How would one provide an evaluation plan describing a clear explanation of how the project will be evaluated after it is implemented?

How would one provide an evaluation plan describing a clear explanation of how the project will be evaluated after it is implemented?

The project is preventing 30- day heart failure readmission rates within a 1-year timeframe. The intervention will consist of an educational discharge program, similar to the one that we have but it will staff a specialized heart failure nurse consultant. Think of a lactation consultant but for heart failure. The hospital may need to staff a few HF nurse consultants since the goal would be to have someone on call even for weekend discharges. The HF nurse consultant will spend time with the patient prior to discharge and discuss the new HF diagnosis, signs, and symptoms to monitor and when to call the doctor, newly prescribed medications, the importance of checking daily weights, sticking to a low sodium diet, fluid restrictions and the importance of attending the cardiac rehabilitation exercise program. The HF nurse consultant will visit the patient’s home within 48 hours of discharge to make sure they have received their medications, go over the medication list and set up a medication regimen for the patient. If the patient was unable to get the prescribed medication d/t cost, the consultant will bring samples and reach out to the medication assistance program through the hospital for help or reach out to the cardiologist to see if a change of medication is warranted. The consultant will bring the remote monitoring equipment to set up at the patient’s home and show them how to use it. The remote monitoring equipment allows the patient to track their daily weight, blood pressure and heart rate while it sends directly to our heart failure clinic for review. The HF nurse consultant will also review the patient’s typical diet and provide teaching, references, and resources on grocery shopping and cooking for a heart failure diet. Lastly, the nurse consultant will ensure the patient has an appointment with their family doctor within 1 week of discharge, the outpatient heart failure clinic within 2 weeks and the cardiologist in 4 weeks. The patient will also be given easy to follow educational materials to keep for reference.

The evaluation plan requires measurable outcome indicators along with the frequency by which each indicator would be measured, e.g. once a week, twice a month, every six months, annually.  Who will be responsible for collecting the measurement data and how will the data be collected?  In addition, please describe to whom the data will be reported and the person responsible for adjusting the plan to ensure its sustainability over time.