Nursing's role and staffing in accountable care

Heart Failure and Care Delivery

Heart failure is a major factor to the majority of deaths seen in most hospitals around the world. Most health facilities ensure that patients with this illness receive competent care, with the major goals of reducing the number of deaths and permanently curing the patients (Delaney at al., 2013). This life-threatening and persistent condition occurs when the heart muscles weaken. The purpose of this study is to establish an orientation course plan, care coordination, and a discharge education plan for a hospital that has seen significant readmission rates owing to heart failure. Excellent care delivery is crucial in managing incidences of readmission due to heart failure.

Orientation Course Plan

Excellent care delivery is crucial in managing incidences of readmission due to heart failure. The accountable care model would be the most appropriate model that would be the most appropriate for this case (Mensik, 2013). Hospitals would work closely with other care groups, patients, and their families with the key goal of achieving the quality of services and avoiding readmissions. The most appropriate topic for the course would be, “An evidence-based course for reducing incidences of readmission of patients with heart failure.” The key objectives would be to ensure that all patients and their families are acquainted with the various techniques of taking care of them, educate nurses on the appropriate care models, and to ensure that the hospital engages in evidence-based practices when dealing with patients with heart failure. The primary points would be to advocate for safety and quality of services offered to the patients (Mensik, 2013). Secondly, the program would emphasize the need to adhere to the guidelines given by the healthcare providers. The only patient resources that would be required of the patients would be writing items, laptops, and some tutorial videos that would help the patients in recapping the things taught in the clinic. The key components of the course would be the care for individuals with heart failure, physical responsibilities for these patients, and the role of relatives in the curative support for these individuals. The best way of determining whether or not the patients have understood the concepts taught is when they ask questions. Asking question would be an indicator that the audience has comprehended whatever a speaker has communicated thereby they have an urge to gather more information relating to the topics. Secondly, a proper comprehension of the topic would be evident when the when the speaker asks questions and the audience answer unanimously. The modalities and avenues utilized in delivering information include the use of PowerPoint presentations and brochures that have information relating to the topic. The supplementary materials include handouts and leaflets. Videos of the clinical session would also act as excellent supplementary materials. Accountability tools and procedures used to measure effectiveness include questionnaires and interviews. A reduction in the number readmissions related to heart failure would be the best indicators of a successful education plan and overall effectiveness.

A Discharge Education Plan

The discharge education program would be based on the on the different models of healthcare such as the accountable care model. The objectives of this discharge plan would be to educate the care nurses in charge of the discharge process on the evidence-based approaches that he or she should use, to provide patients with the relevant information that would assist them in knowing the best practices before and after discharge, and to use the clinic as a means of reducing the number of readmissions that occur due to improper handling of the patients during the discharge process. Patient understanding would be evaluated by the use of questions. The various speakers would ask the audience questions regarding the contents of the discussion. The audience’s ability to respond to these questions appropriately would mean that they properly understand the topic on discharge plan. The different platforms and modalities used in delivering information would include the use of visual teaching tools and audios. Each patient’s lifestyle and culture would be evaluated before providing any further direction so that the instructions given would meet their cultural and language backgrounds (Lingle, 2013) All the care plans must be evidence-based and supported by the standards enlisted by the ANA and FDA (Ivany, & While, 2013). The accountability procedures used would include interviewing the patient and family regarding their take on the discharge process. A reduction in the number readmissions related to heart failure would be the best indicators of a successful discharge plan and overall effectiveness.

Care Coordination Plan

An evidence-based plan for the service delivery would entail the use of only documented practices in the care coordination plan. The key procedure of the coordinating services would be identifying the family’s perspectives, healthcare professionals’ perspectives and those of the system (Ivany, & While, 2013). Consequently, the care coordination can be created to identify the different patients’ needs. The patients with lung disease and other pulmonary illnesses might require excess resources and time basing on the complexity of their illnesses (Ivany, & While, 2013). The care coordination team would comprise of the various health professionals working with the patient and their families. The team could be activated a few moments before discharge by allocating them duties. The coordinating services would require up to one year depending on the services. The intervention plan would be monitored remotely by telemonitoring systems after their discharge (Delaney at al., 2013). The different standards advocated by the Agency for Healthcare Research and Quality would be used to support the care plan. The specific standards aligned to heart failure include ensuring safety, quality of service, and monitoring progress. A reduction in the number readmissions related to heart failure would be the best indicators of a successful education plan and overall effectiveness as well as the measurement tool for effectiveness. Information would be gathered using questionnaires and interviews.


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.

Ivany, E., & While, A. (2013). Understanding the palliative care needs of heart failure patients. British Journal of Community Nursing, 18(9), 441–445.

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)

Mensik, J. S. (2013). Nursing's role and staffing in accountable care. Nursing Economics, 31(5), 250–253.

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