NURS FPX 6030 Assessment 6 Final Project Submission
Phillip October 3, 2023 No Comments

NURS FPX 6030 Assessment 6 Final Project Submission

NURS FPX 6030 Assessment 6 Final Project Submission

Student Name

Capella University

NURS-FPX 6030 MSN Practicum and Capstone

Prof. Name


Final Project Submission


The purpose of the capstone project was to enhance patient comprehension of post-discharge regimens, reduce hospital readmissions, and increase patient satisfaction after cardiac catheterization through a tailored educational program and the integration of telehealth services. This initiative aimed to address the evident knowledge gap and continuity of care for post-cardiac catheterization patients, ensuring they are well-informed and have sustained support post-discharge. The approach adopted involved individualized discharge education and the incorporation of multimodal education delivery, which included audiovisual and remote monitoring devices and communication tools to disseminate information and address concerns. Two pivotal findings from the project were the potential of nurses transforming into key knowledge brokers, enhancing the overall patient care experience, and indicating that a well-informed and educated patient has a reduced chance of hospital readmission, offering potential cost savings for healthcare institutions.


The pressing need of this capstone project is to address the high 30-day hospital readmission rates among the target population of patients who have Coronary Artery Disease (CAD) and were discharged after cardiac catheterization at Manatee Memorial Hospital in Bradenton, Florida, as our target setting. The particular emphasis is on enhancing post-discharge patient education.

The intervention plan aims to strengthen post-discharge outcomes through comprehensive and individualized discharge education, encompassing customized educational programs based on individual needs and preferences and the integration of telehealth services whereby multimodal delivery methods, such as audiovisual devices, communication tools, and remote-monitoring devices were used to interact with patients, disseminate information, and address pressing concern study that justifies our intervention that emphasizes the effectiveness of tailored discharge education, underpinned by modern telehealth technologies, as a pivotal strategy to postoperative outcomes and boost patient satisfaction.

NURS FPX 6030 Assessment 6 Final Project Submission

Furthermore, our implementation plan focused on achieving the desired outcomes using transformational leadership, where clear goals and vision were developed to foster a shared decision-making environment. Effective planning and execution were performed along with practicing patient-centered care. Other aspects included using multiple delivery methods and adhering to the policies and regulatory guidelines (HIPAA and HRRP). The implementation timeline was 12 to 18 months. Significant components of evaluation detailed pre-intervention assessments, periodic follow-ups, a control group for comparison, and the utilization of Electronic Health Records and specialized software tools for comprehensive data analysis.


Need Statement

For patients who were discharged from Manatee Memorial Hospital in Bradenton, Florida, how does implementing a comprehensive and personalized post-discharge education program compare to providing basic discharge instructions after cardiac catheterization influence the 30-day hospital readmission rates and improved patient outcomes over 12 months after the implementation of the education program? According to the Healthcare Cost and Utilization Project National Readmission Database study conducted over eleven months, 30 percent of patients discharged after having percutaneous coronary intervention (PCI) were readmitted within 30 days (Madan et al., 2019). This statistic presents the urgency to address the need to minimize readmission rates to improve health outcomes and reduce healthcare costs. 

Population and Setting

The target population is patients discharged after cardiac catheterization. Addressing this need within this population is vital because they are at a heightened risk of post-discharge complications. Ensuring these patients have a deep understanding of their care regimen can significantly reduce potential complications, decrease the rare admission rate, and alleviate the burden on the healthcare system. Additionally, this tailored approach to care aims to improve patient satisfaction by comprehensively addressing their unique needs and concerns. The target setting is Manatee Memorial Hospital, where readmission rates are around 16% among patients who underwent cardiac catheterization, significantly higher than that presented by the American Heart Association’s study. The reason is inadequate comprehensive and personalized education. Thus, it is essential to address the problem within the organization.

Intervention Overview

Two central interventions are proposed to reduce readmission rates among cardiac catheterization patients at Manatee Memorial Hospital: tailored discharge education and telehealth services. The former ensures patients receive individualized information about their health status, while the latter offers consistent post-discharge support without requiring a hospital visit. The QI method of the Plan-Do-Check-Act (PDCA) cycle was applied to developing an individualized post-cardiac catheterization education program to reduce readmissions. The problem of high readmission rates among post-cardiac catheterization patients was identified in the planning phase. Next, we set the goal of reducing 30-day readmission rates by 20% within the next 12 months.

Once we formed a multidisciplinary, data on current readmission rate factors was gathered and analyzed to identify the patterns and factors contributing to readmissions and determine gaps in the current education program. The phase involved creating an individualized post-cardiac catheterization education program, which included medication management, lifestyle modification guidance, symptom recognition education, and early follow-up appointments. Feedback was collected from patients and healthcare providers while assessing outcomes during the check phase, and necessary adjustments were made. At the same time, we continuously monitor the outcome during the act phase.

Manatee County’s significant portion of the population comprises middle-aged to older adults while this area is culturally very diverse and includes individuals from various ethnic and racial backgrounds. When we execute this education program, I expect the most significant challenge to be healthcare illiteracy and the language barrier among Manatee County residents. 

Comparison of Approaches 

Inter-professional collaboration is essential for delivering comprehensive care to post-cardiac catheterization patients with coronary artery disease (CAD). While customizing patient-specific education plans is a practical approach, there are alternative inter-professional strategies that can also address patients’ needs. These potential alternatives include standardized education plans developed based on best practices and evidence-based guidelines. Standardized plans can ensure consistent and thorough education delivery to all patients. Another alternative would be group education sessions led by inter-professional teams, including nurses, dietitians, and physiotherapists.

Initial Outcome Draft

Our goal is to reduce 30-day readmission rates by 20% within the next 12 months and increase the number of patients who consistently adhere to their medication post-discharge by 15 percent. We also aim for a 30 percent increase in follow-up appointment attendance and a 25 percent increase in patients who report symptoms promptly.

Time Estimate

Developing and implementing a customized education program for post-cardiac catheterization patients with coronary artery disease (CAD) involves several phases. Timelines can vary based on specific challenges, such as the program’s complexity, available resources, and the specific healthcare setting. We expect the planning and assessment phase to be approximately two months, platform development to take four months, pilot testing to 2 months, full-scale implementation to 4 months, and ongoing monitoring to be continuous, while the total estimated timeframe is approximately 12 months. 

Literature Review 

Comprehensive education before discharge for patients post-cardiac catheterization has shown a notable reduction in out-of-hospital cardiac arrest incidents. The detrimental impact of medication non-compliance post-cardiac catheterization emphasizes the importance of patient education, with a noted correlation between medication non-compliance and readmission rates. Patients who receive individualized post-cardiac catheterization education tend to show fewer readmissions.

The importance of comprehensive education post-procedure becomes evident as it ensures better adherence to medical advice, further enhancing the recovery process and reducing the chances of hospital readmission. This randomized control trial showed the effectiveness of tailored post-procedure patient education against standard discharge instructions for cardiac patients. The study found that patients receiving customized educational interventions showcased a 30% reduction in 30-day readmission rates compared to their counterparts (Madan et al., 2019).

NURS FPX 6030 Assessment 6 Final Project Submission

The customized approach incorporated individual health literacy, cultural background, and preferred learning methods, emphasizing the significance of personalized touch in patient education. For Medicare beneficiaries, around 19.6% were readmitted within 90 days post-procedure, showcasing the dire need for improved patient education within such settings. Assessing patient readiness for discharge after myocardial infarction further underscores the importance of adequate pre-discharge education (Bolton et al., 2021).

Current telehealth policies can provide continued education and care for post-cardiac catheterization patients. Such policies alleviate the need for regular in-person consultations, particularly beneficial for remotely located patients. Additionally, remote monitoring tools, supported by relevant policies, allow for an extended care framework where patient metrics can be continuously monitored, allowing timely interventions (Ullah et al., 2023). The literature strongly advocates for enriched education for patients post-cardiac catheterization. Modern health policies supporting telehealth and remote monitoring further augment this process, ensuring continuous and tailored patient support and reducing readmission rates.

Interventional Plan

Intervention Plan Components

The intervention plan for improving post-discharge outcomes is based on providing comprehensive and individualized discharge education. The major components of this plan include customized educational programs and telehealth services. 

Customized Educational Plans:

The first step of this component is to perform patients’ assessments and profiling, where we will understand and evaluate patients’ health literacy levels, their learning needs and preferences, and other socio-cultural factors that may impede the learning and self-management process. This step is essential to tailoring our educational program, integrating patient-centeredness, and leading to better patient governance.

After the assessment, individualized discharge instructions will be developed, considering patients’ cultural beliefs, health needs, language preferences, and health practices.(Al-Noumani et al., 2023) A holistic training of procedural details, medication management, and dietary and physical activity advice is essential. This component of the intervention plan will result in patient engagement in their healthcare process and shared decision-making, thus enabling patients to adhere to the instructions and ultimately improving health conditions and reducing readmission rates (Chen et al., 2023).

Telehealth Services:

Another component is integrating technological communication methods and digital health services for effective discharge education and post-discharge adherence to the instructions. Since the advent of telemedicine, a significant improvement in achieving quintuple aims has been observed. This includes improvement in patient experiences, cost-effectiveness, enhanced health outcomes, healthcare equity, and well-being of the providers (Chen et al., 2023). In our intervention plan, telehealth services can be used for post-discharge patient education, monitoring, and measuring outcomes.

A multimodal education delivery approach can be used, whereby various technological tools, such as audiovisual, remote-monitoring devices, and communication tools, can be utilized for delivering important information and addressing patients’ concerns. This component is essential for our intervention plan so patients can be monitored and constantly guided for treatment adherence and self-management of health issues, eventually reducing hospital visits and readmission rates. 

Cultural Needs and Characteristics 

The target population for this capstone project is the patients undergoing cardiac catheterization at Manatee Memorial Hospital in Bradenton, Florida. Generally, the cultural needs of the patient population significantly influence the development of an intervention care plan as it assists the providers in developing personalized care based on individual needs and preferences, considering the social and cultural barriers. This aspect of care is vital for prioritizing public interest while providing healthcare services.

The statistics presented by the U.S. Census Bureau reveal that the total population in Bradenton city is 56,961, belonging to different ethnic and racial groups. The population comprises 74.3% White Americans, Black or African alone constitute 14.8%, Hispanic/Latino is 21.4%, and the rest are in traces (U.S. Census Bureau, n.d.). This diverse population advocates the need for a culturally competent intervention plan where the customized educational plans, as a component of our intervention, focus on respecting patients’ language preferences, cultural beliefs, and health practices. This will further ensure patients’ inclusivity and effectiveness of care.

NURS FPX 6030 Assessment 6 Final Project Submission

Moreover, customized communication strategies in multimodal educational delivery will ensure patients are fully engaged and involved in the interventional plan using easy-to-understand language, catering to their literacy levels and language differences. In the organizational setting, the corporate culture of Manatee Memorial Hospital (MMH) plays a crucial role in developing our intervention plan. Cultural awareness among healthcare professionals about their own and patients’ cultural beliefs facilitates communication between patients and providers.

Within the MMH care setting, the established cultural competence training programs for healthcare professionals impact the development of our intervention plan, whereby the objectives are to improve interprofessional teamwork, patient engagement, and patient-centered discharge planning and education for post-cath patients (Walkowska et al., 2023). The underlying assumption is the importance of culturally competent care as the studies support the development of culturally tailored interventions for the patients to observe effective health outcomes and patient satisfaction. Moreover, studies also promote the integration of cultural factors in discharge planning and education to reduce hospital readmission rates (Walkowska et al., 2023).

Theoretical Foundations 

Of several nursing theories, Dorothea Orem’s Self-Care Theory primarily applies to designing our intervention plan. The theory’s strength is that it accentuates patients’ role in managing their health conditions. Comprehensive discharge education for post-operative cardiac patients is aligned with the goal of this theory to encourage patient engagement in their recovery through appropriate self-care practices. A study concluded that education on self-care using this theory showed positive patient outcomes and improved quality of life for hypertensive patients (Labani, 2022). Thus, the theory can be effectively used for post-surgery patients. Using this theory, healthcare providers can develop a comprehensive discharge education that includes information about medication plan compliance and lifestyle modifications.

One of the areas for improvement of this model is that it assumes patients’ motivation and ability to adhere to the treatment plans, which may not match the reality, and several factors may impede, such as education levels and socio-cultural and economic barriers. Secondly, motivational interviewing (MI) can influence patients’ behavioral changes as a strategy from other disciplines. In discharge education for post-cardiac catheterization patients, this strategy enormously helps healthcare providers evaluate patients’ readiness for the change, adhere to the treatment plan, and address any uncertainties.

NURS FPX 6030 Assessment 6 Final Project Submission

However, implementing MI is time-consuming to engross patients in significant conversations and manage potential resistance. Lastly, the use of telecommunication methods like video conferencing and remote monitoring devices will impact the design of our intervention plan, where one of the components is to add telehealth services. This assists healthcare providers in keeping patients’ records and monitoring their progress after the surgery, along with constantly helping them through self-management, improving patient outcomes (Chen et al., 2023). Conversely, the effectiveness of telehealth depends on the user’s accessibility and comfort. Internet connectivity can become another significant obstacle in the care coordination process.  

  • Orem’s Self-Care Theory can be justified by the study, which concluded that patients with hypertension showed positive outcomes because of their training in self-management practices (Labani, 2022). Our interventional design of comprehensive discharge education primarily fits this theory of encouraging self-care practices to improve adherence and reduce hospital readmission rates. 
  • Since our comprehensive education program is based on customized education plans, motivational interviewing is justified as it focuses on patient-centered instructions instead of providing patients with primary and general discharge instructions.
  • As one of the components in our intervention plan is based on telehealth services, a study by Chen et al. (2023) reflects on the effectiveness of telehealth and telecommunication in enhancing patient education and treatment adherence, minimizing the risks of hospitalization. 

Stakeholders, Policy, and Regulations

Our intervention plan is primarily focused on the needs of the patients and their families as our concerned stakeholders. Customized educational programs and telehealth services are influenced by patients’ need to manage their health conditions post-surgery, reduced readmission rates, and improved outcomes. The comprehensive discharge training and implementation are supported by the necessity of hospital management and healthcare providers to augment patients’ satisfaction levels, minimize costs associated with higher readmission rates, and improve healthcare quality. Since telehealth is included in our intervention plan, healthcare policies related to data protection and patient confidentiality are applicable. Health Insurance Portability and Accountability Act (HIPAA) is one of the crucial health policies that entails maintaining patient privacy, data security, and confidentiality when using telecommunication tools (Rahim & Alshahrani, 2023).

NURS FPX 6030 Assessment 6 Final Project Submission

Also, directing healthcare professionals to avoid unauthorized access. Other than this, the regulations from governing bodies like the Centers for Medicare & Medicaid Services (CMS) define guidelines for telehealth reimbursement, and various state medical boards determine licensure and practice regulations, which assist providers in aligning their practices with standardized protocols. The underlying assumptions for this analysis are based on the factors that healthcare facilities should abide by national and state-level regulations to maintain care standards. Moreover, addressing the needs of the stakeholders will ensure their active involvement in the care process and adherence to the intervention plan. 

Ethical and Legal Implications 

The ethical implication in our intervention plan is autonomy vs. beneficence. While addressing patients’ right to receive care based on their preferences, it is essential to balance patients’ autonomy with the healthcare provider’s duty to act in the patient’s best interest. Customized educational plans can raise this ethical concern, where organizational changes should follow the moral principle of informed decision-making. This will allow providers to give detailed information on risks and benefits, respecting patients’ choices for their healthcare.

On the other hand, organizations may face legal issues under the HIPAA act of maintaining patient privacy and data security while implementing telehealth services (Rahim & Alshahrani, 2023). The use of healthcare technologies is governed by the legal duty of protecting patients’ health information. To fulfill legal standards, organizations must adhere to HIPAA policies, make stringent data protection security channels, inform patients about using their personal information, and safeguard the data using authorized access. Moreover, organizations must apply strict rules on healthcare providers to improve their compliance with HIPAA regulations. 

Implementation Plan

Management and Leadership 

Since our intervention is based on comprehensive and personalized discharge education, multidisciplinary coordination is imperative through leadership, management, and nursing practices. 

Leadership Strategies:

Transformational leadership style will be beneficial for successfully implementing the interventional plan by utilizing clear vision and goals – clearly defining the goals and vision of the project will stipulate a shared direction for the inter-professional team, ensuring they understand the value and objectives of the initiatives. Other leadership strategies include interdisciplinary training, which will enhance teams’ understanding of each other’s roles and responsibilities, nurturing empathy and respect for each other, and regular meetings to provide a platform for interdisciplinary collaboration to address the challenges collectively (Mistretta et al., 2023).

Management Strategies:

Project planning and execution is a strategy used by the management to cultivate distinctly defined milestones and deadlines, which will ensure inter-professional team members stay on track and work to achieve long-term goals and maintain the sustainability of the project’s success. Other strategies may include feedback and monitoring, which will foster interdisciplinary collaboration where the team members will come together, provide their input, monitor the performance, and follow a shared goal to improve patient outcomes within the organization (Mistretta et al., 2023).

Nursing Practices:

Patient-centered care, where the care is tailored to the individual patient’s needs, preferences, and circumstances, will ensure that our intervention of comprehensive discharge education programs is customized for the patients, improving their adherence and enhancing care coordination among the healthcare team to deliver holistic care. Additionally, digital health literacy will help nurses assist patients in utilizing technology and communicating effectively through virtual platforms. Inter-professional collaboration with technological experts will ensure a seamless telehealth experience for providers and patients (Mistretta et al., 2023). While these strategies and nursing practices will help our project succeed and foster inter-professional collaboration, conflicting perspectives about limited resources, resistance to change, inter-professional dynamics, and regulatory barriers must be addressed concurrently. 

Implications of Change to Improve Outcomes and Cost-effectiveness 

The proposed strategies for leading, managing, and implementing nursing practices will generate a shared direction for the care setting. These shared objectives will align the efforts of the inter-professional team, enhancing their communication, strength, and coordination throughout the implementation phase to successfully implement comprehensive discharge education plans for post-cardiac catheterization patients. These changes will enable us to provide patient-centered discharge education for post-cardiac catheterization patients, increasing patients’ experiences of personalized attention, trust in providers, and satisfaction related to healthcare, positively impacting healthcare quality (Madan et al., 2019).

Moreover, they will experience seamless transitions from inpatient to residential settings due to the telehealth services, empowering patients to self-manage and adhere to the care plans. Additionally, efficient and well-coordinated care enabled remote monitoring and early interventions, and empowered patients will mitigate unnecessary expenditures for complications and hospital readmissions. These monetary resources can be utilized for necessary adjustments to improve the quality of care and patient outcomes. However, the knowledge gaps and uncertainties lie where resistance to change, leadership changes, regulatory modifications, and organizations’ policy amendments are observed. These situations may require strategic changes, leading to unexpected outcomes. 

Delivery and Technology 

A combination of in-person and digital delivery methods will be appropriate for implementing personalized discharge education plans and telehealth services. Traditional physical education methods include one-on-one consultations, group sessions, and hands-on training. These methods are appropriate for our interventional plan as they will aid in creating direct patient-provider connections to address concerns and plan and tailor educational plans according to personal needs (Liu et al., 2022). Group sessions, on the other hand, will develop peer support and facilitate a shared learning environment for patients through different experiences. Hands-on training will help demonstrate and re-demonstrate discharge instructions, such as changing wound dressings, emptying drainage bags, and hygiene care post-cardiac surgeries.

Digital delivery methods include the provision of digital resources and virtual telehealth platforms. Digital resources enhance the accessibility of healthcare information for patients, promoting information comprehension and retention. On the other hand, virtual educational platforms will ensure real-time interaction between providers and patients, allowing professionals to monitor patients’ conditions and provide ongoing education. These methods overcome geographical barriers and enhance patient engagement in the healthcare process (Liu et al., 2022). This proposal assumes that considering patients’ needs and preferences is essential for enhancing their adherence to the care plan. Moreover, patient engagement through digital and virtual health platforms is imperative for empowering patients and enhancing their self-management ability to reduce hospital readmissions and improve patient outcomes. 

Current and Emerging Technological Options 

Current technologies that can be used for in-person education are PowerPoint presentations and interactive videos, which can make our education sessions more engaging and enlightening for the patients. This will make it easier for patients to understand complex medical terms and concepts. However, the emerging augmented reality (AR) and virtual reality (VR) tools can create mesmerizing experiences for patients where they can visualize the discharge instructions and comprehensively understand the concepts (Jung et al., 2022). These tools can be used for demonstrating the instructions mentioned earlier related to post-cardiac surgeries.

Digital resources can be disseminated through existing videos, interactive courses, and downloadable materials, which can become handy guides for patients to use at their own pace. On the other hand, emerging technologies of personalized apps and wearable devices can deliver customized health information directly to patients, promoting continuous engagement and self-management. While currently available video conferencing and messaging would help build patient-provider interactions, emerging remote monitoring devices and AI-driven chatbots can collect real-time data, enabling professionals to suggest data-driven interventions for their patients. Several knowledge gaps and uncertain situations include the readiness of patients to transition into technologies, the effectiveness of these technologies in our care setting, resource constraints, and challenges related to the accessibility and utilization of these technological advancements. 

Stakeholders, Policy, and Regulations

Patients and their caregivers are critical stakeholders in our interventional plan for comprehensive discharge education. Meeting patient’s needs will enhance their engagement, satisfaction levels, and adherence to the care plans, eventually leading to successful aftermaths as desired in our interventional plan (reduced readmission rates and improved health outcomes). Besides patients, healthcare professionals support our educational intervention through collaboration and care coordination. Administrators, managers, and IT professionals are crucial for managing human, financial, and technological resources. They will assist in resource allocation, budget management, and technological support throughout the planning and implementation phase.

External stakeholders, including insurance providers and regulatory bodies, are essential for providing reimbursements and maintaining legal and ethical standards, respectively. Healthcare regulations like Medicare’s Hospital Readmission Reduction Program (HRRP) and the Health Insurance Portability and Accountability Act (HIPAA) are relevant to our interventional plan. According to HRRP, hospitals with higher-than-expected readmission rates for chronic health conditions are given penalties that may burden the organization with financial consequences. This policy focuses on across-the-board discharge planning to reduce readmission rates (CMS, 2023). Likewise, the policy of our program focuses on comprehensive discharge education to reduce readmission rates, augment patient education, improve patient outcomes, and boost healthcare quality.

NURS FPX 6030 Assessment 6 Final Project Submission

Another policy that impacts our interventional plan is the HIPAA Act, which emphasizes the protection of patients’ privacy, security, and confidentiality during telehealth interactions (Rahim & Alshahrani, 2023). As our plan involves using digital resources and educational virtual platforms, safeguarding the security and confidentiality of patient information is fundamental to obeying HIPAA guidelines. Moreover, this analysis assumes that stakeholders and regulations directly impact the plan’s successful implementation, as it is imperative to receive adequate support, funding, and collaboration from the internal and external stakeholders. Moreover, regulatory compliance is essential to maintain ethical and legal standards of care for patient satisfaction. 

Existing and New Policies 

Specific existing and new policies imply our interventional plan, for instance, telehealth reimbursement policies. Existing reimbursement policies can ensure healthcare workers receive compensation for telehealth services (, 2023). If not available in the state, such policies can be developed to incentivize providers to offer telehealth services, eventually increasing healthcare accessibility for patients. Standardization of digital health educational material is equally important to ensure accurate and reliable information is circulated to the patients. Policies that encourage collaborative care, promote interdisciplinary teamwork, and emphasize the importance of involving various healthcare disciplines in patient education and care planning could be established. Lastly, policies like the Affordable Care Act (ACA) can target health disparities within the state. These policies will also provide funding and resources to underserved communities for access to telehealth services and digital educational resources (CMS, 2023).


The proposed timeline for implementing our comprehensive discharge education plan’s two-pronged approach, customized education plans, and telehealth services depend on various factors, including the patient’s specific needs, the availability of resources, stakeholders’ commitment, patients’ readiness to adapt to the change, and availability of technological infrastructure. However, a reasonable time frame for implementation will be 12-18 months. This is a realistic time frame as allocating resources, developing telehealth and digital platforms, and staff training and development are time-consuming processes.

However, there can be multiple uncertain situations that may require the extension of the time frame. These factors include the need for stakeholder buy-in; as we have understood that stakeholders play a crucial role in the plan’s successful implementation, it is essential to have buy-in from all stakeholders, including patients, healthcare providers, and hospital administrators. Secondly, adequate resources, such as staff, technological materials, and finances, are essential. The unavailability or scarcity of such possessions may lead to delayed implementation. Other considerable factors are patients’ valuable input and readiness to adapt to the changes, staff training, and compliance with the regulations and policies.

Evaluation Plan

The intervention plan combines two primary strategies: developing a tailored educational program and integrating telehealth services for patients discharged after cardiac catheterization. The targeted outcomes of this intervention are threefold: enhanced patient comprehension of their post-discharge regimen, reduced hospital readmissions and heightened patient satisfaction (King-Dailey et al., 2022). These outcomes delineate the core purpose of our intervention. By fostering a deeper understanding of their care regimen among patients, we anticipate a decline in post-discharge complications, reducing the rate of readmissions.

Such a reduction not only signifies improved patient adherence and understanding but also alleviates the financial and logistical burdens on the healthcare system. Elevating patient satisfaction, conversely, indicates our commitment to individualized care, ensuring that each patient’s unique needs and concerns are addressed comprehensively. The combined emphasis on tailored discharge education and telehealth services portrays our ambition to create a healthcare system where patients are empowered with knowledge and have sustained access to healthcare professionals even after discharge.

NURS FPX 6030 Assessment 6 Final Project Submission

Furthermore, our intervention promises benefits through these dual pathways, from the patient’s health outcomes to systemic improvements. Our intervention establishes a concrete framework for improving the quality, safety, and care experience. Personalized education is a cornerstone, bridging the knowledge gap and ensuring patients are well-prepared for post-hospitalization care (Al-Noumani et al., 2023). This, in tandem with telehealth services, provides a continuity of care, promoting safety and a more seamless healthcare experience, even from the comfort of one’s home. However, like all ambitious projects, challenges are anticipated. Crafting tailored educational content can be resource-intensive and might introduce variations due to differing expertise among healthcare professionals. Moreover, the high level of personalization could lead to patients becoming overly reliant on medical professionals for even minor clarifications.

Evaluation Plan and Assumptions

Our evaluation plan is rooted in two foundational assumptions to evaluate the efficacy of our intervention. Firstly, individualized discharge education and telehealth services will significantly improve patient comprehension and adherence post-discharge. Secondly, a measurable reduction in readmissions will indicate the successful implementation of our intervention. The strategy starts with a comprehensive pre-intervention assessment using detailed questionnaires to gauge patients’ baseline understanding of discharge directives (King-Dailey et al., 2022). This initial measure offers a reference for subsequent evaluations.

We will then measure the lasting effects of our intervention with follow-ups scheduled at 1-month, 3-month, and 6-month intervals. The intervention will initially target a select group, allowing us to maintain a control group that continues to receive the standard discharge instructions. However, this method facilitates a comparative study, clarifying our approach’s advantages or potential shortfalls. For data collection, we will incorporate patient feedback forms to gain insights into their experiences and comprehension, alongside hospital readmission records as a direct metric of intervention outcomes.

NURS FPX 6030 Assessment 6 Final Project Submission

To optimize data collection and monitoring, Electronic Health Records (EHRs) will be employed for real-time tracking of patient readmissions. Furthermore, we will introduce dedicated patient portals, ensuring a two-way channel for disseminating tailored educational content and gathering feedback. We will utilize specialized software tools for data analysis to ensure accuracy and depth. These tools will process quantitative metrics, such as readmission rates, and qualitative data, like patient feedback, to offer a rounded perspective. This blend of qualitative and quantitative analysis will enable us to thoroughly gauge the intervention’s impact on health promotion and education.



Nurses emerge as transformative leaders in the vast healthcare landscape, especially when innovation and change are at play. With close patient interactions, nurses gain insights into individual needs and identify areas ripe for improvement. Our intervention – a tailored educational strategy for discharged cardiac catheterization patients – is poised to amplify the nurse’s role in this transformative journey. In a professional context, nurses are no longer confined to traditional caregiving; they evolve into vital knowledge brokers. Moreover, empowered by the intervention, they actively spearhead a shift towards bespoke patient education, ensuring that complex medical directives are seamlessly translated into layperson’s terms for post-cardiac cath patients. This proactive shift augments the quality and experience of care as nurses treat and educate, guiding patients toward better health outcomes.

It is grounded in the belief that nurses can become formidable change catalysts in healthcare settings when armed with the appropriate tools (Mistretta et al., 2023). Beyond the immediate patient-nurse interaction, the ripples of this intervention enhance inter-professional dynamics. Tailoring educational content to each patient’s needs demands a symphony of inputs from diverse healthcare professionals, from doctors to therapists. Moreover, this necessitates and strengthens collaboration, ensuring comprehensive educational materials are tailored to each patient’s unique recovery journey. Such a collaborative endeavor accentuates the nursing profession’s pivotal role in patient education and establishes a cohesive, multidisciplinary approach to post-cardiac cath care. Zooming out to the broader healthcare paradigm, this intervention promises multifaceted benefits.

NURS FPX 6030 Assessment 6 Final Project Submission

From an economic lens, a well-informed and educated patient stands a reduced chance of hospital readmission, paving the way for substantial cost savings. Healthcare institutions that pioneer such patient-centric approaches can also expect enhanced trust and reputation among their patient base. Specifically, for our target demographic – post-cardiac cath patients – this intervention equips them with a robust understanding of their recuperation, empowering them to mitigate potential complications and ensure optimal long-term health (Madan et al., 2019). However, embracing such a tailored educational paradigm is not without its challenges. It mandates robust training regimes for nurses, ensuring they are well-equipped to deliver personalized content. Consistently delivering quality education across diverse medical cases also remains an intricate task. However, with persistence, feedback, and continual refinement, we believe this intervention can herald a new patient care and education era.

Future Steps      

In healthcare interventions, we aspire to enrich our strategies further to serve patients better. While robust, our intervention for post-cardiac catheterization patients can be expanded upon for more significant impact and alignment with emerging technologies and care models. Expanding its reach and depth, the educational content could benefit from more nuanced personalization. Although our current model leverages telehealth services, introducing Augmented and Virtual Reality (AR/VR) systems can make patient education more immersive. This allows patients to visualize and understand their post-surgery care and potential complications in a three-dimensional, interactive space (Jung et al., 2022). Such an in-depth view can lead to better retention of information and a deeper understanding of their recovery journey.

As for care models, the Chronic Care Model (CCM) emphasizes the need for health systems to be proactive and prepared, placing the patient at the center. Our intervention can adopt this model by emphasizing stronger relationships and transparent communication between healthcare providers and patients. Doing so creates an environment where patients are more involved, informed, and empowered in their recovery process. Regular feedback sessions can be institutionalized, fostering a two-way communication channel. This ensures that the intervention remains dynamic and evolves based on real-world feedback.

NURS FPX 6030 Assessment 6 Final Project Submission

The intervention can integrate advanced AI-driven patient monitoring systems, continuing on the technological frontier beyond AR/VR. These systems can predict potential issues before they become severe, enhancing patient safety significantly. Moreover, immediate alerts can be sent to the patient and their healthcare provider if any deviations from the optimal recovery path are detected, allowing for early interventions and corrections. In closing, the proposed enhancements are anchored on two primary assumptions. Firstly, there is an inherent belief that technology, especially AR/VR and AI-driven systems, will foster a more profound understanding and commitment to post-discharge instructions. Secondly, a shift towards a more feedback-intensive, patient-centric approach, drawing inspiration from the Chronic Care Model, promises improved patient outcomes and enhanced safety protocols (Jung et al., 2022).

Reflection on Leading Change and Improvement

Engaging deeply with this capstone project has profoundly impacted my ability to lead change in my current care setting and personal practice. It has revealed the critical nature of individualized patient care and how this approach can shape better health outcomes. By introducing and managing a customized educational plan, I have realized the magnitude of responsibility leaders hold in championing such initiatives. Every step taken in this project has enhanced my confidence and capability in spearheading similar change-driven tasks in the future. The project’s challenges and successes have taught me invaluable lessons I will carry into future leadership roles.

My understanding of adaptive patient care, bolstered by this project, will be instrumental in guiding teams, strategizing healthcare initiatives, and ensuring that the patient remains at the core of all decisions. Also my primary objective is to remain a lifelong learner, constantly updating my knowledge base and skills. I also aim to bridge the gaps identified during this project, especially in ensuring effective delivery and comprehension of patient education. Completing this project has provided a highly transferable framework to my existing practice. The essence of the project, a bespoke patient-centric approach, can be integrated across various facets of patient care.

NURS FPX 6030 Assessment 6 Final Project Submission

The methodology of implementing a tailored educational plan, the feedback mechanisms, and the evaluation methods can all be adapted to different scenarios within my current care setting, ensuring consistent quality improvement. While the project was designed for a specific purpose, its foundational elements have universal relevance. Considering its application to other care settings and contexts, its principles can drive improvements across the board. Whether in outpatient care, specialized clinics, or community health setups, the focus on customized care, informed by this project, can be the cornerstone of impactful interventions. However, it is essential to remain receptive to alternative perspectives and conflicting evidence, always ensuring that the strategies adopted are grounded in evidence-based practices and cater to the diverse needs of the patient population.


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NURS FPX 6030 Assessment 6 Final Project Submission

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NURS FPX 6030 Assessment 6 Final Project Submission

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