NUR 650 Module 5 Milestone Two Example

Milestone Two: Designing a Tiered Heart Failure Discharge and Follow-Up Bundle

[Student Name]

Southern New Hampshire University

NUR 650: Care Coordination and Outcomes Management

Module Five Milestone Two

[Instructor Name]

[Date]

Milestone Two: Designing a Tiered Heart Failure Discharge and Follow-Up Bundle

An intervention described in general terms, such as improved discharge teaching or better follow-up, gives staff little to act on and leaders little to measure. A bundle is a small set of specific practices, each supported by evidence, delivered together and reliably to every eligible patient. At Brookhaven, the composite regional hospital whose heart failure readmission rate stands at 24%, the Module Three analysis identified four main causes of readmission, and Module Four recommended combining components of Project RED, the Care Transitions Intervention and the Naylor model in two tiers. This milestone designs the bundle in operational detail. It argues that specifying every component by time, role and standard, including a protocol for acting on early warning signs, and testing it in small cycles before rollout, gives the intervention the best chance of being delivered as intended.

Bundle Components and Timeline

Table 1 sets out the bundle. Every patient receives the universal components; patients flagged by the risk score, the social screen or nurse judgment also receive the high-risk components. Assigning one owner per step keeps accountability from slipping away at each handoff, the problem the process map identified.

Table 1. Heart Failure Transitional Care Bundle by Time Point and Role

Note. Every component has a time point and an owner, which makes it possible to track whether each was delivered.

Teaching That Checks Understanding

The Module Three chart review found that 22 readmissions involved patients who stopped or reduced their diuretic and 15 who did not weigh themselves or did not know what to do with a weight gain. Teaching must therefore confirm understanding, not only deliver information. Schillinger et al. (2003) audiotaped visits between physicians and patients with diabetes who had limited health literacy and found that physicians rarely checked whether patients understood new concepts; when they did ask patients to restate or explain what they had been told, their patients tended to reach better glucose targets. Brookhaven's bundle therefore requires teach-back for three essential points: why the diuretic is taken even when the patient feels well, how and when to weigh and what to do if weight rises. Teaching begins on the first full hospital day and is repeated daily, so that the day of discharge is a review rather than the first exposure. The bedside nurse documents the patient's own words for each point.

Medications and Follow-Up

The 2022 AHA/ACC/HFSA guideline recommends guideline-directed medical therapy when ejection fraction is reduced and supports seeing patients soon after they leave the hospital, typically inside the first week (Heidenreich et al., 2022). The bundle builds both into the discharge process. The pharmacist reviews the discharge medication list against the guideline and flags omissions for the prescriber, and confirms before discharge that each medication is covered by the patient's insurance and affordable, arranging assistance or alternatives when it is not. The case manager books the follow-up visit before the patient leaves, choosing the clinic closest to home and arranging transportation for rural patients when needed, rather than instructing the patient to call.

Acting on Weight Gain

Early weight gain signals fluid accumulation days before symptoms become severe, but only if someone acts on it. High-risk patients will report daily weights by phone or through a simple text message system. A standing protocol, approved by the cardiology section, allows the transitional care nurse to respond: when the scale shows 2 pounds more than yesterday, or 5 pounds more than a week ago, the nurse calls the patient to assess symptoms, reviews diet and adherence and, if the patient is stable, contacts the cardiology nurse practitioner for a one-time diuretic adjustment; for gains with shortness of breath at rest or chest pain, the nurse directs the patient to emergency care. Every protocol action is documented and reviewed weekly.

Testing Before Rollout

Launching the whole bundle at once would make it hard to learn what works and would overwhelm staff. Langley et al. (2009) set out an approach in which a team first agrees on its target and on how progress will be counted, then tries each candidate change on a handful of patients through quick Plan-Do-Study-Act loops, keeping what works. The first cycle will test pre-booked follow-up appointments with five patients on one unit for one week, measuring whether the appointment was booked, whether it fell within seven days and whether the patient attended. Later cycles will test teach-back documentation, the pharmacist call and the weight protocol, each on a small scale, before combining them. Each cycle's results will be reviewed with staff, who will be invited to suggest adjustments.

Staff Preparation and Barriers

Staff were consulted during design, and three barriers emerged. Bedside nurses worried about time for daily teaching; the team responded by building short teaching modules into the electronic record, with prompts for teach-back that take about five minutes per session. Case managers noted that clinics rarely had openings within seven days; the hospital negotiated reserved weekly slots with two primary care practices and the cardiology clinic. Pharmacists raised concerns about reaching patients by phone; the call will be scheduled at discharge at a time the patient chooses. A brief training session for each role and a laminated bundle card will support the launch.

Conclusion

The bundle translates evidence and local analysis into specific actions with owners and time points: teaching with teach-back from the first day, medication access and pre-booked follow-up before discharge, early contact for everyone, coaching and a weight protocol for high-risk patients. Testing each component in small cycles, with staff involved, will show whether the bundle can be delivered reliably before Brookhaven asks whether it lowers readmissions.

References

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. https://doi.org/10.1161/CIR.0000000000001063

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., & Bindman, A. B. (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90. https://doi.org/10.1001/archinte.163.1.83