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Preliminary Coordinated Care Plan for Stroke Patient

Preliminary Coordinated Care Plan for Stroke Patient

Preliminary Coordinated Care Plan for Stroke Patient

Introduction: Analysis of Stroke as a Healthcare Concern

Statistically speaking, stroke is the world’s second major cause of death and a top contributor to global disability (Kuriakose & Xiao, 2020). Stroke is caused or associated with heart disease, high blood pressure, atrial fibrillation, high cholesterol, and diabetes. Stroke prevalence is highest in developing countries. However, stroke incidences and mortality vary with age and across regions and ethnic groups (Katan & Luft, 2018). Additionally, strokes vary in type and severity. Incidences can either be ischemic or hemorrhagic strokes. Although ischemic stroke incidences are reported frequently, hemorrhagic stroke is more lethal and causes more deaths, disability, and loss of crucial life years (Katan & Luft, 2018).

According to the Centers for Disease Control and Prevention (CDC) (2022), people who have had previous stroke incidents are at a higher risk of having another episode of stroke. The chances of another stroke incident are as high as 17% within 90 days after a transient ischemic attack (TIA). The CDC also notes that 1 in every 4 stroke patients has a recurring stroke incident within five years. Gilmore-Bykovskyi et al. (2018) concluded that almost 20% of stroke and hip fracture patients discharged to post-acute care facilities lack sufficient clinical follow-ups, leading to an increased risk of hospital readmission and, in the worst outcomes, death.

Patients with complex health needs require extensive coordinated care. Coordinated care interventions enable hospital delivery systems to provide comprehensive, quality, patient-centered care in complex health situations (Perez Jolles et al., 2019). Accordingly, this makes it important to have a team of various health professionals to check a stroke patient and identify and treat all underlying health issues that risk stroke incidents.

Care coordination is the organization of patient care activities to enable health professionals and the patient to share information to improve the effectiveness of care and help achieve positive health outcomes. The coordination plan seeks to best satisfy the needs of the patient through the delivery of quality patient-centered care. Empirical studies have proved care coordination for stroke patients to be an effective strategy to improve care and health outcomes, reduce the overall cost of care, and impact patient satisfaction. For instance, Deutschbein et al. (2020) found that care coordination for a vulnerable patient population led to improved utilization rates of essential health services, impacting risks of readmission, costs of care, and mortality. Successful stroke treatment, recovery, and prevention of future stroke insults are dependent on the efficiency and efficacy of stroke care coordination.


Stroke patients may recover completely. However, some recover with minor impairments, while a majority recover with moderate to severe impairments and mostly end up in need of special care. Therefore, it is important to implement a coordinated care plan or goals within primary care settings to achieve the best health outcomes for stroke patients.

Outline of the coordinated care plan:

Assessment for Readiness of Coordinated Care

Stroke Coordination Care Plan Goals

Facility Management Support

Physical, Psychosocial, and Cultural Components

Health Records Tool

Coordinated Primary Care Team and Tasks

Opportunities for Quality Improvement

Assessment for Readiness of Coordinated Care

A successful stroke coordination care plan will require the full commitment of all players. The current budget cuts and relocation of case management staff to in-patient care mean that all resources must be systematically analyzed for availability and readiness to support the coordinated care plan. There is also a need to assess the factors that impact the care plan.

Stroke Coordination Care Plan Goals

This coordinated care plan for the stroke patient aims to:

Reduce cases of injury to the brain,

Focus on achieving maximum patient recovery,

Provide appropriate emergency medical care on demand,

Manage any disabilities and impairments associated with stroke

Provide required emotional support to the patient,

Optimize patient health outcomes,

Provide care based on the patient’s state of health and care preferences

Facility Management Support

The success and sustainability of the stroke coordination care plan are dependent on its alignment with the facility’s care plans and priorities. The resources may overlap, which may be in support of the plan or affect the safety and quality of the coordinated care planned. Therefore, the management leadership must be informed of the plan and request the support of the facility leadership to achieve its goals.

Physical, Psychosocial, and Cultural Components

The coordination care plan considers physical, psychosocial, and cultural components that influence stroke and impact the success of interventions. According to Vecchia et al. (2019), post-stroke patients have extreme emotional responses to illnesses. They have difficulties developing disease beliefs required to cope with the disease or post the illness period. Psychosocial diagnoses will be carried out frequently to ensure that the patient does not develop stroke-related secondary illnesses. Physical and psychosocial factors act as barriers to or facilitators of interventions for stroke (Meadmore et al., 2019). For that reason, the patient’s physical and psychosocial components will also be considered to ensure that the patient receives culturally sensitive social, psychological, and spiritual care throughout the treatment period.

Health Records Tool and Monitoring Plan

The plan will adopt electronic health records (EHRs) to easily support and coordinate care and efficiency of the care flow. Essentially, EHRs record and provide health information and data on individual patients and communities and allow other health professionals to make health decisions that define the quality of care provided (Kruse et al., 2018). The readily available and accessible health information provided by EHRs helps health teams design and deliver safe, appropriate, and effective care. In addition, EHRs will enable the team to communicate efficiently, easily identify the needs of the patient in real-time, monitor, update, and share progress, and determine if other forms of care are needed. The EHRs will also double as a monitoring tool for the coordinated care of the stroke patient. Lastly, the EHRs will assist the care team in designing and updating care based on health outcomes and progress and as per the patient’s preferences.

Coordinated Stroke Care Team and Tasks

The coordinated stroke care plan requires a multidisciplinary and professional team to carry out various tasks. These include:

Care-coordinator: To coordinate all tasks between specialists and follow through with the progress of the plan.

Medical assistant (MA): To assist with data entry into the EHR system and support other specialists.

Physicians/Registered Nurses: To examine stroke history, carry out physical examinations, test and identify other medical issues, review and manage current medications, recommend specialist care, and discuss other care approaches appropriate for the patient.

Pharmacists: To review medication, propose mediation changes, and identify medication risks and, advise the patient on the use of medication, raise awareness on managing stroke and coping during and post the illness.

Family and Community partners: To provide social support, cooperate with the specialists to create an environment for the patient to recover quickly.

The patient: To adhere to the treatment plan and communicate with other team members openly about how they feel.

Opportunities for Quality Improvement

All team members are allowed to contribute to the plan in all possible ways that improve the quality of care for the patient on a more personal level.


CDC. (2022). Treat and Recover from Stroke. [online] Centers for Disease Control and Prevention. Available at: <> [Accessed 16 April 2022].

Della Vecchia, C., Préau, M., Carpentier, C., Viprey, M., Haesebaert, J., Termoz, A., Dima, A. And Schott, A. (2019). Illness beliefs and emotional responses in mildly disabled stroke survivors: A qualitative study. PLOS ONE, 14(10).

Deutschbein, J., Grittner, U., Schneider, A. and Schenk, L. (2020). Community care coordination for stroke survivors: results of a complex intervention study. BMC Health Services Research, 20(1).

Gilmore-Bykovskyi, A., Kennelty, K., DuGoff, E., & Kind, A. (2018). Hospital discharge documentation of a designated clinician for follow-up care and 30-day outcomes in hip fracture and stroke patients discharged to sub-acute care. BMC Health Services Research, 18(1).

Katan, M. & Luft, A. (2018). Global Burden of Stroke. New York: Thieme Medical Publishers.

Kuriakose, D. and Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International Journal of Molecular Sciences, 21(20), p.7609.

Kruse, C., Stein, A., Thomas, H. and Kaur, H. (2018). The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature. Journal of Medical Systems, 42(11).

Meadmore, K. L., Hallewell, E., Freeman, C., & Hughes, A. M. (2019). Factors affecting rehabilitation and use of upper limb after stroke: views from healthcare professionals and stroke survivors. Topics in stroke rehabilitation26(2), 94-100.

Perez Jolles, M., Lengnick-Hall, R., & Mittman, B. S. (2019). Core functions and forms of complex health interventions: a patient-centered medical home illustration. Journal of General Internal Medicine34(6), 1032-1038.

Zimmerman, W., Grenier, R., Palka, S., Monacci, K., Lantzy, A., Leutbecker, J., Geng, X. and Denny, M. (2021). Transitions of Care Coordination Intervention Identifies Barriers to Discharge in Hospitalized Stroke Patients. Frontiers in Neurology, 12.


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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 Coordinated Care Plan for Stroke Patient

Preliminary Coordinated Care Plan for Stroke Patient


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.


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.
Note: Remember that you can submit all or a portion of your draft plan to Smarthinking Tutoring for feedback before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.


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:
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.
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 APA format.

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