Final Care Coordination Plan

Final Care Coordination Plan

Care coordination increases accountability among the stakeholders involved in patient care. Each member of the interdisciplinary team completes their unique role in patient care. As such, the quality of healthcare services is improved. Furthermore, care coordination promotes patient-centeredness because the stakeholders collaborate to address the unique needs of each patient. This paper evaluates a preliminary care coordination plan for patients with diabetes mellitus.

Patient-Centered Health Interventions and Timeline

Patients with diabetes mellitus are faced with various healthcare uses. They can be categorized into three: psychosocial, cultural, and physical healthcare issues. Examples of psychosocial problems this population faces include fear, distress, depression, anxiety, and changes in feeding habits. Fear and anxiety among these patients have been attributed to diabetic complications such as hypoglycemia (Kalra et al., 2018). People with diabetes are usually worried about both acute and chronic complications. Data indicate that people with diabetes are twice as risk for depression compared to the general population (Kalra et al., 2018). Depression is caused by the necessity for lifestyle modification that accompanies diabetes mellitus. Furthermore, these patients are likely to consider themselves a burden to their families (Kalra et al., 2018). Psychosocial problems worsen the prognosis of the disease by lowering patient adherence to treatment plans.

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Various psychotherapy interventions can be used to address psychosocial problems. They include cognitive behavior therapy, motivation, interpersonal therapy, family behavior therapy, and social rhythm therapy (Kalra et al., 2018). The timeline is three sessions per week for eight months. Examples of community resources that support psychosocial interventions include Four Rivers Behavioral Health, River Valley Behavioral Health, and NorthKey Community Care (Kentucky.gov, n.d.).

Lack of cultural congruence is the main cultural issue associated with diabetes mellitus. People from different ethnic backgrounds are affected by diabetes mellitus. Findings indicate that the highest incidences of the disease have been recorded among African Americans, Latinos, and American Indians, respectively (CDC, n.d.). As such, the healthcare workforce should embrace cultural sensitivity when managing these patients. They should respect patients’ beliefs and perspectives. Findings reveal that cultural sensitivity increases access to healthcare services because patients feel that they are understood and respected (Henderson et al., 2018). Cultural sensitivity can be achieved by initiating various strategies. Healthcare providers should collaborate with community contacts to understand patients’ cultures. Furthermore, they should conduct thorough research to learn about patients’ beliefs and perspectives (Henderson et al., 2018). Recruitment of language translators will eliminate language barriers between healthcare providers and patients. Regarding the timeline, cultural congruence should be upheld perpetually during healthcare service provision. Community resources include the Kentucky Diabetes Prevention and Control Program, Kentucky Diabetes Network, and Kentucky Health Collaborative (Kentucky.gov, n.d.).

Physical problems associated with diabetes mellitus emanate from the poor management of the disease. Both macrovascular and microvascular complications cause physical problems. Non-adherence to medication and lifestyle modification increases the risk of physical problems associated with diabetes mellitus (Martinez et al., 2019). Diabetic retinopathy is a microvascular complication associated with diabetes mellitus. Late diagnosis of this complication has a poor prognosis and can lead to blindness (Martinez et al., 2019). Diabetic neuropathy causes diabetic foot. Diabetic foot can be classified as neuropathic, ischemic, and neuro-ischemic (Martinez et al., 2019). Diabetic foot is the leading cause of amputation among people with diabetes (Martinez et al., 2019). These complications can be addressed via three major strategies. Patients should be educated on the importance of lifestyle modifications. This entails both dietary modification and physical activity (Martinez et al., 2019). The timeline is four sessions of both aerobic and anaerobic physical exercises per week. In addition, the second strategy is educating the patient on the importance of medication adherence, and the third is conducting routine screening exercises. Community resources include the Kentucky Diabetes Prevention and Control Program, the Kentucky Prescription Assistance Program, and the Kentucky Diabetes Network (Kentucky.gov, n.d.).

Ethical Decisions in Designing Patient-Centered Health Interventions

Healthcare providers should uphold the principles of healthcare ethics when formulating patient-centered health interventions. Notably, they should embrace justice, non-maleficence, beneficence, and autonomy (DeCamp et al., 2018). To fulfill the provisions of justice, healthcare providers should embrace equality. In this context, discrimination should be avoided when addressing the physical, cultural, and psychosocial needs of patients with diabetes mellitus. Justice ensures that patients with similar needs receive the same interventions. When patients have different needs, justice is demonstrated by ensuring that each patient receives individualized care that addresses their unique needs. Accordingly, the arising ethical question is, have we shared the benefits and risks of an intervention equally among diabetes patients at the healthcare facility?

According to DeCamp et al. (2018), autonomy acknowledges the importance of patients in the clinical decision-making process. Patients are key stakeholders whose opinions should be considered and respected. By so doing, holistic care and cultural congruence are achieved. In this context, diabetes patients should be active participants in selecting interventions to address their physical, cultural, or psychosocial needs (DeCamp et al., 2018). Healthcare providers should provide detailed information concerning the benefits and risks of each intervention. This helps the patient to make informed decisions. However, a healthcare provider’s decision should not supersede a patient’s opinion and decision. The ethical question is, does this intervention uphold the patient’s opinion and choice?

Non-maleficence champions actions that do not harm patients. On the other hand, beneficence advocates for actions that benefit the patient (DeCamp et al., 2018). These principles reiterate the importance of quality healthcare services and patient safety. Healthcare providers should ensure that the best evidence-based intervention is adopted (DeCamp et al., 2018). The benefits of these interventions should outweigh the potential risks. Furthermore, the interventions should be individualized. For example, the number of psychotherapy sessions may differ based on a patient’s psychosocial needs. The ethical question is, does this intervention address the patient’s best interests?

Health Policy Implications

According to Schillinger et al. (2022), the National Clinical Care Commission is established under Public Law 115-80. The National Clinical Care Commission works in concert with the Department of Health and Human Services to advocate for policies that promote the mitigation of diabetes mellitus (Schillinger et al., 2022). Notably, the National Clinical Care Commission formulated the government and public policy to promote coordination and a continuum of care for patients with diabetes mellitus (Schillinger et al., 2022). This policy emphasizes various aspects. Firstly, it champions the reformation of the healthcare sector. These transformations focus on organizational support and general treatment services (Schillinger et al., 2022). An interdisciplinary approach should be used in making clinical decisions. Furthermore, healthcare technology such as telehealth should be used to improve information systems and the quality of service delivery. Healthcare providers should uphold continuous screening and patient education.

Secondly, the National Clinical Care Commission advocates for patient-centered services. These services are an embodiment of holistic care. Healthcare services should address a patient’s psychosocial, physical, and cultural needs. An interdisciplinary approach ensures that patient-centeredness is embraced in various healthcare facilities (Schillinger et al., 2022). The government and public policy also advocate for an increase in the number of community resources for people with diabetes mellitus. These resources facilitate continuous patient education and equip patients and their families with pertinent coping strategies (Schillinger et al., 2022). Global, federal, state, and local stakeholders should collaborate to ensure that this policy is implemented successfully.

Priorities When Discussing the Plan with Patients and Their Families

When discussing with patients and their families, a care coordinator should prioritize various aspects. The acute and chronic complications of diabetes mellitus should be emphasized. Non-compliance to the treatment plan is the risk factor for both acute and chronic complications. Examples of acute complications include hypoglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state (Martinez et al., 2019). Diabetic nephropathy, retinopathy, neuropathy, and peripheral vascular disease are examples of chronic complications associated with diabetes mellitus. Medication adherence and lifestyle modification avert both acute and chronic complications (Martinez et al., 2019). Physical activity and dietary modification are the key aspects of lifestyle modification (Martinez et al., 2019).

Follow-up is the other aspect that a care coordinator should emphasize. Patient follow-up enables the healthcare providers to evaluate and monitor the patient’s prognosis. Furthermore, follow-up enables healthcare providers to clarify patients’ concerns about the treatment plan. As a result, higher levels of adherence to the treatment plan are achieved. Adequate follow-up can facilitate timely screening of complications. For example, patient follow-up enables healthcare providers to make a timely diagnosis of diabetic retinopathy. As such, prompt interventions are initiated. Findings indicate that timely initiation of therapy, such as photocoagulation, is associated with a good prognosis of diabetic retinopathy (Forouhi & Wareham, 2019).

A care coordinator should inform the patient about factors that can necessitate changing the treatment plan. Poor response to prescribed medication can lead to changes in the treatment plan. These changes optimize the treatment plan to ensure that the plan benefits the patient. Additionally, the plan should be altered when the patient develops other comorbidities (Htoo et al., 2022). For example, when a patient with type 2 diabetes mellitus develops atherosclerotic cardiovascular disease, the treatment plan should be modified. In this context, a sodium-glucose cotransporter–2 antagonist or glucagon-like peptide 1 is added to the plan (Htoo et al., 2022). Sodium-glucose cotransporter-2–2 antagonists and glucagon-like peptide 1 agents are cardio-protective and hence will be beneficial in this scenario (Htoo et al., 2022).

Comparing Learning Session Content with Best Practices

Literature evaluation emphasizes patient and family engagement. It is worth noting that patients and their families are key stakeholders in the treatment process. Therefore, patient and family engagement enables compliance with the treatment plan. Patients are allowed to make important clinical decisions about treatment interventions. This makes them recognize that they are integral team members in deciding their healthcare interventions. Essentially, patient and family engagement can be achieved via therapeutic communication and cultural congruence. Therapeutic communication creates a rapport between patients and healthcare providers (Kwame & Petrucka, 2021). Cultural congruence requires healthcare providers to recognize and respect patients’ beliefs.

According to the National Clinical Care Commission, interdisciplinary collaboration, patient-centeredness, and the use of community resources are examples of beneficial practices for patients with diabetes mellitus. Healthcare providers should collaborate with patients, their family members, and other interdisciplinary team members to provide patient-centered healthcare services (Schillinger et al., 2022). The importance of medication adherence to lifestyle modification should also be emphasized.

Healthy People 2030 aims to increase the percentage of diabetic patients receiving an annual urinary albumin test. This objective addresses diabetic nephropathy, a microvascular complication (Healthy People 2030, n.d.). Annual screening facilitates the timely diagnosis of nephropathy. A definitive diagnosis of diabetic nephropathy is dependent on persistent albuminuria. This is defined as urinary excretion of more than or equal to 300 milligrams per day (mg/d) on at least two occasions within six months (Umanath & Lewis, 2018). This objective should be incorporated into the teaching sessions. Further, patients should be educated on the importance of routine screening for both microvascular and macro-vascular complications. Besides, annual screening facilitates the timely diagnosis of complications and initiation of therapy.

Conclusion

Patients with diabetes mellitus are faced with various healthcare uses. They can be categorized into psychosocial, cultural, and physical healthcare issues. Healthcare providers should uphold the principles of healthcare ethics when formulating patient-centered health interventions. The Government and Public Policy was formulated by the National Clinical Care Commission to promote coordination and a continuum of care for diabetics.

References

CDC. (n.d.). Diabetes Basics. https://www.cdc.gov/diabetes/basics/index.html

DeCamp, M., Pomerantz, D., Cotts, K., Dzeng, E., Farber, N., Lehmann, L., Reynolds, P. P., Sulmasy, L. S., & Tilburt, J. (2018). Ethical Issues in the Design and Implementation of Population Health Programs. Journal of General Internal Medicine, 33(3), 370–375. https://doi.org/10.1007/s11606-017-4234-4

Forouhi, N. G., & Wareham, N. J. (2019). Epidemiology of diabetes. Medicine (United Kingdom), 47(1), 22–27. https://doi.org/10.1016/j.mpmed.2018.10.004

Healthy People 2030. (n.d.). Diabetes Mellitus. https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes/increase-proportion-adults-diabetes-who-get-yearly-urinary-albumin-test-d-05

Henderson, S., Horne, M., Hills, R., & Kendall, E. (2018). Cultural competence in healthcare in the community: A concept analysis. Health and Social Care in the Community, 26(4), 590–603. https://doi.org/10.1111/hsc.12556

Htoo, P. T., Buse, J., Cavender, M., Wang, T., Pate, V., Edwards, J., & Stürmer, T. (2022). Cardiovascular Effectiveness of Sodium‐Glucose Cotransporter 2 Inhibitors and Glucagon‐Like Peptide‐1 Receptor Agonists in Older Patients in Routine Clinical Care With or Without History of Atherosclerotic Cardiovascular Diseases or Heart Failure. Journal of the American Heart Association, 11(4), e022376. https://doi.org/10.1161/JAHA.121.022376

Kalra, S., Jena, B. N., & Yeravdekar, R. (2018). Emotional and psychological needs of people with diabetes. Indian Journal of Endocrinology and Metabolism, 22(5), 696–704. https://doi.org/10.4103/ijem.IJEM_579_17

Kentucky.gov. (n.d.) Diabetes Prevention and Control Program. https://chfs.ky.gov/agencies/dph/dpqi/cdpb/Pages/diabetes.aspx

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(1), 1–10. https://doi.org/10.1186/s12912-021-00684-2

Martinez, L. C., Sherling, D., & Holley, A. (2019). The Screening and Prevention of Diabetes Mellitus. Primary Care – Clinics in Office Practice, 46(1), 41–52. https://doi.org/10.1016/j.pop.2018.10.006

Schillinger, D., Bullock, A., & Herman, H. W. (2022). An All-Of-Government Approach To Diabetes: The National Clinical Care Commission’s Report To Congress. https://www.healthaffairs.org/do/10.1377/forefront.20220111.855646/

Umanath, K., & Lewis, J. B. (2018). Update on Diabetic Nephropathy: Core Curriculum 2018. American Journal of Kidney Diseases, 71(6), 884–895. https://doi.org/10.1053/j.ajkd.2017.10.026

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NOTE: You are required to complete this assessment after Assessment 1 is successfully 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 play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. 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.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

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

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon 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 in length, not including title page and reference list.

Supporting Evidence
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. 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 be sure to 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 health care problem.
Address three health care 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 that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon 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 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; contains 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.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.
Design patient-centered health interventions and timelines for a selected health care problem.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
Competency 3: Create a satisfying patient experience.
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.
Competency 4: Defend decisions based on the code of ethics for nursing.
Consider ethical decisions in designing patient-centered health interventions.
Competency 5: Explain how health care policies affect patient-centered care.
Identify relevant health policy implications for the coordination and continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
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; contains few errors in grammar/punctuation, word choice, and spelling.