Preliminary Care Coordination

Preliminary Care Coordination

Care coordination necessitates interdisciplinary collaboration. In this context, each member is assigned unique roles and responsibilities. In addition, care coordination promotes an interdisciplinary approach to the clinical decision-making process. As such, care coordination improves the quality of healthcare services. This paper evaluates a care coordination plan for hypertension.

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Health Concern and the Associated Best Practices

Hypertension is a cardiovascular disease that presents with elevated blood pressure. According to the American College of Cardiology and the American Heart Association, hypertension is categorized into two stages. Stage 1 presents with a systolic pressure of 130 to 139 mmHg and a diastolic pressure of 80 to 90 mmHg (CDC.gov-a, 2022). On the other hand, stage 2 presents with a systolic pressure of more than or equal to 140 mmHg and a diastolic pressure of more than or equal to 90 mmHg (CDC.gov-a, 2022). Findings indicate that approximately 116 million Americans have been diagnosed with hypertension (CDC.gov-a, 2022). About 37 million of these individuals have uncontrolled hypertension. Accordingly, the USA spends approximately $131 billion annually on the management of hypertension (CDC.gov-a, 2022).

Healthcare providers and other stakeholders should provide holistic care that addresses the cultural, physical, and psychosocial needs of hypertensive patients. Firstly, the disease has an ethnic predilection. The prevalence of the disease among non-Hispanic blacks, non-Hispanic whites, non-Hispanic Asians, and Hispanics is about 57 percent, 49 percent, 46 percent, and 39 percent, respectively (CDC.gov-a, 2022). As a result, all stakeholders should uphold cultural congruence when providing healthcare services. This includes providing language translators and respecting cultural practices and various coping mechanisms (Göl & Erkin, 2019).

According to Oliveros et al. (2020), hypertensive patients are likely to have psychosocial problems such as anxiety and depression. These problems emanate from the disease process, including the need for medication adherence and the fear of developing complications such as stroke (Oliveros et al., 2020). Stakeholders should provide relevant embrace techniques such as counseling and motivation to address this problem. Furthermore, hypertension is associated with physical issues such as headache, epistaxis, fatigue, and muscle tremors (Zie et al., 2020). Healthcare providers should emphasize medication adherence and lifestyle modification, including physical activity and dietary modification. Subsequently, this will optimize blood pressure control and minimize the physical issues associated with the disease.

Specific Goals to Address the Health Care Problem

The first goal is to declare hypertension a problem of national concern and provide comprehensive health education to patients and the public. Health education is important because it equips patients and communities with relevant facts about the disease (Zie et al., 2020). This should address aspects such as the risk factors, complications, and prevention of hypertension. Prevention of hypertension depends on lifestyle modification. Examples of preventive strategies include regular physical activity, limiting alcohol consumption, reducing sodium intake, and adopting a DASH diet (taking plenty of fresh fruits and vegetables and consuming low-fat meals) (Rabi et al., 2020). Education should also focus on complications associated with the disease, such as stroke, and the risk for cognitive decline (Rabi et al., 2020). Education should also focus on the economic impact of the disease. For example, approximately $131 billion is used annually to manage the disease in the USA (CDC.gov-a, 2022).

The second goal is to optimize the management of patients diagnosed with hypertension. Healthcare providers should embrace evidence-based practice when formulating treatment plans. Evidence-based practice ensures that the best interventions are adopted and implemented. Furthermore, healthcare providers should conduct periodic patient follow-ups to avoid the risk of clinical inertia. Clinical inertia happens when the treatment plan is not optimized to achieve the desired therapeutic outcomes (Rabi et al., 2020). This is relevant because hypertension is a chronic disease that requires regular follow-up and treatment optimization. The importance of medication adherence should be emphasized. Adherence to the treatment plan is associated with improved clinical outcomes and reduces the risks of developing complications (Rabi et al., 2020).

The third goal is to create an environment and culture that promotes hypertension control. Various strategies can be used to achieve this. Firstly, community resources should be availed to the general public. These resources should provide avenues for physical activity and support groups (Zie et al., 2020). Physical activity is an essential factor in the prevention of hypertension. Secondly, community programs that advocate for healthy nutrition and public education should be available (Zie et al., 2020). Healthcare providers should help patients and their families select these community resources.

Community Resources for a Safe and Effective Continuum of Care

The American Heart Association (AHA) is an example of a community resource in Minnesota dedicated to providing care for hypertensive patients and their families. AHA has established blood pressure centers in Minneapolis to target patients with uncontrolled hypertension (Heart.org, 2019). Additionally, AHA collaborates with nurses to offer services to patients with hypertension. Examples of these services include blood pressure monitoring and screening for complications (Heart.org, 2019). Also, AHA advocates for healthy nutrition by collaborating with the local government and food production industries (Heart.org, 2019). The other community resource is Minnesota’s WISEWOMAN Program. This program uses telehealth technology to connect hypertensive women to pharmacists (CDC.gov-b, 2022). By so doing, medication therapy management achieved better patient outcomes. This program has served more than 600 hypertensive patients (CDC.gov-b, 2022).

Conclusion

Hypertension is a problem of concern in the USA. This is evidenced by the prevalence of the disease and its economic impact. Healthcare providers are key stakeholders in the management of this disease. These stakeholders should uphold holistic care that identifies and addresses all patient needs. The availability of community resources facilitates a continuum of care for patients with hypertension.

References

CDC.gov-a. (2022). Facts About Hypertension in the United States. https://www.cdc.gov/bloodpressure/facts.htm

CDC.gov-b. (2022). Improving Medication Adherence Through Telehealth in Minnesota. https://www.cdc.gov/dhdsp/evaluation_resources/wisewoman_innovation/minnesota.htm

Göl, İ., & Erkin, Ö. (2019). Association between cultural intelligence and cultural sensitivity in nursing students: A cross-sectional descriptive study. Collegian, 26(4), 485–491. https://doi.org/10.1016/j.colegn.2018.12.007

Heart.org. (2019). Minnesota Resources: American Heart Association – Our Work in Minnesota. https://www.heart.org/en/affiliates/minnesota-resources

Oliveros, E., Patel, H., Kyung, S., Fugar, S., Goldberg, A., Madan, N., & Williams, K. A. (2020). Hypertension in older adults: Assessment, management, and challenges. Clinical Cardiology, 43(2), 99–107. https://doi.org/10.1002/clc.23303

Rabi, D. M., McBrien, K. A., Sapir-Pichhadze, R., Nakhla, M., Ahmed, S. B., Dumanski, S. M., Butalia, S., Leung, A. A., Harris, K. C., Cloutier, L., Zarnke, K. B., Ruzicka, M., Hiremath, S., Feldman, R. D., Tobe, S. W., Campbell, T. S., Bacon, S. L., Nerenberg, K. A., Dresser, G. K., Daskalopoulou, S. S. (2020). Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. The Canadian Journal of Cardiology, 36(5), 596–624. https://doi.org/10.1016/j.cjca.2020.02.086

Zie, G., Kerr, Z. Y., & Moore, J. B. (2020). Universal Healthcare in the United States of America : A Healthy Debate. 1–7.

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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 healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

Preliminary Care Coordination

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.
Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

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.
Analyze a health concern and the associated best practices for health improvement.
Competency 2: Collaborate with patients and families to achieve desired outcomes.
Describe specific goals that should be established to address a selected healthcare problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered 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