Author name: nursfpxmassivedynamics

NHS FPX 6008 Assessment 4
MSN, Capella, NHS FPX 6008, Nursing

NHS FPX 6008 Assessment 4 Lobbying for Change

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NHS FPX 6008 Assessment 4 Lobbying for Change Student Name Capella University NHS 6008 Professor Name Submission Date Lobbying for Change Governor Greg Abbott Office of the GovernorState CapitolAustin, TX 78701 Dear Mr. Greg Abbott This letter aims to support a policy action in regard to the growing alarm on economic limitations to access affordable mental health care services in Texas. Restricted access to mental health care, including the high cost out-of-pocket expenditure, low rates of insurance coverage as well as lack of mental health practitioners have caused massive economic and health effects on Texans. Having one of the largest numbers of uninsured people and a low number of mental health providers, Texas boasts 246 counties of 254 that can be classified as mental health shortage areas and 5 million uninsured people (Simpson and Messmer, 2024). This has led to constituents waiting to receive the required care, and is now in need of emergency care, which may not only be costly but also include hospitalizations. Policy intervention opportunities in this problem include but are not limited to, the integrated behavioral health in primary care, extension of telehealth, and the program of incentives for workforce development. On 100 dollars spent on behavioral health sponsored by an employer, 190 savings is possible on overall health claims as shown in numerous studies (Hawrilenko et al., 2025). Behavioral health interventions that are technology-based have also been demonstrated to become cost-effective when attempting to target differences in underserved groups (Ali et al., 2024). Those states that have workforce plans related to the behavioral health workforce pipeline and systems of value-based integrated care reach higher access to care, higher compliance rates with care, and reduced use of emergency services (Connors and Mayes, 2026; Galbreath, 2025). Therefore, to tackle the problem, via evidence-based approaches is important in order to enhance the health outcomes of the community. Conversely, if the problem is not resolved, it will continue to drive up ED costs, homelessness, loss of workforce productivity, and the disparities between rural and urban health care. Untreated costs of mental illness are related to higher comorbidity costs and billions of dollars annually in avoidable costs (Hawrilenko et al., 2025). It translates to an increase in Medicaid expenditure within the Texas communities, an increase in police calls due to mental health problems, and missed economic opportunities that would not have occurred. To the professional aspect, I have seen first-hand the difficulties it has created for mental health, which has resulted in a higher level of symptomatology and more extensive coordination and visits. That is why my resource planning and risk analysis focus lies on the role of a balance of cost management and the stabilization of the workforce. The embeddedness of primary care providers into the local community helps with the degradation of stigma and cultural acceptability, and behavioral health providers support the process on the ground (Ahad et al., 2023). There is also an increased penetration of telehealth and programs, including the loan forgiveness and tuition support, which further achieve geographic diversity and workforce resiliency. This will coincide with the ethical value of justice and beneficence, whereby care/welfare will not be determined by its price. This, in addition, contributes to a prevention and value-based health care approach as opposed to a reactive approach to health care or a crisis approach in the state of Texas, and will have positive implications on the financial sustainability of health care in the state. I beg you to take seriously the need for state legislation and investments in integrated behavioral health, growth of telehealth, and incentives to develop the workforce. This will not only result in increased benefits to Texans, but will also reduce unnecessary spending in public dollars and increase a healthier, more prosperous State of Texas. Thanks, you are the one who leads, guides, and directs. Yours Truly, References Ahad, A., Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(5), e39549. https://doi.org/10.7759/cureus.39549 Ali, S., Alemu, F. W., Owen, J., Eells, T. D., Antle, B., Lee, J. T., & Wright, J. H. (2024). Cost-Effectiveness of computer-assisted cognitive behavioral therapy for depression among adults in primary care. Journal of the American Medical Association Network Open, 7(11), e2444599. https://doi.org/10.1001/jamanetworkopen.2024.44599 Connors, E. H., & Mayes, L. (2026). Value-based care for behavioral health: A more measured approach to achieve true value. Nature Partner Journal Mental Health Research, 5(1). https://doi.org/10.1038/s44184-026-00198-2 Galbreath, L. (2025, January 31). Key strategies for strengthening the behavioral health workforce – NASHP. NASHP. https://nashp.org/key-strategies-for-strengthening-the-behavioral-health-workforce/ Hawrilenko, M., Smolka, C., Ward, E., Ambwani, G., Brown, M., Mohandas, A., Paulus, M., Krystal, J., & Chekroud, A. (2025). Return on investment of enhanced behavioral health services. Journal of the American Medical Association Network Open, 8(2), e2457834. https://doi.org/10.1001/jamanetworkopen.2024.57834 Simpson, S., & Messmer, E. N. (2024, July 17). A look at the Texas mental health workforce shortage. The Texas Tribune. https://www.texastribune.org/2024/07/17/texas-mental-health-workforce-explainer

NURS FPX 4015 Assessment 2
Uncategorized, BSN, Capella, NURS FPX 4015, Nursing

NURS FPX 4015 Assessment 2: Enhancing Holistic Nursing Care with the 3Ps

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NURS FPX 4015 Assessment 2 Enhancing Holistic Nursing Care with the 3Ps Student Name Capella University NURS FPX 4015 Professor Name Submission Date Holistic Nursing Care with 3Ps The emphasis of holistic nursing care is to care for all patients in a way to meet each patient’s physical, emotional, social, and spiritual needs. All components of a person’s health are encouraged to be taken into consideration by health professionals, which helps to achieve good health outcomes (Gripshi, 2021). BSN students are expected to give more advanced care to their patients than basic care in a nursing role. They should also apply knowledge of the symptoms, different medications, and the examination of a patient. This paper explores the cooperation of the different areas to promote enhanced and safe care delivery to consumers. Holistic Nursing Care and Its Benefits Holistic nursing is a concept that values the total person through body, mind, spirit, and social dimension in regard to healthcare. The concept of holistic care implies considering the patient not only regarding their health issues, but through the lens of personal lives, thoughts, and individual demand as well (Sassen,2023). Healthcare workers can consider the social influences that may come into play when dealing with psychiatric issues, and can examine the family history, emotional issues, and religious beliefs of a patient. Cooperation and collaboration between patient and nurse is therefore promoted with holistic nursing, along with the development of a friendly care that is appropriate to the patient and the patient’s culture. Many benefits of holistic nursing could apply to the patient and to the healthcare system providers.In a holistic caring setting, the patient is more willing and capable of taking responsibility for his/her health, resulting in increased wellness and patient satisfaction. Moreover, it can be used to eliminate stress, bring some comfort, and simplify the process of adhering to the medication regimen in patients (Ferreira et al., 2023). Holistic care means considering patients’ physical, emotional, and spiritual needs, and it is a time when patients feel more powerful and nervous, especially when they are facing a chronic illness. The model is of use to nurses. It enhances the reward of a profession through the fostering of stronger and more trusted relations with the patients. This is because if they do not have sufficient knowledge about all health issues and get into the habit of working on all issues, they will become proficient in their jobs, which will help them improve their skills in their jobs (Ambushe et al., 2023). In addition, it helps nurses to care for themselves and reduces the risk of burnout. To summarize, with regard to the whole person caring model, nurses can come across patients’ demands earlier and provide improved care. Pathophysiology and Its Role in Nursing Practice Pathophysiology is a crucial concept within the field of nursing because it provides nurses with knowledge about how diseases affect the body, making it easier for them to provide better patient care. Nurses with knowledge of the biology of a condition, such as diabetes or heart failure, will be better prepared to deal with an issue and develop strategies for caring for it appropriately. (Zou & Huang, 2021) For instance, if a nurse knows the effects of insulin resistance on glucose, it is possible to monitor and control this blood sugar for diabetic patients (Zou & Huang, 2021). With such knowledge, nurses would be able to pay attention to signs of problems with individual organs in their early stages to modify their treatment courses in time. Besides dealing with the material objects, pathophysiology also calls for nurses to study the emotional effects of illness on a patient and their social life. This understanding of the cardiac failure process allows the nurses to clearly understand the approach that should be taken to promote the well-being and mental health of the patient. With this knowledge, nurses will be able to treat their disease in a way that not only takes care of their health and well-being, but also cares for them as a whole (Son et al., 2021). Pathophysiology knowledge helps a nurse provide relevant and evidence-based health care to enhance the patient’s outcomes and satisfaction. Pharmacology and Its Role in Nursing Practice Pharmacology is one of the fields that nurses are involved in, as it helps nurses to handle drugs in a safe and effective way. Pharmacokinetics: The study of how drugs are absorbed, distributed, metabolized, and excreted by the body. While pharmacodynamics is the understanding of the effects of drugs in the body, knowledge of drugs is also important to nurses who are to make decisions on the selection of a drug that best suits a patient (Marino et al., 2023). Nurses, for instance, take into consideration the right amount of antihypertensive medicine for a patient, how the medication should be administered, the performance of a nurse delivering this medicine, and the patient’s reaction to the dosage. Others, including medicines taken to treat diabetes mellitus, affect the kidneys. Being aware of this, nurses can prevent side effects, optimize the treatment effect (Hannan et al., 2022), and skip the hassles associated with it. With such knowledge, nurses will be able to draw safe and personal health plans for those with complex health conditions. Pharmacology teaches nurses about the different impacts some medications can have on the health, emotional, and social life of an individual. For instance, the medication given for pain is opioids, which are also known for causing sleepiness, confusion, and addiction. The role of the nurse is to ensure that the dose will not cause any addiction, and it helps to relieve pain (Cleave et al., 2021). Similarly, antidepressant drugs and other medications affect the mood and behavior of an individual and alter his/her mental state of being and daily life. Both physical and emotional problems are important to consider, and if new RNs understand the working mechanism in all these aspects, they can create strategies accordingly (Liu et al., 2024). Nurses, as colleagues with other medical workers,

NURS FPX 4005 Assessment 3
Capella, BSN, NURS FPX 4000, NURS FPX 4005, Nursing

NURS FPX 4005 Assessment 3 Interdisciplinary Plan Proposal

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Get Expert Help with NURS FPX 4005 Assessment 3 Interdisciplinary Plan Proposal Student name Capella University FPX4005 Professor Name Submission Date Interdisciplinary Plan Proposal Successful care transitions are vital in hospital settings in order to keep patients safe, prevent readmission to the hospital, and enhance health outcomes. Inadequate transitions can lead to problems with timely care, fragmented or repeated services, and/or confusion around care plans (Marsall et al., 2024). The purpose of this proposal is to tackle the problem of poor care transitions within the hospital departments and with external health care providers, which result in sub-optimal communication and patient dissatisfaction. The plan will be carried out in the coordination/discharge patient units of Riverstone Medical Center. The desired outcome is to have an improvement in interdisciplinary collaboration, continuity of care, and outcomes of patients during transition. NURS FPX 4005 Assessment 3 Quick Answer Assessment Type: Interdisciplinary Plan Proposal Course: NURS FPX 4005 Focus Area: Leadership and Collaboration Recommended Theory: Lewin’s Change Theory Communication Tool: SBAR Key Goal: Improve patient outcomes through interdisciplinary teamwork Objective This plan’s goal is to standardize the care transition process at Riverstone Medical Center with structured interdisciplinary communication tools and regular team huddles. The idea is to minimize communication failures and delays in the passages of patients from one department to another and/or from one agency to another (Sheehan et al., 2021). This goal is in line with the hospital’s overall goal of improving the continuity of care and their patient centered outcome. Ultimately, if it is successful, the plan should result in increased patient satisfaction, fewer avoidable readmissions, and improved and more efficient use of resources. In the end, it will help foster a mindset of teamwork and responsibility among teams at Riverstone Medical Center. Change Theories and Leadership Strategies Lewin’s Change Theory is a change theory that will be used in this change plan at Riverstone Medical Center, which entails three sections: unfreeze, change, and refreeze. During the unfreezing, staff will be informed of the existing problems associated with the care transition (delay, communication problems, etc.) to give them an idea of what needs to be changed (Stanz et al., 2021). In the transition period, standardized transition procedures will be implemented, communication tools will be used in a structured manner, and interdisciplinary team huddles will be introduced to enhance communication. Reinforcement of these new practices will be done during the final refreezing stage, which is achieved via policy changes, continuous staff training, and examination of staff performance (Stanz et al., 2021). This theory offers a clear plan for change, and can make change more palatable for employees, who are more likely to embrace it if they feel engaged in and ready for change, which can improve their compliance with the new protocol. Bornman & Louw (2023) will be implemented as a guiding strategy, Collaborative Leadership, to support this change. On the waterfront of teamwork, the charge nurse in the Riverstone Medical Center said there were instances of a lack of communication among team members and the daily use of teamwork. What charges the nurse said she saw in the Riverstone Medical Center could be addressed by collaborative leadership: “There are some examples of lack of team communication and lack of teamwork day to day.” This approach is focused on the management of the project, shared decision making, open communication, and multi-disciplinary accountability. Leaders will involve the nurses, physicians, case managers, and allied health professionals in creating and optimizing the care transition process (Geese & Schmitt, 2023). This builds trust and inclusiveness, leading to greater staff buy-in, cross-disciplinary collaboration, and making the new protocol a part of staff practice. In the end, it is consistent with the hospital’s mission to provide “patient-centred” care with good multi-disciplinary teamwork. Team Collaboration Strategy This plan will focus on a collaboration method that will include interdisciplinary team-based communication and strategies. It comprises standard handoff tools such as Situation, Background, Assessment, Recommendation (SBAR), frequent interdisciplinary team “huddles”, and has well-defined care transition strategies (Fernández et al., 2022). This ensures that all those within the care bubble (nurses, doctors, case managers, allied health workers, and others) remain informed and involved in the decision-making process related to patient transitions (Fernández et al., 2022). Last but not least, whenever care transfer came up in the discussion, Riverstone Medical Center described it as a murky process with room for misunderstandings.This structured ‘handoff’ can help to establish a strong framework for enhancing continuity and coordination across care settings. Horizontal collaboration of staff within the same level – e.g., across different shifts, across departments – is one type of collaboration and teamwork that will support this plan. It also involves vertical coordination among staff across different roles and departments, such as between the nursing staff, case management, and rehabilitation staff (Baek et al., 2023). Regular (daily or shift-based) interdisciplinary huddles will help to build a sense of shared understanding of patient care plans and provide for real-time communication. Further, by taking staff on board to co-develop and improve transition procedures, processes, and pathways, this fosters ownership and accountability, which ensures continuity of staff engagement (Bhati et al., 2023). Team members will also be able to better understand each other’s job roles with the assistance of cross-functional training sessions, which will minimize friction and increasingly effective handoff. The partnership is a direct result of the challenges Riverstone Medical Center faced with regard to teamwork, as a value they already know and consider important to implement, but in practice, it is lacking. The plan prioritizes communication skills and habits, as well as facilitating routine and inclusive collaboration – all the things that are missing from the care transitions process today. In the end, these are the main strategies that will lead to a more uniform interdisciplinary environment and, subsequently, safer, more efficient patient transfers, along with better organizational outcomes. Required Organizational Resources The protocol for care transitioning is a standard protocol that will need to be implemented at Riverstone Medical Center and will require several resources in

NURS FPX 4005 Assessment 2
Uncategorized

NURS FPX 4005 Assessment 2: Interview and Interdisciplinary Issue Identification

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NURS FPX 4005 Assessment 2 Interview and Interdisciplinary Issue Identification | Complete Guide & Sample Student name Capella University NHS 6008 Professor Name April 12, 2026 NURS FPX 4005 Assessment 2: Interview and Interdisciplinary Issue Identification The interdisciplinary collaboration is now a vital part of contemporary healthcare since intricate patient needs tend to demand knowledge and skills from various fields cooperating towards a common setup (Warren and Warren, 2023). As a baccalaureate-prepared nurse, having the skillset for how to determine what problems are inherent in the system, how to structure a solution as a team effort, and then how to make sure the solution will work is essential in improving patient and system outcomes. This process begins with such an evaluation when an interview with a health care professional is performed to explore real-life problems related to communication, workflow, or coordination that exist in a given organization. NURS FPX 4005 Assessment 2 Interview and Interdisciplinary Issue Identification For this assessment, you will interview a health care professional, identify an interdisciplinary issue, and recommend evidence-based strategies for collaboration. Many Capella FlexPath learners struggle with choosing the right issue, applying change theories, and connecting leadership approaches to interdisciplinary practice. In this guide you will find a full example, tips for writing, key requirements and professional academic help to successfully complete the assessment. Interview Summary The nursing leader interviewed was an employee of a 200-bed community hospital that provided community, urban, and suburban-based acute medical surgical care, obstetric, and outpatient specialty clinic. It has a diverse adult and older population that has a wide range of chronic and acute illnesses; recent developments regarding service usage include a large number of inpatients turning over and a rising pressure on outpatients’ follow-up. During the interview, the participant described a variety of stressors to the operation, especially the lack of discharge coordination between nursing, case management, and outpatient, which creates delays in discharge and can even result in readmission (Cadel et al., 2022). These pressures were put into perspective within a system where changes in staffing and conflicting priorities make smooth communication and/or transitions of care challenging. The interviewee mentioned being a nurse manager in two inpatient units of the medical-surgical unit, with duties that include: managing the nursing staff, communication with the case manager and physician, and quality indicators like LOS and readmission. Explaining organizational issues, the interviewee indicated that breaking down of communication between various disciplines (discharge plans, lack of knowledge of out-hospital visits, etc.) were the problems associated with the working process, leading to an increase in nursing loads and decreasing patient satisfaction and continuity of the treatment. Girnius et al. (2024) suggested that leadership had already made a number of changes, such as short interdisciplinary huddles, ad hoc electronic reminders, and specific staff education, but these were not successful at a whole-school level as they were only partial changes, due to poor engagement and not standardized processes. Two themes emerged: culture—general positive attitude towards teamwork, though inconsistencies noted between different departments working together to participate in any formal interdisciplinary team activity; leadership support, and the use of formal tools for communication was important for success based on past interdisciplinary team experience. Since there is a broad spectrum of information that could be collected to be analyzed afterwards, broad questions, reflective probing, and active listening were the methods used to facilitate the interview. Issue Identification The biggest issues discussed during the interview are the coordination of the discharges; the interface between nursing staff, case managers, doctors, and outpatient service providers is not effective. It is also interdisciplinary in nature as successful discharge planning requires working together amongst different departments to carry out the processes, joint decision making, and information sharing in a timely manner to ensure patients make a safe transition. Therefore, an interdisciplinary approach is important as no one department has all the information or the authority to maximize discharge, and the individual departments’ experience (such as education or case management led by individual nurses) did not achieve lasting improvement (Tseng et al., 2025). The interviewee’s statements on the lack of communication, lack of appropriate workflow, and lack of consistency of discharge involvement from day to day indicate that this is an inter-disciplinary problem that needs to be solved through teamwork and collaboration. Requirements Conduct a professional interview Identify an interdisciplinary issue Apply change theories Discuss leadership strategies Recommend collaboration approaches Support analysis with scholarly evidence Change Theories That Could Lead to an Interdisciplinary Solution Two dynamic models for change – Lewin’s Change Theory and Kotter’s 8-Step Change Model – can be applied as a strategy to facilitate an interdisciplinary intervention to improve discharge coordination. The Lewin model has emphasized three phases: unfreezing, changing, and refreezing, all of which are quite natural in helping the team-based practice change: bring stakeholders to understand the need for change, implement new behaviours in the team, and consolidate the communication process between disciplines. The model developed by Kotter builds on this, with much emphasis on steps, such as ‘creating a sense of urgency’, ‘forming a guiding coalition’, ‘creating a vision’, ‘communicating a vision’, and ’empowering action’, that were echoed in the collective leadership and the coordinated effort that is necessary in multi-disciplinary teams. Both theories encourage a planned approach towards communication, planned common ownership, and slow implementation of new workflows – all critical to overcome the breakdowns in communication as voiced in the interview. The peer-reviewed literature is full of reports that these models are effective in a medical setting, especially if the change to be implemented entails the coordination of activities between the members of different professions (Persson et al., 2022). Especially the discharge coordination issue, because they provide systematic ways to provide resistance, involve staff, and implement new communication in the different departments. Lewin’s unfreeze, change, and refreeze model might help organizations to appreciate that they have a problem with the lack of aligned communication leading to poor patient outcomes, and the change stage to implement system- or interdisciplinary discharge huddles or standardized

NURS FPX 4005 Assessment 1
Capella, BSN, NURS FPX 4000, NURS FPX 4005, NURS FPX 4045, Nursing

NURS FPX 4005 Assessment 1 Collaboration and Leadership Reflection

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NURS FPX 4005 Assessment 1 Collaboration and Leadership Reflection Guide for Capella FlexPath Students Student name Capella University NURS- FPX4005 Professor Name Submission Date Collaboration and Leadership Reflection Quality healthcare delivery is dependent on teamwork and leadership where there is respect for one another, decisions are made as a group, and sharing of responsibility.  Collaborating among the different professions helps utilize all experts’ theoretical knowledge and skills and, in the long run, improve the provision of safe and holistic care for patients (Dib & Belrhiti, 2025). Since the healthcare needs are becoming more complex, nurse, health worker, is more needed to demonstrate collaborative leadership and interpersonal skills. Transformational leadership is a leadership style that best fits the needs of my own job! Other consequences associated with this are enhanced work relations, increased job satisfaction, and better patient outcomes (Ystaas et al., 2023). This involves efforts geared towards uniting the group and ensuring effective communication and awareness about the significance of the contributions of each individual to patients’ care. NURS FPX 4005 Assessment 1 Collaboration and Leadership Reflection is designed to assess teamwork, leadership styles, and interprofessional collaboration in the healthcare environment. Many Capella FlexPath nursing students ask us how to evaluate leadership styles, reflect on collaborative experiences, and incorporate evidence-based approaches into professional nursing practice. This guide describes the key assessment requirements, transformational leadership concepts, interdisciplinary teamwork examples, and best practices that can help students successfully complete the assessment and improve their understanding of patient-centered care. Interdisciplinary Collaboration Experience The latest experience I had was while caring for one patient suffering from co-morbid conditions which necessitated neurological assessment, pharmacological management, and complex wound care management. This interprofessional team comprised a neurologist, OT, pharmacist, and nurses. The neurologist discussed the diagnostic considerations, the occupational therapist discussed plans of functional rehabilitation, the pharmacist discussed possible interactions of the medications, and I presented information on nursing related to time management of the wound-care, safety, and pain management during the arranged meetings. Process communication was done with respectful and solutions-oriented communication. Team members were highly engaged listeners and paid heed to the feedback incorporated under the umbrella of the common care plan. When many different views were expressed, a plan was developed that was comprehensive. I was encouraged to share clinical problems and suggestions. Having to make decisions jointly resulted in more respect for the needs of the patients and in the emergence of a feeling of shared responsibility and patient advocacy. There were difficulties with this experience, but communication was achieved.  Some of the younger members were, however, reluctant to participate, and follow-up tasks were not clearly delegated to some of them. This caused delays in wound dressing schedules and therapy sessions. Besides, there was a lack of organization for the post-meeting coordination, which resulted in uneven implementation, although the first meeting was a success. This collaboration could have been enhanced in a number of ways. A written follow-up plan and structured agenda could have helped to minimize the delays. The introduction of responsibilities and periodic checks of progress should have been leveraged to enhance accountability as well (Wang et al., 2024). A greater sense of equality would be achieved if a culture of psychological safety is begun at the beginning to develop, that is, the sense that everyone in the team can speak their concerns irrespective of their status. Effective vs. Ineffective Leadership Good leadership has a participatory approach, empowers, is good at communicating, values everyone’s contribution, and promotes collective responsibility. On the other hand, ineffective leadership is somewhat of a top-down approach that doesn’t allow for the involvement of all team members and involves the decision-making of those higher up on their own. The lack of structure and minimal participation by some members in the aforementioned collaborative situation was also a sign of poor leadership (Specchia et al., 2021). In turn, a transformational leadership style of empowerment and collective accountability will enhance collaboration, working relationships, and the best care for the patient (Ystaas et al., 2023). The takeaway from this experience is again that leadership does not mean power; it is about helping others, whether it’s other professionals, understand that they can get to the same end—patient-centered, safe care that everyone longs to achieve. Best-Practice Leadership Strategies For the nursing practice, effective leadership is one in which there is a high level of trust, cooperation, and open communication. Transformational leadership has been shown to have a positive impact on professional satisfaction and burnout prevention, as well as patient outcomes (Ystaas et al., 2023). These leaders can develop an environment for nurses to feel important, supported, and motivated to work to the best of their ability.  A second model that has been developed is collaborative leadership, based on common concepts, respect for each other’s views, and open communication between disciplines. Studies by Silva et al. (2022) indicated that collaborative leadership enhances the level of innovation, collaboration, and clinical performance. Team leaders act as glue that ties and holds teams together and keeps lines of communication clear, and create a team culture where everyone can free up the “me” and release it psychologically to eliminate error, improve coordination of care, and achieve patient-centered outcomes. Best-Practice Interdisciplinary Collaboration Strategies Collaboration is interdisciplinary and is based on good practice – communication, joint planning, and implementation. Structured communication approaches such as the Situation, Background, and Assessment, Recommendation (SBAR) approach (Ghosh et al., 2021) help to improve the clarity of communication, reduce errors, and efficiently plan care.  Creating a psychological sense of safety is also crucial as it will enable individuals to feel comfortable in voicing their questions and concerns without fear of committing a mistake and boost team learning (Patil et al., 2023). Interdisciplinary planning activities, if frequently held, can be used to describe the roles of the individuals, synchronize their objectives, and recognize the efforts of the various professionals that eventually result in improvements in patient outcomes. In addition, by teaching future health care professionals how to effectively communicate, collaborate, and work together to

NHS FPX 6008 Assessment 3
Capella, MSN, Nursing

NHS FPX 6008 Assessment 3 Business Case for Change

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NURS FPX 6008 Assessment 3: Business Case for Change Myoshi Capella University NHS 6008 Professor Name April 12, 2026 Hi, my name is Myoshi. This presentation outlines a business case for addressing the critical issue of understaffing in primary healthcare settings. It will also discuss the impacts of economic, clinical and organizational impacts of the labor shortage and it will also elaborate a more possible and more affordable alternative; which happens to be the creation of the ideal patient outcomes, employee outcomes and health care provision. The current study can be considered an extension of the previous ones since it generalizes the content on the evidence and implements the financial incentives on proving the strategic component of investment in working force by the healthcare. Introduction and Objectives One of the clearly remarkable economic and clinical strain are the lack of primary healthcare, negatively affecting patient care quality, organizational and workforce performance as well as the underserved group of patients. It has also revealed that poor patient waiting, workload and access to care has also provided an explanation to inadequate workforces hence has ultimate impacts on the disparity in health (Ballout, 2025). This presentation will expound on economics of understaffing, suggest potential and cost effective strategy of staffing out and justify financial and practical benefits of proposed intervention to ensure that given intervention will be ethically acceptable and would equally apply to other groups of people. The Critical Need to Address Rural Healthcare Disparities The primary healthcare setting implication of the understaffing issue has a left flanking implication of the patient, professionals and organizations as well as to the community; namely on the less-served population, and the rural population. This type of understaffing puts the patients in the danger of medical error, treatment procrastination, subpar health, and subjects the nurses to the very edge of burnout and stress and the highest rates of job dissatisfaction up to the 20% turnover (Oshodi and Sookhoo, 2024). Organizational level: the low staffing reduces its performance and is now neither cost-effective to run and only helps at growing patient safety, yet the communities, particularly the low-income and minorities no longer have access to timely and quality care, which can only add to the already existing health disparity. The ripple effects of these are that the short term and doable solutions of staffing are in great demand. Feasibility and Cost-Benefit Considerations Its answer to the healthcare organizations, which entails under staffing (invoking even more nurses) is low cost. It would be assessed against two registered nurses each of them towards a tax of at least 80,000/year and against the three ordinary registered nurses the pointers towards a tax of at least 000 year each (no registration) but would certainly not levy on the pointers a tax of registered nurses of both of which one, as would otherwise have levitated, or of three/fourths of the five (no But, at this cost it will be in position to achieve colossal savings and revenue increases. It will have saved about 40-60, 000 per nurse on the list plus 50, 000 a year saved patient safety/adverse outcome as a result of saved turnover of the nurses. Additionally, it could have additional staff members on the services, which boosts patient flow/efficiency making the services bring in an additional 100,000. These extras will lead to the ultimate outcome of the combination either a break even or a positive (solution)-investment pay-off in the first year since it will also imply the solution provided will be economically viable too (Candio and Frew, 2023). Risk Mitigation Strategies Although the positive outcomes of the sharpened investments in more nursing workers will also be important, certain financial and other work-related risk factors will be forced to be tackled and eliminated. These would lead it to reduce its employment in the short-run due to the budget constraint but would be counterbalanced with some strategies to integrate into the budget on progressive hiring and other work force resources such as grants on personnel development. Competitive advantages- Competitive advantages W is also given a chance to provide competitive hiring (competitive hiring to underserved areas in particular), and can be provided as sign-on bonuses, or a collaboration with nursing education schools. This good working conditions factor too can e.g. work flexible, mental health which might be transferred over into a possibility to take off risk of retention also influenced the turnover on top of job satisfaction (Aust et al., 2023). They will form the perceived strategic and targets that will be followed in providing sustainability, and realistic implementation of the proposed staff intervention in the long-run. Proposed Solutions and Their Benefits The solution above is based on the concept of developing the multidimensional staffing approach that implies that the number of registered nurses will be increased, either to retain the workers and regulate the working flow making the working process as fruitful as possible. Work load inequity, direct the Staffing the staffing nurses will be reversed to the other work load inequities: professional development will be provided to the staffing nurses and working schedules will be intriguing. The other team that will be featured will be the team not going to introduce care modelling, this will result in increased coordination and productivity of health facilities. The most crucial outcomes/results of these interventions could be referred to reduction in the number of medical errors and burnout and the workforce turnover rates, patient satisfaction and safety rates. On the organizational-level, organizational efficiency (i.e. enhanced performance) of the organization in terms of work flows and revenue collection, also instils the applicability of the investment to enhance workforce. Cultural Sensitivity and Equitable Implementation Any defence of the unfairness of the healthcare provision to the underserved constituencies as part of curbing the healthcare disparity would have been a stroke of genius-to guarantee that any new staff in the implementation comes in a culturally transparent and reasonable manner. It is the minorities organization and the low-income-group that needs to be prioritized more as the two groups

NURS FPX 6008 Assessment 2
Capella, MSN, Nursing

NURS FPX 6008 Assessment 2: Needs Analysis for Change

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NURS FPX 6008 Assessment 2: Needs Analysis for Change Student name Capella University NHS 6008 Professor Name Submission Date Needs Analysis for Change The medical technology is rapidly developing, and this has brought drastic changes in various areas such as clinical practices, organizational operations, and interaction with patients in the healthcare setting in the USA. The introduction of EHRs, telemedicine solutions, artificial intelligence applications in decision support, and remote monitoring of patient technologies has become an inseparable part of health care services (World Health Organization, 2025). Due to its beneficial impact on the increase of efficiency, diagnostic abilities, and collaboration between health care specialists and institutions. However, the economic implications associated with using innovative technology have become the major stumbling block to implementation in health care institutions. The cost of implementing new technologies and providing further maintenance, protection, and training of personnel can be identified as rather high costs to smaller health care institutions that are remote and far. Summarizing the Chosen Economic Issue and Its Impact The economic issue selected is regarding the high cost of the advanced technology in healthcare organizations and the inequality in accessing the technology. Even though advanced technology plays an essential role in improving efficiency and safety, among other factors, its expenses pose a challenge to implementing it. Advanced technology can be easily embraced by rich healthcare organizations due to their financial capability. Conversely, the small hospitals and rural clinics are unable even to use simple technological innovations because of financial problems (Stoumpos et al., 2023). The economic issue has a great impact on the practice environment, organizational performance, peers, and the community in general. Research has established that a lack of preparation to adopt new systems influences the workload of health care professionals and causes stress and inefficiency (Lee et al., 2025). The system always requires clinicians to adapt to the system in order to deliver quality services in the healthcare field. Such a situation puts pressure on health care professionals, especially when adopting new systems. Impacts on Colleges and Organizations The practical implications of unequal use of medical technology will impact the medical colleagues and organizational performance. When health care providers switch between one technology and another, and especially when they lack the opportunity to get training, these health care providers will be compelled to experience an escalation in their cognitive load, which will result in poor job satisfaction, burnout, and inefficiency in the provision of services to the clients. Moreover, uneven utilization of technology will have an impact on organizations. The lack of funds will cause the institutions to have outdated technology and, therefore, increase their chance of making mistakes in the documentation and management of care processes. Yusuf et al. (2025) are correct in pointing out that organizations that lack an adequate technological capability will be faced with inefficiencies in the provision of patient care and management of the organization. The poor organizational processes will put organizations in a situation of financial troubles. Rationale for Pursuing the Issue It is necessary to address this problem immediately as it has a direct relation to the issues of patient safety, organizational sustainability, and health inequities. Nowadays, technologies are becoming increasingly vital in terms of the provision of high-quality medical services; nevertheless, the issue is related to their access, as it is limited due to a lack of funding. Studies indicate that patient well-being, short length of stay, and improved organizational results are the outcomes of the usage of the technologically advanced facilities in the hospital setting (Thacharod et al., 2024). In addition, due to their restricted availability, all these advantages can only be enjoyed by bigger health organizations. The final rationale to discuss this issue is due to the need to reduce health disparities. Telemedicine can give easier access to medical assistance to the rural population; however, its underdevelopment does not allow this to happen. Existing Gap in the Issue The lack of fair access to the financial resources and technological devices needed to implement the technology is yet another major gap that exists in consideration of the discussed economic issue. Particularly, large or urban hospitals are financially stable, and small and rural hospitals have less financial means at their disposal. This aspect affects the rate of implementation and the efficiency of the implementation of new technologies like AI software tools and EHRs. As an example, as Ahmed et al. (2023) say, the implementation of artificial intelligence in health care is more prevalent in well-funded hospitals than in those located in rural areas due to the differences in financial and technological literacy. Ethical, Evidence-Based Practice Guidelines and Stakeholder Impact In the intervention, evidence-based interventions should be justified using ethical considerations in order to minimise the reported gaps in performances in order to make the implementation of such interventions fair and effective across different populations. The systematic reviews indicate that structured discharge planning that integrates drug reconciliation, patient education, and early follow-up can reduce heart failure readmission by 16.6 to 50%, respectively, depending on the intensity of the interventions (Tran et al., 2025). A set of culturally modified instructional materials in different languages, consideration of the level of health literacy, assessment of social determinants of health, such as transportation and housing stability, and attention to patient autonomy are all that is needed to make an ethical decision considering the discharge planning decision-making (Browder et al., 2023). The proposed guidelines directly impact the nursing staff, with an increase in the patient education roles, pharmacists, as they are obliged to balance more of the medication reconciliation roles, physicians, as they are obliged to increase the discharge documentation requirements, and the case managers, as they are obliged to increase the follow-up coordination efforts. Identification of Disparity          These factors associated with the socio-demographic and geographical inequities are regarded as critical as they could influence the access to the new technological advancements by patients. Thus, in this situation, it is worth noting that those problems may primarily target individuals living in rural areas and belonging to

NHS FPX 6008 Assessment 1
Capella, MSN, Nursing

NHS FPX 6008 Assessment 1: Identifying a Local Healthcare Economic Issue

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NHS FPX 6008 Assessment 1: Identifying a Local Healthcare Economic Issue Jennifer McGoran Capella University FPX 6008 Prof Name March 05, 2026 Submission Date Identifying a Local Health Care Economic Issue The quick uptake of advanced medical technologies has brought about changes in the way healthcare services are provided in the United States. The introduction of technologies such as electronic health records (EHR), artificial intelligence (AI), and telehealth solutions has become an inseparable part of modern health systems. However, the economic impacts of the cost of adoption and maintenance of these technologies are a significant issue (Butt & Alghababsheh, 2025). The given issue is particularly relevant, taking into account the growing expenditures and the necessity to offer quality care to all. The economic impact of adopting medical technologies is thus an important healthcare concern. Healthcare Economic Issue The uptake of medical technology is a complex economic issue due to the enormous amount of money that must be invested to implement such technologies into effect. That is, healthcare facilities will have to pay high costs in respect of constructing a sufficient infrastructure, acquiring special programs, and training employees. The issue is that, although they are good in terms of delivering services, these innovations are very expensive and, therefore, they can be unaffordable to healthcare organizations (Donovan et al., 2023). Recently, there have been studies that have demonstrated the potential of technology as well as the gap that exists in this sphere. First of all, the 2024 research on the introduction of the EHR proved that these systems are quite effective yet costly and need long-term resource commitment (Modi et al., 2024). The statistics show that about 71% of all U.S. hospitals had introduced predictive AI technologies by 2024 (ONC, 2025). At the same time, the rate of technology adoption is significantly lower in small and rural healthcare facilities. The problem should be addressed immediately to successfully embrace technology. The Rationale for Selecting the Healthcare Issue This issue has been selected due to its significance in the quality of health care, safety, and sustainability. Professionally speaking, the use of new technologies in health care practice has become crucial nowadays since it provides better treatment coordination, decreases mistakes, and makes it possible to make more sound decisions (Thacharodi et al., 2024). However, there are problems related to the financial aspect of such practices. Individual values associated with health care provision have contributed to making this decision. It is critical to discover whether innovations can help enhance the well-being of patients or result in inequalities. Thus, the contemporary subject is to be investigated to avoid the adverse effects of technologies on accessibility and safety of health care services offered to various people. Significant Impacts of Healthcare Economic Issues The introduction of new medical technologies has had significant impacts on clinical practice, management of the organization, other health professionals, and society as a whole. The process of adoption can also result in increased workload on the side of professionals who have to go through the process of training, navigating various systems, and adjusting to new processes within the organization. These activities may decrease efficiency and create stress among clinicians and other healthcare personnel (Jeilani & Hussein, 2025). The considerations on the organizational level encompass a major financial strain due to the investments in the costly equipment and the maintenance costs. Health professionals who work in organizations that have limited funds will have an extra burden due to the absence of integration. The use of medical technologies has far-reaching consequences on a variety of less wealthy and more diverse groups (Thacharodi et al., 2024). Medical institutions that provide health care services to such populations may not have enough resources to implement the recent technologies, thereby denying the patients the quality health care Gap to Address the Healthcare Economic Issue The environmental factors give a direct cause-and-effect relationship, which can either result in the successful realization of evidence-based practice guidelines in healthcare settings. It will lead to the lack of the proper staffing ratios, hence, the lack of the relevant discharge education and medication reconciliation, which in turn, will result in the patient’s bafflement, as well as in non-regulation of medicine and patient readmissions (Moges et al., 2022). Unless enabled to use electronic health record functionality, inconsistent protocol utilization and lack of coordination in care will occur, due to failure to provide automated notification on high-risk patients and provide standardized documentation templates. The seven-day gap in the outpatient cardiology follow-up in this case necessitates scheduling delays to exceed evidence-based time intervals, and it is impossible to keep the protective effect of an early follow-up (Bilicki and Reeves, 2024). The detection of these causal pathways will enable the resources in a strategic way, minimize the barriers to the maximum effectiveness of the policy, and offer a fair implementation process. Ethical, Evidence-Based Practice Guidelines and Stakeholder Impact One of the reasons for this problem is an uneven distribution of financial and other resources needed for implementing new technologies among healthcare organizations. It implies that more financially endowed and larger healthcare organizations deploy technological innovations, whereas the other healthcare organizations, particularly the small ones, are unable to invest in such innovations due to a shortage of funds. As revealed by the literature, it was found that adoption of AI and machine learning technologies was significantly higher in big and funded hospitals than in small and rural hospitals (Huang et al., 2025). Moreover, the disparity in adoption does not decrease even with increasing levels of usage, which means that there are issues related to money and structure that do not allow applying the technology equally (ONC, 2025). This gap means that there should be relevant policy interventions to enable the equal spread of medical technology. In addition, there is an issue with training and support that could disrupt the use of the medical technology implemented. The lack of training and support can lead to failure to properly use the system, therefore, eliminating any potential economic benefits of using the system.

NHS FPX 6004 Assessment 3
Capella, MSN, NHS FPX 6004, Nursing

NHS FPX 6004 Assessment 3: Training Session for Policy Implementation

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NHS FPX 6004 Assessment 3 Training Session for Policy Student name Capella University NHS-FPX6004: Healthcare Law and Policy Professor Name Submission Date Training Agenda Presentation for Policy Implementation This session will be aimed at offering you the overall picture of the policy guidelines and how each of you will contribute to the successful implementation of the policy. The prepared discharge checklist, medication reconciliation measures, and the patient education plan will be discussed, which will help to reduce the rate of heart failure rehospitalization and improve patient outcomes. This training is where you will learn the professional skills and knowledge to translate these practices into practice in your working environment on a daily basis. Through our collaboration, we will enhance the standards of care and eventually attain our benchmark goals of enhancing patient safety and regulatory compliance. Desired Impact of Implementing the New Policy on Benchmark Performance The new policy aims to bring the current readmission rate of 21.56% amid the heart failure patients of the Southeast Health Medical Center to 19.7 or so within the next 12 months. A systematic review and a meta-analysis showed that the communication and, as well as, the structured discharge intervention at hospital discharge had a significant relationship with the lower rate of readmission in hospitals and better patient outcomes (Becker et al., 2021).  Systematic discharge checklist, pharmacist-led drug reconciliation, patient education using a teach-back, and seven days after discharge, using calls, will be useful to bring about this change. The nurse navigators, pharmacists, and care managers were also included in the pilot group since they were directly responsible for the discharge planning and follow-up care. This team will also be the first to carry out the changes in order to provide valuable feedback on how the changes will be further implemented. Readmission rate of patients, the level of patient satisfaction, and the timeliness of post-discharge visits will be fine-tuned to the required results. These will directly affect the performance of the hospital and its compliance with the Hospital Readmissions Reduction Program (HRRP) to avoid the risk related to fines. Implementation and Effects on the Role Group’s Daily Work Routines The novel policy will require adjustment to the everyday work practices of the group of pilots. At this stage, the nurse navigators can now follow a standardized checklist during discharge, ensuring that medication reconciliation has been done, and that they should educate their patients using the teach-back method. More of the pharmacists will be involved in the medication management process, where all the prescriptions will be reconciled during admission and discharge. The care managers would implement the process of coordinating post-discharge follow-ups and their attendance at their appointments. They were also highly relieving to the patient care process, but the changes were again time-consuming and coordination-intensive (Coppa et al., 2021). The pilot group will also give valuable experiences towards the efficiencies of the different workflows, which will be included in the entire implementation plan as the policy is rolled out. This will ease the day-to-day operation so that staff can perform more tasks without compromising the quality of care they provide. Role and Importance of the Pilot Group in Implementing the New Policy The pilot group that will include heart failure nurse navigators, pharmacists, and care managers is also the key to the successful implementation of the new policy. Their direct contribution to reducing readmission rates is their participation directly in patient care, discharge planning, up to follow up. They will leave behind them their knowledge in the areas of medication reconciliation, patient education, and their coordination of care, so that the new policy will be put in place in a correct manner, and the barriers that arise will be identified at the initial stages. The design discharge strategies have been shown to have a significant impact on the readmission preparedness in heart failure patients and reduced the number of readmission preparedness of 32.6 to 6.8 at three months (Shan et al., 2025). To empower the group, this needs to be actively involved in the implementation process in making decisions, as their feedback should be taken into account and included. Personal communication, incentives, and appreciation of their role in the change process will be essential in changing their attitude towards ownership and responsibility, which is key to the success of the policy. Empowering Future Vision: Positive Contributions of the Group This will make the heart failure nurse navigators, pharmacists, and care managers key in becoming the driving force behind the development of the culture of continuous improvement in the healthcare facility in the future. With such a new policy, they not only decreased the readmissions but also helped to enhance the overall outcomes of the patients and the quality of care (Inam et al., 2025). Their efforts will be an example to other departments and prove the usefulness of evidence-based interventions in preventing avoidable readmissions. The success of this group will make other groups embrace this type of practice, and this will create a cooperative environment that practices patient-centered care. As a result, they will assist in transforming the organization into a leader in terms of the quality of healthcare, patient safety, and adherence to the regulations. Their services will ultimately result in quality and safety in the delivery of care; therefore, they are priceless commodities to the mission of the hospital, which includes the provision of high-quality and safe care. Resources Needed to Effectively Implement the Training Session Several resources will be needed in order to successfully realize the training session of the new policy. They consist of the instructional resources, which are a step-by-step description of the training manual and slides with an outline of the policy elements, handouts for the structured discharge checklist, and medication reconciliation guidelines. It will also be a requirement that a professional facilitator/trainer who would preferably be conversant with the policy and its applications in clinical settings will be required. It was also important to set aside time for all activities. The agenda was divided into sections

NHS FPX 6004 Assessment 2
Capella, MSN, NHS FPX 6004, Nursing

NHS FPX 6004 Assessment 2 Policy Proposal

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NHS FPX 6004 Assessment 2 Policy Proposal Student name Capella University MHA-6004 Professor Name Submission Date Policy Proposal Healthcare organizations must develop successful policies to address the performance deficiencies and deliver compliance with regulatory standards in all clinical services. The policy develops protocols of evidence-based heart failure discharge planning designed to decrease Southeast Health Medical Center’s discharge readmission rate of 21.56% to 19.7 or less during the following twelve months (Centers for Medicare & Medicaid Services, 2023). The suggested interventions will include the use of structured discharge checklists, pharmacist-led medication reconciliation, educating patients using teach-back, following up with patients after discharge through telephone follow-ups, and educating patients about regulatory adherence after the intervention. Evidence-based protocols with implementation allow healthcare facilities to enable benchmark compliance as well as improve patient safety and organizational performance outcomes. Need for Policy and Practice Guidelines To enhance the success of a good patient outcome in clinical operations, the concerned healthcare organizations need to have good policy frameworks to avoid performance gaps, which risk regulatory compliance in clinical operations. The current heart failure 30-day readmission rate of Southeast Health Medical Center is 21.56, which is higher than the national readmission rate of 19.7 per cent and the expected readmission rate of 20.35 per cent that should be anticipated in the facility (Centers for Medicare & Medicaid Services, 2023). The readmission rate in the hospital is 1.0597, which is an inappropriately high rate, i.e., the performance result of the hospital is lower than the performance result of a well-operating hospital would be expected to be. This poor performance is a direct violation of the requirements of the Hospital Readmissions Reduction Program in pursuance of Section 1886(q) of the Social Security Act, which says that immediate corrective action must be taken. The policy development (based on the evidence) will provide an organizational structure, which will be a necessity to transform underperformance into long-term clinical excellence and compliance with regulations. The implications of low performance at the current benchmark have far-reaching implications on many aspects that form concurrent benchmarks of patient care and efficiency of operations within an organization. Any preventable cases of readmission subject the patient to the increased possibility of acquiring hospital-acquired infection, medication errors, failing functioning, and mental distress the patient experiences due to readmission (Bichescu and Hilafu, 2023). This extraneous 11-13 excess readmission per year wastes resources of the organization that are primarily in nature, such as beds in inpatient facilities, capacity of the emergency department, hours of the nursing staff, as well as clinical support services. Additionally, the rate of readmission is suggestive of the system-wide inefficiency of the discharge planning, coordination of the care process, patient education, and transitional care processes that should be performed by 42 CFR 482.43 (Centers for Medicare & Medicaid Services, 2020). Due to the poorly working discharge procedure, the following inefficiencies in the operations of the discussed organization appeared: the working process was not organized properly, the staff were irritated, and the organization was negatively influenced in terms of providing high-quality care. Failure to have proper corrective policies will be translated into high financial punishment, reputation, and any other harming the patient, which will jeopardize the sustainability of the organizations. The possible fines of the hospital readmissions reduction program (HRRP) that could be applied to the Southeast Health Medical Center are up to 3 percent of all Medicare reimbursement to the facility, of which, in turn, is estimated to compose an annual loss of revenue of 103,000 dollars (Kaiser Family Foundation, 2022). As long as the non-examined systematic deficiencies in the discharge planning are not mitigated through systematic documented efforts, there is a risk of the organization being sentenced to regulatory fines, including the possible loss of Medicare certification (Centers for Medicare & Medicaid Services, 2020). The stakeholders need to understand that implementation of the policy does not just bring about a compliance agenda, but is actually a strategic imperative to survive as an organization and work towards its mission. Proposed Organizational Policy and Practice Guidelines Empowerment of evidence-based interventions and the regulatory requirements should be combined in practical healthcare policies to achieve quantifiable changes in clinical outcomes and organizational performance. The policy requires full protocols of heart failure discharge planning, which should include standardized discharge checklists that the patients have been signed off on by the pharmacists, follow-ups with the patient within seven days of discharge, patient education by the nurse through the teach-back methodology, and follow-ups with the patient within seven days of discharge. It is an implementation in line with requirements of the HRRP (Section 1886(q) of the Social Security Act) and CMS discharge planning regulations (42 CFR §482.43) that have patient-centered care transition requirements (Shenoy et al., 2022). Implementation of policies can be carried out in a strategic manner to ensure compliance with regulations and also ensure that it promotes the organizational mission, which is to provide safe, high-quality, patient-centered care in any clinical setting. Environmental Factors: Regulatory Considerations The success of the policy implementation is considerably affected by the environmental conditions, imposing restrictions and demands that determine the feasibility of the proposed practice recommendations. They need to have secure systems of communication about post-discharge telephone calls and electronic health information exchange (Wei et al., 2022). In order to preserve the accreditation, the Joint Commission standards provide that documentation of the patient education, medication reconciliation, and discharge directions should be documented in the medical record (The Joint Commission, 2023). The scope of practice of the registered nurses provided in state nursing practice acts enables the registered nurses to provide the teach-back education and telephone follow-up assessment that needs protocol development within the legal limits. When building a relationship of referral with a post-acute care provider and making follow-up appointments, the United States anti-kickback laws and the provisions related to the relationship of referral in the Stark Law should also be considered. Accessibility of resources in respect of staffing, financial muscle, and logistical infrastructure is the key to the extent and sustainability of the

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