D028 – CPE Task 1: Clinical Practice Experience Details

Student Name

Western Governors University

D028 Advanced Health Assessment for Patients and Populations

Prof. Name:

Date

MSN Core Word E-Portfolio Template

Student Name:
Course Name: Advanced Health Assessment for Patients and Populations – D028

Instructions for Course Completion

To complete the course requirements, students must fill out the Clinical Practice Experience (CPE) Record. Specific deliverables required for assessment are outlined in the CPE Record, accessible under “Supporting Documents” in the Assessment Task Overview.

Students should incorporate all necessary deliverables, such as written reflections, into this e-portfolio template for each phase of the course. Previously created documents can be inserted directly into this Word document or submitted separately by following these steps:

Click where the content will be inserted.
Navigate to Insert > Object (click the arrow).
Choose Text from File.
Select and double-click the desired file.
Repeat to insert additional documents as needed.

D028 CPE Schedule Table

Below is the recommended timeline for completing course deliverables. Copy, paste, and complete this table in your e-portfolio.

Required CPE Activities (Deliverables)	Estimated Time	Anticipated Completion Date
1a. CPE schedule table	20 minutes	September 6, 2024
1b. Discussion of CMS HRRP	1 hour	September 6, 2024
1c. Discuss selected patient:		September 6, 2024
– One Social Determinant of Health (SDOH) impacting the patient
– One intervention to prevent readmission related to SDOH	2 hours
2a. Evidence-based practices that reduce hospital readmission		September 7, 2024
– Identify one practice to prevent readmission for the patient	30 minutes
2b. Public health intervention for the patient at each practice level	1 hour	September 7, 2024
3a. Discuss five standards of Transitions of Care	1.5 hours	September 7, 2024
3b. Develop communication plan (Standard 5) for patient	1.5 hours	September 7, 2024
3c. GoReact Video and Peer Responses	1 hour	September 7, 2024
3d. Reflection Summary	45 minutes	September 7, 2024

What Is the Hospital Readmissions Reduction Program (HRRP)?

The Hospital Readmissions Reduction Program (HRRP), developed by the Centers for Medicare & Medicaid Services (CMS), aims to lower hospital readmission rates for certain conditions and surgeries after discharge. These include acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, coronary artery bypass graft surgery (CABG), and elective primary total hip or knee arthroplasty (THA/TKA) (CMS, n.d.).

Annually, CMS provides confidential Hospital-Specific Reports (HSRs) to healthcare organizations. Advanced practice nurses (APNs) use this data to identify areas needing improvement, tailor interventions, enhance care coordination and communication, and apply evidence-based strategies to reduce readmissions. These efforts not only improve patient outcomes but also decrease healthcare costs.

Patient Case Scenario

The patient is a 55-year-old Hispanic male who experienced a myocardial infarction (MI) after symptoms of chest tightness, nausea, and shortness of breath during gardening. His medical history includes hypertension, obesity, and hyperlipidemia. His family history is notable for a father who died of MI at 62 and a mother with Type II diabetes, hypertension, and osteoporosis.

Lifestyle factors include frequent eating out (6-8 times weekly) at restaurants, cafeterias, or fast food, daily consumption of coffee and soda, and social alcohol intake (2-4 beers on weekends, 3-4 times monthly). Physical activity is minimal—only a 15-20 minute walk once a week. His last primary care visit was seven months ago.

What Are Social Determinants of Health (SDOH) and How Do They Affect the Patient?

Social determinants of health (SDOH) refer to the environmental conditions where people live, work, and age that influence their health outcomes (Social Determinants of Health, n.d.). For this patient, the most relevant SDOH category is the neighborhood and built environment, which encompasses access to safe, affordable, and nutritious food options (Healthy People 2030, n.d.).

The patient’s diet, heavily reliant on dining out and fast food, underscores the need for intervention focused on improving access to healthier food within his community.

Intervention:
A practical intervention would be arranging consistent consultations with a dietary coach or nutritionist. This expert can collaborate with the patient to design heart-healthy meal plans that consider portion control and offer feasible, community-specific eating-out recommendations. Encouraging active patient involvement in meal planning is crucial to lowering the risk of hospital readmission.

What Evidence-Based Practices Can Reduce Hospital Readmission?

For post-MI patients, maintaining health and preventing readmissions is essential. One proven intervention is participation in a cardiac rehabilitation (CR) program.

CR is a comprehensive approach combining endurance training, education on diet, and lifestyle modifications designed to decrease morbidity and mortality related to cardiovascular disease (Grochulska, Glowinski, & Bryndal, 2021). It offers supervised exercise counseling, stress reduction techniques, and heart-healthy lifestyle education.

Applying CR to our patient would support his recovery by promoting healthier habits and preventing future cardiac events (American Heart Association [AHA], 2024).

What Public Health Interventions Can Support the Patient?

Public health strategies for this patient should include interventions at individual, community, and systemic levels.

Level	Intervention
Individual	Help the patient schedule regular follow-ups with the primary care provider to manage comorbidities, medication adherence, and lifestyle modifications. Facilitate referrals to CR programs.
Community	Encourage participation in heart health education outreach, where the patient can share his experience, provide prevention information, and engage in workshops or media campaigns.
System	Advocate for policies mandating standardized discharge procedures for MI patients, including scheduled follow-ups, CR referrals, and clear medication plans.

What Are the Five Standards of Transitions of Care?

The Transitions of Care Standards (TOC) from the American Case Management Association (ACMA) outline five standards to ensure seamless patient transitions and avoid readmission (ACMA, 2023):

Standard	Description
1	Identify patients at risk for poor transitions and apply targeted interventions.
2	Perform comprehensive transition assessments for high-risk patients.
3	Ensure medication reconciliation at every care transition, including prescribed and over-the-counter drugs.
4	Develop ongoing care management plans with input from patients and caregivers, shared across care providers.
5	Communicate essential care transition information promptly to stakeholders such as caregivers, providers, payers, and care managers.

How Should Care Transitions Be Communicated to Stakeholders?

Effective communication among stakeholders is critical during patient transitions to prevent readmissions and support recovery.

For the 55-year-old MI patient, key stakeholders include:

Primary Care Provider (PCP): Should receive updates on hospital discharge, angioplasty details, medication regimens, and scheduled follow-ups to manage ongoing care and comorbidities.
Cardiologist: Needs information about the patient’s recovery, angioplasty, and rehabilitation plan to adjust treatments and address patient concerns.
Cardiac Rehabilitation Team: Must be informed promptly to begin tailored exercise programs, health education, and stress management. They also provide progress updates to the healthcare team and patient.

Reflection

Throughout my nursing career in the emergency department, the primary mindset has been rapid patient assessment and discharge—often summarized as “treat them and street them.” This assignment challenged me to rethink this approach by exploring the complexities of care continuity after hospital discharge.

Selecting a fictional MI patient allowed me to analyze the influence of medical history, social determinants, and lifestyle on health outcomes. This reinforced the importance of integrating social and clinical data to tailor effective care plans and reduce hospital readmission risks.

Reviewing the Transitions of Care Standards enlightened me about the structured processes required to ensure smooth transitions, avoid medication errors, and engage stakeholders effectively. Learning about the HRRP further deepened my understanding of systemic efforts to improve healthcare outcomes.

As an advanced practice nurse, I now appreciate the vital role I will play in discharge planning, patient education, care coordination, and follow-up to enhance patient success post-discharge.

References

American Case Management Association. (2023). Transitions of care standards [PDF]. https://transitionsofcare.org/wp-content/uploads/2023/06/ACMA-Transitions-of-Care-Standards_Final_06132023.pdf

American Heart Association. (2024, April 24). What is cardiac rehabilitation? Cardiac Rehab. https://www.heart.org/en/health-topics/cardiac-rehab/what-is-cardiac-rehabilitation

Centers for Medicare & Medicaid Services. (n.d.). Hospital readmissions reduction program (HRRP). https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp