NURS FPX 6030 Assessment 2 Problem Statement (PICOT)


NURS FPX 6030 Assessment 2 Problem Statement (PICOT)

NURS FPX 6030 Assessment 2 Problem Statement (PICOT)


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NURS-FPX 6030 MSN Practicum and Capstone

Prof. Name


Problem Statement (PICOT)

Addressing the complex needs of adult chronic care patients with heart failure in outpatient settings is the primary focus of this project. It aims to develop and implement a multifaceted intervention to enhance patient outcomes and healthcare quality. The project is grounded in a detailed analysis of current evidence, health policies, and best practices. Its goal is to bridge critical gaps in care through personalized education, coordinated healthcare strategies, and enhanced medication management.

PICOT Question

In adult chronic care patients with heart failure (P), how does a comprehensive care plan including personalized self-management education, regular care coordination, and meticulous medication management (I), compared to standard care with medication management alone (C), affect medication adherence, symptom management, quality of life, and reduction in hospitalizations (O) over six months (T)?

Needs Assessment

This project explicitly targets a critical need in health promotion and quality improvement for patients with chronic heart failure. The primary need is implementing a comprehensive care model beyond traditional medication management, including personalized self-management support, care coordination, and patient education. This need arises from the complex nature of heart failure management, where successful outcomes depend on effective medication and the patient’s ability to manage their condition through lifestyle changes and symptom monitoring. Addressing this need is essential due to the high rates of hospital readmissions and poor quality of life experienced by heart failure patients, mainly attributable to inadequate self-management and lack of coordinated care.

Evidence supporting the urgency of this need can be seen in the research conducted by Zhao et al. (2021), which found that comprehensive self-management programs significantly improve patient outcomes in heart failure, leading to better quality of life and reduced hospital readmissions. Similarly, Chih Wen Chen et al. (2023), identified that coordinated care interventions, including regular follow-ups and patient education, are crucial in preventing complications and improving overall patient well-being in heart failure cases. These studies highlight the importance of a multifaceted approach to managing heart failure, addressing medical and lifestyle-related aspects of the condition. The underlying assumption in this analysis is that a comprehensive, patient-centered approach will lead to better health outcomes for heart failure patients, as it addresses the broader aspects of their condition that go beyond medication adherence, such as lifestyle modifications, symptom management, and psychological support.

Population and Settings 

The target population for this project is specifically adult patients with chronic heart failure, a group characterized by high hospital readmission rates and complex healthcare needs. This population is notably affected by challenges in self-managing their condition, often leading to frequent hospital readmissions. According to a study by Leavitt et al. (2020), approximately 24% of heart failure patients are readmitted within 30 days of discharge, underscoring the critical need for improved post-discharge care and self-management support. The importance of addressing this need within this population is amplified by the fact that heart failure patients often have comorbid conditions like hypertension and diabetes, which make their care management even more complex (Dunlay et al., 2019).

The setting targeted by this project is outpatient clinics specializing in chronic heart failure management. This setting is chosen because it provides an ongoing care context where regular monitoring, education, and support can be offered to patients. Outpatient clinics are essential for executing interventions like self-management education and care coordination, as they allow for direct and continuous patient-provider interactions. This is crucial, as a study by Zhao et al. (2021), highlights the effectiveness of outpatient clinic follow-ups in reducing the rate of readmissions for heart failure patients. However, working with this population in an outpatient setting presents challenges, including varying levels of health literacy among patients, which can affect their ability to adhere to self-management protocols and logistical issues like ensuring consistent follow-up visits. Overcoming these challenges is key to successfully implementing the intervention, ensuring it effectively addresses the identified need in both the target population and the chosen setting.

Intervention Overview

The proposed intervention for adult chronic heart failure patients in outpatient settings is a multi-faceted, comprehensive care model comprising personalized self-management education, regular care coordination, and meticulous medication management. These components are carefully selected to address this patient group’s challenges in the targeted environment. Personalized self-management education is critical as it empowers patients with the knowledge and skills required for effective disease management. Studies, such as Cravo et al. (2022), have demonstrated that tailored self-management education can significantly improve self-care behaviors in heart failure patients. This education includes training in medication adherence, symptom recognition, and lifestyle adjustments. However, the challenges lie in customizing the education to cater to varied patient literacy and health levels and the potential high resource demand for personalized training.

Regular Care Coordination involves streamlined communication among healthcare providers, ensuring cohesive and adaptable care plans. The importance of this component is highlighted by a study from Zhao et al. (2021), which showed that coordinated care effectively reduces hospital readmissions in heart failure patients. This coordination is essential in managing these patients’ complex treatment regimens and monitoring requirements. However, the challenges include potential gaps in communication across different care providers, and the integration of care plans into existing healthcare systems.

Meticulous medication management gives the complexity of polypharmacy in heart failure management, and this component focuses on ensuring that patients correctly understand and adhere to their medication regimens. Mikhail Kosiborod et al. (2023), found that improved medication management is associated with better patient outcomes in heart failure. The challenge here is managing the complex drug regimens, especially for patients with limited health literacy or cognitive issues, and ensuring consistent patient education and follow-up.

Comparison of Approaches

In considering alternatives to the initial comprehensive care model for chronic heart failure patients in outpatient settings, one notable alternative is integrating telehealth services and involving a broader range of specialists in the care team, such as nutritionists, psychologists, and exercise physiologists. Telehealth services, as an alternative, offer a unique advantage in providing remote monitoring and consultation, which is especially beneficial for patients with mobility issues or those living in remote areas. A study by White-Williams et al. (2020), demonstrated that telehealth interventions could lead to a 15.4% reduction in heart failure-related hospitalizations. This approach also encourages interprofessional collaboration by allowing various specialists to contribute remotely, thus expanding the range of services accessible to the patient.

Involving a diverse team of specialists can address more holistic aspects of patient health, such as diet, mental health, and physical activity, which are often critical components of heart failure management. Zhao et al. (2021), highlighted the positive impact of exercise-based cardiac rehabilitation on reducing hospital readmissions and mortality in heart failure patients. Additionally, psychological support, as part of the care model, can address the mental health challenges associated with chronic illness, which are often overlooked in standard care models. While these alternatives promote a more interprofessional and comprehensive approach to care, they come with challenges. Telehealth requires reliable technology infrastructure and patient digital literacy. The involvement of multiple specialists may also lead to potential coordination challenges and overwhelm patients with complex schedules and multiple appointments.

Initial Outcome 

The designated outcome for the intervention tailored to adult chronic heart failure patients in outpatient settings is a significant reduction in the 30-day hospital readmission rate, aiming for at least a 20% decrease. This specific outcome aligns with the project’s overarching goal to improve the management of heart failure, and it is directly linked to the effectiveness of the implemented components of the intervention – personalized self-management education, consistent care coordination, and detailed medication management. This outcome is a critical measure as it directly reflects the effectiveness of the intervention in enhancing patient self-care capabilities and the efficiency of healthcare coordination.

According to a study by Leavitt et al. (2020), interventions focusing on enhanced patient education and post-discharge planning resulted in a 20% reduction in 30-day readmission rates for heart failure patients. The reduction in readmissions indicates improved patient health and a decrease in the overall burden on the healthcare system, aligning with the broader objective of quality improvement in healthcare. Furthermore, this outcome sets a tangible benchmark for evaluating the success of the intervention. Quantifying the reduction in readmission rates provides a clear, measurable goal. The effectiveness of the intervention can be assessed by comparing the readmission rates before and after its implementation, using hospital records and patient follow-up data. This approach not only evaluates the immediate impact of the intervention but also contributes to long-term strategies for heart failure management.

Time Estimate 

For the intervention targeting adult chronic heart failure patients in outpatient settings, a detailed and realistic time frame is crucial for both development and implementation. The development phase, encompassing the planning, resource allocation, and creation of intervention materials, is proposed to take approximately four months. This phase includes designing personalized education programs, establishing care coordination protocols, and developing medication management guidelines. This time frame is realistic given the complexity of the intervention but assumes that sufficient resources and stakeholder cooperation are available. Challenges impacting this phase include potential delays in securing funding, coordinating with healthcare professionals, and tailoring educational materials to patient needs. The implementation phase, where the intervention is actively rolled out to patients, is anticipated to span six months.

This period allows for the gradual introduction of the intervention components, monitoring initial patient responses, and adjustments based on feedback. A six-month implementation phase aligns with the need for adequate time to observe tangible impacts on patient outcomes, such as readmission rates. However, this time frame could be affected by challenges such as patient adherence to the intervention, the consistency of care coordination among healthcare providers, and the effective integration of the intervention into existing clinical workflows. Additional challenges may include patient variability in health literacy and engagement levels, which could necessitate ongoing adjustments to the intervention approach.

Literature Review

The critical need for a comprehensive care model in chronic heart failure, especially in outpatient settings, is substantiated by compelling evidence. Edmonston et al. (2019), research is pivotal as it highlights a significant gap in current heart failure management: about 42.3% of patients are readmitted within 90 days post-discharge. This high readmission rate validates the need for an intervention that addresses the deficiencies in post-discharge care and management. Similarly, Agostinho et al. (2019), found that only 22% of heart failure patients receive follow-up care within the first week post-discharge, emphasizing improved support and monitoring. The evidence supporting the intervention’s appropriateness for the target population is substantial.

Van et al. (2023), study shows a 25% improvement in medication adherence and a 20% increase in patient-reported self-care competence, underlining the effectiveness of personalized education in empowering patients. This is particularly relevant for heart failure patients who often struggle with complex medication regimes and lifestyle modifications. In terms of the setting, Stephenson et al. (2019), research indicating a 15% reduction in emergency department visits through coordinated care approaches is particularly relevant. This supports the need for such interventions in outpatient settings where continuous patient engagement and care coordination can significantly impact patient outcomes.

Zazzara et al. (2021), study emphasizes the effectiveness of structured medication management in outpatient settings, significantly reducing adverse drug events for heart failure patients. Agostinho et al. (2019), further support this by showing a 22% reduction in readmission rates due to improved medication practices at discharge. Complementing these, Olson et al. (2023), report a comprehensive care model leading to a 35% decrease in readmission rates and healthcare costs, highlighting the model’s overall efficiency and effectiveness in managing heart failure in outpatient settings. The evidence from these studies is relevant, current, sufficient, and trustworthy, providing a solid foundation for the proposed intervention. Each study contributes a unique perspective, building a solid case for the need and appropriateness of a comprehensive care model in managing chronic heart failure, particularly in outpatient settings. This in-depth analysis ensures the intervention is grounded in solid evidence, enhancing its potential for success in the targeted population and setting.

Relevant Health Policies for Chronic Heart Failure Management

Several specific health policies are pivotal in treating chronic heart failure in outpatient settings. As Hollenberg et al. (2019), analyzed, the Heart Failure National Clinical Guideline emphasizes comprehensive care that includes medication management, patient education, and regular monitoring. This guideline impacts the intervention by necessitating a structured approach to medication adherence and patient education. Secondly, policies regarding patient-centered care, as outlined in Daley et al. (2020), research, stress the importance of involving patients in decision-making processes about their treatment. This policy impacts the intervention by requiring it to facilitate patient engagement and empowerment, ensuring that care plans are tailored to individual patient needs and preferences.

A third significant policy is the Readmission Reduction Program, highlighted in the Blecker et al. (2019), study. This program penalizes hospitals with higher-than-expected readmission rates for heart failure patients. It influences the intervention approach by creating an imperative to develop strategies that effectively reduce readmissions, such as through enhanced post-discharge care and follow-up. Lastly, expanding telehealth services, especially after the COVID-19 pandemic, as discussed in Hegde and Eid (2021), allows for excellent patient monitoring and consultation flexibility. This policy change encourages the integration of telehealth into the intervention, offering an effective way to provide continuous support to heart failure patients. However, a significant gap in current policies is the need for standardized guidelines for integrating multidisciplinary teams in outpatient heart failure management. This oversight could restrict the intervention’s ability to offer all-encompassing care, addressing the physical and psychological aspects essential for effective heart failure management.


In conclusion, this project has successfully developed a comprehensive intervention for managing chronic heart failure in adult patients in outpatient settings. It integrates personalized education, coordinated care strategies, and effective medication management, addressing key gaps in existing treatment models. The intervention is based on a thorough analysis of current research, health policies, and clinical best practices. Ultimately, this initiative promises to significantly improve patient outcomes and the overall quality of healthcare delivery for those suffering from chronic heart failure.


Agostinho, J. R., Gonçalves, I., Rigueira, J., Aguiar-Ricardo, I., Nunes-Ferreira, A., Santos, R., Guimarães, T., Alves, P., Cunha, N., Rodrigues, T., André, Ńz., Pedro, M., Veiga, F., Pinto, F. J., & Brito, D. (2019). Protocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life. Revista Portuguesa de Cardiologia (English Edition)38(11), 755–764. 

Blecker, S., Herrin, J., Li, L., Yu, H., Grady, J. N., & Horwitz, L. I. (2019). Trends in hospital readmission of medicare-covered patients with heart failure. Journal of the American College of Cardiology73(9), 1004–1012. 

Chih Wen Chen, Lee, M., & Shu‐Fang Vivienne Wu. (2023). Effects of a collaborative health management model on people with congestive heart failure: A systematic review and meta‐analysis. Journal of Advanced Nursing  

Cravo, A., Attar, D., Freeman, D., Holmes, S., Ip, L., & Singh, S. J. (2022). The importance of self-management in the context of personalized care in COPD. International Journal of Chronic Obstructive Pulmonary Disease17(17), 231–243. 

Daley, C. N., Cornet, V. P., Toscos, T. R., Bolchini, D. P., Mirro, M. J., & Holden, R. J. (2020). Naturalistic decision making in everyday self-care among older adults with heart failure. Journal of Cardiovascular NursingPublish Ahead of Print 

Dunlay, S. M., Givertz, M. M., Aguilar, D., Allen, L. A., Chan, M., Desai, A. S., Deswal, A., Dickson, V. V., Kosiborod, M. N., Lekavich, C. L., McCoy, R. G., Mentz, R. J., & Piña, I. L. (2019). Type 2 diabetes mellitus and heart failure: A scientific statement from the American Heart Association and the Heart Failure Society of America. Circulation140(7). 

NURS FPX 6030 Assessment 2 Problem Statement (PICOT)

Edmonston, D. L., Wu, J., Matsouaka, R. A., Yancy, C., Heidenreich, P., Piña, I. L., Hernandez, A., Fonarow, G. C., & DeVore, A. D. (2019). Association of post-discharge specialty outpatient visits with readmissions and mortality in high-risk heart failure patients. American Heart Journal212, 101–112. 

Hegde, S., & Eid, N. S. (2021). Telehealth and remote patient monitoring after the COVID-19 pandemic. Pediatric Allergy, Immunology, and Pulmonology 

Hollenberg, S. M., Warner Stevenson, L., Ahmad, T., Amin, V. J., Bozkurt, B., Butler, J., Davis, L. L., Drazner, M. H., Kirkpatrick, J. N., Peterson, P. N., Reed, B. N., Roy, C. L., & Storrow, A. B. (2019). 2019 ACC expert consensus decision pathway on risk assessment, management, and clinical trajectory of patients hospitalized with heart failure. Journal of the American College of Cardiology74(15), 1966–2011. 

Leavitt, M. A., Hain, D. J., Keller, K. B., & Newman, D. (2020). Testing the effect of a home health heart failure intervention on hospital readmissions, heart failure knowledge, self-care, and quality of life. Journal of Gerontological Nursing46(2), 32–40. 

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NURS FPX 6030 Assessment 2 Problem Statement (PICOT)

Olson, M. F., Thompson, Z., Xie, L., & Nair, A. (2023). Broadening heart failure care beyond cardiology: Challenges and successes within the landscape of multidisciplinary heart failure care. Current Cardiology Reports 

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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. Circulation141(22). 

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