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. Your team is to develop a nurse team outpatient heart failure clinic. This clinic is to ensure that proper education is given in order to improve the 30 day readmissions. The leadership team has asked you to provide a evidenced based plan for one of the components of the clinic. You may use any combination of documents, such as spreadsheet or a table in addition to explanatory information to convey information clearly and succinctly. Develop any one of the three Plans – (1) an orientation course plan; (2) a discharge education plan or (3) Care Coordination Plan. I chose a Discharge Education Plan which needs to include the following: develop an evidenced 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? Be sure to apply professional and legal standards in support of care plan * explain the alignment to the most recent Heart Failure Guidelines and specific professional standards. * describe accountablilty 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?
