Care Coordination Plan

Care coordination plays an essential role in managing chronic diseases, such as diabetes and cardiovascular disease, which are leading causes of mortality and morbidity in the United States. Proper coordination can prevent fragmented care, improve outcomes, and reduce the healthcare burden. Building on the preliminary care coordination plan developed for chronic disease management, this paper will evaluate and expand the initial plan, incorporating evidence-based practices and aligning it with Healthy People 2030 objectives. The plan focuses on addressing the healthcare needs of individuals with chronic diseases through patient-centered interventions and community resource integration.

 Patient-Centered Health Interventions and Timelines

Managing chronic diseases effectively requires targeted interventions focused on medication adherence, self-management education, and continuous monitoring. With the input of community resources and a time perspective of actions, all these interventions are supposed to help patients achieve better outcomes and have sustainable positive effects on their health.

Medication Adherence

Medication adherence is crucial for patients with chronic diseases, as non-compliance can lead to worsening symptoms, hospital readmissions, and increased healthcare costs. To respond to this, mobile health applications like the proposed Medisafe will be used to consult the patient on the times to take the medication and the dosage and notify the healthcare providers if the dosage is missed. Some counseling sessions shall also be timed to make the individuals understand the importance of adherence to the prescribed treatments. The target is to achieve a 30 percent higher compliance level within one year. Many facilities in and around Illinois, including but not limited to the Illinois Department of Public Health, will avail of educational support. Local pharmacies will offer medication synchronization services where the refills on most prescriptions will be due on the same date. Remote consultations through the use of telemedicine will be employed in the follow-up visits to assess patient progress.

Self-Management Education

Compliant patients who are fully aware of their ailment and the treatment offered are more likely to assume personal responsibility for their illness without developing complications. Patients will attend workshops regularly, with additional online support for reviewing the process, receiving instructions on symptom management, and making lifestyle changes. The goal of this intervention is to improve by at least 25% the level of participation of the patients in the management of their condition in the next year. These workshops will be made available through community health centers designed to ensure that individuals can get together and learn better ways of handling their health. Telehealth platforms will provide learning resources to ensure that people in remote locations can be educated on better ways of handling their health. Finally, patient support groups will provide peer coaching where patients can be encouraged by others who have recovered and have learned better ways of handling their health.

Monitoring and Follow-Up Care

Telemonitoring technology will evaluate patients’ predisposing factors, including blood pressure and glucose levels. At the same time, face-to-face visits will be conducted every six months to evaluate the patient’s general health and improvement. The goal is to cut the usage of the emergency center, as well as re-hospitalizations, by 20 percent within the following 18 months. The Illinois Telehealth Network (ITN), local emergency services, and chronic disease support programs will ensure that patients receive timely interventions and the resources they need to manage their conditions effectively (Haleem et al., 2021).

Ethical Considerations

Ethical decision-making is integral to patient-centered care, particularly in the management of chronic diseases, where various complexities arise. The following sections outline key ethical dilemmas and how they are addressed through patient-centered approaches.

Ethical Dilemmas in Care Coordination

Several ethical questions arise when making patient-centered health interventions. One major area of uncertainty is balancing patient autonomy with clinical guidelines. For example, if a patient prefers to use alternative medicine instead of evidence-based treatments, healthcare providers face the challenge of respecting the patient’s autonomy while also ensuring that the patient fully understands the risks of their choices. Is it ethical to allow the patient to proceed with alternative treatments if it could worsen their condition? This ethical dilemma often generates uncertainty, as providers must navigate between respecting patient choice and their responsibility to provide safe, evidence-based care (Adel Mehraban et al., 2024).

Cultural Competence and Patient Autonomy

Cultural competence is critical in ethical decision-making, especially when dealing with patients from diverse backgrounds. Preferential use of some form of treatment may be due to the cultural beliefs held by a particular culture regarding medical treatment. Such concerns mean that healthcare providers must be culturally sensitive to embrace these religious observations while extending research-based suggestions (Kwame & Petrucka, 2021). For instance, if a patient is comfortable with herbal medicines and not regular medicines, the provider should honor this choice provided the patient is emphasized on the pros and cons of both systems. This kind of respectful talk strengthens trust and cooperation in care setup.

Confidentiality in Care Coordination

Maintaining patient confidentiality is another crucial ethical consideration in care coordination. Healthcare providers must protect sensitive patient information while ensuring that relevant team members have access to the necessary data to deliver effective care. Adhering to confidentiality protocols ensures patient privacy and complies with legal and ethical standards.

Integrating patient self-governance, cultural awareness/sensitivity, and patient confidentiality to care coordination addresses all ethical issues while caring for the patient to prevent possible compromise between ethical theories and real-life care plans. The cultural component of these ethical principles is motivated by literature advocating for patient involvement and cultural competence in patient relationships.

Health Policy Implications

Health policies are critical in supporting the care coordination and management of chronic diseases. These policies directly influence how care is delivered, particularly for patients with long-term conditions requiring continuous monitoring and tailored interventions. Below are five essential health policy acts that are pivotal in chronic disease management.

Medicare’s Chronic Care Management (CCM) Services
Medicare’s CCM program pays healthcare providers to coordinate care for patients with two or more chronic illnesses. This policy ensures that the providers are paid to coordinate care needs, such as developing care plans and overseeing compliance with them. It cultivates constant interaction with patients and prevents frequent readmissions due to timely chronic disease monitoring.

Medicaid’s Health Homes Program
The Health Homes Program follows the Medicare care plan for every eligible enrollee with a medical condition and coordinates all care services. This way, a specific health home deals with primary, behavioral, and long-term care, decreasing fragmentation and increasing its integration. This policy improves patient-centered care by targeting the multiple needs of patients with chronic diseases.

The Affordable Care Act (ACA) – Section 2703
The ACA’s Section 2703 permits states to develop Medicaid Health Homes to provide physical, mental, and social support services for chronic conditions. Coordinated one-on-one care for the team-based care model provides the best results for vulnerable groups.

Telehealth Reimbursement Policies
Remarkably, electronic health reimbursement under Medicare and Medicaid supports the provision of virtual care services such as remote monitoring and teleconsultations. This makes care more available for people with chronic illnesses and boosts the ability to make necessary adjustments to patients they serve due to real-time information.

The Medicare Access and CHIP Reauthorization Act (MACRA)
MACRA’s Merit-based Incentive Payment System (MIPS) is based on the concept of measuring physician’s performance and providing incentives for delivering more effective, efficient, and collaborative care. It motivates patient care providers to select more efficient preventive measures and disease management interventions meant for patients with chronic illnesses.

Priorities for Care Coordinator

A care coordinator’s primary role is to ensure that patients with chronic diseases receive comprehensive, personalized care that addresses their specific needs. When discussing the care plan with the patient and their family, the coordinator must prioritize several critical areas based on evidence-based practices and patient input.

Improving Medication Adherence

The top priority in managing chronic diseases is ensuring that patients adhere to their prescribed medication regimens. Medication non-compliance is a leading cause of poor health outcomes and hospital readmissions. The care coordinator will focus on implementing tools like mobile health applications, such as Medisafe, to help patients track their medication schedules and send reminders for doses. Counseling sessions will be conducted to reinforce the importance of adherence. This priority is supported by evidence that shows improving adherence significantly reduces complications and hospitalizations (Aremu et al., 2022)​.

Changes to the care plan are often necessary to accommodate new evidence-based practices, patient preferences, and evolving health conditions. For example, if a patient is struggling with medication adherence due to a complex schedule, simplifying the medication regimen through the use of synchronized prescription refills may be necessary. This change would allow patients to manage their medications more effectively, reducing the risk of non-adherence and complications.

Patient Education

Empowering patients and their families through education is another crucial priority. Educating patients about their chronic condition, the importance of medication adherence, lifestyle changes, and self-management techniques helps improve their engagement in managing their health. Workshops and digital platforms will be provided to enhance understanding of their disease and treatment options. Evidence supports that educated patients are more likely to follow their care plans, improving long-term care.

Reducing Emergency Room Visits and Hospital Readmissions

Another important goal is to minimize emergency room visits and hospitalizations when they are avoidable. The care coordinator will ensure that telemonitoring devices are installed to monitor patient progress in case of complications and enable the healthcare givers to act appropriately.

Subsequent visits with the patient will be employed to check the patient’s compliance and overall improvement to affect the necessary changes. This priority is clearly linked to best practices since minimizing hospital readmissions enhances the quality of patient care and lowers the costs of the charges.

Shared Decision-Making and Patient Input

These priorities are based not only on best practices but also on patient and family input. Participation of patient empowers them and makes the treatment plan compatible with their desires, daily activities, and culture. For instance, when a patient has a problem with the complexity of the schedule of different medicines to take, the care coordinator can reorganize to make prescriptions from schedules that include simplified medication synchronization services that many pharmacies provide (Montori et al., 2022). Making a care plan in collaboration contributes to the improvement of the care plan by enhancing commitment to and quality results of the plan.

Applying such priorities based on evidence and engaging the patient and his family, the care coordinator guarantees that the care plan is going to be efficient and tailored. In particular, patient involvement in decision-making is key as it engenders a physician-patient relationship, leading to better patient status and increased satisfaction with the care process.

Learning Session Content and Best Practices

Education sessions should accompany chronic illnesses, and it is critical to integrate such sessions with best practices. Studies show that the education sessions should be centered on disease prevention, patient participation, and health disparity. With these learning sessions paralleled to best practices, healthcare providers are in a position to guarantee that the patients deliver the requisite tools regarding the ailment.

These sessions should follow Healthy People 2030 goals and objectives, including eliminating avoidable chronic disease complications and reducing health disparities. Self-management education, which involves learning how to take medications and what signs to look out for to indicate that a complication is imminent, fulfills these goals. Lecture teaching techniques are justified based on the effort to achieve patient activation, decrease admissions, and improve patients’ general quality of life.

Conclusion

To sum up, the final care coordination plan for chronic disease includes patient-centered interventions, ethical issues, and health policy aspects. The plan aims to ensure that patients receive an appropriate care plan that is personalized through medication adherence consultation, self-management education, and continuous monitoring. Issues of ethics, particularly self-determination, cultural sensibility, and legal requirements, are contained within this plan, and the standards of health care policies promote further care. Dedicated assessment or constant feedback from the patient will be needed to fine-tune this plan and reap the best results.

References

Adel Mehraban, M. S., Mosallanejad, A., Mohammadi, M., Tabatabaei Malazy, O., & Larijani, B. (2024). Navigating ethical dilemmas in complementary and alternative medicine: a narrative review. Journal of Medical Ethics and History of Medicine, 17(78), 3. https://doi.org/10.18502/jmehm.v17i3.15391

Aremu, T. O., Oluwole, O. E., Adeyinka, K. O., & Schommer, J. C. (2022). Medication adherence and compliance: Recipe for improving patient outcomes. Pharmacy, 10(5). https://doi.org/10.3390/pharmacy10050106

Haleem, A., Javaid, M., Singh, R. P., & Suman, R. (2021). Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International, 2(2), 100117. https://doi.org/10.1016/j.sintl.2021.100117

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(158). https://doi.org/10.1186/s12912-021-00684-2

Montori, V. M., Ruissen, M. M., Hargraves, I. G., Brito, J. P., & Kunneman, M. (2022). Shared decision-making as a method of care. BMJ Evidence-Based Medicine, 28(4), bmjebm-2022-112068. https://doi.org/10.1136/bmjebm-2022-112068

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