Final Care Coordination Plan

Final Care Coordination Plan

High blood pressure (HBP) is a common lethal health condition. It is affecting millions of people globally. In the U.S., HBP affects an estimated one in every four adult Americans. Unmanaged HBP is a risk factor for multiple health complications. Managing HBP requires a well-coordinated care plan across the continuum of care. This final care coordination plan for HBP prioritizes care to meet the patient’s and family’s needs and preferences by considering health issues related to HBP and designing a care intervention for each issue. It also bases its care decisions on existing ethical guidelines for HBP care, related policies and provisions, and the best available evidence.

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

High blood pressure patients are at an increased risk of other health care issues that affect the outcomes of the health care goals. The three common healthcare issues affecting most HBP patients are severe anxiety, kidney damage, and cognitive decline.

Three Healthcare Issues, an Intervention for Each Issue, and Community Resources for Each Health Intervention

Severe Anxiety

HBP patients majorly develop episodes of severe anxiety. This is a mental health disorder in which the patient will consistently experience episodes of intense fear, worries over life and health, and the future outcomes of their health due to the HBP. Severe anxiety significantly lowers the quality of life of HBP patients. The mental disorder is closely associated with morbid depression, and stress can also reduce the capacity of the patient to perform their daily life activities (Ponte Márquez et al., 2019).

Interventions for Severe Anxiety. The developed intervention for severe anxiety in HBP patients focuses on reducing the stress the patient is experiencing due to their health conditions. It applies mindfulness meditation as the main intervention. Mindfulness meditation focuses on ensuring that the patient is aware of their senses and how they feel about their condition without having negative interpretations of their thoughts and feelings. It will involve deep breathing exercises, imagery, sounds and music, and other exercises that will help the patient feel at ease with themselves, both in the body and mind. The use of mindfulness meditation in patients with stress and high arterial blood pressure after an amputation showed that the exercises help them accept their situation with less judgment, which helps patients become less depressed (Ponte Márquez et al., 2019).

Community Resources. The available community resources to support the intervention for severe anxiety include the local mental health center, the community gym and play center, and the local community center. These resources provide care and a peer support network.

Timeline. The interventions for severe anxiety will be implemented in three months, with patient progress reviews in managing their anxiety done every two weeks.

Kidney Damage

Kidney damage associated with HBP can lead to a reduced efficiency of kidney functions which further risks the development of multiple health complications. An estimated one in every five people with high blood pressure has or is at risk of developing chronic kidney disease (Centers for Disease Control and Prevention, 2019). Kidney damage requires a multidimensional care intervention to improve care outcomes, especially in patients with HBP.

Interventions for Kidney Damage. The developed intervention for kidney damage will include both pharmacological and non-pharmacological management approaches. The pharmacological intervention will include using the medications prescribed to manage high blood pressure, such as angiotensin-converting enzyme (ACE) inhibitors. In case the kidney damage remains progressive, kidney dialysis is proposed. Kidney dialysis can manage both blood pressure and volume and allow the kidneys to recover (Flythe et al., 2020). The non-pharmacological interventions for the kidney damage associated with HBP include making significant dietary and lifestyle changes that involve the intake of healthy foods with reduced unhealthy fats and sodium, reduced alcohol consumption, and better management of blood sugar. HBP patients will also be educated on self-management of blood pressure and other conditions that exacerbate kidney damage.

Community Resources. The available community resources for kidney damage interventions include the local farmers market, the local hospital with specialized kidney care services, and the local community center. These resources provide care and support to HBP patients with kidney problems. Top of Form

Timeline. The interventions will be implemented within a period of six months.

Cognitive Decline with High Blood Pressure

Cognitive decline and eventual dementia can occur with HBP due to the damage to blood vessels done by high blood pressure. Since HBP is common mostly in the aging population, damage to the brain’s blood vessels can lead to the early onset of cognitive decline and dementia. Dementia can have a significant impact on the patient’s daily living and their quality of life. Managing cognitive decline and dementia in HBP patients requires employing approaches that slow the onset of the cognitive decline and improve memory, attention, and processing speeds.

Interventions for Cognitive Decline. The intervention for cognitive decline and dementia is the implementation of various brain-simulating exercises. These include activities in which the patient can participate alone or in a group. These exercises include the use of various puzzles such as crosswords, sudoku, chess, group art, and drawing exercises, among others. These exercises challenge cognitive functions such as the ability of the patient to memorize patterns, pay attention, and socialize.

Community Resources. The available resources for the cognitive decline intervention include the resources provided by the local Alzheimer’s Association, the local community center, and the local art center. These resources provide a readily available support network.

Timeline. The interventions will be implemented within a period of six months, and observations will be made.

Ethics and Ethical Decisions in Designing Patient-Centered Health Interventions

A care coordination plan for HBP and interventions for associated health issues needs to be designed around the needs and preferences of the patient and their families. Deciding on the interventions to include in the care coordination plan requires a consideration of the ethical guidelines. Ethically made care decisions for the interventions for severe anxiety, cognitive decline, and kidney damage associated with HBP consider each decision’s practical effects and ethical implications. There are potential ethical conflicts of concern in patient-centered such as in privacy, autonomous decision-making, and safeguarding medical quality (Hansson & Fröding, 2021). Considering these potential conflicts can help design care that aligns with the patient’s needs and interests.

Patient- and person-centered care is only possible if the patient fully participates in the care decision-making process and autonomously makes well-informed decisions (Yun & Choi, 2019). Therefore, a patient-centered health intervention requires the patient to be fully informed of the care interventions, including the benefits and risks and their decision regarding whether to take the treatment or not. Patients should also be allowed to make their decisions autonomously based on the provided and well-understood information provided by healthcare professionals. Additionally, assuring the privacy of the patient and confidentiality of the information shared can improve the design of the care coordination plan and make it more patient-centered. Furthermore, considering the ethical principle of beneficence ensures that the health interventions employed in managing health issues maximize benefits to the patient and reduce the risks of patient harm across the care continuum.

Each decision made during the design of health interventions affects the patient-centeredness of the care interventions and the entire care coordination plan. For instance, a decision to override the patient’s decision not to get involved in an intervention that requires being a part of a support group and pushing them to get involved in the support group can make the patient feel violated and affect their recovery process. In fact, patient autonomy has been found to improve self-management and care outcomes in patients with chronic conditions such as hypertension (Audthiya et al., 2021). Another example of a specific decision is to focus most therapy interventions on managing the blood pressure status rather than the associated health issues. These decisions lead to ethical questions and create uncertainty in the decisions made. They can lead to questions like, does pushing the patient to get involved in certain interventions for their own benefit create a conflict between beneficence and autonomy? Is wanting the best for the patient a personal interest or a benefit to the patient? Do the decisions made to prioritize certain interventions risk potential harm in the long term? Other ethical questions include whether the interventions actually align with the patient’s personal, cultural, and religious views.

Relevant Health Policy Implications for the Coordination and Continuum of Care

Health policy provisions have significant implications for the coordination and continuum of care in HBP patients. Care coordination must consider the various related health policy provisions to ensure compliance and avoid regulatory issues and consequences. The major health policies with significant implications on care coordination and the continuum of care include the Affordable Care Act (ACA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The ACA has major specific policy provisions that have expanded access to care services for chronic conditions without charging a deductible, copayment, or coinsurance. The ACA significantly improves access to health services and reduces preventable hospitalizations (Myerson & Crawford, 2020). The ACA provisions on the coverage of chronic conditions will mean that the care coordination plan accommodates all HBP patients and helps manage the associated health issues regardless of their level of income. Therefore, the care coordination across the continuum of care is expected to be as affordable as possible.

On the other hand, HIPAA requires the protection of all personally identifiable patient information and the need for patient consent to share such information. Technologies for health, such as electronic health records (EHR) systems, have supported the efficient sharing of patient information, impacting care coordination even in hard-to-reach rural areas (Gill et al., 2020). Specific HIPAA provisions, such as the Privacy and Security Rules, have significant implications for care coordination. The care coordination plan must consider the security of the EHRs and always obtain the authorization of the patient before sharing the health information. Although ethical and complies with the policy provisions, this slows the process of care delivery across the continuum.

Priorities to Establish When Discussing the Plan with a Patient and Family Member, Making Changes Based Upon Evidence-Based Practice

An effective and efficient care coordination plan has well-established care priorities. The priorities to establish with the patient and their family for the care plan include the specific care goals for the plan based on the patient’s and family’s values, needs, and preferences. The priority goals may include improving blood pressure readings to more tolerable levels, managing their mental health, and preventing complications such as cognitive decline and kidney damage. The other priorities would be to assess the patient’s and their family’s social and economic aspects, such as level of income and education, housing conditions, and access to care services and other social support systems. The outcomes of such assessment have a significant effect on the care coordination plan and can direct changes to the plan, such as on how the care will be delivered, the care professionals to participate in the care plan, and the required levels of economic and social support. A simple change to reduce the economic burden of caring for the patient would be to move the patient from an in-patient setting to home-based care. Notably, according to Peters et al. (2019), improving the patient’s self-efficacy can support self-management with a positive impact on the quality of life in patients with multi-morbid conditions.

Learning Session Content Comparison with Best Practices and Alignment with Healthy People 2030

The learning sessions have been beneficial to the understanding of best practices, such as assessing patient needs, making ethical decisions, involving the patient in the decision-making processes, and shaping interventions based on patient needs to deliver patient-centered care. The learning sessions have also improved one’s skills in searching for, analyzing, interpreting, and applying the best evidence in patient care. Evidence-based nursing education improves the nurses’ knowledge of evidence-based processes and their self-efficacy in practice after training (Oh & Yang, 2019). Evidence-based nursing education methods such as the flipped classroom improve the nurses’ grasp of the concepts of evidence-based practice (EBP) (Chu et al., 2019). The overall impact of the learning sessions has been on how to utilize social determinants of health to best design the care to improve patient outcomes, disease awareness, and testing, as well as reduce the prevalence and effects of chronic diseases such as HBP on the local communication in accordance to the Healthy People 2030 objectives. In the future, the care coordination plan may be revised to either add or remove certain interventions based on the progress achieved in managing HBP and the associated health conditions. Some anticipated revisions may include pushing all care to home settings rather than hospital settings and a caring approach that is more preventive than responsive.

Conclusion

In conclusion, coordinating care for HBP patients requires the consideration of other associated health issues and managing them as well. Regardless of the status of the patient, all decisions made when designing the care coordination plan must follow the ethical principles in nursing and the existing health policy requirements. Furthermore, it is important to always consider the patient’s needs and preferences and the best available evidence to design the best patient-centered care coordination plan to effectively achieve set care goals.

References

Centers for Disease Control and Prevention. (2019). Fluoride Action Network | Chronic Kidney Disease in the United States, 2019. Flouride Action Network. https://fluoridealert.org/studytracker/38332/

Chu, T. L., Wang, J., Monrouxe, L., Sung, Y. C., Kuo, C. li, Ho, L. H., & Lin, Y. E. (2019). The effects of the flipped classroom in teaching evidence-based nursing: A quasi-experimental study. PLOS ONE, 14(1), e0210606. https://doi.org/10.1371/JOURNAL.PONE.0210606

Audthiya, P., Pothiban, L., Panuthai, S., & Chintanawat, R. (2021). Enhancing Autonomy and Self-Management Behaviors Through a Patient-Centered Communication Program for Older Adults with Hypertension: A Randomized Controlled Trial. Pacific Rim International Journal of Nursing Research, 25(4), 525–538. https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/253312

Flythe, J. E., Chang, T. I., Gallagher, M. P., Lindley, E., Madero, M., Sarafidis, P. A., Unruh, M. L., Wang, A. Y. M., Weiner, D. E., Cheung, M., Jadoul, M., Winkelmayer, W. C., Polkinghorne, K. R., Adragão, T., Anumudu, S. J., Chan, C. T., Cheung, A. K., Costanzo, M. R., Dasgupta, I., … Wilkie, M. (2020). Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney International, 97(5), 861–876. https://doi.org/10.1016/J.KINT.2020.01.046

Gill, E., Dykes, P. C., Rudin, R. S., Storm, M., McGrath, K., & Bates, D. W. (2020). Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics, 137, 104102. https://doi.org/10.1016/J.IJMEDINF.2020.104102

Hansson, S. O., & Fröding, B. (2021). Ethical conflicts in patient-centered care. Clinical Ethics, 16(2), 55–66. https://doi.org/10.1177/1477750920962356/ASSET/IMAGES/LARGE/10.1177_1477750920962356-FIG1.JPEG

Myerson, R., & Crawford, S. (2020). Coverage for Adults with Chronic Disease under the First 5 Years of the Affordable Care Act. Medical Care, 58(10), 861–866. https://doi.org/10.1097/MLR.0000000000001370

Oh, E. G., & Yang, Y. L. (2019). Evidence-based nursing education for undergraduate students: A preliminary experimental study. Nurse Education in Practice, 38, 45–51. https://doi.org/10.1016/J.NEPR.2019.05.010

Ponte Márquez, P. H., Feliu-Soler, A., Solé-Villa, M. J., Matas-Pericas, L., Filella-Agullo, D., Ruiz-Herrerias, M., Soler-Ribaudi, J., Roca-Cusachs Coll, A., & Arroyo-Díaz, J. A. (2019). Benefits of mindfulness meditation in reducing blood pressure and stress in patients with arterial hypertension. Journal of Human Hypertension 2018 33:3, 33(3), 237–247. https://doi.org/10.1038/s41371-018-0130-6

Yun, D. W., & Choi, J. S. (2019). Person-centered rehabilitation care and outcomes: A systematic literature review. International Journal of Nursing Studies, 93, 74–83. https://doi.org/10.1016/J.IJNURSTU.2019.02.012

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

Introduction
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 assessments.

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 healthcare 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 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 in length, 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. 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 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 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 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.