Final Care Coordination Plan

Final Care Coordination Plan

Demographic trends reveal a steady increase in chronic disorders. Despite these increases and the growing prevalence of chronic disorders, chronic care has not significantly improved (Lee & Bae, 2019). Care coordination approaches provide a groundwork for quality improvements in chronic care. Care coordination details the systematic organization of healthcare activities to patients towards enhancing their patient experiences and clinical outcomes. Coordination approaches maintain significance in heart diseases. Their use in these conditions has been associated with better clinical outcomes and enhanced patient experiences. This paper details the healthcare issues apparent in patients with heart diseases, interventions to manage these issues, and ethical and policy provisions affecting care coordination for these health issues.

Patient-Centered Health Interventions and Timelines for a Selected Health Care Problem

The patient-centered model remains a valuable care model in modern healthcare. This model details the provision of care that is responsive to and respectful of patients’ needs, demands, and preferences. This caring approach maintains significance in the coordination and continuum of care for patients with heart diseases. Health issues that may influence care processes for patients with heart disease include poor disease control, the development of complications, and community preventive programs to lower the incidence of the disease.

Healthcare Issues, Interventions, and Community Resources

Optimizing disease control in heart diseases may sometimes present a challenge to the healthcare system. These challenges are mainly attributable to patient factors such as medication adherence. Optimal disease control in heart diseases is warranted to prevent disease exacerbation, complications of these diseases, and deaths. Poor medication adherence is a source of compromise to high-value, high-quality care for patients with heart diseases. Rehman et al. (2019) report that poor adherence and non-adherence are common among patients with heart diseases. Poor disease control has been implicated in disease exacerbation, increased hospital admissions and readmission, and even death. This highlights the need to address this issue.

Several interventions can be applied to address poor disease control in heart diseases. Educating and empowering the patients to understand their medication and therapeutic regimen may enhance their medication compliance. Another intervention is ensuring access to caregivers during the care continuum by nurturing healthy patient-caregiver relationships, which may also be valuable. Lessening barriers to accessing medication, such as implementing policies on medication pricing, may also be helpful (Rehman et al., 2019). These measures may effectively enhance compliance and enable optimal control of heart diseases.

The community resources that could be valuable in implementing these interventions include healthcare institutions, the CDC, and the American Heart Association (AHA). AHA champions quality care for patients with heart diseases. It also gives recommendations on therapeutic approaches that optimize disease control. The CDC provides information on effective interventions necessary for managing heart disease. These resources are valuable in optimizing disease control.

Implementation of preventive approaches for heart diseases is another healthcare issue in heart diseases. Preventive interventions against heart diseases effectively lower the likelihood of developing these diseases. This has, however, been a challenge in some community groups. Gupta & Yusuf (2019) assert that the prevention of heart diseases and the consequent complications from these diseases remain poor among persons from low socioeconomic backgrounds. This is because these groups are disproportionately affected by traditional problems of poor access to healthcare, high illiteracy levels, and poverty.

Enhancing access to healthcare and healthcare resources plays a role in increasing the utilization of the available preventive measures for heart diseases. This can be attained by improving these groups’ healthcare availability, affordability, and acceptability. Primary preventive intervention in this regard should be centered on addressing the social determinants of health. It should also focus on policies and behavioral interventions for modulating risk factors for these diseases.

Community resources valuable in implementing these interventions include the American Heart Association, the CDC, and the National Heart, Lung, and Blood Institute (NHLB). NHLB and the CDC provide information on heart diseases and preventive interventions for these diseases. These resources also encourage preventive measures for these diseases to lower their incidence. They are thus helpful in promoting preventive approaches to heart diseases.

Heart disease complications remain a concerning healthcare issue among patients with heart disease. McClellan et al. (2019) report that failure to diagnose heart diseases presents a missed opportunity to manage the disease effectively. The rate of cardiovascular complication is high among undiagnosed patients, with up to 40% of complications given to the acute care being of undiagnosed patients. Cardiovascular complications have been implicated in many hospitalizations and deaths, underlining the need for addressing them. Timely diagnosis of heart disease is key in preventing cardiovascular complications among patients with heart diseases.

Community screening for heart diseases may enable early detection of heart diseases before they progress to develop complications. Early detection of heart diseases enables the initiation of therapeutic interventions that are critical in slowing the progression of these diseases. This may considerably lower the incidence of cardiovascular complications. Community screening programs for heart diseases are a concerted effort that requires input between communities and the healthcare system. Their effectiveness in increasing the number of patients under therapeutic management underpins their significance.

Community resources valuable in community screening for heart diseases include healthcare institutions, the CDC, and the AHA. Healthcare institutions are involved in the actual implementation of community screening programs. The CDC and AHA encourage screening by providing evidence-based information on the significance of screening and advocating for them. This increases the uptake of these programs at the community level.

Ethical Decisions in Designing Patient-Centered Health Interventions

Designing patient-centered health interventions requires ethical decision-making to address various ethical concerns that may present. The ethical provision of beneficence, non-maleficence, and autonomy remains vital. Beneficence and non-maleficence require that healthcare providers, constituting interdisciplinary healthcare teams, design therapeutic approaches that promote the welfare of the patients and do no harm to them. This means that these approaches must respect their personal beliefs and meet their preferences. This may be useful when initiating therapy.

Autonomy implores caregivers to give patients greater authority over their healthcare decisions. In this regard, providers should only facilitate their patients’ decision-making process. Uncertainties may arise during clinical ethical decision-making processes. Ethical dilemmas that often accompany ethical decision-making processes may generate points of uncertainty in ethical decision-making. An example of a moral question that may arise is a patient refusing an effective therapeutic plan because it is not aligned with their beliefs or values.

Relevant Health Policy for the Coordination and Continuum of Care

Policy provision maintains significance in the coordination and continuum of care. The Health Information Technology for Economic and Clinical Health (HITECH) Act is an example of a relevant health policy. This policy encourages the use of meaningful health technologies in healthcare. It remains an enabler for telehealth use in healthcare. Telehealth is a communication healthcare technology in the coordination and continuum of care. It provides a platform for monitoring the patients, educating them on drug use, and addressing their concerns (Ford et al., 2020). Policies that encourage the adoption of such technologies positively impact the coordination and continuum of chronic diseases such as heart disease.

Priorities that a Care Coordinator would Establish when Discussing the Plan with Patients and Family Members, Making Changes Based on Evidence-Based Practice

Care coordinators play a significant role in discussing care plans with their patients and family members involved in therapy. Information sharing and collaboration are the priority areas when discussing healthcare plans and making changes based on evidence-based practice. Information sharing is necessary to bring the patients and their families on board with the evidence-based change. Comprehensive care for heart diseases often warrants specific patient-based changes, such as behavior changes to optimize disease control. Such behavioral changes often target modifiable behaviors perpetuating the disease process, such as poor dieting (Laddu et al., 2021). Sharing this information with the patients and their family members may enable them to understand the significance of these changes. Collaboration creates healthy partnerships between the caregiver, the patients, and the family members, allowing them to give feedback on the therapeutic processes and their care needs. All these will positively impact the therapy process and enhance outcomes.

Literature on Evaluation and Healthy People 2030 Provisions

The goal of Healthy People 2030 on heart diseases is to improve cardiovascular health and lower mortalities attributable to heart disease and cardiovascular complications such as stroke. It reinforces the need for preventive measures for cardiovascular diseases to lower the likelihood of the disease and mortalities attributable to these disorders. The specific recommendation outlined in this regard includes improving the proportion of heart attack survivors who access rehabilitation centers and participate in rehabilitative programs, reducing deaths from stroke and coronary heart diseases, and reducing the proportion of adults with CKD who have high blood pressure. Healthy People 2030 also advocates for emergency preparedness for patients with cardiovascular complications and the availability of hospital and emergency services for patients with these diseases.

These provisions are aligned with the requirements of the literature on health diseases. They both advocate for preventive measures and disease control to lower the likelihood of these diseases and consequent morbidity and mortality. However, Healthy People 2030 is diverse and more specific in its approach. It focuses on individual heart diseases and details particular objectives for every healthcare issue that each heart disease presents. It also recommends government-level initiatives to tackle these illnesses. These additions can be effectively integrated into the teaching session to broaden the scope for addressing these issues.

Care coordination approaches in heart disease remain essential in comprehensively managing these diseases. These diseases often present specific healthcare issues that influence interventions on them. Optimal disease control and prevention are some problems that directly affect care interventions for heart diseases. Ethical decision-making is warranted in designing patient-centered interventions for these issues. Policies such as the HITECH Act that have implications on disease interventions also maintain relevance in the comprehensive management of these diseases. Coordinating care between the patients and their family members is also valuable in ultimately managing heart disease.

References

Ford, D., Harvey, J. B., McElligott, J., King, K., Simpson, K. N., Valenta, S., Warr, E. H., Walsh, T., Debenham, E., Teasdale, C., Meystre, S., Obeid, J. S., Metts, C., & Lenert, L. A. (2020). Leveraging health system telehealth and Informatics Infrastructure to create a continuum of COVID-19 screening, testing, and treatment services. Journal of the American Medical Informatics Association, 27(12), 1871–1877. https://doi.org/10.1093/jamia/ocaa157 

Gupta, R., & Yusuf, S. (2019, November 26). Challenges in management and prevention of ischemic heart disease in low socioeconomic status people in LLMICs – BMC Medicine. BioMed Central. Retrieved November 24, 2022, from https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1454-y 

Laddu, D., Ma, J., Kaar, J., Ozemek, C., Durant, R. W., Campbell, T., Welsh, J., & Turrise, S. (2021). Health behavior change programs in primary care and community practices for cardiovascular disease prevention and Risk Factor Management among midlife and older adults: A scientific statement from the American Heart Association. Circulation, 144(24). https://doi.org/10.1161/cir.0000000000001026 

Lee, J. J., & Bae, S. G. (2019). Implementation of a care coordination system for chronic diseases. Yeungnam University Journal of Medicine, 36(1), 1–7. https://doi.org/10.12701/yujm.2019.00073

McClellan, M., Brown, N., Califf, R. M., & Warner, J. J. (2019). Call to action: Urgent challenges in cardiovascular disease: A presidential advisory from the American Heart Association. Circulation, 139(9). https://doi.org/10.1161/cir.0000000000000652

Rehman, Z. U., Siddiqui, A. K., Karim, M., Majeed, H., & Hashim, M. (2019). Medication non-adherence among patients with heart failure. Cureus. https://doi.org/10.7759/cureus.5346.

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For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices in the literature.

Introduction
NOTE: You must complete this assessment after Assessment 1 is completed.

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses must provide the necessary knowledge and communication to ensure seamless care transitions. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected healthcare problem.

Before completing this assessment, you are encouraged to complete the Vila Health: Cultural Competence activity. Completing course activities before submitting your first attempt has been shown to make the difference between primary and proficient assessments.

Preparation
In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices in the literature.

You will research the literature on your selected healthcare problem to prepare for your assessment. When discussing the plan with a patient and family, you will describe the priorities a care coordinator would establish. You will identify changes to the plan based on EBP and discuss how the plan includes elements of Healthy People 2030.

Instructions
Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

Build on the preliminary plan developed in Assessment 1 to complete a comprehensive care coordination plan.
Document Format and Length
Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages long, not including a title page and reference list.

Supporting Evidence
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. https://health.gov/healthypeople. Cite at least three credible sources.

Grading Requirements
The requirements outlined below correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Design patient-centered health interventions and timelines for a selected healthcare problem.
Address three healthcare issues.
Design an intervention for each health issue.
Identify three community resources for each health intervention.
Consider ethical decisions in designing patient-centered health interventions.
Consider the practical effects of specific decisions.
Include the ethical questions that generate uncertainty about the decisions you have made.
Identify relevant health policy implications for the coordination and continuum of care.
Cite specific health policy provisions.
Describe priorities a care coordinator would establish when discussing the plan with a patient and family member, making changes based on evidence-based practice.
Clearly explain the need for changes to the plan.
Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
Use the literature on evaluation as a guide to compare learning session content with best practices.
Align teaching sessions to the Healthy People 2030 document.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Organize content so ideas flow logically with smooth transitions; contain few errors in grammar/punctuation, word choice, and spelling.
Additional Requirements
Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.