Preliminary Care Coordination Plan
Chronic disorders remain a concern to the global healthcare system. Notably, these disorders are a leading cause of morbidity and mortality. They are complex in presentation and fetch significant healthcare considerations. Nonetheless, care coordination approaches provide a framework for the effective management of chronic disorders. These coordinative approaches draw multiple healthcare professionals and tailor them towards care optimization and the enhancement of patient experiences. This caring approach has been lauded for its effectiveness in ensuring the provision of quality and safe care that realizes better clinical outcomes and patient experiences. This paper details a comprehensive care coordination plan for hypertension.
Designing Patient-Centered Health Interventions and Timelines for a Selected Healthcare Problem
Patient-centered and comprehensive approaches in the management of hypertension target specific issues that contribute to health promotion and preservation efforts that have long been targeted to the American public. These are interventions to increase hypertensive awareness, treatment, and optimal control.
Health Issues
Creating awareness of hypertension remains a health promotion strategy targeted at lowering the prevalence of the disease. It remains one of the most population-based strategies to prevent hypertension. Hypertension awareness targets populations at high risk for developing the disease. During this community awareness program, the public should be educated on the modifiable risk factors for the disease, such as consumption of tobacco, excessive use of alcohol, physical inactivity, high dietary salt intake, and overweight/obesity.
Treatment of hypertension is another issue in hypertensive control. Aggressive hypertensive control to the optimal clinical level is the target for pharmacotherapy. Early detection and subsequent initiation of anti-hypertensive medications are critical in the prevention of life-threatening hypertensive complications. Many societies, especially impoverished communities of ethnic minority groups, still lag. This is mainly due to poor access to care that traditionally affects these societies.
Optimal control of hypertension is another issue in the comprehensive management of the disease. Due to its chronic nature, patients with hypertension often require lifelong pharmacotherapy with anti-hypertensives. This is, however, challenging. Burnier & Egan (2019) report that suboptimal adherence to hypertension pharmacotherapy is a recognized contributory factor to poor hypertension control. Consequently, patients with poor hypertension control develop fatal complications such as cerebrovascular accidents and myocardial ischemia.
Interventions for the Issues
Hypertensive awareness can be conducted through community outreach programs, structured school educative programs, and at primary healthcare levels. Bosu & Bosu (2021) note that community awareness of modifiable risk factors for hypertension effectively encourages at-risk populations to adopt positive behaviors that reduce their risk of developing the disease. In the era of communication technologies and social media, community awareness can also be conducted through social media spaces. Social media offers a cheap yet expansive platform for sharing information on hypertension.
Communities should be encouraged to undertake hypertension screening regularly to ensure early detection and subsequent initiation of anti-hypertensive pharmacotherapy. All persons presenting to primary healthcare should have their blood pressures checked and be advised appropriately if found high. Access to care should also be enhanced in communities with poor access. Encouraging these communities to obtain insurance coverage may improve their health-seeking behavior and consequently facilitate early detection of the disease.
Medication compliance is essential in the optimal control of hypertension. It is the responsibility of healthcare providers and patients to ensure medication compliance. Healthcare providers should offer appropriate drug education on the importance of compliance with anti-hypertensive medication to their patients. They should also monitor their patients to ascertain their compliance level and to encourage them to continue taking their medications. The patients should also take it as a personal initiative to comply as a measure to preserve their lives.
Community Resources
Several community resources are valuable in creating hypertensive awareness. The American Society of Hypertension (ASH) is one such group. This is a non-profit organization that educates the American public on the disease. This organization is devoted to creating awareness of hypertension through structured education programs and community outreach programs. Other community resources that play similar roles include the Inter-American Society of Hypertension and the American Heart Association. The CDC, ASH, and the International Society for Hypertension are front liners in ensuring hypertensive patients adhere to their treatment. The American Heart Association, the CDC, and the Inter-American Society for Hypertension are also involved in ensuring optimal control of hypertension.
Ethical Decisions in Designing Patient-Centered Health Interventions
The patient-centered model in hypertension management remains valuable in optimizing care for hypertensives. This model takes into consideration patients’ values, beliefs, and preferences when designing care plans for them. Designing patient-centered health interventions requires ethical decision-making by the professionals involved in the inter-professional healthcare teams. The ethical principles of beneficence, justice, and non-maleficence remain valuable in the ethical decision-making process during the design of patient-centered approaches.
When initiating a pharmacotherapy treatment option for hypertensive patients, it is important to take into consideration their values and beliefs on the approaches utilized to better their future compliance with the medications. Beneficence requires that the caregiver promotes the welfare of the patients, while non-maleficence requires them to do no harm. By tailoring caring processes to the preferences of their patients, healthcare providers uphold beneficence, and by ensuring that their patients adhere to their medications and consequently prevent complications, they uphold non-maleficence. An ethical question that may arise revolves around whether the selected treatment plan is in concert with the patient’s preferences, beliefs, or values.
Relevant Health Policy Implications for the Coordination and Continuum of Care
Access to anti-hypertensive medications and healthcare resources necessary for monitoring and controlling hypertension remains challenging for some Americans. Impoverished communities, especially ethnic minority groups, traditionally affected by poor access to healthcare and health disparities, may find it difficult to access hypertension screening and medications. The Affordable Care Act (ACA) reforms of 2010 saw the expansion of insurance coverage to Americans of low incomes. Additionally, this legislative reform implored insurers to provide free health screenings to their customers. These reforms in preventive health have proved advantageous to communities that would have otherwise not accessed these programs. Besides, Nguyen et al. (2021) report that the screening for cardiovascular disorders such as hypertension increased considerably after the enactment of the ACA. This act enhanced access to preventive measures such as screening and increased insurance coverage for millions of Americans. The overall effect was observed in enhanced health-seeking behavior for many low-income Americans and increased community and health resource utilization.
Priorities When Discussing the Plan with a Patient and Family Member, Making Changes Based Upon Evidence-Based Practice
Care coordinators are tasked with communicating changes to other team members, patients, and the patients’ families. Healthcare interventions for the patients may sometimes require change processes for the patients and the caregivers. Cigarette smoking and excessive alcohol use are modifiable risk factors for hypertension. Nagao et al. (2021) posit that cigarette cessation and minimization of alcohol intake considerably lower the risks of developing hypertension. Coordinating care among cigarette smokers and heavy alcohol consumers may require a health coordinator to encourage behavior change among these individuals. Priorities to consider include understanding the demographic of the population and adopting effective communication skills. Understanding the population demographics will help the coordinators to tailor their communication approach, while effective communication skills will help them communicate effectively with these population groups.
Literature versus Healthy People 2030
Healthy People 2030 aims to create healthy communities with minimal health threats from hypertension. In this regard, it continues to emphasize community screening for hypertension to help in the early detection of the disease. It also aims at increasing blood pressure control among adults by rational use of anti-hypertensive medications. These provisions of Healthy People 2030 on hypertension control are in concert with literature findings on the same. Both aim at attaining blood pressure control by rational use of medications. Early detection through community screening programs is also a priority for both. The Healthy People 2030 is more elaborate in total coverage. It details specific contributory factors to hypertension and outlines key objectives for addressing them. The learning sessions will integrate specific objectives of Healthy People 2030, including those that emphasize secondary causes of hypertension.
Conclusion
Cardiovascular disorders remain a challenging health issue concern to many healthcare systems. The complexities in their presentation and the care demand they fetch make them challenging to the caregivers. Nevertheless, care coordination provides the groundwork for the effective management of these disorders. Hypertension, just like other cardiovascular disorders, presents specific health issues. Patient-centered approaches can adequately resolve these issues. Ethical decision-making, however, maintains significance in these decision-making processes. Observing the ethical principles that govern medical practice may help caregivers navigate these challenges.
References
Bosu, W., & Bosu, D. (2021). Prevalence, awareness, and control of hypertension in Ghana: A systematic review and meta-analysis. PLOS ONE, 16(3), e0248137. https://doi.org/10.1371/journal.pone.0248137
Burnier, M., & Egan, B. (2019). Adherence in Hypertension. Circulation Research, 124(7), 1124-1140. https://doi.org/10.1161/circresaha.118.313220
Nagao, T., Nogawa, K., Sakata, K., Morimoto, H., Morita, K., Watanabe, Y., & Suwazono, Y. (2021). Effects of Alcohol Consumption and Smoking on the Onset of Hypertension in a Long-Term Longitudinal Study in a Male Workers’ Cohort. International Journal of Environmental Research and Public Health, 18(22), 11781. https://doi.org/10.3390/ijerph182211781
Nguyen, T., Barefield, A., & Nguyen, G. (2021). Social Determinants of Health Associated with the Use of Screenings for Hypertension, Hypercholesterolemia, and Hyperglycemia among American Adults. Medical Sciences, 9(1), 19. https://doi.org/10.3390/medsci9010019
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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.
Preliminary Care Coordination
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.
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 healthcare problem.
Competency 2: Collaborate with patients and families 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 healthcare 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; contain few errors in grammar/punctuation, word choice, and spelling.
SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.
VIEW SCORING GUIDE