who buys and prepares the food in the home? •Can the patient verbalize when to seek medical assistance? Questions to Consider To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. •What factors contribute to inadequate quality of care? •How effective are organizational mandates for quality? •How do financial concerns impact health and safety goals? Suggested Resources The following optional resources are provided to support you in complet.

1. Overview
Write a 3-4 page evidence-based health care delivery plan for
one component of a heart failure clinic.
Nursing within an organization is a critical component of health
care delivery and is an essential ingredient in patient outcomes
(Kelly & Tazbir, 2014). The concern for quality care that flows
from evidence-based practice generates a desired outcome.
Without these factors, a nurse cannot be an effective leader. It
is important to lead not only from this position but from
knowledge and expertise.
By successfully completing this assessment, you will
demonstrate your proficiency in the following course
competencies and assessment criteria:
•Competency 2: Explain the accountability of the nurse leader
for decisions that affect health care delivery and patient
outcomes. ◦Describe accountability tools and procedures used to
measure effectiveness.
•Competency 3: Apply management strategies and best practices
for health care finance, human resources, and materials
allocation decisions to improve health care delivery and patient
outcomes. ◦Develop an evidence-based plan for health care
delivery.
•Competency 4: Apply professional standards of moral, ethical,
and legal conduct in professional practice. ◦Apply professional
and legal standards in support of a care plan.
•Competency 5: Communicate in manner that is consistent with
the expectations of a nursing professional. ◦Write content
clearly and logically, with correct use of grammar, punctuation,
and mechanics.
◦Correctly format citations and references using current APA
style.
Reference
Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership
and management (3rd ed.). Clifton Park, NY: Delmar.

2. Context
In an effort to improve the patients' health literacy concerning
heart failure, it is important that the clinic staff and the hospital
staff present a consistent, evidence-based message on self-care
to these patients and their families in order to decrease acute
exacerbation and re-admissions. Review current evidence for
clinical practice guides or protocols when developing your
patient teaching plans and materials. Consider the following:
•What does the patient know about the disease process as a
baseline?
•What does the patient need to do understand as far as the best
self-care processes?
•Can the patient identify proper medication compliance?
•Is there a financial issue that affects compliance?
•Who buys and prepares the food in the home?
•Can the patient verbalize when to seek medical assistance?
Questions to Consider
To deepen your understanding, you are encouraged to consider
the questions below and discuss them with a fellow learner, a
work associate, an interested friend, or a member of your
professional community.
•What factors contribute to inadequate quality of care?
•How effective are organizational mandates for quality?
•How do financial concerns impact health and safety goals?
Suggested Resources
The following optional resources are provided to support you in
completing each assessment. They provide helpful information
about the topics in this unit. For additional resources, refer to
the Research Resources and Supplemental Resources in the left
navigation menu of your courseroom.
Click the links provided below to view the following
multimedia pieces:
•Riverbend City: Insurance Issues Mission | Transcript.

3. •Leadership Styles | Transcript.
•Leadership, Theories, Models, and Styles | Transcript.
Library Resources
The following resources are provided for you in the Capella
University Library and are linked directly in this course. These
articles contain content relevant to the topics and assessments
that are the focus of this unit.
•Mensik, J. S. (2013). Nursing's role and staffing in accountable
care. Nursing Economics, 31(5), 250–253.
•Ganz, F. D., Wagner, N., & Toren, O. (2015). Nurse middle
manager ethical dilemmas and moral distress. Nursing Ethics,
22(1), 43–51.
•Ott, J., & Ross, C. (2014). The journey toward shared
governance: The lived experience of nurse managers and staff
nurses. Journal of Nursing Management, 22(6), 761–768.
•Tait, G. R., Bates, J., LaDonna, K. A., Schulz, V. N., Strachan,
P. H., McDougall, A., & Lingard, L. (2015). Adaptive practices
in heart failure care teams: Implications for patient-centered
care in the context of complexity. Journal of Multidisciplinary
Healthcare, 8, 365–376.
•Boyde, M., Song, S., Peters, R., Turner, C., Thompson, D. R.,
& Stewart, S. (2013). Pilot testing of a self-care education
intervention for patients with heart failure. European Journal of
Cardiovascular Nursing, 12(1), 39–46.
•Brennan, E. J. (2015). Heart failure care for patients who do
not speak English. British Journal of Nursing, 24(20), 1004–
1008.
•Coordinating the medical home for heart failure patients;
transitioning to palliative care: Adjusting locus of care and
focusing on integrated medicine sheds light on best practices
and patient-centered care in heart failure clinics. (2010,
September 15). PR Newswire.
•Ivany, E., & While, A. (2013). Understanding the palliative
care needs of heart failure patients. British Journal of
Community Nursing, 18(9), 441–445.

4. •Limpahan, L. P., Baier, R. R., Gravenstein, S., Liebmann, O.,
& Gardner, R. L. (2013). Closing the loop: Best practices for
cross-setting communication at ED discharge. American Journal
of Emergency Medicine, 31(9), 1297–1301.
•Lingle, C. L. (2013). Evidence based practice: Patient
discharge education barriers to patient education (Master's
thesis). Available from ProQuest Dissertation Publishing. (UMI
No. 1542582)
•Delaney, C., Apostolidis, B., Bartos, S., Morrison, H., Smith,
L., & Fortinsky, R. (2013). A randomized trial of
telemonitoring and self-care education in heart failure patients
following home care discharge. Home Health Care Management
and Practice, 25(5), 187–195.
•Wolfson, B. J., & Campbell, R. (2014, February 9). With
Medicare watching, hospitals make changes: Orange County
medical centers put new focus on discharge practices to reduce
patient readmissions. Orange County Register.
•Berry, L. L., Rock, B. L., Houskamp, B. S., Brueggeman, J., &
Tucker, L. (2013). Care coordination for patients with complex
health profiles in inpatient and outpatient settings. Mayo Clinic
Proceedings, 88(2), 184–194.
•Veenstra, W., op den Buijs, J., Pauws, S., Westerterp, M., &
Nagelsmit, M. (2015). Clinical effects of an optimised care
program with telehealth in heart failure patients in a community
hospital in the Netherlands. Netherlands Heart Journal, 23(6),
334–340.
•Aller, M., Vargas, I., Coderch, J., Calero, S., Cots, F.,
Abizanda, M., ... Vázquez, M. L. (2015). Development and
testing of indicators to measure coordination of clinical
information and management across levels of care. BMC Health
Services Research, 15(323), 1–16.
Internet Resources
•National Council of State Boards of Nursing (NCSBN). (n.d.).
Retrieved from https://www.ncsbn.org/index.htm
•American Nurses Association (ANA). (2015). Code of ethics

5. for nurses. Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStand
ards/CodeofEthicsforNurses.asp
Bookstore Resources
The resources listed below are relevant to the topics and
assessments in this course. Unless noted otherwise, these
materials are available for purchase from the University
Bookstore. When searching the bookstore, be sure to look for
the Course ID with the specific –FP (FlexPath) course
designation.
•Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership
and management (3rd ed.). Clifton Park, NY: Delmar. ◦Chapter
2.
◦Chapters 11–15.
Assessment Instructions
Preparation
Refer to the library and the Internet for supplemental resources
to help you complete this assessment.
Instructions
Deliverable: Develop an evidence-based plan for health care
delivery.
Scenario:
The hospital where you work has an issue with increased
readmissions within 30 days of discharge. After examining the
core measures, it was found that heart failure was the most
common core measure disease process experiencing the highest
rate of readmissions. The leadership team has given your team
the charge of developing a nurse-run outpatient heart failure
clinic. The purpose of this clinic is to ensure that discharge
education is presented to the patient in an orderly, consistent
manner and complies with evidence-based practice protocols.
Since these patients may be discharged from a variety of areas
in the facility, having the heart failure clinic staff take

6. ownership of the process will improve both consistency and
compliance. There are cardiologists that interact with the staff
and patients, but the day-to-day operations of the clinic are
designed and supported by the nurses as they interact with
appropriate members of the other health care team disciplines
promoting the best care for the heart failure patients.
As a member of the nurse team, you have been asked to develop
one component of the clinic.
The hospital leadership established these objectives for the
clinic services:
•Evaluate and maximize proper medication therapy.
•Conduct regular diet, exercise, and stress management classes
for the patients.
•Monitor physiological indicators for the patients (lab work,
weights, vital signs, ECGs).
•Provide a case management system for patients in the program
post-discharge.
The overall goals for the heart failure clinic are to:
•Enroll greater than 90 percent of the patients with a primary or
secondary diagnosis of HF prior to discharge.
•Facilitate discharge planning to achieve 100 percent
compliance with patient education prior to discharge (discharge
planning).
•Decrease readmission rates in this population by 5 percent over
the next year.
The leadership team has asked you to provide them with an
evidence-based plan for one of the components of the clinic.
You may use any combination of documents (for example, a
spreadsheet or a table) in addition to explanatory information to
convey information clearly and succinctly.
Develop one: an Orientation Course Plan, a Discharge

7. Education Plan, or a Care Coordination Plan.
An Orientation Course Plan:
•Develop an evidence-based plan for health care delivery.
•Include a comprehensive schedule of topics, objectives, key
points, and patient resources for the orientation course. ◦What
are the components of an evidence-based education plan?
◦How will you know that patients will understand what to do?
◦What modalities will you use to deliver information?
◦How will you adapt the plan to meet the needs of patients from
diverse cultural and language backgrounds?
◦Identify specialized and supplementary material needs.
•Apply professional and legal standards in support of a care
plan. ◦Explain the alignment to the most recent Heart Failure
Guidelines and specific professional standards.
◦Describe the accountability tools and procedures used to
measure effectiveness.
◦How will you know if the patient education plan is successful?
◦What are the indicators of success or effectiveness?
A Discharge Education Plan:
•Develop an evidence-based plan for health care delivery.
◦Develop a discharge plan with objectives and resources, and
tools for patients to monitor their progress.
◦How will you know that patients understand what to do?
◦What modalities will you use to deliver information?
◦How will you adapt the plan to meet the needs of patients from
diverse cultural and language backgrounds?
•Apply professional and legal standards in support of a care
plan. ◦Explain the alignment to the most recent Heart Failure
Guidelines and specific professional standards.
◦Describe accountability tools and procedures used to measure
effectiveness.
◦How will you know if the discharge plan is successful?
◦What are the indicators of success or effectiveness?

8. Care Coordination Plan:
•Develop an evidence-based plan for health care delivery.
◦Develop a procedure for coordinating services. ◦Consider the
needs of "outliers." For example, someone with lung disease
may need extra resources.
◦Who should be on the team?
◦When would the team be activated?
◦How would it be activated?
◦What is the time frame required to coordinate services?
◦How would the intervention plan be monitored for
effectiveness?
•Apply professional standards in support of a care plan.
◦Explain the alignment to the most recent heart failure
guidelines and specific professional standards.
◦Describe accountability tools and procedures used to measure
effectiveness. ◦How will you know if the care coordination plan
is successful?
◦What are the indicators of success or effectiveness?
◦How will information be collected or communicated?
Additional Requirements
•Written communication: Written communication should be free
of errors that detract from the overall message.
•APA formatting: Resources and in-text citations should be
formatted according to current APA style and formatting.
•Length: The report should be 3-4 pages in content length,
double-spaced.
•Font and font size: Times New Roman, 12 point.
•Number of resources: Support your plan with a minimum of
three peer-reviewed resources, in addition to professional
standards. Current < 5yrs old