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Final Care Coordination Plan

Final Care Coordination Plan

Cardiovascular disease is one of the major causes of mortality and morbidity worldwide. There is increasing evidence suggesting that patients who actively participate in their own care are more likely to adhere to treatment plans are inclined to have better outcomes, and are also more satisfied with the care they obtain. Patient-centered care is considered the cornerstone in the management of heart disease. The American College of Cardiology (2020) outlines the importance of understanding the perception of the patients about their disease, together with their life experience and goals in order to collaboratively chart a course for management of the disease. Interventions for heart disease should focus on the promotion of cardiovascular health as opposed to an excessive focus on the reduction of the burden. Hire our assignment writing services in case your assignment is devastating you.

The first intervention involves physical activities that involve biking, aerobic exercises, and other forms of exercise that can be organized at the community and individual levels. The community can take part in the organization of physical activity events to encourage individuals to indulge in healthy behaviors that can enhance their general well-being. In New Jersey, The New Jersey at Heart (2020) is a community resource that collaborates with city leaders to support more biking routes, walking and drive initiatives that make healthier food options accessible to individuals and offer children the opportunity to stay active in school. Having a 9-month supervised physical activity program in the community can help patients lessen the risk of cardiovascular disease or help in its management. Research shows that community-based physical activity has the probability of improving cardiovascular health and promoting physical activity among individuals (Arija et al., 2017). With a 9-month physical activity intervention, it is expected that patients will develop this pattern and incorporate it into their lifestyle. Individualized training should also be offered to meet the individual physical needs of patients.

Another intervention involves diet regulation or modification. Heart disease is one of the chronic conditions that require a change in one’s diet. However, diet modification should involve patients’ cultural beliefs and values. Having a community-based program that highlights the diet that can be followed by individuals is important. Communities have individuals of varying cultures, and therefore such diet recommendations can be made based on every culture. The Deborah Heart and Lung Cancer (2020) is one of the community resources that can be used by individuals within the New Jersey community. This resource distributes information on the management of cholesterol and blood pressure, heart-healthy cooking and recipes, as well as eating tips. In regard to diet, it is important to ensure that every diet emphasizes the individual and cultural needs of everyone, but in most cases, a high intake of whole grains, vegetables, fruits and a low intake of sodium are commonly recommended.

Yu et al. (2018) claim that a proper individualized prudent diet that is rich in legumes, vegetables, whole grains, and fruits can lessen the risk of cardiovascular mortality by 31 percent, whereas a Western diet that involves sugar-sweetened beverages, French fries, and red meat among others can enhance the risk by 14 percent. Therefore, it is important for proper education on proper diet to be made to ensure that individuals make informed decisions on their diet. Having a dietician or physician make the recommendation will have an increased impact since Aggarwal et al. (2018) claim that physicians are a more trusted source of information on diet recommendations, and most patients tend to modify their diet following a physician’s or dietician’s recommendation. The diet modification should be accompanied by a campaign and education on the reduction or quitting of alcohol and smoking at the community and individual level. The Healthy Lives Program (2020) can play an important role in providing in-depth information in regard to general lifestyle changes that need to be made to lessen the risk of cardiovascular disease. This diet modification should also run for a period of 9 months to ensure that patients are able to adhere to it.

Ethical Decisions in Patient-Centered Health Interventions

Ethical decision-making is dependent on the skills and knowledge of the practitioner as well as a good understanding of the ethical principles and good relations with the patients. In coordinated care plans, ethical decisions are important, given that information is to be shared among different parties. High levels of confidentiality, patient protection, and ethics are needed. Having an ethical approach to patients’ coordinated care is needed to ensure that all parties uphold the ethical regulations and standards of care and that care is patient-centered to increase the quality of care offered to patients.

In the interventions for heart disease, ethical considerations should be made in regard to the nutrition interventions. Various moral considerations such as preventing harm, producing benefits, liberty of action, distributing health benefits in a fair way, and respecting individual autonomy should be made. Hurlimann et al. (2017) claim that interventions for nutrition or diet modifications can be stigmatizing and can infringe on individual autonomy of individuals, besides increasing inequalities among people. It is, therefore, important to make interventions that are suitable and acceptable to individuals’ cultural, socio-economic, and physical needs.

Ethical decision-making should also be guided by the principles of justice, beneficence, autonomy, and nonmaleficence. It is assumed that an individual has perfect information, resources, and cognitive ability to make a choice after evaluating all the alternatives before making a choice, and therefore, ethical decision-making is expected during coordinated care plans.  If the individual lacks the cognitive abilities to make such decisions, then it is the duty of their closest family member or the caregiver to make a wise and ethical decision on their behalf while upholding the value of “do no harm.”

Health Policy Implications

Various studies have shown positive outcomes of an integrated care program for patients who are chronically ill. Hospitals can play a critical role in transitional care interventions as well as the coordination of chronic care with improved outcomes for the patients by taking on leadership roles in integrated care programs (De Regge, 2017). Specialized care settings are said to facilitate the care coordination processes. With the transformations that are taking place in the healthcare system, care coordination is considered by insurers, health systems, and hospitals as important in enhancing patient satisfaction and health as well as controlling healthcare costs. The relevant health policy implications for the coordination and continuum of care include matters on generating provisions for care coordination payments based on various common tasks delineating qualifying providers for payment as well as offering payment with supporting documentation and advocating for team-based and inclusions in transparency and accountability (Lamb et al., 2015). Heart disease is often associated with poor lifestyles, which result in obesity and diabetes. The fact that most vulnerable patients from low-income places are also highly underinsured; through coordinated care, with the help of social workers, health insurance can be offered to them. Fan et al. (2019) state that public health insurance could have positive impacts on the health of individuals, such as increased utilization of healthcare and increased health-related behaviors. The Affordable Care Act has improved insurance coverage for individuals, but health disparities are still prevalent. Through this act, more patients, especially those from vulnerable populations, are covered, and this enhances their affordability and access to quality and affordable healthcare.

Coordination and continuum of care also enhance the traditional goals and values of the nursing practice, which entails caring for the unique patient and family with healthcare needs over a prolonged period of time. Nurses have a unique education and ability to generate holistic healing environments by helping people to make more informed and better choices, thereby resulting in the promotion of higher-quality health and illness prevention.

Establishment of Priorities

When discussing the plan with a patient and their families, some of the priorities that a care coordinator can establish involves the patient’s ability to care for themselves outside the healthcare facility, the ease of access to various facilities, and the patient’s ability to adhere to the plan. The success of the care plan is highly based on the patient’s ability to adhere to the various components of the care plan. For instance, if the patient is unable to comprehend the plan, it is important to offer detailed information and education to enhance their ability to adhere to the plans and goals. This should be done by actively involving the patient and their families in the plan of care. Patient education can help enhance the health outcome of the patient by reducing hospital readmissions and mortality risk (Anderson et al., 2017). Additionally, with the help of a social worker, it is important for nurses to make sure that the patient and their families have the resources required to stick to the plan. For instance, in the case of heart disease patients, nutritional and general lifestyle changes are required, and patients from low-income families might be unable to meet some of the requirements needed to improve their health outcomes. Ensuring that the patients have access to appropriate resources should be a top priority. The patients’ accessibility to various services, such as therapy sessions for their psychological needs and checkup trips, is also important, and this can be made possible with the help of a case manager or social worker.

References

Aggarwal, M., Devries, S., Freeman, A. M., Ostfeld, R., Gaggin, H., Taub, P.,& Conti, R. C. (2018). The deficit of nutrition education of physicians. The American Journal of Medicine, 131(4), 339-345.

Anderson, L., Brown, J. P., Clark, A. M., Dalal, H., Rossau, H. K. K., Bridges, C., & Taylor, R. S. (2017). Patient education in the management of coronary heart disease. Cochrane Database of Systematic Reviews, (6).

Arija, V., Villalobos, F., Pedret, R., Vinuesa, A., Timón, M., Basora, T., … & Basora, J. (2017). Effectiveness of a physical activity program on cardiovascular disease risk in adult primary health-care users: the “Pas-a-Pas” community intervention trial. BMC Public Health, 17(1), 1-11.

De Regge, M., De Pourcq, K., Meijboom, B., Trybou, J., Mortier, E., & Eeckloo, K. (2017). The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions. BMC Health Services Research17(1), 1-24.

Deborah Heart and Lung Center. (2020). Community Outreach. Retrieved from https://demanddeborah.org/patients-and-visitors/community-resources/community-outreach/

Fan, H., Yan, Q., Coyte, P. C., & Yu, W. (2019). Does public health insurance coverage lead to better health outcomes? Evidence from Chinese adults. Inquiry: The Journal of Health Care Organization, Provision, and Financing, 56, 0046958019842000.

Healthy Lives Program. (2020). Heart Failure Intervention. Retrieved from https://www.rwjbh.org/community-medical-center/treatment-care/heart-and-vascular-care/programs-and-specialties/healthy-lives-program/

Hurlimann, T., Peña-Rosas, J. P., Saxena, A., Zamora, G., & Godard, B. (2017). Ethical issues in the development and implementation of nutrition-related public health policies and interventions: A scoping review. Plos one12(10), e0186897.

Lamb, G., Newhouse, R., Beverly, C., Toney, D. A., Cropley, S., Weaver, C. A., … & Peterson, C. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook63(4), 521-530.

New Jersey at Heart. (2020). Home. Retrieved from https://www.heart.org/en/affiliates/new-jersey/new-jersey

The American College of Cardiology. (2020). ACC Provides Roadmap for Shift to Patient-Centered Care to Support Quality Heart Disease Management. Retrieved from https://www.acc.org/about-acc/press-releases/2012/05/11/15/17/health-policy-statement

Yu, E., Malik, V. S., & Hu, F. B. (2018). Cardiovascular disease prevention by diet modification: JACC health promotion series. Journal of the American College of Cardiology72(8), 914-926.

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Question 


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