Final Care Coordination Plan

Final Care Coordination Plan: Chronic Disease Management

Chronic management of diseases such as diabetes, hypertension and heart disease remains the leading cause of public health that requires chronic care and lifestyle modification. These diseases are particularly difficult for patients, carers and clinicians because they are chronic and require long-term care. Patients with chronic disease are known to have poor adherence to medication, limited self-management capability, and mental problems, which often lead to frequent hospitalization, high healthcare costs, and impaired quality of life: Final Care Coordination Plan.

Without a highly structured, patient-oriented system of chronic disease care, patients can experience adverse health outcomes and avoidable complications of disease. However, it is essential to coordinate care because it plans healthcare service, improves communication among providers, and ensures that patients receive continuous, coordinated care. This revised care coordination plan is superior to the original one because it integrates evidence-based practices, ethical issues, health policy considerations, and adherence to the Healthy People 2030 objectives.

Here, the focus is medication compliance, self-care education, and mental healthcare, essential pillars of a chronic disease management plan. Using community-based resources, properly designed patient-centred interventions and evidence-based disease management, the plan will improve outcomes for chronic disease management and patient results.

Patient-Centered Health Interventions and Timelines for Chronic Disease Management

To improve outcomes and improve quality of life, a structured and patient-centered approach to dealing with chronic diseases such as diabetes, hypertension and heart disease is needed. When focused interventions are offered to key health issues, these interventions are made in a specific frame, and the community’s resources are used to ensure continuity and patient adherence. This plan addresses three major healthcare issues, i.e. medication adherence, self-management education and mental health support.

Chronic disease management is one of the most challenging aspects of medication adherence. Due to factors including forgetfulness, cost, and adverse drug reactions to which they are allergic or because they are unaware of how crucial it is to take their medications as prescribed, many patients neglect to take them as directed. Fallatah et al. (2023) state that non-adherence leads to disease progression, increased hospitalizations, and poor health outcomes.

To tackle this problem, a multitude of broad interventions will be handled, including medication counselling, which is aimed at aiding patients to perceive the significance of adherence or even the side effects of the treatment. Introducing digital medication reminders applications like mobile apps and electronic pill dispensers will help patients maintain a consistent medication schedule. In addition, medication therapy management programs directed by pharmacists will be implemented to provide ongoing support, correct dosages, and management of the side effects of the patients.

This intervention will start with an initial medication adherence assessment, counselling of patients, and enrollment into a pharmacist-led program during the first month. This will be followed by the introduction of digital reminder tools during the second month, including a third-month assessment of adherence levels and determining barriers. Pharmacists will be tracked for monthly follow-ups for adherence and any new concerns.

To use this intervention, community resources available include community pharmacies with medication therapy management programs, telehealth systems that include virtual pharmacist consultations, and not-for-profit health organizations, the American Diabetes Association and American Heart Association, that offer education and support programs for adherence to increase patient compliance.

Notably, another fundamental element of chronic disease care is self-management education, as many patients have little educational or skill background that allows them to manage their condition effectively. Delayed interventions, preventable complications, and an increase in emergency healthcare services in part can be attributed to poor health literacy. Bahari and Kerari (2024) note that a structured patient education program will empower patients with better self-management skills, including disease-specific workshops, personalized coaching, and peer-led support groups.

Hands-on training on recognizing symptoms, dietary modifications, and self-monitoring techniques will be provided to patients to prevent disease exacerbation. Within the first two weeks, this intervention will begin with the baseline assessment of the patient’s health literacy and self-care practices. Over the third and fourth weeks of the program, there will be biweekly education sessions on themed topics of nutrition, exercise, and symptom management.

Then, monthly check-ins will be held between the third and sixth months to reinforce self-management strategies. Community resources to support this intervention include community health centres that offer free disease management workshops; YMCA programs designed to increase the amount of physical activity and provide nutrition education; and hospital-based self-management programs that provide educational sessions and support groups.

Furthermore, mental health support is often overlooked in chronic disease management as patients frequently suffer stress, anxiety and depression, which compromise treatment compliance and overall well-being. According to Swathi et al. (2023), patients who are socially isolated long experience financial stress and emotional distress and withdraw from care. To cope with the psychological challenges, this plan will set up routine mental health screening, counselling referrals and peer-supported groups.

The patients will also receive psychological assessment strategies, customized therapy programs, and social engagement activities. With an initial mental health screening and a mental wellness plan set up, the intervention will start in the first month. In the second month, patients will be enrolled in peer support groups or therapeutic sessions.

Every three to six months, mental health check-ins to ensure they stay well mentally and in support. This intervention will also include community resources, including behavioural health clinics, which would offer counselling and therapy services where necessary online mental health support groups to patients and peer-led networks providing intervention and faith-based counselling services offering spiritual and emotional support.

Ethical Considerations in Patient-Centered Health Interventions

People with chronic diseases need to consider ethical issues in the development and implementation of patient-centred health interventions. Given that, ethical decision-making should take into account the balance that has to be struck in providing beneficent care while respecting the autonomy of patients and cultural sensitivity, and equitably allotted resources. In the design of interventions in this chronic disease management, decisions have to be informed by a strong awareness of how patients will feel, and such decisions have to be with integrity of ethics. There are, however, a few ethical issues that will have to be dealt with once these interventions are implemented, as careful thoughts about potential conflicts or uncertainties are necessary.

Patient autonomy is one of the most critical ethical considerations because individuals should have the right to choose how to see and how to be physically treated. However, some people who take medication may stop or modify their medication regimen because of religious, financial, or fear of side effects.

Varkey (2021) indicates that though healthcare providers must educate and counsel, forcing compliance will violate patient autonomy. What this ethical stance means in practical effect is that some patients have a higher chance of a worse prognosis than others. That raises a moral question of a health care provider intervening aggressively or respecting the right of a patient to refuse treatment, resulting in harm.

Consequently, the issue of cultural sensitivity in self-management education adds another ethical problem. The patients come from various backgrounds with various beliefs on what causes disease or how treatment should be performed. Traditional healing practices or dietary customs that may conflict with recommended guidelines over pharmaceutical interventions are some that some patients would prefer.

In making ethical healthcare practices a requisite, providers must attend to these cultural differences and provide evidence-based care to patients (Varkey, 2021). Healthcare practitioners must modify interventions to patient values in order to effectively manage illness while maintaining patients’ values, which has practical implications. In this case, the ethical dilemma is between evidence-based recommendations and cultural beliefs, mainly to make concessions to cultural beliefs when they will likely not be in the patient’s best interests.

Subsequently, another issue is resource allocation, especially in mental health support for chronic disease management. However, such financial limitations, insurance barriers, and workforce shortages may prevent many patients from accessing the counselling and therapy services they need and may increase the need for support.

According to Varkey (2021), ethical principles of justice require that healthcare resources are distributed equitably and that patients with the highest need receive appropriate support. But the truth is that there’s often not enough funding and not enough mental health services for all patients to get to mental health services promptly. The ethical question here relates to how to provide help to healthcare providers for patients with chronic illnesses when resources are scarce, as some mental health issues are more critical than others.

Health Policy Implications for Care Coordination

Health policies depend on care coordination and continuous care in patients with chronic diseases. Effective policy implementation leads to broader access to care, scientifically grounded interventions, and an end to disparities in patient care. Several important health policy provisions stemming from coordinated care delivery concerning medication adherence, self-management education, and mental health support are mentioned.

Within health policy, the Affordable Care Act (ACA) has been one of the most influential policies, increasing the accessibility of preventive services, enhancing coordination of care for people with chronic conditions, and reducing the number and highest rate of uninsured individuals. As per Isola and Reddivari (2021), preventive services, including blood pressure screenings, cholesterol tests and diabetes management programs, are free of cost-sharing under Section 2713 of the ACA.

This also ensures early diagnosis and continuous monitoring for people with chronic diseases so that they do not suffer from complications and frequent readmission to the hospital. The ACA also includes such care coordination models as patient-centred medical homes (PCMH) or Accountable Care Organizations (ACOs), enabling some of these providers to integrate seamlessly into the transfer of care.

Another significant policy that enables coordinated care for people with chronic diseases is the Medicare Chronic Care Management (CCM) Program. The CCM program reimburses non face-to-face care coordination services including medication management, patient education, and remote monitoring with the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 (CMS, 2021). Delivering this support over continuous, structured time helps healthcare providers deliver this support to patients, who would otherwise make emergency department visits and admissions.

Additionally, the Mental Health Parity and Addiction Equity Act (MHPAEA) requires mental health benefits to be the same as or less than medical and surgical benefits but without extra requirements from providers. Second, insurance carriers cannot impose stricter mental health limits than other healthcare services, which is necessary to integrate mental health care into chronic disease management.

Priorities in Care Coordination and Plan Adjustments Based on Evidence-Based Practice

During care coordination planning meetings with patients and their families, the care coordinator must define priorities aligned with their health needs, lifestyle, and personal goals. The most important priorities are improving medication adherence, increasing self-management education, and taking care of mental health. Chronic disease management requires these priorities to be effective and improve long-term health outcomes. The care coordinator needs to involve the patient and their family in the shared decision-making by considering their preferences and barriers to care.

One of the priorities is to improve medication adherence, as relevant evidence-based studies reveal that non-adherence is a leading cause of disease complications and hospital readmissions. Suppose a pertinent patient does not adhere consistently due to some degree of forgetfulness or complicated dosing strategies.

In that case, adjustments must be made to insert simple dosing schedules, pharmacist interventions or digital reminders. The number of adherence apps used today is proving effective, and studies indicate that they increase compliance rates by an average of 20–30% (Fallatah et al., 2023). Thus, the plan may be adjusted to include technology-driven adherence strategies.

The second priority is to manage education. It reduces complications and improves disease control. According to Bahari and Kerari (2024), patients with health literacy issues who cannot make lifestyle changes are supposed to be coached directly one-on-one and have culturally adapted materials and workshops, but not only with written material alone. Tailored education follows evidence-based guidelines and helps increase self-care behaviours and patient engagement.

Finally, mental health support needs to be addressed. There is evidence to suggest that CBT, peer support groups and routine mental health screening may be included in patients with high levels of anxiety or depression associated with the chronic illness (Nakao et al., 2021). That might consist of moving mental health checks from as infrequent as possible to more frequent and making telehealth counselling available.

Evaluating Learning Session Content and Aligning with Best Practices and Healthy People 2030

To ensure the effectiveness of chronic disease management learning sessions, such sessions should be evaluated against evidence-based best practices and aligned with Healthy People 2030 objectives. Elendu et al. (2024) argue that research on patient education indicates that interactive, patient-centred teaching methods lead to better health outcomes than traditional lecture-based education.

Personal coaching, hands-on demonstrations, and digital tools are emphasized as best practices. Also, in their studies, Bahari and Kerari (2024) stated that self-management programs that include behavioural change tactics, peer support and real-world application effectively encourage patient adherence and disease management.

It is important to compare the content of learning sessions with best practices by tailoring education to the individual’s health literacy levels, including culturally relevant information and focusing on skill building rather than knowledge acquisition. Goal-setting strategies, motivational interviewing techniques, and feedback mechanisms to track patient progress should be incorporated at sessions.

According to Healthy People 2030, healthy people should also improve health literacy, enhance access to chronic disease education and decrease preventable complications (Office of Disease Prevention and Health Promotion, 2024). To accomplish these goals, the teaching session must be evidence-based, completely accessible to patients and most importantly, controlled by the patient. The promotion of best practices for patient education programs can be adopted to enhance the effectiveness of the programs in driving patients’ long-term disease self-management and health outcomes.

Conclusion

Optimizing chronic disease management through patient outcomes depends on a well-structured care coordination plan. This plan pays direct attention to one of the key challenges faced by patients with chronic conditions by focusing on medication adherence, self-management education and mental health support. Interventions also consider ethical issues like respect for patient autonomy, cultural values, and equitable resource distribution.

Health policy implications require affordable healthcare access, preventive services, and telehealth integration. Interventions link the plan to Healthy People 2030 goals, thereby establishing the work related to national health improvement. This plan aims to improve patients’ chronic disease outcomes and the best course of action through continuous patient engagement, evaluation, and adaptation of best practices based on evidence.

References

Bahari, G., & Kerari, A. (2024). Evaluating the effectiveness of a self-management program on patients living with chronic diseases. Risk Management and Healthcare Policy, Volume 17, 487–496. https://doi.org/10.2147/rmhp.s451692

CMS. (2021). Centers for Medicare & Medicaid Services. Cms.gov. https://doi.org/99908

Elendu, C., Amaechi, D. C., Okatta, A. U., Amaechi, E. C., Elendu, T. C., Ezeh, C. P., & Elendu, I. D. (2024). The Impact of simulation-based Training in Medical education: a Review. Medicine, 103(27), 1–14. https://doi.org/10.1097/MD.0000000000038813

Fallatah, M. S., Alghamdi, G. S., Alzahrani, A. A., Sadagah, M. M., & Alkharji, T. M. (2023). Insights Into Medication Adherence Among Patients With Chronic Diseases in Jeddah, Saudi Arabia: A Cross-Sectional Study. Cureus, 15(4). https://doi.org/10.7759/cureus.37592

Isola, S., & Reddivari, A. K. R. (2021). Affordable Care Act. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/31747174/

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w

Office of Disease Prevention and Health Promotion. (2024). Healthy People 2030. Health.gov. https://odphp.health.gov/healthypeople

Swathi, M., Manjusha, S., Vadakkiniath, I. J., & Gururaj, A. (2023). Prevalence and correlates of stress, anxiety, and depression in patients with chronic diseases: a cross-sectional study. ProQuest, 30(66), 66. https://doi.org/10.1186/s43045-023-00340-2

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

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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.
  

  Final Care Coordination Plan

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.

Use the resources linked below to help complete this assessment.

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Managing Chronic Illnesses

Read through the resource on the following reading list to identify the role of care coordination in managing chronic illnesses. Pay close attention to similarities between your community and the patient population:

• Assessment 4: Managing Chronic Illnessesreading list.

Website Reducing care fragmentation: A toolkit for coordinating care [PDF] https://www.act-center.org/application/files/7016/3112/2157/Toolkit_Reducing_Care_Fragmentation.pdf

Article Experiences of care coordination among older adults in the United States: Evidence from the Health and Retirement Study.

Eastman, M. R., Kalesnikava, V. A., & Mezuk, BPatient Education and Counseling105(4)20222429 – 2435 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9203919/

Academic Resources

A variety of writing resources are available in the NHS Learner Support Lab, linked in the courseroom navigation menu.

Scholarly Writing and APA Style

Use the following resources to improve your writing skills and find answers to specific questions.

• Academic Honesty & APA Style and Formatting.
• APA Module.

Library Research

Use the following resources to help with any required or self-directed research you do to support your coursework.

• BSN Program Library Research Guide.
• Capella University Library.
• Journal and Book Locator Library Guide.
• Library Research and Information Literacy Skills.

ePortfolio

Use the following resource to understand how to save your assessments to ePortfolio:

• Online ePortfolio Guidelines [PDF].

Additional Resources for Further Exploration

You may use the resource on the following reading list to further explore topics related to the competencies. Consider how health care scientists assess and evaluate a diverse cultural setting and the impact on needed health care.

• Assessment 4: Additional Resources for Further Exploration reading list.