HLTH 4913 Module 4 Capstone Implementation and Evaluation Plan Example

An Appointment on Page One, a Ride Before the Door and a Nurse by Day Three: The Capstone Implementation and Evaluation Plan for Heart Failure Follow-Up

Student Name

American College of Education

HLTH4913: Senior Capstone Experience: Healthcare Administration

Module 4 Assignment

Instructor Name

October 26, 2026

Goals

The previous module recommended a bundle for heart failure patients leaving the composite community hospital for home: book every patient's follow-up before discharge and print it where the patient will see it first; add a transportation navigator who arranges rides through existing benefits or a hospital fund; send a nurse to the homes of the highest-risk quarter of patients within three days; and offer a video visit when travel fails. This plan sets out how to put the bundle in place and how to judge it.

The plan has two primary goals for the first twelve months: raise the share of patients seen within seven days from 41% to 65%, and lower 30-day readmission for these patients from 23.8% to 20% or below. The first goal is within the hospital's direct control; the second depends on it and on much else, so it is a target rather than a promise.

Phases and Timeline

Implementation runs in three phases. In the preparation phase, months one and two, the informatics team builds the discharge rule and the new first page, the hospital hires the half-time navigator, the home health partner agrees on a referral pathway, and the cardiology practice sets aside two same-week slots a day. In the pilot phase, months three and four, the bundle starts on one of the hospital's two medical units, so that problems appear on a small scale; weekly huddles review every missed appointment. In the spread phase, from month five, the bundle extends to the second unit and to patients discharged from the observation unit, with adjustments from the pilot. The months after spread are for holding the gains and preparing the final report.

Roles and Governance

The chief nursing officer acts as executive sponsor and leads a steering group meeting once a month with the directors of case management, quality, finance and the cardiology practice. The case management director owns day-to-day implementation. Discharge nurses ask the transportation question and confirm the appointment is printed; unit secretaries book appointments into the reserved slots; the navigator arranges rides and checks the day before the visit that the patient still has one; the home health partner's nurses make the visits; and the quality analyst collects the data. Naming each role matters because the baseline analysis found that every piece of the current process existed but no one owned the connections between them.

Communication and Training

Staff will judge the bundle by how it changes their day, so communication starts before the pilot. The chief nursing officer will introduce the project at the two medical units' staff meetings, explaining the baseline numbers and the story of a patient readmitted after missing a follow-up visit for lack of a ride, told with permission and without identifying details. Discharge nurses will receive a fifteen-minute training on the two new questions they ask, whether the patient has a ride to the appointment and who will help at home, and on where the answers go in the record. Unit secretaries will be trained to book directly into the cardiology practice's reserved slots. The navigator will meet the county transit office, the Medicaid transportation broker and the Medicare Advantage plans most of these patients carry, all within the first month, to learn how each ride benefit is booked, and will write a one-page guide for the care management team. During the pilot, a short weekly note to both units will report how many patients left with an appointment and how many kept it, so that staff see results within days rather than at the end of the year.

Budget and Business Case

First-year costs total about $78,300: $32,000 for the half-time navigator, about $9,100 for roughly 120 round-trip rides for patients with no transport benefit, about $34,200 for about 190 nurse home visits, and about $3,000 for informatics time. Video visits use the practices' existing platform.

The business case rests on avoided readmissions. If the readmission rate falls from 23.8% to 20% among 762 patients, about 29 readmissions a year are avoided. At the hospital's average variable cost of about $9,800 per heart failure readmission, that is about $284,000 in avoided costs, before any effect on the Medicare readmission penalty. Van Spall et al. (2017) found nurse home visits had the largest pooled cost savings among transitional care services, which supports the largest line in the budget. Even if the readmission target is only half met, avoided costs would exceed the program's cost.

Risks and Responses

The team expects four problems in particular. Discharge could be delayed while appointments are booked; the rule allows a patient ready to leave to go with the appointment booked within one business day by phone. Ride uptake may be low, as in a trial where only about a quarter of patients offered free rides used them (Chaiyachati et al., 2018); the navigator will therefore confirm rides the day before rather than simply offering them. The home health partner may lack capacity in winter; a backup agency will be contracted. And staff may treat the new steps as paperwork; weekly huddles during the pilot will share stories of patients helped, not only numbers. A plan that names its likely failures in advance is far more likely to survive them.

Evaluation Design

The evaluation measures three kinds of results. Implementation outcomes come first, because a bundle that is not delivered cannot work. Proctor et al. (2011) proposed eight such outcomes, including acceptability, adoption, feasibility, fidelity, implementation cost, penetration and sustainability, as distinct from clinical outcomes. The plan tracks four of them monthly: fidelity, the share of patients leaving with an appointment on page one and the share asked about transport; penetration, the share of eligible patients reached by the navigator; adoption, the share of high-risk patients receiving a home visit within three days; and implementation cost against budget.

Process and outcome measures follow: the share of patients seen within seven days, the primary measure; 30-day readmissions; and emergency visits within 30 days. The balancing measure is the time from discharge order to departure, to detect any delay the bundle adds. All measures are displayed monthly on run charts with twelve months of baseline, so change can be judged against the process's own history. Results are stratified by payer and distance, since the analysis found those groups most affected.

Decision Points

The steering group will make formal decisions at three points. At the end of the pilot, it will decide whether to spread, adjust or stop, based on fidelity above 85% and no increase in discharge delays. At month nine, it will review whether seven-day follow-up has shifted on the run chart and whether ride uptake justifies the fund. At month twelve, it will decide whether to make the navigator permanent, whether to extend home visits to more patients, and whether the results justify planning the heart failure clinic that was deferred. Each decision will be documented and reported to the hospital's quality committee.

References

Chaiyachati, K. H., Hubbard, R. A., Yeager, A., Mugo, B., Lopez, S., Asch, E., Shi, C., Shea, J. A., Rosin, R., & Grande, D. (2018). Association of rideshare-based transportation services and missed primary care appointments: A clinical trial. JAMA Internal Medicine, 178(3), 383-389. https://doi.org/10.1001/jamainternmed.2017.8336

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7

Van Spall, H. G. C., Rahman, T., Mytton, O., Ramasundarahettige, C., Ibrahim, Q., Kabali, C., Coppens, M., Haynes, R. B., & Connolly, S. (2017). Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: A systematic review and network meta-analysis. European Journal of Heart Failure, 19(11), 1427-1443. https://doi.org/10.1002/ejhf.765