Preliminary Care Coordination Plan for Chronic Disease Management

Chronic diseases, such as diabetes, cardiovascular diseases, and chronic respiratory conditions, are among the leading causes of mortality and disability in the United States. These conditions necessitate consistent healthcare and treatment, leading to several healthcare expenses. Illinois, like other states, has embarked on the noble task of managing chronic diseases since they are a major cause of morbidity and mortality in the community. These diseases are indicative of chronic systems, and therefore, the management of these diseases needs to address patients’ physical, psychosocial, and cultural needs. This care coordination plan describes a strategic system for managing chronic diseases at a community level. It reveals a change in the nursing staff’s role due to the recent budget limitations. The importance of chronic diseases in the healthcare system has prompted the development of care coordination plans to manage diseases at a community level. Here, key facets of care at different times are discussed, as well as the important use of local resources to increase the quality of life of chronic disease patients.

Analysis of Chronic Disease Management as a Health Concern

Physical Considerations

Chronic diseases can severely limit a patient’s ability to perform daily activities due to pain, fatigue, or mobility issues. For example, patients with chronic obstructive pulmonary disease (COPD) may experience difficulty breathing, while those with arthritis may face joint pain that hinders movement (Xiang et al., 2022). The physical restrictions mean that residents require ongoing health monitoring, individualized care plans, and support from occupational and physical therapists and other professionals in order to remain as active as possible. Managing medications, vital signs data, and specialists are also useful for handling the bodily elements of chronic diseases.

Psychosocial Considerations

The emotional toll of chronic illness cannot be overlooked. Many patients face depression, anxiety, or feelings of isolation due to the long-term nature of their conditions. These mental health issues can worsen a patient’s physical condition and also interfere with their compliance with treatments. Also, counseling and support services must be added to chronic disease management programs. Patients should also have a source of mental health follow-ups, such as a therapist or a support group, where patients can voice their worries and get support. This type of psychosocial support helps patients feel that they are a part of a community, which is vital for the survival of a precedence ailment (Akyirem et al., 2021).

Cultural Considerations

In Illinois, where the population is diverse, cultural beliefs and practices can influence how individuals manage their health. For example, some patients may prefer alternative therapies, such as herbal remedies, over conventional medications. Indeed, cultural competence with respect to these issues is central to obtaining the trust and concordance of patients with their treatment regimes. Also, the different language used makes it hard for patients to comprehend their treatment. Additionally, language barriers may prevent patients from fully understanding their treatment plans. Therefore, offering health education materials in multiple languages and providing interpreters during consultations are essential for effective communication.

Best Practices for Improvement

Chronic diseases require patient-centered care models with self-management and monitoring based on global best practices. This includes patient counseling programs whereby patients are taken to their homes and informed on how to manage their diseases at home. This approach also involves follow-up care, where patients are revisited, and new plans can be made depending on what the doctor finds. Collaborative care teams, consisting of primary care providers, specialists, mental health professionals, and community health workers, are essential for coordinating care and ensuring all aspects of a patient’s health are addressed.

Goals for Chronic Disease Management

Effective chronic disease management requires setting clear, realistic goals that are measurable and attainable. These goals provide direction and allow for continuous evaluation of patient progress. For this care coordination plan, the following objectives have been established.

Goal #1: Increase Patient Engagement in Self-Management by 25% within the Next 12 Months

This will be done by attending educational classes, coaching the patients, and availing them of mobile health applications that help them record their symptoms and medication adherence. These tools will help patients serve themselves and help them better manage their health conditions.

Goal #2: Reduce Emergency Room Visits and Hospital Readmissions by 20% Over 18 Months

Regular follow-ups and consistent monitoring will ensure that potential complications, such as medication side effects, worsening symptoms, or disease progression, are identified early enough before they escalate into emergencies. This approach will involve biannual physical examinations conducted remotely via telehealth or face-to-face, depending on the patient’s needs and access to healthcare services (Grudniewicz et al., 2023).

Goal #3: Improve Medication Adherence by 30% within the Next Year

Most chronic disease patients face challenges in medication compliance, which leads to poor health. By providing patients with individualized medication regimens, implementing a system for timely administration, and offering clear explanations regarding the importance of medication adherence, healthcare providers can significantly enhance patient compliance and, in turn, improve their long-term health outcomes.

Community Resources for Chronic Disease Management in Illinois

Chronic disease management in Illinois is supported by a variety of community health resources. These resources allow healthcare providers and community organizations to develop comprehensive care plans that address patients’ physical, psychosocial, and cultural needs throughout their illness.

Illinois Department of Public Health (IDPH)

The IDPH offers various tools to cope with chronic diseases, such as diabetes, cardiovascular diseases, and asthma. The organization also offers health promotion, which aims to ensure that patients change their ways and prevent the outcomes of the diseases.

Illinois Chronic Disease Prevention and Control Program

This program has partnered with the local health departments to provide chronic illness prevention and control services. The program aims to offer relevant educational information regarding screening in order to promote healthy lifestyle factors to reduce the incidence and progression of embodied chronic diseases.

Telehealth Services

Illinois Telehealth Network (ITN) and Illinois Health and Hospital Association (IHA) are widely used in Illinois to provide remote consultation and follow-up with chronic disease patients. It benefits patients living in rural areas or those who are physically challenged to ensure they continue seeing their doctor without having many appointments (Nguyen et al., 2021).

Greater Chicago Food Depository’s Health and Nutrition Programs

Individuals with chronic diseases that are worsened by poor diet are given an opportunity to make adequate choices on the proper diet that will help improve their health.

Chicago Family Health Centers (CFHC)

CFHC has put in place intensive interpretation of chronic diseases such as diabetes, hypertension, and asthma. These centers offer routine health check-ups, follow-up care patient enrollment meetings, and education to ensure patients receive the necessary care to manage their illnesses.

Conclusion

The care of chronic diseases is not only a therapeutic model but also a systematized and coordinated model that includes the psychological and ethical aspects of the patient’s therapy. By setting clear goals and utilizing the many community resources available in Illinois, this care coordination plan aims to improve the quality of life for patients with chronic conditions while reducing the burden on healthcare systems. Continuous evaluation and adaptation of the care plan will ensure that patients receive comprehensive, effective care that meets their evolving needs.

References

Akyirem, S., Forbes, A., Wad, J. L., & Due-Christensen, M. (2021). Psychosocial interventions for adults with newly diagnosed chronic disease: A systematic review. Journal of Health Psychology, 27(7), 135910532199591. https://doi.org/10.1177/1359105321995916

Grudniewicz, A., Gray, C. S., Boeckxstaens, P., Maeseneer, J. D., & Mold, J. W. (2023). Operationalizing the chronic care model with goal-oriented care. The Patient: Patient-Centered Outcomes Research, 16(6), 569–578. https://doi.org/10.1007/s40271-023-00645-8

Nguyen, K. H., Fields, J. D., Cemballi, A. G., Desai, R., Gopalan, A., Cruz, T., Shah, A., Akom, A., Brown, W., Sarkar, U., & Lyles, C. R. (2021). The role of community-based organizations in improving chronic care for safety-net populations. The Journal of the American Board of Family Medicine, 34(4), 698–708. https://doi.org/10.3122/jabfm.2021.04.200591

Xiang, X., Huang, L., Fang, Y., Cai, S., & Zhang, M. (2022). Physical activity and chronic obstructive pulmonary disease: A scoping review. BMC Pulmonary Medicine, 22(1). https://doi.org/10.1186/s12890-022-02099-4

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Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Introduction
The first step in any effective project is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

NOTE: You are required to complete this assessment before Assessment 4.

Preparation
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.

Scenario
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 health care concern.
  

  Preliminary Care Coordination Plan for Chronic Disease Management

Instructions
Note: You are required to complete this assessment before Assessment 4.

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] Download 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.