Telehealth for Cardiac Patients: Change Model

The problem of an excessively high level of readmission among patients with congestive heart failure (CHF) determines the need to find an actual solution. One of the ways of nursing intervention is the use of the telehealth monitoring system, an innovative therapy aimed at helping patients through an educational program. The ACE Star model will be used as an analytic algorithm, which can help to consider the task of improving patient outcomes.

Change Model Overview

The procedure of evaluating the effectiveness of the proposed program will be based on the ACE Star model. This method includes five main areas of analysis. First, the scope of the problem and its stakeholders are clarified. Further, evidence of the relevance of the intervention and the need for action is provided. Then, the translation of the plan should take place. The fourth step is practical recommendations for implementation, and finally, the analysis ends with the assessment of potential changes and their impact on the issue under consideration. The ACE Star model can be used by nurses for patients with CHF because the problem needs to be revealed entirely, not only offering the therapy through telehealth but also proving why the intervention is relevant.

Scope of the EBP

The issue of the high level of readmission among patients with CHF is a significant problem. According to Messina (2016), “congestive heart failure is recognized as the leading cause of hospitalization in the elderly” (p. 146). In nursing practice, the need to provide care for people with CHF is a habitual activity, and that is why it is essential to find a way to reduce the risk of progression of this disease and to achieve higher rates of successful treatment. Also, there is a need to support patients after their discharge from hospitals. The problem has an impact on the healthcare system as a whole, adversely affecting recovery statistics and the high level of readmission. Therefore, the need for intervention is obvious.


For the intervention to be effective, it is essential to identify specialists who will be involved in the program of helping patients with CHF through telehealth therapy. Three or four nurses should be included in this list to conduct interviews with the target group and visit them during the post-discharge period. Also, an expert in working with multimedia equipment should be involved. A professional physician will monitor the health of patients and evaluate the effectiveness of the intervention. A charge nurse will be responsible for assigning duties among junior medical personnel and monitoring compliance with the program conditions.

Responsibility of Team Members

The members chosen for the project will perform different tasks. Nurses will support patients and check their health indicators. The physician will be responsible for monitoring the course of treatment and evaluating the results of therapeutic measures. The telehealth specialist will control the smooth operation of the multimedia system and ensure patient access to the program.


The search for evidence for the necessity to conduct an intervention can be done by analyzing the academic literature and identifying the problem as widespread. In addition, it is significant to take into account the interest of medical institutions in resolving the issue. Both insurance companies and clinics are forced to spend additional funds in case of high readmission rates. Therefore, many parties are interested in taking possible measures to solve the current issue. This study can be useful for different participants, including patients and their relatives, medical workers, and clinic managers.

Evidence Summary

The application of telehealth practice has examples in the academic literature. O’Connor et al. (2016) note that the use of such therapy showed significant results, and for a year, the percentage of 30-day readmission rate declined from 19.3% to 4.2% (p. 238). Rosen, McCall, and Primack (2017) who also researched in this area argue that “adherence to this telehealth protocol was excellent and consistent,” and half of the participants in their target group confirmed health improvement (p. 1329). The study conducted by Messina (2016) confirms the satisfaction of a large number of patients with the therapy. Therefore, the urgency of adopting the described measures is proved in practice.

Recommendations for Change Based on Evidence

To achieve positive results, it is necessary to evaluate the effectiveness of using the telehealth program on the example of two target groups. For three months, it is possible to compare the rates of those who use the therapy options and those who are not included in the list of participants. At the end of the study, the level of readmission can be compared in both groups. If the indicators of those who have passed the telehealth program will be higher than those who did not have such an opportunity, the need for intervention will be evident.


Action Plan

First, it is required to involve two groups of patients with CHF. Further, appropriate equipment should be prepared, and the participants of one group should be explained how to use the program. The period of intervention is ninety days. At the end of the study, the results of both groups will be analyzed, and the percentage of readmission rate, as well as the overall health indicators, will be considered. The evaluation plan will include such parameters as patient satisfaction with the program, their well-being, and the number of requests for medical care.

Process, Outcomes Evaluation, and Reporting

The expected outcomes are to find out whether the telehealth program can be effective in helping patients with CHF and reduce the level of readmission. These results will be measured based on the research data, and the indicators of the two target groups will be calculated to make an accurate picture. Key stakeholders will receive all necessary information about the outcomes at the general meeting.

Next Steps

The proposed plan can also be used on a larger scale, that is, not only within one clinic but also at the district level. Other medical institutions can also join the program and recruit volunteers to participate in the study. To ensure the ongoing implementation of the program, data on the success of the project to help patients with CHF should be disseminated to the public and stakeholders.

Findings Dissemination

Data on the program and its success can be disseminated internally, that is, within a specific medical organization, and externally (outside its borders). The employees of a particular clinic can learn about the effectiveness of the intervention at the meeting and through immediate supervisors. To distribute information outside the organization, it is possible to use social networks, placing the results of the research with the consent of its participants, and publishing a printed version so that anyone could read about the work progress.


The program for helping patients with CHF via the telehealth protocol and aimed at reducing the level of readmission can be useful. The issue is topical, which explains the need for active measures. The scope of the problem affects patients with CHF. The evidence of the issue is described in medical practice. The results are evaluated based on the observation of two groups of participants. Recommendations for the application of the program will be based on the data as a percentage. The dissemination of results can be internal and external, and the change plan may be maintained by the involvement of as many stakeholders as possible.


Messina, W. (2016). Decreasing congestive heart failure readmission rates within 30 days at the Tampa VA. Nursing Administration Quarterly, 40(2), 146-152.

O’Connor, M., Asdornwised, U., Dempsey, M. L., Huffenberger, A., Jost, S., Flynn, D., & Norris, A. (2016). Using telehealth to reduce all-cause 30-day hospital readmissions among heart failure patients receiving skilled home health services. Applied Clinical Informatics, 7(02), 238-247. Web.

Rosen, D., McCall, J. D., & Primack, B. A. (2017). Telehealth protocol to prevent readmission among high-risk patients with congestive heart failure. The American Journal of Medicine, 130(11), 1326-1330.

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