Preliminary Care Coordination Plan
High blood pressure (HBP) is a health problem of concern that most nurses encounter in their daily practice. This care coordination plan analyzes high blood pressure and the best practices for improving the health of high blood pressure patients. It also establishes specific goals to address high blood pressure as well as physical, cultural, and psychosocial considerations made when dealing with high blood pressure patients. It further identifies and lists the available community resources to support a safe and effective continuum of care for high blood pressure.
Analysis of High Blood Pressure
The major risk factors for HBP include age, a family history of HBP, being overweight and obese, and a sedentary lifestyle combined with a high intake of alcohol, smoking, and high-sodium foods (World Health Organization, 2023). HBP is also a common comorbid disease with other chronic diseases such as diabetes and kidney issues. HBP progresses in stages. Readings of 120-129 systolic and less than 80 mm Hg diastolic indicate elevated blood pressure; 130-139 systolic or 80-89 mm Hg diastolic indicates hypertension stage one, while 140/90 mmHg indicates hypertension stage two (American Heart Association, n.d.). Readings above 180/120 mmHg lead to a hypertensive crisis. HBP is a health problem of concern as it increases the development of other chronic diseases. For instance, people with high blood pressure have an increased risk of developing cardiovascular diseases (CVD) and possible organ damage (Fuchs & Whelton, 2020). HBP also increases the costs of care and reduces an individual’s level of productivity as well as quality of life. According to the WHO data on hypertension, 1.28 billion adults aged 30-79 years live with HBP, and the condition affects an estimated one in every four American adults (World Health Organization, 2023). There are notable disparities in the prevalence of HBP as it is mostly in the elderly, with a majority of the problem experienced among individuals of African American backgrounds (World Health Organization, 2023).
Best Practices for Health Improvement in High Blood Pressure Patients and Points of Uncertainty
There are multiple best practices for improving the health of patients with high blood pressure. The major best practice for health improvement for an HBP patient is a total lifestyle change. This includes a change in eating and activity habits. The WHO recommends avoiding fast foods and substituting such foods with healthy alternatives such as vegetables, home-cooked organic foods, and increasing physical activity (World Health Organization, 2023). The lifestyle changes further focus on losing extra weight and engaging in lifestyles that help maintain healthy body weight. There is also a need to support the patient to quit smoking and limit the amount or total elimination of alcohol in the patient’s life.
A high number of people with HBP are not yet diagnosed (World Health Organization, 2023), which makes HBP further an issue of concern. A best practice for improving the health of HBP patients is to improve the rate of people checking their blood pressure status. It is also important to keep track of blood pressure readings. As a best practice, providing HBP patients with tools and education help monitor their blood pressure at home. A combination of regular screening and monitoring of HBP can help detect blood pressure fluctuations and support early management to reduce the risk of complications. Educating the patient on the benefits of adhering to their medication plans is also important.
The analysis of HBP to support the development of this care coordination plan is based on available data. However, there are underlying assumptions and points of uncertainty that can affect its effectiveness in delivering well-coordinated care to patients. For instance, due to factors such as income level, education, and access to healthcare services, some elements of the plan may not be generalizable across the general population. Additionally, due to differences in stages of hypertension, the plan will require to be individualized to fit specific patient needs.
Specific Goals Established to Address High Blood Pressure
The goals established to address the problem of HBP are guided by the SMART (specific, measurable, achievable, relevant, and time-bound) goal-setting process. There are five SMART goals set for this care coordination plan for HBP.
The specific goal of the care coordination plan is to improve the patient’s HBP outcomes and overall well-being. The measurable goal for addressing HBP is to increase the level of awareness of HBP, risk factors, and associated risks and improve the rate of screening and monitoring for blood pressure among the patients and the general population. The achievable goal in addressing HBP as a healthcare problem of concern is to change the lifestyle of the patient and other at-risk populations. This will include improving physical activity, eating healthy foods, limit alcohol and tobacco consumption. Next, the relevant goal of the care coordination plan for HBP is to support the patient with relevant educational materials to help understand HBP and improve their adherence to their medication plans and other interventions adopted for this plan. Lastly, the time-bond goal is to achieve all the set goals within a period of six months.
Physical, Psychosocial, and Cultural Considerations for High Blood Pressure Care Coordination Plan
Designing a care coordination plan for HBP requires making the patient the focus of the care delivered. Evidence shows that applying the element of patient-centered care in managing HBP patients influences care practices with significant impacts on the outcome of care (Buawangpong et al., 2020). Patient-centered care considers the patient’s physical, mental, and psychological status, as well as their culture, beliefs, and other world views.
Physical Considerations
Coordinating care for HBP patients must consider the physical well-being of the patient. This includes both body weight, physical and mental abilities, ability to read and write, and other aspects of the individual, such as daily activity levels. These are essential for deciding on medications, dosage, and designing the care plan and the level of need required to take the right medication, doses, and at the right time.
Psychosocial Considerations
The care coordination plan for HBP considers the patient’s mental health, living conditions, region, emotional state, and available support. These are essential to model the care plan to further meet the patient’s psychosocial needs to best manage their HBP status as well as improve their access to needed care.
Cultural Considerations
Cultural considerations are critical facilitators for a patient-centered care plan (Kwame & Petrucka, 2021). When coordinating care for HBP patients, one must understand and appreciate the cultural values and beliefs of the patients and how they influence their participation in the care plan. This helps deliver care the patient can easily relate to and adhere to the plan.
Community Resources for a Safe and Effective Continuum of Care
The available community resources for a safe and effective continuum of care for HBP include:
- Locally accessible health clinics and community health centers.
- Online support groups across the U.S. focused on improving HBP awareness.
- Online educational resources provided by reputable organizations, such as the CDC and the American Heart Association
- Emergency health and lifestyle coaches accessible via video call services
- Home health services that support the delivery of patient-centered HBP care (Pourat et al., 2019).
Conclusion
HBP is a healthcare issue of concern due to its adverse effects on the health and quality of life of affected persons as well as its risk for developing chronic health conditions. However, HBP is manageable and reversible. Conclusively, a patient-centered coordination care plan can help achieve or improve patient and health outcomes and ensure a safe and effective continuum of care for HBP patients.
References
American Heart Association. (n.d.). Understanding Blood Pressure Readings. Retrieved May 11, 2023, from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
Buawangpong, N., Pinyopornpanish, K., Jiraporncharoen, W., Dejkriengkraikul, N., Sagulkoo, P., Pateekhum, C., & Angkurawaranon, C. (2020). Incorporating the patient-centered approach into clinical practice helps improve quality of care in cases of hypertension: A retrospective cohort study. BMC Family Practice, 21(1), 1–8. https://doi.org/10.1186/S12875-020-01183-0/TABLES/5
Fuchs, F. D., & Whelton, P. K. (2020). High Blood Pressure and Cardiovascular Disease. Hypertension, 75(2), 285–292. https://doi.org/10.1161/HYPERTENSIONAHA.119.14240
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/FIGURES/1
Pourat, N., Chen, X., Lee, C., Zhou, W., Daniel, M., Hoang, H., & Sripipatana, A. (2019). Assessing the Impact of Patient-Centered Medical Home Principles on Hypertension Outcomes Among Patients of HRSA-Funded Health Centers. American Journal of Hypertension, 32(4), 418–425. https://doi.org/10.1093/AJH/HPY198
World Health Organization. (2023, March 16). Hypertension. WHO. https://www.who.int/news-room/fact-sheets/detail/hypertension
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Question 
Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.
Preliminary Care Coordination Plan
Introduction
NOTE: You are required to complete this assessment before Assessment 4.
The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular healthcare problem.
Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.
As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.
Preparation
Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.
To prepare for this assessment, you may wish to:
Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen healthcare concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
Stroke.
Heart disease (high blood pressure, stroke, or heart failure).
Home safety.
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
Pain management.
Mental health.
Trauma.
Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
Remember to use active voice, which means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.
Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.
Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the healthcare problem.
Identify available community resources for a safe and effective continuum of care.
Organize content so ideas flow logically with smooth transitions; contain few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.