Final Care Coordination Plan for Stroke Patients

Final Care Coordination Plan for Stroke Patients

Care coordination is vital in the continuum of care, especially for patients with complex care needs (Karam et al., 2021). The main objective of coordinating care is to achieve better health outcomes at the lowest costs of care possible. Care coordination achieves this by eliminating care provision silos and scattered procedures that affect timely care delivery. Stroke is a disease that results from reduced blood supply to parts of the brain. It can occur as an ischemic stroke or as a hemorrhagic stroke. People with high blood pressure, smoking habits, high cholesterol, diabetes, and atrial fibrillation have the highest risk of stroke attacks (Boehme & Esenwa, 2018). Stroke attacks, especially hemorrhagic strokes, can result in death, disability, and other complications that impact the patient’s quality of life. Stroke is the second leading cause of death globally and the third cause of global disability (Hay et al., 2017). Care coordination is, therefore, essential in the management of stroke patients.

Health Care Issues Related to Stroke

Stroke survivors experience severe healthcare issues that require coordinated care, including paralysis, clinical depression, and aphasia. Paralysis after a stroke is related to loss of muscle function and muscle movement. Post-stroke paralysis may cause overall muscle and body immobility (McGlinchey et al., 2018). Patients may experience paralysis on a particular side of the body and loss of muscle control on multiple parts of the body. Extended immobility affects all aspects of daily living and may lead to other complications, such as the inability to speak, eat, sleep, and bladder dysfunction, among other related functional complications (Lui & Nguyen, 2018).

Clinical depression is another serious healthcare issue related to stroke. Post-stroke depression is associated with a majority of poor quality-of-life outcomes (Medeiros et al., 2020). Patients experiencing depression are likely to feel sad, easily irritated, develop difficulties concentrating, and experience health-impacting changes in sleep and food appetite (Lui & Nguyen, 2018). Patients may also express feelings of emptiness, self-worthlessness, and helplessness, leading to further complications and issues such as suicidal thoughts and suicide attempts.

Aphasia is the reduced ability of stroke survivors to communicate effectively (Rohde et al., 2018). The patient experiences issues with speech, such as the expression of words or understanding expressions. It results from the damage of certain parts of the brain post-stroke attack, with others due to brain damage after a stroke. Aphasia can complicate the treatment process of stroke patients with a negative impact on their daily living. Aphasia can lead to secondary and tertiary healthcare issues of concern, such as isolation.

Interventions for Stroke-Related Health Care Issues

The interventions for post-stroke healthcare issues require multidisciplinary professional inputs and efforts to manage. Interventions for post-stroke paralysis must focus on supporting the patient in their daily living. According to McGlinchey et al. (2018), interventions need to focus on rehabilitating and optimizing physical function to manage immobility-related complications better. The interventions for paralysis are physical therapy, including assisted and self-performed movements. The interventions also consider the diet of the patient during the recovery process.

Patients recovering from stroke and experiencing clinical depression require psychological treatments such as psychotherapy and counselling (Medeiros et al., 2020). Post-stroke depression hurts the recovery of the stroke patient. Psychosocial therapy interventions for clinical depression and related complications require diagnosis and treatment from certified mental health providers. In addition, the management of aphasia in the continuum of stroke care requires accurate diagnosis, including both informal and formal speech assessments (Rohde et al., 2018); speech therapy is the best recommended intervention for aphasia.

Available Community Resources for Health Care Issues

The optimization of the coordinated care for stroke patients requires the integration of community resources into the care coordination plan to support the recovering patient and related caregivers. The integration of community resources includes the use of community-based interventions to facilitate patient recovery, including the community in the recovery process and raising awareness of stroke and stroke survivors (Magwood et al., 2020).

Community resources are available throughout the United States to support stroke recovery. The US has well-equipped adult daycare centres, meal programs, home health aide services, and home and respite care resources across all communities. Assistance services and resources for both stroke survivors and caregivers are also available and accessible from the National Stroke Association, the American Stroke Foundation, the American Stroke Association, and The Stroke Network.

Ethical Decisions in Designing Patient-Centered Health Interventions

Due to the complications and healthcare needs associated with stroke, stroke survivors need more patient-centred health interventions to achieve positive care outcomes. The decisions on the health interventions must abide by the ethics of care that consider the state of the patient. Ethics of care require the providers to consider the autonomy of patient decisions and the provider’s moral duty to provide beneficial care. For instance, a patient experiencing immobility, aphasia, and depression accompanied by reduced cognitive abilities may have an issue with making autonomous decisions about their care. Therefore, every action the caregiver takes can create ethical issues. Mahanes (2020) suggests using skilled communication between clinicians and patients or their surrogates to facilitate shared decision-making to prevent ethical issues from arising.

Caring for stroke patients and survivors raises many ethical questions. In the case of a paralyzed patient who wants to change their clothes, the question of whether assisting the patient in getting undressed and dressed violates their privacy arises. Further, patients or their surrogates may opt to withdraw the treatment to reduce costs that the nurse must include. This is an ethical dilemma with regard to autonomy in decisions, and the nurse’s duty is to do no harm. Another ethical question is whether the nurse is providing the right level of care based on the state of the stroke patient.

Health Policy Implications for the Coordination and Continuum of Care

The coordination of care for stroke patients throughout the stroke continuum of care has various policy implications. The optimization of stroke care requires huge funding to coordinate all care functions efficiently. The costs of stroke care may push a number of patients and their families to opt out of care due to affordability issues, especially if the patient does not meet the eligibility for Medicaid services. This requires reforms in the Patient Protection and Affordable Care Act (ACA) to make special provisions for stroke patients covering the entire stroke continuum of care. It will require changing the eligibility for Medicare and Medicaid health insurance programs for stroke patients. It will also require the Patient Protection and Affordable Care Act to improve its stroke provisions that cover prevention, treatment, and recovery.

Stroke care coordination also includes the use of community input. The direct involvement of the community identifies the gaps in awareness of stroke within the population. These findings will push Medicaid, Medicare, ACA policies, and CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) to develop policies that optimize stroke systems and community awareness to prevent stroke and improve preparedness and response.

Establishing Care Coordination Plan Priorities

Successful care coordination requires identifying and establishing care priorities. It is important that the patient and a family member get engaged in developing the plan. Weerasekara et al. (2021) suggest first identifying what stroke survivors value the most. From a professional perspective, it is important to prioritize actions that help manage blood pressure and post-stroke fatigue and restore basic physical functions (Rudberg et al., 2020). Patient, family, and professional inputs help develop a patient-centred care plan. The stroke coordination will also need to be changed to accommodate established needs and eliminate the functions that are no longer needed as the patient recovers.

Comparison of Learning Session Content with Best Practices

Learning sessions have provided the basic knowledge required to design a care coordination plan in accordance with the best practices of care. The learning content has informed me on how to make ethical decisions when faced with ethical dilemmas with regard to patient care and the delivery of care in situations where the patient is incapacitated to make autonomous decisions. The learning sessions have also helped me understand how to identify issues or actions in the continuum of care that may be ignored but may lead to the violation of ethics of care. Conclusively, the learning sessions form the basis for understanding the best practices in health care and coordinated care.

Alignment of Teaching Sessions to the Healthy People 2030

Healthy People 2030 document establishes the national objectives for data-driven and evidence-informed health practices to improve overall well-being for the next ten years. The teaching sessions have emphasized the use of data to make evidence-based decisions for better health outcomes. It has also provided knowledge on healthcare statistics, how they are collected, the databases, how to access such statistics, and how they inform healthcare policies, decisions, and practices. Therefore, the teaching sessions are aligned with the objectives of the Healthy People 2030 document.

Conclusion

In conclusion, coordination of care harmonizes different resources from multiple providers and specialists to meet the patient’s and their family’s needs along the care continuum. Accordingly, this impacts the quality of care delivered and the costs of care. Stroke survivors require coordinated care that includes both professional care and informal care interventions to improve the quality of life for the patient post-stroke. Care coordination can help develop insights into the healthcare system with implications for healthcare policies.

References

Boehme, A. & C. Esenwa, M. E. (2018). Stroke: Risk factors and prevention. Journal of the Pakistan Medical Association, 60(3).

Hay, S. I., Abajobir, A. A., Abate, K. H., Abbafati, C., Abbas, K. M., Abd-Allah, F., Abdulle, A. M., Abebo, T. A., Abera, S. F., Aboyans, V., Abu-Raddad, L. J., Ackerman, I. N., Adedeji, I. A., Adetokunboh, O., Afshin, A., Aggarwal, R., Agrawal, S., Agrawal, A., Kiadaliri, A. A., … Bryane, C. E. G. (2017). Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet, 390(10100), 1260–1344. https://doi.org/10.1016/s0140-6736(17)32130-x

Karam, M., Chouinard, M. C., Poitras, M. E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1). https://doi.org/10.5334/ijic.5518

Lui, S. K., & Nguyen, M. H. (2018). Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges. Current Gerontology and Geriatrics Research, 2018. https://doi.org/10.1155/2018/9853837

Magwood, G. S., Nichols, M., Jenkins, C., Logan, A., Qanungo, S., Zigbuo-Wenzler, E., & Ellis, C. (2020). Community-Based Interventions for Stroke Provided by Nurses and Community Health Workers: A Review of the Literature. The Journal of Neuroscience Nursing : Journal of the American Association of Neuroscience Nurses, 52(4), 152. https://doi.org/10.1097/JNN.0000000000000512

Mahanes, D. (2020). Ethical Concerns Caring for the Stroke Patient. Critical Care Nursing Clinics of North America, 32(1), 121–133. https://doi.org/10.1016/J.CNC.2019.11.001

McGlinchey, M. P., James, J., McKevitt, C., Douiri, A., McLachlan, S., & Sackley, C. M. (2018). The effect of rehabilitation interventions on physical function and immobility-related complications in severe stroke – Protocol for a systematic review. Systematic Reviews, 7(1), 1–8. https://doi.org/10.1186/S13643-018-0870-Y/TABLES/2

Medeiros, G. C., Roy, D., Kontos, N., & Beach, S. R. (2020). Post-stroke depression: A 2020 updated review. General Hospital Psychiatry, 66, 70–80. https://doi.org/10.1016/J.GENHOSPPSYCH.2020.06.011

Rohde, A., Worrall, L., Godecke, E., O’Halloran, R., Farrell, A., & Massey, M. (2018). Diagnosis of aphasia in stroke populations: A systematic review of language tests. PLOS ONE, 13(3), e0194143. https://doi.org/10.1371/JOURNAL.PONE.0194143

Rudberg, A. S., Berge, E., Laska, A. C., Jutterström, S., Näsman, P., Sunnerhagen, K. S., & Lundström, E. (2020). Stroke survivors’ priorities for research related to life after stroke. Https://Doi.Org/10.1080/10749357.2020.1789829, 1–6. https://doi.org/10.1080/10749357.2020.1789829

Weerasekara, I., Baye, J., Burke, M., Crowfoot, G., Mason, G., Peak, R., Simpson, D., Walker, F. R., Nilsson, M., Pollack, M., & English, C. (2021). What do stroke survivors value about participating in research, and what are the most important research problems related to stroke or transient ischemic attack (TIA)? A survey. BMC Medical Research Methodology, 21(1), 1–10. https://doi.org/10.1186/S12874-021-01390-Y/TABLES/2

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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 health care 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.

Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.

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.