Annotated Training Agenda for Interprofessional Implementation of Medication Therapy Transition Care Program in Heart Failure Units
Overview
This document outlines a structured two-hour training agenda designed to equip an interprofessional pilot group of nurses, pharmacists, and care coordinators with the knowledge and skills to implement a Medication Therapy Transition Care Program (MTCP) in heart failure units. The training emphasizes reducing 30-day readmission rates, achieving HRRP compliance targets, and improving patient self-management through evidence-based transitions of care including teach-back education, medication reconciliation, follow-up calls, and social determinants of health screening.
What this coursework covers
- Introduction and training objectives focused on MTCP implementation, HRRP compliance, and readmission reduction
- Understanding MTCP with overview of key provisions including teach-back education, medication reconciliation, follow-up protocols, and SDOH screening
- Roles and responsibilities clarifying interprofessional duties for nurses, pharmacists, and care coordinators with emphasis on team collaboration
- Training strategies employing hands-on activities including skill stations, role-play scenarios, and return demonstrations
- Q&A session and next steps with resource distribution and follow-up meeting scheduling
Preview
Annotated Training Agenda
Objective:
Equip the interprofessional pilot group, including nurses, pharmacists, and care coordinators on the heart failure unit, with the knowledge, skills, and confidence to implement the MTCP. This will improve 30-day heart failure readmission rates, reduce ERR under HRRP, and enhance patient self-management and care coordination.
Date, Time, Duration:
February 15, 2026
Time: 9:00 AM – 11:00 AM (2 Hrs.)
Training Agenda
Training Agenda Outline | Annotation |
Introduction Welcome and icebreaker (quick round-robin: share one challenge in HF transitions) Overview of training goals and agenda Importance of MTCP and its impact on patient care and organizational goals (HRRP compliance, reduced penalties up to 3%, better outcomes) | This sets a collaborative tone, builds buy-in by connecting policy to real-world benefits, and addresses why the pilot matters. Interactive start empowers participants early. |
Understanding MTCP Brief overview of MTCP purpose, scope, and objectives (reduce 30-day HF readmissions via evidence-based transitions) Key provisions: Teach-back education, medication reconciliation, 72-hour/weekly follow-up calls, SDOH screening, community linkage Link to HRRP benchmark (ERR ≤1.0 target) and organizational underperformance | Clear explanation ensures foundational knowledge. Visual aids (policy one-pager handout) reinforce understanding of how components address root causes like non-adherence and poor coordination. |
Roles and Responsibilities Identify pilot roles: Nurses (education/follow-up), Pharmacists (reconciliation/calls), Care Coordinators (SDOH navigation) Discuss responsibilities within MTCP (e.g., nurses lead teach-back, pharmacists verify meds) Highlight interprofessional collaboration (shared dashboard, handoffs). | Emphasizes team synergy in multidisciplinary care, critical for success in transitional programs. Discussion promotes ownership and clarifies workflow changes. |
Training Strategies Brainstorming: Share insights/questions on MTCP integration Group discussions: Practical scenarios (e.g. More Nursing samples |