NRS 460 Complex Disease Management and EBP Assignments

The goal of NRS-460 Complex Disease Management Course is to integrate knowledge from pathophysiology, pharmacology, nursing theory, and current evidence-based practice to inform clinical judgment and to ensure safe, effective, and holistic care. It applies the nursing process to provide safe, quality care reflecting cultural humility across the life span. The course pays particular attention to interprofessional collaboration in the process of disease management and care coordination.

Complex Disease Management and Care Plan

Heart disease is the leading cause of increased mortality rates, comorbidities, prolonged hospitalization, high rates of readmissions, compromised quality of life, and a steady increase in care costs. According to Roth et al. (2020), cardiovascular diseases like heart disease, stroke, and heart failure accounted for approximately 19.7 million deaths in 2019.

Similarly, the global trends for disability-adjusted life years (DALYs) and years of life lost doubled from 17.7 million to 34.4 million from 1990 to 2019. The modifiable and non-modifiable risk factors for heart disease include physical inactivity, smoking, unhealthy diet, obesity, poor stress management, family history of cardiovascular disease, age, and genetics.

When developing a care plan for people with heart disease, it is vital to address modifiable risk factors to prevent complications and improve disease management approaches. Therefore, this final care coordination plan focuses on issues facing people with heart disease, patient-centered interventions, ethical considerations for individualized care approaches, relevant health policy implications for coordinating care, and the priorities for the care coordination plan.

Patient-centered Health Interventions

People with heart disease face various issues and challenges, including unfamiliarity with self-management interventions, limited access to timely care, and unawareness of early vital sign identification, reporting, and monitoring. Jaarsma et al. (2020) state that self-management approaches for heart disease entail pharmacologic and non-pharmacologic interventions like adherence to prescribed medications, engaging in physical activity, complying with healthy diet plans, and self-care monitoring competencies.

Patient-centered interventions for improving patients’ self-management competence include educating them on disease management activities, linking them to community resources, incorporating technology like telehealth to promote remote monitoring, and fostering effective communication. Equally, patients with heart disease can leverage community resources, including community-based health organizations, expert offices, and online databases like the American Heart Association (AHA) to improve self-management competencies.

Secondly, limited access to timely and convenient care exacerbates heart disease complications. According to White-Williams et al. (2020), poor social determinants of health, including poverty, low-level education attainment, health illiteracy, uninsurance, and infrastructure deficiencies, are the profound causes of limited access to quality and timely care for people with heart disease.

It is possible to address these issues by educating people about the causes, effects, and management approaches for heart disease, collaborating with local authorities to modify the environment, and providing infrastructures like accessible sidewalks, gymnasia, and other public opportunities for physical activity. Equally, it is possible to utilize community resources like recreational parks, community amenities for physical activity, and health institutions that provide information regarding heart disease management and prevention.

Thirdly, people with heart disease grapple with the challenge of unawareness of early vital sign detection, reporting, and management. According to Conn et al. (2019), in-home vital sign monitoring can transform the healthcare system by facilitating care transition from reactive to proactive and preventive care.

Improving individual awareness of vital sign monitoring and reporting is possible by strengthening the use of mHealth and telehealth technology to foster communication, educating people on how to use these technologies, and coordinating care with community-based organizations to ensure timely response in the case of deteriorating signs. In this sense, individuals with heart disease and other cardiovascular conditions can utilize community resources like healthcare institutions, expert offices, and free-access databases to gain insights into appropriate interventions for conducting vital sign monitoring.

Ethical Decisions in Designing Patient-centered Health Interventions

Patient-centered interventions for improving heart disease management and control should rely massively upon ethical considerations. Tomaselli et al. (2020) contend that patient-centered care entails respecting patients’ demands, preferences, and principles. This care dimension results in patient empowerment and enhancement of individual decision-making competencies necessary for influencing care trajectories. According to Varkey (2021), healthcare professionals have an ethical obligation to benefit patients, prevent harm, ensure justice and fairness, and respect values, preferences, and decisions.

The four bioethical principles of beneficence, non-maleficence, autonomy, and justice enshrine these moral obligations by requiring healthcare professionals to provide care consistent with individual needs and interests. When designing and implementing patient-centered interventions to improve the health of people with heart disease, it is vital to involve them, understand their learning priorities, empower them to make decisions, and ensure that the subsequent approaches are consistent with established collective goals and objectives.

Health Policy Implications for Coordination and Continuum of Care

Developing a care coordination plan for managing heart disease and improving the health of people grappling with this disease is consistent with the Affordable Care Act (ACA) 2010 provision, which requires hospital and healthcare professionals to prevent avoidable readmissions. According to the Centers for Medicare and Medicaid Services [CMS] (2022), the Hospital Readmissions Reduction Program (HRRP) is a value-based program that encourages hospitals to improve communication and enhance care coordination to reduce avoidable readmissions perpetrated by various diseases, including acute myocardial infarction (AMI), Chronic Obstructive Pulmonary Disease (COPD). Further, this program enables CMS to track hospital readmission rates (HRRs) and determine benefits and penalties based on the organizational ability to reduce preventable readmissions. 

In this sense, CMS can provide incentives for hospitals that reduce preventable readmissions to the acceptable benchmarks while reducing Medicare payments to institutions with high readmission rates. Gai & Pachamanova (2019), the HRRP program proposes various interventions for reducing preventable readmissions, including coaching patients on discharge instructions and self-management, improving care coordination and care setting transition planning, and performing medication reconciliation. These approaches align with the proposed patient-centered interventions for improving the health and wellness of people with heart disease.

Priorities for Care Coordination

Notably, it is essential to communicate the plan with patients and family members before enacting it. Equally, making changes consistent with patients’ feedback, external evidence, and contextual issues is vital. For example, patients with heart disease may fail to adhere to the requirement of 150 to 300 minutes of physical exercise per week due to the underlying complications associated with the disease. Therefore, altering the intervention schedule should be consistent with patients’ preferences, needs, and values.

Equally, the care coordinator should emphasize various priorities when discussing the plan with patients and family members and when making changes based on evidence-based practice. These priorities include improving patients’ health literacy, enhancing their self-management competencies, and bolstering their knowledge of appropriate technologies for care coordination and effective communication.

Learning Sessions

The learning sessions for improving the health and wellness of people with heart disease contain various topics, including practices of a healthy diet, recommended measures and length of physical exercise, smoking cessation approaches, and strategies for vital sign monitoring. These sessions align with the evidence from the current scholarly literature that supports the process of improving patients’ self-management competencies and enabling them to prevent disease progression by addressing modified risk factors for heart disease.

According to Podvorica et al. (2021), education sessions for people with heart disease should focus on increasing patients’ knowledge in improving modifiable factors like nutrition, physical activity, body mass index (BMI) monitoring, glycemia, and cholesterol. Undoubtedly, focusing on these themes is fundamental in improving self-management competencies, enhancing the quality of life, reducing readmissions, and minimizing eventual complications associated with heart disease.

Equally, the proposed patient-centered interventions for improving the health and wellness of people with heart disease are consistent with Healthy People 2030’s objectives. For instance, Healthy People 2030 aims to reduce cholesterol in adults to about 186.4 mg/dL by emphasizing physical activities and healthy weight management approaches (Healthy People 2030, n.d.). Other Healthy People 2030 objectives for heart disease include reducing the proportion of adults with high blood pressure, increasing aspirin use for secondary prevention of atherosclerotic cardiovascular disease, and enhancing control of high blood pressure in adults.


While heart disease is the leading cause of increased mortality rates, comorbidities, prolonged hospitalization, increased care costs, and compromised quality of life, implementing patient-centered interventions and ensuring care coordination can improve the health and wellness of people living with the disease. Examples of patient-centered approaches for addressing the disease include emphasizing physical activity sessions, educating patients on self-management interventions, linking patients to community resources, improving their health literacy, and coordinating with community-based organizations to foster communication, timely care delivery, information transfer, and consultations.

When implementing these approaches, it is vital to incorporate ethical considerations, align them with external evidence, and make changes consistent with patients’ preferences, needs, and values. Finally, it is crucial to uphold the Hospital Readmissions Reduction Program (HRRP) provisions and evaluate the Healthy People 2030 objectives to ensure consistency with the final care coordination plan.


Centers for Medicare and Medicaid Services. (2022). Hospital readmissions reduction program (HRRP).

Conn, N. J., Schwarz, K. Q., & Borkholder, D. A. (2019). In-Home cardiovascular monitoring system for heart failure: Comparative study. JMIR MHealth and UHealth, 7(1), e12419.

Gai, Y., & Pachamanova, D. (2019). Impact of the Medicare hospital readmissions reduction program on vulnerable populations. BMC Health Services Research, 19(1).

Healthy People 2030. (2020). Heart disease and stroke.

Jaarsma, T., Hill, L., Bayes‐Genis, A., La Rocca, H. B., Castiello, T., Čelutkienė, J., Marques‐Sule, E., Plymen, C. M., Piper, S. E., Riegel, B., Rutten, F. H., Ben Gal, T., Bauersachs, J., Coats, A. J. S., Chioncel, O., Lopatin, Y., Lund, L. H., Lainscak, M., Moura, B., & Mullens, W. (2020). Self‐care of heart failure patients: Practical management recommendations from the heart failure Association of the European Society of Cardiology. European Journal of Heart Failure, 23(1).

Podvorica, E., Bekteshi, T., Oruqi, M., & Kalo, I. (2021). Education of the patients living with heart disease. Materia Socio Medica, 33(1), 10.

Roth, G. A., Mensah, G. A., Johnson, C. O., Addolorato, G., Ammirati, E., Baddour, L. M., Barengo, N. C., Beaton, A. Z., Benjamin, E. J., Benziger, C. P., Bonny, A., Brauer, M., Brodmann, M., Cahill, T. J., Carapetis, J., Catapano, A. L., Chugh, S. S., Cooper, L. T., Coresh, J., & Criqui, M. (2020). Global burden of cardiovascular diseases and risk factors, 1990-2019: Update from the GBD 2019 study. Journal of the American College of Cardiology, 76(25), 2982–3021.

Tomaselli, G., Buttigieg, S. C., Rosano, A., Cassar, M., & Grima, G. (2020). Person-Centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: A scoping review. Frontiers in Public Health, 8(44).

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28.

White-Williams, C., Rossi, L. P., Bittner, V. A., Driscoll, A., Durant, R. W., Granger, B. B., Graven, L. J., Kitko, L., Newlin, K., & Shirey, M. (2020). Addressing social determinants of health in the care of patients with heart failure: A scientific statement from the American Heart Association. Circulation, 141(22).