MSN Core Word E-Portfolio Template
Student Name:
Course Name:
Instructions:
To fulfill the requirements for this course, you must complete the CPE Record. Refer to the CPE Record under “Supporting Documents” in your Assessment Task Overview for specific deliverables. You must include the required deliverables from that CPE Record in this e-portfolio: MSN Core Word E-Portfolio Template.
Enter your written deliverables (e.g., reflections, etc.) into this template for each phase. Download and save this template, then type directly into the template.
If necessary, you may also insert content from previously created Word documents into this Word document template by using the following instructions. You can upload a Word or PDF file as a separate document only if the instructions indicate it is appropriate to do so.
To insert text from a previously created Word file, follow these instructions:
- Highlight the text you want to insert into the ePortfolio template. (You can choose to “Select All” if you want to copy and paste the entire content of the text into the ePortfolio template.)
- Copy the text.
- Paste the text into the ePortfolio template. You can reformat the content once it is pasted into the ePortfolio template if necessary.
To insert text or an image from a previously saved PDF document follow these instructions:
- Highlight the text or image you want to insert into the ePortfolio template. (You can choose to “Select All” if you want to copy and paste the entire content of the PDF document into the ePortfolio template.)
- Copy the text/image.
- Paste the text/image into the ePortfolio template at the appropriate location in the template. You can reformat the content once it is pasted into the ePortfolio if necessary.
NOTE: DO NOT insert a screen shot of the text from the word document or a PDF as it will not show the complete content on the ePortfolio template. However, you may use a screen shot when indicated in the instructions such as for the GoReact deliverables or if you are inserting an image such as a certificate, etc.
PHASE 1: EVIDENCE BASED PRACTICES FOR EFFECTIVE TRANSITION OF PATIENT CARE
| CPE Activity | Date Completed | |
|
1a. |
o All deliverables required for the e-portfolio o Anticipated completion date for each deliverable o Estimated time (in hours and minutes) to complete each deliverable |
5/26/2025 |
|
1b. |
· Review the Centers for Medicare & Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP)
· Briefly discuss the HRRP in one paragraph including the following: o Purpose of the plan o Conditions and surgical procedures included in the plan o How the advanced professional nurse utilizes the CMS Hospital-Specific Report (HSR) to promote health outcomes |
5/27/2025 |
|
1c. |
· To begin the transition of care plan, go to the task Supporting Documents “CDM2 Patient Case Scenarios”.
o Select one patient case scenario to complete a comprehensive review and provide the following information:
§ Describe one intervention that addresses the identified SDOH to prevent readmission within 30 days or less |
5/27/2025 |
PHASE 1: CPE ACTIVITY EVIDENCE & TASK DELIVERABLES
1b. Discuss in one paragraph the Hospital Readmissions Reduction Program (HRRP).
The Centers for Medicare & Medicaid Services (CMS) launched the Hospital Readmissions Reduction Program (HRRP) as a value-based purchasing program that incentivizes hospitals to avoid hospital readmissions where possible. The HRRP aims to improve transitions in care and coordination to improve patient outcomes and ultimately reduce healthcare costs. The specific conditions and procedures targeted by HRRP for high readmission rates are acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), coronary artery bypass graft (CABG), total hip/knee arthroplasty (THA/TKA) and pneumonia.
The CMS hospital-specific report (HSR) provides information on institutional performance on readmissions through advanced practice registered nurses (APRNs) (Rachoin et al., 2024). APRNs can use this report to identify at-risk populations, assess needed gaps in transitional care, and implement appropriate evidence-based strategies, specifically patient education, medication reconciliation, and linkage to community resources to improve health outcomes and prevent unnecessary rehospitalizations.
1c. Select one patient case scenario from the “CDM2 Patient Case Scenarios” and:
- Describe the pre-existing conditions that predisposed the patient to the condition and hospitalization.
A 55-year-old Hispanic man presented with several chronic conditions that would increase the risk of a myocardial infarction. These conditions included 15 years of hypertension, obesity (BMI of 35 kg/m²), and hyperlipidemia, a prototypical set of conditions that predispose to coronary artery disease. Adding to his increased cardiovascular risk was his sedentary life, his consumption of a large amount of fast food, and his lack of exercise. More importantly, his most recent primary care visit was more than seven months prior, signifying poor continuity of care in managing chronic disease.
- Discuss one SDOH that could impact the patient condition.
One of the real SDOHs that may affect this patient’s recovery and future status is nutrition and diet. While he lives within walking distance of a grocery store and in a neat, walkable neighborhood, the patient eats fast or cafeteria food 6–8 days a week. This could represent time limitations from his work in teaching, limited meal planning ability, or minimal education on a healthy diet (Jiao, 2024). This eating habit is a risk factor for controlling lipid and blood pressure and is counter to the American Heart Association dietary guidelines at discharge.
- Describe one intervention that addresses the SDOH to prevent readmission within 30 days or less.
Referral to a cardiac rehabilitation program that also includes nutrition education and counseling is essential to treat this SDOH and avoid 30-day readmission. The patient also must be referred to a registered dietitian in his network of primary care providers to create personalized meal plans (Zaree et al., 2023). Motivational interviewing and culturally sensitive education materials will prompt sustainable dietary changes.
In addition, the APRN has to set up a follow-up appointment with the primary caregiver between 7 days and 10 days after discharge to check if medications are being taken, review the changes in habits and reinforce learning; all these strategies focus on lowering early readmissions.
PHASE 2: IDENTIFYING EBP FOR THE PREVENTION OF HOSPITAL READMISSION
| CPE Activity | Date Completed | |
| 2a. | In the next step of the transition of care plan for the selected patient case scenario in Phase 1, research evidence-based practices that reduce hospital readmissions.
Note: information is located in Unit 2 of the course of study or search other scholarly sources. · Describe one evidence-based practice that could prevent hospital readmission for the selected patient case scenario in Phase 1. |
5/27/2025 |
| 2b. | · Review Public Health Interventions (Population-Based):
o Identify and describe one public health intervention for your selected patient within each level of practice: ▪ Individual/family-focused population based practice ▪ Community-focused population based practice ▪ Systems-focused population based practice |
5/27/2025 |
PHASE 2: CPE ACTIVITY EVIDENCE & TASK DELIVERABLES
2a. Describe one evidence-based practice that could prevent hospital readmission for the selected patient case scenario in Phase 1.
A highly evidence-based practice to reduce hospital readmission for myocardial infarction (MI) is enrollment in a structured cardiac rehabilitation (CR) program. Cardiac rehabilitation is a multidisciplinary approach combining supervised exercise training, education regarding risk factors and lifestyle modification, support with adherence to medication and psychosocial counseling (Taylor et al., 2021). The American Heart Association reports that patients participating in cardiac rehab see a 20–30% decrease in rehospitalization and a healthier cardiovascular profile.
For this patient, with risk factors including obesity, hypertension, hyperlipidemia, and a poor diet, cardiac rehabilitation allows for a customized plan to overcome these issues through education and behavior modification. Attending a program of this nature after discharge helps reinforce discharge guidelines, promotes American Heart Association diet adherence, helps discourage smoking and alcohol consumption, and stimulates the uptake of daily exercise, all of which are crucial to sustained recovery and minimizing 30-day readmission.
2b. Identify and describe one public health intervention for your selected patient within each level of practice:
- Individual/family-focused population based practice.
A home-based health coaching intervention can also be applied at the family member/individual level. The intervention involves assigning a case manager or nurse coach to support a one-on-one telephonic or home-based counseling session with the patient and his spouse (Mackintosh et al., 2020). The coach encourages adherence to medicine, tracks blood pressure and weight, and conducts diet and exercise counseling according to the patient’s cultural and lifestyle requirements. The individualized connection enhances self-efficacy, decreases apprehension, and fosters trust in the recovery process.
- Community-focused population-based practice.
Support groups and community-based cardiovascular health workshops are effective at the community-based level. For instance, a neighborhood community center or church-based organization can offer bilingual monthly workshops on healthy heart habits, stress reduction, and recovery from MI. These interactive sessions promote peer support and collective learning. The intervention leverages pre-existing social connections to facilitate a support network as the patient is also active in church and neighborhood-based organizations.
- Systems-focused population based practice.
At the system level, placing an integrated electronic health record (EHR) system between the hospital, primary care physician, cardiologist, and cardiac rehabilitation clinic ensures seamless communication (Font & Davoody, 2025). A system like that preempts missed appointments, facilitates real-time reconciliation of medications, and makes it possible for stakeholders to see the patient’s status after discharge. It also facilitates appointment scheduling and care coordination. System-wide integration is one of the pillars of avoiding fragmentation of care and enhancing patient outcomes at a population level.
PNASE 3: DEVELOPMENT OF A HOSPITAL PREVENTION PLAN
| CPE Activity | Date Completed | |
| 3a. |
o Review the five standards from Transitions of Care Standards: A New Way Forward at ACMA-Transitions-of-Care-Standards_Final_06132023.pdf (transitionsofcare.org) o Briefly describe each the five standards (approximately 200-300 words). |
5/27/2025 |
| 3b. |
identified stakeholder about the selected patient. |
5/27/2025 |
| 3c. | · Record and post one 3–5 minute GoReact
· https://lrps.wgu.edu/provision/303936046 · Discuss what you accomplished and learned from each of the three phases of the CPE. · Watch two peers’ videos and provide them encouraging and constructive feedback. · Take a screenshot of your video including your name and your peers’ videos with your comments and paste them into your document prior to the references. |
5/27/2025 |
| 3d. | · Write a brief reflection summary of your GoReact video discussing what you accomplished and learned from each of the three phases of the CPE.
|
5/28/2025 |
PHASE 3: CPE ACTIVITY EVIDENCE AND TASK DELIVERABLES
3a. Describe the five Transitions of Care Standards in 200-300 words.
Identify Patients at Risk for Ineffective Transitions of Care
This standard prioritizes the early discovery of those patients at increased risk of negative results after hospital discharge to home or alternative care environments. Risk factors include chronic conditions, limited health literacy, language issues, or a readmission history (Shahid et al., 2022). For instance, a 55-year-old Hispanic man with hypertension, hyperlipidemia, and obesity is at risk and needs to be identified early to allow support systems to be engaged before discharge.
Complete a Comprehensive Transition Assessment
It calls for a holistic evaluation of the patient’s medical, psychological, social, and functional requirements before discharge. It also ensures the care plan is tailored to address the patient’s circumstances. For the patient, assessment of lifestyle habits, activity limitations, and family support assists in formulating a transition plan that addresses lifestyle modification and extended recovery from myocardial infarction (Sachdeva et al., 2023).
Perform and Communicate a Medication Reconciliation:
A proper reconciliation of the medication ensures that the discontinued, new, and changed drugs are screened and clarified. It avoids drug-related adverse events and confusion. It includes assuring that the new drugs like atorvastatin, atenolol, and clopidogrel are confirmed and the patient and his primary physician are provided with a reconciled list of drugs.
Establish a Dynamic Care Management Plan
According to this standard, care plans are developed flexibly so that patients can have the same support as they move from one care environment to another. The plan must accommodate clinical requirements, lifestyle interventions, and patient preferences (Ricci et al., 2021). For the MI patient, these include drug management, diet modification, cardiac rehabilitation, and follow-up with providers. Updates on a routine basis allow the plan to adjust to fluctuating health status and recovery.
Communicate Essential Care Transition Information to Key Stakeholders
Timely discharge details must be communicated to involved providers. The patient’s hospital summary, medications, and rehabilitation referral must be communicated to his PCP, cardiologist, and rehabilitation coordinator. Having well-kept information reduces the chances of misunderstandings, keeps them from making errors and maintains consistency (Elmore et al., 2024). It is critical to coordinate care this way to guide a safe recovery and reduce the likelihood of being readmitted in the first 30 days.
3b. Identify 3 relevant stakeholders and describe what should be communicated to each stakeholder about the selected patient.
Clear communication is needed for the 55-year-old Hispanic male recovering from a heart attack to make his transition safe and keep him from being readmitted. Key stakeholders include the Primary Care Provider (PCP), the cardiologist and the cardiac rehabilitation coordinator. The PCP wants a discharge summary including the admission diagnosis, the angioplasty and stent placement description, and all medications prescribed (clopidogrel, aspirin, lisinopril, atenolol and atorvastatin).
Additionally, the provider must know the patient was last seen 7 months ago and is supposed to return within 7 days after leaving the hospital (Lee et al., 2020). Important instructions also include changing a person’s diet and activity based on the guidelines provided by the American Heart Association. It also helps with the management of ongoing health problems such as hypertension and hyperlipidemia and with ongoing follow-up after discharge.
Cardiologists are the most important for cardiac recovery and the continuation of chronic diseases. Cardiologists must be able to produce hospitalization records, angioplasty test results and details of the stent. Communication must include drug regimens, hospital complications, and cardiac function status
. It is crucial to confirm the follow-up appointment with the cardiology clinic within two weeks of discharge (Zwack et al., 2023). The cardiologist will follow the patient’s cardiovascular recovery, adjust prior medications as needed, and advise on secondary prevention measures like lipid management and stress testing.
The cardiac rehabilitation coordinator will initiate the patient’s recovery process. The stakeholder must be provided with referral documentation, patient contact information, and insurance for timely registration. The patient’s current physical status, any activity limitation or restriction of mobility, and psychosocial factors must also be indicated.
There must also be communication to ensure cardiac rehabilitation is set to start within a week (Tessler et al., 2025). Early incorporation into rehab fosters recovery of body functions, adherence to medication, and education, greatly minimizing the chance of readmission.
3c. Three screenshots from your GoReact activities:
Hello. My name is [Deiokie Rambally], and here is my reflection on Phase 3 of the D028 Clinical Practice Experience. This CPE opened my eyes to how crucial individualized, patient-oriented care is to effective care transition and hospital readmission reduction. I enjoyed how the three phases complemented one another and assisted me in developing a complete picture of transitional care’s public health and clinical dimensions.
In Phase 1, I selected a 55-year-old Hispanic man who was hospitalized following a myocardial infarction. What impressed me the most in this phase was how pre-existing conditions such as hypertension, obesity, and hyperlipidemia synergize with environmental and lifestyle factors to determine patient risk. I understood the importance of evaluating the patient’s clinical diagnosis and the patient’s routine, support network, and social determinants of health. For instance, the patient eats fast food and walks once a week, even if he lives in a walkable area.
These factors may not register on lab tests, but they significantly impact recovery and readmission risk. I also learned that we cannot issue comprehensive discharge plans. Instead, we have to create care plans that consider the patient’s actual life, such as what they can and are willing to do, culturally appropriate advice, and achievable goals.
During Phase 2, I delved into cardiac rehabilitation as the best evidence-based practice to decrease hospital readmission. I enjoyed this portion of the project immensely because I could clearly appreciate the power of formal post-discharge programs. Cardiac rehabilitation not only deals with recovery from a physical standpoint, but nutrition, education, and patient support are also addressed. I also understood how public health interventions on the individual, community, and systems levels assist in supporting those endeavors.
For instance, one-on-one health coaching reinforces the individual, whereas education workshops in the community and electronic health records assist in weaving a support network around the patient. These aspects of the project brought home how connected our systems are and how nurses can positively impact outside of the bedside.
Phase 3 also brought everything together. Studying the ACMA Transitions of Care Standards provided a framework to analyze and enhance care transitions. I especially resonated with the focus on communication and accountability. Standard 5 (Communicate Essential Information to Stakeholders) resonated with me because I could see how frequently care falls through when providers are not communicating with one another. For my patient, the primary care physician, cardiologist, and cardiac rehab manager each needed the same info but often failed to document it unless someone prioritized it.
I saw how crucial it is for nurses to be at the forefront of accurate, timely communication during these transitions. Even minor delays can lead to significant issues. Just scheduling follow-ups too late or avoiding medication changes can put the patient at risk.
Overall, I viewed the whole picture of discharge planning and readmission reduction. I learned skills in evaluating SDOH, crafting individualized interventions, and collaborating with interprofessional teams. It also brought back to mind the ability that we, as advanced practice nurses, have to advocate clinically, socially, and structurally.
I recognize now that readmission reduction isn’t about sending somebody home with instructions; it’s about putting a safety net of education, assistance, follow-up, and communication into place. I will take this experience with me into my future practice and apply it to enhance how I transition patients out of the acute care environment and into safe and supported recovery.
- one screenshot of your video, including your name.
- two screenshots of your peers’ videos with your written feedback.
3d. Written reflection summary of your GoReact video discussing what you accomplished and learned from each of the three phases of the CPE.
Completing the GoReact video and reflection after each phase of the Clinical Practice Experience (CPE) permitted me to consolidate and apply advanced nursing concepts to fundamental care transitions. Through Phase 1, I mastered identifying pre-existing conditions and evaluating social determinants of health (SDOH) to individualize care plans and proactively minimize readmission hazards. Through Phase 2, I learned evidence-based practices, including cardiac rehabilitation and public health interventions at individual, community, and systems levels, which expanded my view of coordinated care strategies.
Through Phase 3, I learned the ACMA Transitions of Care Standards, emphasizing the timeliness and correctness of provider-to-stakeholder communications. This reinforced my nurse leadership role in ensuring safe, effective discharge. I have learned the most critical skills in holistic assessment, interdisciplinary collaboration and patient advocacy that affect my future practice considerably in decreasing avoidable hospital readmissions.
References
Elmore, C. E., Elliott, M., Schmutz, K. E., Raaum, S. E., Johnson, E. P., Bristol, A. A., Conroy, M. B., & Wallace, A. S. (2024). Assessing patient readiness for hospital discharge, discharge communication, and transitional care management. The Journal of the American Board of Family Medicine, 37(4), 706–736. https://doi.org/10.3122/jabfm.2023.230172r3
Font, M., & Davoody, N. (2025). Optimizing an electronic health record system used to help health care professionals comply with a standardized care pathway for heart failure during the transition from hospital to chronic care: Qualitative semistructured interview study. JMIR Medical Informatics, 13, e63665. https://doi.org/10.2196/63665
Jiao, L. (2024). Social determinants of health, diet, and health outcome. Nutrients, 16(21), 3642. https://doi.org/10.3390/nu16213642
Lee, Y. S., King, M. D., Anderson, D., Cleary, P. D., & Nembhard, I. M. (2020). The how matters. Medical Care, 58(7), 643–650. https://doi.org/10.1097/mlr.0000000000001342
Mackintosh, N. J., Davis, R. E., Easter, A., Rayment-Jones, H., Sevdalis, N., Wilson, S., Adams, M., & Sandall, J. (2020). Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings. Cochrane Library, 2020(12). https://doi.org/10.1002/14651858.cd012829.pub2
Rachoin, J., Hunter, K., Varallo, J., & Cerceo, E. (2024). Impact of time from discharge to readmission on outcomes: An observational study from the US National Readmission Database. BMJ Open, 14(8), e085466. https://doi.org/10.1136/bmjopen-2024-085466
Ricci, L., Villegente, J., Loyal, D., Ayav, C., Kivits, J., & Rat, A. (2021). Tailored patient therapeutic educational interventions: A patient‐centred communication model. Health Expectations, 25(1), 276–289. https://doi.org/10.1111/hex.13377
Sachdeva, P., Kaur, K., Fatima, S., Mahak, F., Noman, M., Siddenthi, S. M., Surksha, M. A., Munir, M., Fatima, F., Sultana, S. S., Varrassi, G., Khatri, M., Kumar, S., Elder, M., & Mohamad, T. (2023). Advancements in myocardial infarction management: Exploring novel approaches and strategies. Cureus, 15(9). https://doi.org/10.7759/cureus.45578
Shahid, R., Shoker, M., Chu, L. M., Frehlick, R., Ward, H., & Pahwa, P. (2022). Impact of low health literacy on patients’ health outcomes: A multicenter cohort study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08527-9
Taylor, R. S., Dalal, H. M., & McDonagh, S. T. J. (2021). The role of cardiac rehabilitation in improving cardiovascular outcomes. Nature Reviews Cardiology, 19(3), 180–194. https://doi.org/10.1038/s41569-021-00611-7
Tessler, J., Ahmed, I., & Bordoni, B. (2025, March 28). Cardiac rehabilitation. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK537196/
Zaree, A., Dev, S., Khan, I. Y., Arain, M., Rasool, S., Rana, M. A. K., Kanwal, K., Bhagat, R., Prachi, F., Puri, P., Varrassi, G., Kumar, S., Khatri, M., & Mohamad, T. (2023). Cardiac rehabilitation in the modern era: Optimizing recovery and reducing recurrence. Cureus, 15(9). https://doi.org/10.7759/cureus.46006
Zwack, C. C., Smith, C., Poulsen, V., Raffoul, N., & Redfern, J. (2023). Information needs and communication strategies for people with coronary heart disease: A scoping review. International Journal of Environmental Research and Public Health, 20(3), 1723. https://doi.org/10.3390/ijerph20031723
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Question 
MSN Core Word E-Portfolio Template
Student Name:
Course Name:
Instructions:
To fulfill the requirements for this course, you must complete the CPE Record. Refer to the CPE Record under “Supporting Documents” in your Assessment Task Overview for specific deliverables. You must include the required deliverables from that CPE Record in this e-portfolio.
Enter your written deliverables (e.g., reflections, etc.) into this template for each phase. Download and save this template, then type directly into the template.
If necessary, you may also insert content from previously created Word documents into this Word document template by using the following instructions. You can upload a Word or PDF file as a separate document only if the instructions indicate it is appropriate to do so.
MSN Core Word E-Portfolio Template
To insert text from a previously created Word file, follow these instructions:
- Highlight the text you want to insert into the ePortfolio template. (You can choose to “Select All” if you want to copy and paste the entire content of the text into the ePortfolio template.)
- Copy the text.
- Paste the text into the ePortfolio template. You can reformat the content once it is pasted into the ePortfolio template if necessary.
To insert text or an image from a previously saved PDF document follow these instructions:
- Highlight the text or image you want to insert into the ePortfolio template. (You can choose to “Select All” if you want to copy and paste the entire content of the PDF document into the ePortfolio template.)
- Copy the text/image.
- Paste the text/image into the ePortfolio template at the appropriate location in the template. You can reformat the content once it is pasted into the ePortfolio if necessary.
NOTE: DO NOT insert a screen shot of the text from the word document or a PDF as it will not show the complete content on the ePortfolio template. However, you may use a screen shot when indicated in the instructions such as for the GoReact deliverables or if you are inserting an image such as a certificate, etc.
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