Background: Heart failure (HF) affects 5.7 million Americans. It is Medicare’s second largest diagnosis-related group and second largest expenditure group. Studies utilizing disease management programs (DMPs) supported the use of advanced practice nurses (APNs) to successfully manage complex HF patient self-care needs in the clinic. Project Significance: Heart failure management is a great challenge to primary care providers (PCPs), patients, and their families. Primary care providers have knowledge gaps and uncertainty about the complex pathophysiology of HF as well as the evidence-based HF disease management program (DMP) clinical practice guidelines (CPGs) for chronic management of HF, especially in rural areas. However, DMPs are not widely implemented systematically by PCPs in urban or rural settings and thus have failed to improve costly outcomes significantly. Implementation of DMP CPGs of self-care of HF in a rural setting was the purpose for this system practice change project. Setting and Participants: A rural, APN-owned, primary care clinic in a rural community in Wyoming. Three APNs participated and 22 patients with HF were identified by HF diagnosis codes. Theoretical and Evidence-Based Framework: Dorothea Orem’s Self-care Deficit Theory of Nursing and Rosswurm and Larrabee’s Model for Evidence-Based Practice Change. Objectives: (1) Literature-based needs assessment; (2) Practice-based needs assessment of knowledge and use of HF DMP CPGs on self-care behaviors; (3) Description of pre-implementation HF self-care behavior teaching documentation by chart audit; (4) Presentation of results of chart audit; (5) Education of APNs and staff on the project, DMP CPGs rationale, how to implement a prompt system to increase utilization and documentation of DMP CPGs; (6) Implementation of the CPGs for four months; (7) Description of the post-implementation level of HF self-care behavior teaching documentation by chart audit; (8) Presentation of chart audit results of change in utilization and documentation before and after the CPG implementation; (9) Evaluation of the success of the CPG implementation by staff questionnaires; and (10) Discussion of ways to improve implementation and plan for sustainability. Methods: The project used a needs assessment questionnaire and chart audit and feedback format for measuring pre- and post-implementation for documentation of APN teaching of self-care, with results presented by PowerPoint presentation. Descriptive statistics were used to quanitify chart audit results. A post-implementation questionnaire was administered about successes and failures of the project and discussion was facilitated about ways to improve implementation and plan for sustainability. Results: Initial chart audit showed a baseline of zero documentation. Of a total of 22 patients identified with HF, 9 received documented self-care behavior teaching from the three APNs. Of the 12 patients seen in the clinic during the project, 9 received the teaching. The project demonstrated increased APN knowledge of HF self-care teaching, successful implementation of HF DMP DPGs into rural practice, and awareness of their practice patterns. Conclusion: Heart failure DMP CPGs on self-care behaviors can be successfully implemented in a rural primary care clinic practice by APNs. Provider education, chart audit and feedback, and consistent monitoring are effective means of implementing and measuring practice change. The APNs plan to sustain the project with the two modules found to be most important and pratical for patients on HF causes and medications.
