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Preliminary Care Coordination Plan- Ensuring Comprehensive Support for Optimal Health Outcomes

Preliminary Care Coordination Plan- Ensuring Comprehensive Support for Optimal Health Outcomes

Chronic Disease Management

The effective management of chronic diseases, especially diabetes, requires the coordination of efforts from an interdisciplinary team. With budget cuts and case management staff being relocated to the inpatient setting, care coordination for diabetes patients in community settings becomes complicated. This paper develops a preliminary care coordination plan for diabetes mellitus integrating best practices, including physical, psychosocial, and cultural needs considerations and available community resources to support the highest level of quality patient-centered case management at the community level.

Diabetes as a Health Care Problem

Diabetes is among the most prevalent chronic conditions in the United States. It develops as a result of the body’s pancreas failing to produce sufficient insulin or due to the inability of the body to effectively utilize the produced insulin (Centers for Disease Control and Prevention (CDC), 2024). New arguments and evidence link and relate autoimmune processes to the development of Type 2 diabetes (De Candia et al., 2019). An estimated 38 million adults in the U.S. have diabetes, and 1 in every 5 who have diabetes remains undiagnosed (Centers for Disease Control and Prevention (CDC), 2024). Type 2 diabetes requires carefully coordinated and comprehensive management as it is a leading cause of cause of kidney failure, lower-limb amputations, and adult blindness (CDC, 2024). It is also associated with other complications, such as cardiovascular disease, the 8th leading cause of death, and a major contributor to cardiovascular and cancer deaths (Zhang et al., 2020). Due to the high prevalence and associated complications, effective care coordination is essential, especially in community settings with restricted staffing and financing levels.

Best Practices for Health Improvement in Diabetes Management

The best practices for effective care coordination for diabetes management at the community level consider the individual needs of each patient case including the physical, psychosocial, and cultural factors in order to improve health.

The best practices consider physical factors for health improvement in regular diabetes monitoring, the use of telehealth services, and physical assessments for associated chronic conditions. Regular monitoring of patients focuses on consistently checking on the levels of blood glucose to avoid complications. It involves the provision of resources for self-monitoring, including glucose meters. The use of telehealth services is an evidence-based best practice that significantly helps overcome physical barriers to access to diabetes care, improves the efficiency of practitioners (Becevic et al., 2020), and supports remote collaboration and patient education for improved diabetes self-management (Sharma et al., 2022).

Psychosocial considerations include patient and family levels of understanding of diabetes and available support. The best practices to improve health for both patients and their families include providing patient- and family-focused health education focusing on best self-management practices such as exercises and diet, identification of symptoms for complications, and strategies to improve medication adherence. Noting that mental health issues such as depression are common with diabetes (Chandra et al., 2020), it is important to provide mental health services, including counseling and establishing access to a community level and an online social support network for diabetes patients to improve coping with the condition.

Further, cultural considerations are critical in developing best practices for health improvement in diabetes case management. These include a consideration of the patient’s and family’s language preferences and fluency, cultural practices with regard to health, foods and culture, eating habits, and cultural views on diabetes. Best practices include ensuring the available members of the interdisciplinary team are culturally competent and respect the culture of the patient and their people during the development of the care plan. It also includes the use of languages the patient and their families prefer or the use of interpreters to overcome any language barriers and deliver more patient-centered, culturally sensitive care (Handtke et al., 2019).

Goals for Addressing Type 2 Diabetes in Community Settings

The care coordination plan for diabetes case management in community settings has three SMART (Specific, Measurable, Achievable, Realistic, and Timely) goals:

SMART Goal 1: Increase the rate of access to diabetes care for diagnosed cases in the community by 50% in the first three months and 90% within nine months. This will be achieved through case-targeted health education, the promotion of diabetes, and the availability of a local base diabetes care kit.

SMART Goal 2: Increase patient and family engagement in diabetes care planning and care for diabetes by 80% within three months after diagnosis. This will be focused on improving self-management among the patients and providing skills to their families to act as a support and social network for the patient.

SMART Goal 3: Increase the rate of screening for diabetes at the community level by 95% within six months. This goal will promote the adoption of a more preventative approach to diabetes management by improving the number of individuals screened and who know their diabetes status. The goal will be achieved through comprehensive community-wide diabetes health education and promotion.

Available Community Resources for a Safe and Effective Continuum of Care

There are sufficient and easily accessible community resources that can sustainably support the safe and effective continuum of care for diabetes patients in community settings despite the budget and staffing cuts. Specifically:

Conclusion

Diabetes type 2, being the most prevalent type of diabetes and a major chronic condition affecting the U.S. population, and with an impact on the healthcare systems, requires a multidisciplinary and multi-faceted approach to manage. Regardless of budget and staffing deficits, care needs to be individualized to the patient’s case with a consideration of the individual’s physical, psychosocial, and cultural needs and the available community resources. Integrating both the best practices with community resources supports the provision of patient-centered and person-focused diabetes care.

References

Becevic, M., Sheets, L. R., Wallach, E., McEowen, A., Bass, A., Mutrux, E. R., & Edison, K. E. (2020). Telehealth and Telemedicine in Missouri. Missouri Medicine, 117(3), 228. /PMC/articles/PMC7302013/

Centers for Disease Control and Prevention (CDC). (2024, January 10). Diabetes Basics. Diabetes | CDC. https://www.cdc.gov/diabetes/about/?CDC_AAref_Val=https://www.cdc.gov/diabetes/basics/diabetes.html

Chandra, M., Raveendranathan, D., Johnson Pradeep R., Patra, S., Rushi, Prasad, K., & Brar, J. S. (2020). Managing Depression in Diabetes Mellitus: A Multicentric Randomized Controlled Trial Comparing Effectiveness of Fluoxetine and Mindfulness in Primary Care: Protocol for DIAbetes Mellitus ANd Depression (DIAMAND) Study. Indian Journal of Psychological Medicine, 42(6_suppl). https://doi.org/10.1177/0253717620971200

De Candia, P., Prattichizzo, F., Garavelli, S., De Rosa, V., Galgani, M., Rella, F. Di, Spagnuolo, M. I., Colamatteo, A., Fusco, C., Micillo, T., Bruzzaniti, S., Ceriello, A., Puca, A. A., & Matarese, G. (2019). Type 2 diabetes: How much of an autoimmune disease? Frontiers in Endocrinology, 10(JULY), 451. https://doi.org/10.3389/FENDO.2019.00451/BIBTEX

Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE, 14(7), e0219971. https://doi.org/10.1371/JOURNAL.PONE.0219971

Sharma, V., Feldman, M., & Sharma, R. (2022). Telehealth Technologies in Diabetes Self-management and Education. Journal of Diabetes Science and Technology, 18(1), 148–158. https://doi.org/10.1177/19322968221093078

Zhang, Y., Pan, X. F., Chen, J., Xia, L., Cao, A., Zhang, Y., Wang, J., Li, H., Yang, K., Guo, K., He, M., & Pan, A. (2020). Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies. Diabetologia, 63(1), 21–33. https://doi.org/10.1007/S00125-019-04985-9

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Question 

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

Preliminary Care Coordination Plan- Ensuring Comprehensive Support for Optimal Health Outcomes

Preliminary Care Coordination Plan- Ensuring Comprehensive Support for Optimal Health Outcomes

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Introduction
The first step in any effective project is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular healthcare problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

NOTE: You are required to complete this assessment before Assessment 4.

Preparation
As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Scenario
Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.