Preliminary Care Coordination Plan: Chronic Disease Management

Chronic diseases such as diabetes, hypertension, and heart disease present significant challenges to patients, caregivers, and healthcare providers. Such conditions usually require long-term medical management and lifestyle modification. Undeniably, effective care coordination is needed for comprehensive, continuous, patient-centered care. Care coordination includes integrating healthcare services, bridging communication gaps, and providing support based on a patient’s physical, psychosocial and cultural needs: Preliminary Care Coordination Plan: Chronic Disease Management.

Notably, patients with chronic illnesses may struggle to manage their symptoms on their own without a planned and coordinated scale, which could result in more hospital stays, more medical expenses, and a lower quality of life. Therefore, adopting a strategy that emphasizes the application of proven best practices, measures of a solid goal, and available community resources will be needed in order to preserve the safe and effective line of care in the administration of chronic diseases. Consequently, the healthcare provider can overcome the barriers to effective disease management, and the patient can become more adherent, increase outcomes, and promote independence in managing chronic illness.

Analysis of Chronic Disease Management and Best Practices

While the management of chronic disease is a complex medical treatment intervention requiring multilevel interventions, including multifaceted medical treatment, patient education, behavioral intervention, and psychosocial support, these undergo assessment and need creative attention to handle them properly. The best practices include early detection, self-management education, and an interdisciplinary team. Well-coordinated care reduces hospital admissions and enhances patients’ adherence to treatment, as Elliott et al. (2011) state in their research.

Chronic diseases, from the physical standpoint, cause a number of symptoms and complications that severely affect daily life. For instance, people with hypertension face an increased risk of stroke, heart failure, and other kidney diseases, and those with diabetes are at significantly high risk of nerve damage (neuropathy), vision problems (retinopathy), and kidney complications (nephropathy). According to Yildiz et al. (2020), these conditions have to be tracked with a holistic program that includes adherence to medication, monitoring of health routine, physical activity each day, and dietary change. Many patients use assistive devices such as blood glucose monitors, mobility aids, and home blood pressure machines to help them control their disease.

Furthermore, chronic illnesses are as significant when considering their psychosocial effects. Because of the limitations and uncertainty of their condition, the majority of patients struggle with emotional distress, depression, and agony. As stated by Niño de Guzmán Quispe et al. (2021), the stress associated with managing a chronic illness, especially in combination with financial constraints, social isolation, and absence of family support, may result in non-adherence to treatment regimens.

However, in some instances, patients become discouraged by a lack of progress or worsening symptoms when they do not see the improvements anticipated by medical recommendations. Psychological therapies, including peer support groups, stress management programs, and counseling, can help patients deal with these emotional difficulties. They also identify patients at risk for severe depression or anxiety, and integrating them into routine chronic disease management can help with screenings.

Besides, cultural factors also affect how patients view their condition, how they adhere to their medication, and whether they seek care. Some cultural beliefs discourage the usage of pharmaceutical medications and prefer the use of holistic or traditional medicine. Further, dietary habits, such as high-fat or high-sugar foods, may be promoted by others and may contribute to the progression of the disease.

Language barriers, mistrust of health care providers, and limited health literacy also make it difficult to manage disease, as noted by Feinberg et al. (2021). Incorporating culturally sensitive interventions such as bilingual education materials, culturally competent healthcare providers, and partnerships with community leaders can positively impact patient engagement and adherence to care plans.

Goals for Addressing Chronic Disease Management

Patient care responsibilities should be specified with clear and measurable goals to secure a successful care coordination plan. The goals are designed to enhance chronic disease management by addressing key challenges faced by patients.

Improve Medication Adherence

One of the most significant barriers to managing chronic diseases is poor medication adherence. Many patients forget to take their medications, discontinue them due to side effects, or lack an understanding of their importance. This plan aims to increase medication adherence by 20% within six months through patient education, medication reminders, and pharmacist consultations. Interventions such as bright pill dispensers, mobile health apps, and medication synchronization programs can also improve adherence.

Enhance Self-Management Skills

Patients must understand their condition and recognize early warning signs of complications. As asserted by Bhattad and Pacifico (2022), this goal focuses on improving patient health literacy by providing one-on-one coaching, disease-specific education programs, and written resources. This will enable the patient to take proactive steps in terms of monitoring their symptoms and their diet, and recognizing signs of deterioration of not only their disease but also their health.

Promote Mental Health and Emotional Well-being

Untreated psychosocial distress may result in poor disease outcomes. In this plan, depression and anxiety symptoms attempted to be decreased by 15% over 6 months by enlisting routine mental health screening, referral, and peer support programs among chronic disease patients. However, additional emotional support for patients can be enhanced by social encouragement of family involvement and caregiver training.

Increase Access to Healthcare Services

Limited access to care is a significant barrier to care in chronic disease. Schwarz et al. (2022) noted that patients often struggle getting transportation, getting initial treatments, paying, or arranging appointments with specialists. Under this plan, efforts will be made to increase care availability at primary and specialty levels by connecting patients with programs offering financial assistance, transportation services, and telehealth. Accessibility will be improved, including timely intervention and prevention of disease progression.

Encourage Healthy Lifestyle Changes

Lifestyle modifications are preventable or ‘manageable’ for many chronic diseases. This goal is to help the patients achieve and maintain a healthier lifestyle by introducing dietary improvements, increasing physical activity, and smoking cessation programs. They will try to encourage patients to put in place personalized health goals like reducing sodium intake, engaging in at least 150 minutes of activity a week, and getting regular sleep schedules.

Community Resources for a Safe and Effective Continuum of Care

A significant reason chronic disease is challenging to treat is inadequate resources. Therefore, a strong network of community resources is critical for helping patients with chronic diseases to maintain them. Consequently, community health centers provide affordable medical care, preventive screenings, and chronic disease education to underserved populations.

These centers ease the monetary burden on the patient as they can balance this condition. Similarly, centralized Disease Management Programs, such as the American Diabetes Association (ADA) and the American Heart Association (AHA), provide programs for subsets of chronic conditions with specialized resources ranging from workshops, nutrition counseling, and printed educational materials.

Subsequently, support groups are essential in supporting people living with a chronic disease through emotional and social support. Patients can gain from peer groups for diabetes, hypertension, and arthritis to share experiences, obtain advice, and receive encouragement. Some of the examples of this are Home Health Services, in which patients with reduced mobility come to their homes searching for nurses, physiotherapists, and social workers. These services provide the type of support to provide adherence to treatment and prevent as many program hospital admissions as possible.

Further, Mobile Health Clinics and Telehealth Services efficiently meet the needs of patients in rural or under-served areas through remote appointments, prescription refills, and health coaching on digital platforms. YMCA fitness initiatives, food assistance programs, and community gardens assist patients in changing their lifestyle for the better in broader terms.

Conclusion

In order to render a comprehensive, well-coordinated approach to chronic disease management, it is necessary to address the patient’s physical, psychosocial, and cultural needs. Best practices implementation, setting goals, and community resources help improve patient outcomes and continuity of care in healthcare providers. Improved care coordination enables effective hospital readmissions, therapeutic compliance to medication, and adoption of healthy lifestyles, which will, in turn, positively influence long-term management of disease and quality of life.

References

Bhattad, P., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7), e27336. https://doi.org/10.7759/cureus.27336

Elliott, M. N., Adams, J. L., Klein, D. J., Haviland, A. M., Beckett, M. K., Hays, R. D., Gaillot, S., Edwards, C. A., Dembosky, J. W., & Schneider, E. C. (2021). Patient-Reported Care Coordination is Associated with Better Performance on Clinical Care Measures. Journal of General Internal Medicine, 36(12). https://doi.org/10.1007/s11606-021-07122-8

Feinberg, I. Z., Smith, A. O., O’Connor, M. H., Ogrodnick, M. M., Rothenberg, R., & Eriksen, M. P. (2021). Strengthening Culturally Competent Health Communication. Health Security, 19(1). https://doi.org/10.1089/hs.2021.0048

Niño de Guzmán Quispe, E., Martínez García, L., Orrego Villagrán, C., Heijmans, M., Sunol, R., Fraile-Navarro, D., Pérez-Bracchiglione, J., Ninov, L., Salas-Gama, K., Viteri García, A., & Alonso-Coello, P. (2021). The Perspectives of Patients with Chronic Diseases and Their Caregivers on Self-Management Interventions: A Scoping Review of Reviews. The Patient, 14. https://doi.org/10.1007/s40271-021-00514-2

Schwarz, T., Schmidt, A. E., Bobek, J., & Ladurner, J. (2022). Barriers to accessing health care for people with chronic conditions: A qualitative interview study. BMC Health Services Research, 22(1), 1037. https://doi.org/10.1186/s12913-022-08426-z

Yildiz, M., Esenboğa, K., & Oktay, A. A. (2020). Hypertension and diabetes mellitus: highlights of a complex relationship. Current Opinion in Cardiology, 35(4), 397–404. https://doi.org/10.1097/hco.0000000000000748

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Develop the Preliminary Care Coordination Plan
Complete the following:

• Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
• 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, this 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 health care problem.
• Identify available community resources for a safe and effective continuum of care.
• Organize content so ideas flow logically with smooth transitions; contains 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.