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.

NRS-460 Complex Disease Management Course Topic 1

NRS-460 Topic 1 DQ 1 & 2 Discussion

NRS 460 Topic 1 DQ 1 Familiarize yourself with the Case Study: John Doe – Emergency Department

To complete this DQ, familiarize yourself with the “Case Study: John Doe – Emergency Department” assignment and document. Which members of the interdisciplinary team are utilized upon the patient’s arrival to the ED? Discuss the responsibilities of each team member at this stage in the patient’s care. Once the patient is stabilized in the ED, what discharge planning would be initiated even though the patient will not be discharged yet?

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to “RN-BSN Discussion Question Rubric” and “RN-BSN Participation Rubric,” located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively.

Topic 1 DQ 2

For patients coming in with severe injuries, discuss what nonmedical resources nurses can provide for the patient and family after initial injury.

NRS-460 Topic 1 Assignment: Case Study: John Doe – Emergency Department

Use the “Case Study: John Doe – Emergency Department” template to complete the assignment.

This case study has indirect care experience requirements. The “NRS-460 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 5.

You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the past 5 years and appropriate for the assignment criteria and relevant to nursing practice.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.3, 2.3, 2.4, 2.5, and 4.2.

NRS-460 Complex Disease Management Course Topic 2

NRS-460 Topic 2 DQ 1 & 2 Discussion

Topic 2 DQ 1

For patients admitted to the ICU, what are two ethical considerations a nurse will use to help facilitate the patient’s mental and spiritual well-being? What are some ways in which you can be an advocate that are consistent with the Christian worldview?

Topic 2 DQ 2

What are some key nursing theories or conceptual models that play a significant role in nursing practice? Select one of these theories or conceptual models and discuss how it can be applied in a health care scenario for a patient with complex needs.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competency 4.1.

NRS-460 Topic 2 Assignment: Benchmark – Case Study: Timothy Smith – Intensive Care Unit

Use the “Case Study: Timothy Smith – ICU” template to complete the assignment.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies and professional standards:

RN-BSN

6.2: Perform effectively in different team roles, using principles and values of team dynamics.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 3.2, 6.1, and 6.2.

NRS-460 Complex Disease Management Course Topic 3

NRS-460 Topic 3 DQ 1 & 2 Discussion

Topic 3 DQ 1

Recognize some ways racism appears is evident in health care and identify factors inside and outside the system that create disparities in health care access and quality for diverse patients. In complex disease management, how can health care providers identify and reduce biases and discrimination that could impact patient care? Consider the system’s internal and external processes and structures that contribute to racism and other forms of discrimination.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 2.5 and 7.3.

Topic 3 DQ 2

The management of complex disease states usually requires care coordination across multiple providers and settings over a long period of time. Describe how two financial and payment models in health care, such as capitation, value-based care, or fee-for-service, impact the delivery, access, and quality of care for patients requiring complex disease management. Students may use other financial and payment models of health care outside of those listed here.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies and professional standards:

RN-BSN

7.2: Incorporate consideration of cost-effectiveness of care.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 7.2a, 7.2c.

NRS-460 Topic 3 Assignment: Benchmark – Case Study: Timothy Smith – Medical Surgical Unit

Use the “Case Study: Timothy Smith – Medical Surgical Unit” template to complete the assignment.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies and professional standards:

RN-BSN

2.6: Demonstrate accountability for care delivery.

2.7: Evaluate outcomes of care.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 2.5, 2.6, 2.7, 2.8, and 3.3.

NRS-460 Complex Disease Management Course Topic 4

NRS-460 Topic 4 Topic 4 DQ 1 & 2

Topic 4 DQ 1

How do nurses help in preparing for and managing complex diseases during disasters and public health emergencies? Provide examples of their roles in protecting population health. What strategies can nurses use to prevent the spread of infectious diseases in high-risk situations? How can nurses ensure the safety of both themselves and patients with complex diseases during public health emergencies?

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competency 3.6.

Topic 4 DQ 2

Throughout the course, we have provided care to Timothy Smith in various environments and discussed various considerations regarding transitions of care. Differentiate between various health care environments across the continuum of care by comparing two health care environments.

Based on the first letter of your first name, compare and contrast the following environments:

A-E: Intensive care unit and medical surgical unit

F-J: Medical surgical unit and inpatient rehabilitative unit

K-N: Inpatient rehabilitative unit and outpatient rehabilitative services

O-R: Inpatient hospice care and outpatient hospice care

S-V: Ambulatory family medicine clinic and urgent care clinic

W-Z: Skilled nursing facility and home health care

Discuss the specific challenges or opportunities encountered in navigating internal and external system processes during care coordination and transitions of care involving these settings.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competency 7.1.

NRS-460 Topic 4 Assignment: Benchmark – Case Study: Timothy Smith – Discharge Planning

Use the “Case Study: Timothy Smith – Discharge Planning” template to complete the assignment.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies and professional standards:

RN-BSN

5.3: Contribute to a culture of provider and work environment safety.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 5.3, 8.2, 8.3, 8.4, and 8.5.

NRS-460 Complex Disease Management Course Topic 5

NRS-460 Topic 5 DQ 1 & 2 Discussion

Topic 5 DQ 1

Discuss the importance of considering not only the physical symptoms but also the psychosocial and emotional aspects of patients with complex disease management. How can nurses incorporate a holistic approach in the care of these patients? Share examples of effective holistic interventions or strategies used for patients with complex diseases. How do these approaches contribute to enhancing patient outcomes and overall well-being?

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competency 2.3.

Topic 5 DQ 2

Based on our professional role, nurses are accountable for maintaining a commitment to personal health and well-being. Share two examples of healthy, self-care behaviors you currently practice that promote wellness and resiliency in your nursing role. Evaluate two community and professional resources that are available to nurses for promoting wellness and building resiliency. In your discussion, include how the Christian worldview supports self-care behaviors to promote wellness.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competency 10.1.

NRS-460 Topic 5 Assignment: Benchmark – Case Study: Timothy Smith – Hospice/Palliative Care

Use the “Case Study: Timothy Smith – Hospice/Palliative Care” template to complete the assignment.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies and professional standards:

RN-BSN

2.1: Engage with the individual in establishing a caring relationship.

2.9: Provide care coordination.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 2.1, 2.2, and 2.9.

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.

Conclusion

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.

References

Centers for Medicare and Medicaid Services. (2022). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

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. https://doi.org/10.2196/12419

Gai, Y., & Pachamanova, D. (2019). Impact of the Medicare hospital readmissions reduction program on vulnerable populations. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4645-5

Healthy People 2030. (2020). Heart disease and stroke. https://health.gov/healthypeople/objectives-and-data/browse-objectives/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). https://doi.org/10.1002/ejhf.2008

Podvorica, E., Bekteshi, T., Oruqi, M., & Kalo, I. (2021). Education of the patients living with heart disease. Materia Socio Medica, 33(1), 10. https://doi.org/10.5455/msm.2021.33.10-15

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. https://doi.org/10.1016/j.jacc.2020.11.010

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). https://doi.org/10.3389/fpubh.2020.00044

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

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). https://doi.org/10.1161/cir.0000000000000767

NRS 460 Complex Disease Management and EBP Assignments