NURS FPX 8006 Assessment 4 Policy: The Culmination of Scholarship Using Evidence-Based Practice with an Interprofessional Team
Student name
Capella University
NURS- FPX8006
Professor Name
Submission Date
The Culmination of Scholarship Using Evidence-Based Practice with an Interprofessional Team
The evidence-based practice is the culmination of the interprofessional team working to solve the complex challenges in healthcare, such as crisis levels of heart failure readmissions. Sharing research evidence, using diversity, equity, and inclusion (DEI) principles, and moving in a shared direction of shared values results in transformative clinical action that rises above the academic sphere. Finally, interprofessional scholarship could and should be the driving force that leads to significant and sustainable improvements in the quality of healthcare and patient outcomes for a variety of populations, including a reduction in preventable readmissions.
Policy Title: The goal of this idea is to reduce heart failure readmissions by implementing interprofessional collaborative practice and adopting evidence-based transitional care practice that includes a focus on diversity, equity, and inclusion.
Policy Statement
The policy is a comprehensive, equity-based strategy that will support interprofessional collaborative practice to lower the risk of heart failure rehospitalization by strategically incorporating diversity, equity, and inclusion. The framework brings together nurse practitioners, cardiologists, pharmacists, social workers, and case managers as joint decision makers and partners in providing culturally sensitive, evidence-based transitional care throughout the care continuum. Implementation strategies focus on key challenges to readmission reduction – such as medication adherence, health literacy, social determinants of health, and poor care coordination – using structured interprofessional huddles, standardizing discharge processes, and establishing care coordination follow-up processes. The policy promotes patient-centred practice by incorporating the values of diversity, equity, and inclusion at each step of the care pathway, thereby ensuring that the underserved, diverse population with heart failure has equal access to cutting-edge, guideline-directed interventions. The framework is designed to have a measurable, sustained impact on heart failure patient outcomes and organisational healthcare quality through a sustained interprofessional working partnership, continuous quality monitoring, and shared accountability.
Supporting Scholarly Literature
The importance of interprofessional working and organised transition care has been consistently identified as key to minimising preventable heart failure re-admissions in a variety of healthcare settings globally. Williams’ research showed that by providing a nurse-led approach to interprofessional collaborative practice, it could have a significant impact in reducing the length of hospital stays and costs among underserved heart failure patients by addressing all of the social determinants of health. The statistically significant 4.32% reduction in 30-day heart failure rehospitalization was accomplished through a comprehensive multidisciplinary approach with nurse practitioners, pharmacists, and case managers, according to Craigi. A disciplined care coordination approach led to a dramatic reduction in the proportion of patients readmitted for heart failure, falling below the national level of 25.5%, to 5.6%, in a study that reported on a multidisciplinary quality improvement effort that carried out coordinated, team-based interventions using rapid improvement cycles. Older patients’ multidisciplinary teams, nurses, and pharmacists were the most effective in providing transition care interventions that had measurable effects on re-hospitalization rates, according to study findings. Tran consolidated and synthesized this extensive body of evidence to support the importance of multidimensional, patient-focused, equity-driven, and system-integrated strategies for reducing readmissions for heart failure in diverse populations in a sustainable manner. Accumulated research thoroughly validates that DEI-centered interprofessional team strategies continue to hold the most promise and evidence in achieving sustainable heart failure readmission reduction.
Guidelines for Practice
To build evidence-based care in interprofessional care teams, it is important that teams follow structured, clearly defined practice guidelines that advance an interprofessional collaborative model of care, equity, and sustainable innovation at all levels of care. The first is to create some common goals and values for all team members – including nurse practitioners, cardiologists, pharmacists, social workers, and case managers – so everyone has a common objective: minimizing heart failure readmissions. The second is to define roles and responsibilities for each member of the team so that there is no duplication or conflicting interventions from different specialties. The third rule is that there are to be regular interprofessional team huddles so that everyone is communicating, transparent, and making decisions together. The fourth guideline is to embed DEI within all care pathways to deliver culturally responsive, equitable, and culturally diverse interventions to different groups of heart failure patients. The fifth guideline, evidence-based frameworks to systematically review existing literature, identify gaps in practice, and inform clinical decisions, should be done using evidence-based frameworks in a systematic way. The sixth guideline is to test interventions before rolling them out, to carefully monitor the impact, to use feedback to influence the interventions, and to consider adapting interventions for their impact in the real world. The seven guidelines together offer a way to continually monitor and evaluate team performance in the light of clear and measurable quality indicators that embrace improvements in both team process and patient outcomes. If these guidelines are consistently applied and ingrained into the culture, interprofessional teams are empowered to turn innovative ideas that are rooted in equity into sustainable practice and evidence-based improvements in patient outcomes.
Conclusion
A multi-agency, collaborative response, based on best practices, shared values, and principles of diversity, equity, and inclusion, is required to reduce heart failure readmissions. Taken together, the literature, practice guidelines, and policy framework support the role of nurse practitioners, cardiologists, pharmacists, social workers, and case managers as shared decision makers working together to change the delivery of health services for a variety of underserved heart failure populations. Innovation, equity, and evidence, when combined in interprofessional practice, can make for positive and sustainable patient outcomes.
References
Chalmers, L. C. (2025). Relationship-centered care and diversity, equity, inclusion, and belonging in action. Nursing, 55(6), 43–51. https://doi.org/10.1097/nsg.0000000000000209
Craigo, C. L., Dow, C. M., Malkhasian, Y. M., Minissian, M. B., Zadikany, R., & Zimmer, R. (2025). A multidisciplinary transition of care approach to reduce 30-day readmissions in heart failure patients. Heart & Lung, 71, 76–80. https://doi.org/10.1016/j.hrtlng.2025.03.001
Dailey, K. K., Frazier, S., Bressler, S., & King-Wilson, J. (2022). The role of nurse practitioners in the management of heart failure patients and programs. Current Cardiology Reports, 24(12), 1945–1956. https://doi.org/10.1007/s11886-022-01796-0
Dusin, J., Melanson, A., & Lawson, L. M. (2023). Evidence-based practice models and frameworks in the healthcare setting: A scoping review. BioMed Journal Open, 13(5), e071188. https://doi.org/10.1136/bmjopen-2022-071188
Hinch, B. K., & Staffileno, B. A. (2021). Implementing a heart failure transition program to reduce 30-day readmissions. Journal for Healthcare Quality, 43(2), 110–118. https://doi.org/10.1097/jhq.0000000000000268
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McLaney, E., Morassaei, S., Hughes, L., Davies, R., Campbell, M., & Prospero, L. D. (2022). A framework for interprofessional team collaboration in a hospital setting: Advancing team competencies and behaviours. Healthcare Management Forum, 35(2), 112–117. https://doi.org/10.1177/08404704211063584
Rapin, J., Gendron, S., Mabire, C., & Dubois, C. A. (2023). Feedback on clinical team performance: how does it work, in what contexts, for whom, and for what changes? A critical realist qualitative multiple case study. BioMed Central Health Services Research, 23(1), e410. https://doi.org/10.1186/s12913-023-09402-x
Ronquillo, Y., Ellis, V. L., & Toney-Butler, T. J. (2023, July 3). Conflict management. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470432/
Suksatan, W., & Tankumpuan, T. (2021). The effectiveness of transition care interventions from hospital to home on rehospitalization in older patients with heart failure: An integrative review. Home Health Care Management & Practice, 34(1), 63–71. https://doi.org/10.1177/10848223211023887
Tran, H. H. V., Thu, A., Brilhante, M., Twayana, A. R., Fuertes, A., Gonzalez, M., Basta, M., James, M., Mehta, K. A., Figaro, Y. M., Frishman, W. H., & Aronow, W. S. (2025). Evidence-based quality improvement strategies to reduce 30-day readmission rates in heart failure patients. Cardiology in Review, 10, e1097. https://doi.org/10.1097/crd.0000000000001039
Varghese, S. K., Francis, T., Shah, J. Z., Gupta, P., Velusamy, E., Varghese, B. S., Selvaraj, S. P., Renyn, L. K., Savarimuthu, I., Mahinay, M., Marri, A., Azeem, A., Thangaraj, P., Natarajan, S., Hamed, M., & Patel, A. (2025). Multidisciplinary initiative to reduce 30-day readmissions in heart failure: A quality improvement perspective. BioMed Journal Open Quality, 14(3), e003382. https://doi.org/10.1136/bmjoq-2025-003382
Williams, C. W., Shirey, M., Eagleson, R., Clarkson, S., & Bittner, V. (2021). An interprofessional collaborative practice can reduce heart failure hospital readmissions and costs in an underserved population. Journal of Cardiac Failure, 27(11), 1185–1194. https://doi.org/10.1016/j.cardfail.2021.04.011
Willmington, C., Belardi, P., Murante, A. M., & Vainieri, M. (2022). The contribution of benchmarking to quality improvement in healthcare. A systematic literature review. BioMed Central Health Services Research, 22(1), 1–20. https://doi.org/10.1186/s12913-022-07467-8
FAQs
What is the use of the abstract in this assessment?
The abstract provides information about the evidence-based practice project, including the clinical problem, the intervention, and possible outcomes.
What is the core of the policy?
The policy addresses issues related to the implementation of evidence-based and standardized practices.
What role does evidence-based practice play in this assessment?
Evidence-based practice helps ensure that all clinical decisions are made according to the latest research, thus increasing the effectiveness and safety of healthcare services.
How can interprofessional collaboration help achieve the goals set by the policy?
Interprofessional collaboration involves healthcare practitioners from various specialties to enhance communication.