The Telehealth Service for Patients With Congestive Heart Failure

Congestive heart failure (CHF) is an issue that presents multiple health constraints. The solution of the telehealth monitoring system is the focus of the proposed health plan targeted at decreasing readmission rates and increasing patient compliance. The current design proposal will focus on providing a change model overview, outline the main evidence to support the Model, and introduce a translation method project implementation.

Change Model Overview

In the context of addressing the problem of CHF with the help of the telehealth monitoring system, the implementation of the ACE Star Model of the Evidence-Based Practice (EBP) Process can bring fruitful results. The Model is used for enhancing different cycles, characteristics, and other components of knowledge used for multiple aspects of EBP. The Model comprises five components: discovery research, evidence summary, translation of guidelines, practice integration, and process, outcome, and evaluation (“The ACE star model,” n.d).

Define the Scope of the EBP

CHF is a problem is a progressive and chronic condition, which can be potentially life-threatening. In the US only, about 610,000 people die of the condition (Centers for Disease and Prevention, 2017). On a broader scale, the issue presents financial challenges for the health care system as a whole and can also depend on the ethnicity of patients, which is an additional problem given the existence of racial disparities in health care access.


To address the issue of CHF, the contributions of multiple healthcare professionals are needed. To provide their expertise, nursing managers, charge nurses, pharmacists, and occupational therapists will be included.

Determine Responsibility of Team Members

The roles of the mentioned team members will be distributed based on their competence and expertise. For instance, occupational therapists are needed for managing the emotional wellbeing of patients; pharmacists will contribute with their knowledge of appropriate medication treatment, charge nurses will be responsible for implementing the telemonitoring system, while nursing managers will guide relationships between other members.


Evidence to support the implementation of the plan is varied, ranging from healthcare research studies to clinical practice guidelines. The strength of the research is associated with the provision of substantial information as to how nurses can implement the use of telehealth mentoring system (Eilat-Tsanani et al., 2016). In addition, the collected evidence offered a comprehensive look at patients’ feedback concerning treatment adherence, which is important in terms of treating patients of older age.

Summarize the Evidence

To support the project, the systematic review by Fox et al. (2013) was used as the main support. The researchers found that discharge planning was beneficial for minimizing the number of readmission cases. Based on this finding, it was suggested to implement discharge planning as an evidence-based solution to the issue of CHF readmissions. Eilat-Tsanani et al. (2016) found that telehealth mentoring programs for patients were beneficial for enhancing patients’ quality of life, thus supporting the need for discharge planning.

Develop Recommendations for Change Based on Evidence

Based on the reviewed research, the key recommendation is conducting discharge planning to cater to the unique needs of CHF patients and adapting telehealth mentoring programs based on patients’ requirements.


Action Plan

The first step in the action plan is finding an appropriate sample of patients: different ages, genders, and ethnicities. The second step is identifying the unique needs of each patient and developing a simple plan for addressing these needs. The third step is implementing the plan itself – telehealth monitoring conducted by shift nurses. The fourth step is the evaluation of results based on comparing outcomes and patients’ feedback through surveys. The timeline of the plan is ninety days.

Process, Outcomes Evaluation, and Reporting

The desired outcome of the project is decreasing the rate of readmissions and increasing the compliance of patients. These will be measured by comparing the pre-and post-intervention readmission rates and surveying patients on compliance. A brief report will be the most suitable reporting method.

Identify Next Steps

The program can be applied to any setting and health issue. For obese patients, telehealth monitoring is a viable solution for improving adherence to the developed dietary plans. Ensuring the permanence of the implementation is possible through the dissemination of the findings that prove the effectiveness of the program.

Disseminate Findings

Externally, using social media as a reporting method can be very beneficial due to the possibility to reach a wide audience of practitioners and patients who struggle with CHF. Internally, the results can be disseminated with the help of printed pamphlets as well as email newsletters, which will be easily accessible to the healthcare team.


The change model for addressing the issue of CHF implies the use of telehealth monitoring for reducing readmissions and increasing compliance. The project was supported by relevant evidence from a systematic review, which was then translated into an action plan that nurses could implement. The maintenance of the change plan will be possible through the efficient dissemination of findings through social media, internal reports-pamphlets, and word-of-mouth to engage practitioners in a conversation about CHF management.


The ACE star model. (n.d.). Web.

Centers for Disease Control and Prevention. (2017). Web.

Eilat-Tsanani, S., Golovner, M., Marcus, O., Dayan, M., Sade, Z., Iktelat, A., … Oppenheimer, Y. (2016). Evaluation of telehealth service for patients with congestive heart failure in the north of Israel. European Journal of Cardiovascular Nursing, 15(3), 78-84.

Fox, M. T., Persaud, M., Maimets, I., Brooks, D., O’Brien, K., & Tregunno, D. (2013). Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: A systematic review and meta-analysis. BMC Geriatrics, 13(1), 1-9.

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