NURSFPX 4050 Capella University Care Coordination Plan Assignment Paper

Primary Care Coordination Plan

The promotion of optimum health outcomes for diverse populations is important in nursing practice. Nurses adopt evidence-based interventions that optimize outcomes such as safety, quality, and efficiency in their practice. Care strategies such as interprofessional collaboration contribute to patient-centered interventions in the care process. Lifestyle diseases such as heart failure due to hypertension, obesity and other comorbid conditions have risen significantly. Patients suffer from poor quality of life, loss of productivity, and potential premature mortalities. Nurses and other healthcare providers should examine best practices that can be used to improve care outcomes in heart failure patients. Therefore, the purpose of this essay is to examine the health issue of heart failure, best practices, agreed goals, and community resources.

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Identified Problem and Associated Best Practices

The selected health problem for this paper is heart failure. Heart failure is a cardiovascular problem that develops when the heart pumping ability reduces or is inadequate. It results in inadequate body tissue perfusion and death if timely interventions are not implemented. The Centers for Disease Control and Prevention estimates that about 6.2 million people in the United States of America have heart failure. Heart failure was reported as part of the causes of deaths in 2018. It was mentioned in 13.5% (379800) death certificates. Heart failure is associated with enormous costs. For example, America lost about $30.7 billion in 2012 due to heart failure (CDC, 2023). The costs included those for medicines, health care services, missed days of work, and premature mortalities.

Heart failure patients have a wide range of needs for them to function optimally and live a healthy life. One of the needs is the provision of culturally-appropriate care. Heart disease patients are individuals from diverse cultural backgrounds and needs. Their cultural values, beliefs, and practices influence their adoption of the recommended treatment interventions. For example, culture influences lifestyle and behavioral risk factors associated with heart failure such as dietary habits (Vogel et al., 2021). As a result, nurses should align the care interventions with the cultural beliefs, values, and practices of their patients for the delivery of culturally appropriate care.

The other need is physical needs. Heart failure patients often experience hardships in meeting their demands of their daily living. Nurses and other healthcare providers should prioritize physiological needs in heart disease management for optimum outcomes. In addition, heart failure is a distressing, chronic problem. Patients often suffer from its associated psychological impacts such as stress, depression, and anxiety disorders (Dar et al., 2019; Kitzman et al., 2021). Care interventions such as counseling services and social support should be provided to help them to overcome these challenges.

Nurses and other healthcare providers should adopt best practices when caring patients with heart disease and their families. One of the best practices that nurses should incorporate into the care process is patient empowerment through education on self-management of heart failure. Education on self-management has been shown to increase patients’ involvement in the management of their health problems. It also minimizes the risk of complications, hence, improved quality of life for the patients (Zhao et al., 2021). The self-efficacy of the patients in managing heart failure also improves.

The other best practice is shared-decision making and active involvement of the patients in managing their health problems. Shared decision-making entails prioritizing the patient’s needs, values, and preferences in heart disease management. Healthcare providers also engage heart disease patients in assessment, planning, implementation, and evaluation of the care outcomes. Shared-decision making and active patient involvement in the care process contributes to their ownership of the care interventions, hence, sustainable outcomes (Rao et al., 2020). The assumptions in shared-decision making and active patient involvement are that patients are likely to change their behaviors when involved in the care process.

The other best practice is the incorporation of healthcare technologies into heart failure management. Novel technologies such as those utilized in blood pressure monitoring, telehealth, and mhealth improve care outcomes in patients suffering from chronic illnesses. Automated blood pressure monitoring enables timely detection and management of potential heart failure complications. Telehealth reduces healthcare costs for heart failure patients by eliminating the unnecessary need for hospital travel. In addition, it increases patient satisfaction with the care since they can access and interact with their healthcare providers virtually whenever they have health concerns (Shaw et al., 2020). The assumptions with the use of health information technologies in heart disease are that patients learn optimally when technologies are incorporated into the care process and they are responsible for data safety and integrity.

Specific Goals

Specific goals must be established to address heart failure among the population. One of the goal is increasing the awareness of the affected populations towards the importance of lifestyle and behavioral modifications. Interventions such as health education helps patients learn about ways to improve their health outcomes. For example, education on heart failure self-management empowers patients to be responsible for their health. The other goal is increasing patient participation in the management of their health problems. Patient participation should be encouraged to ensure the minimization of adverse events in heart disease management and treatment adherence. The last goal that should be established for the effective management of heart failure is care coordination. Interprofessional care teams should be involved in the provision of care to heart failure patients (Rao et al., 2020). The teams explore evidence-based interventions that can be used to achieve safety, quality, and efficiency outcomes in the disease management process.

Available Community Resources

Heart disease patients should utilize the existing community resources for their optimum health and wellbeing. They should access to the different resources that help them cope with the demands of the disease. One of the resources is the social support groups for patients suffering from chronic illnesses. Social support group provides heart failure patients with the social, physical, and emotional support that they need. The groups also help them develop effective coping skills against the distressing experiences of the disease by learning best practices from others. The Heart Foundation also provides heart failure patients resources they can utilize to effectively manage their health problems. The resources include those used for healthy weight gain, cardiac rehabilitation, living well with heart failure, and action plans for comorbidities such as alcohol use and abuse by heart disease patients(Heartfoundation.org, 2021). The additional community resources include transportation services for heart failure patients and sensitization programs targeting the entire population focusing on healthy living.

Conclusion

In summary, heart failure is a chronic cardiovascular condition with increasing rate in America. Best practices should be adopted to improve outcome in heart disease management. The practices should prioritize patient’s cultural, physical, and psychosocial needs. Specific goals should be developed to guide the care interventions adopted for heart failure. Lastly, patients should be linked with the existing community resources for optimum outcomes in heart disease management.

References

CDC. (2023, January 5). Heart Failure | cdc.gov. Centers for Disease Control and Prevention. https://www.cdc.gov/heartdisease/heart_failure.htm

Dar, T., Radfar, A., Abohashem, S., Pitman, R. K., Tawakol, A., & Osborne, M. T. (2019). Psychosocial Stress and Cardiovascular Disease. Current Treatment Options in Cardiovascular Medicine, 21(5), 23. https://doi.org/10.1007/s11936-019-0724-5

Heartfoundation.org. (2021). For Professionals | Heart Foundation. https://www.heartfoundation.org.au/bundles/for-professionals/heart-failure-resources-for-patients

Kitzman, D. W., Whellan, D. J., Duncan, P., Pastva, A. M., Mentz, R. J., Reeves, G. R., Nelson, M. B., Chen, H., Upadhya, B., Reed, S. D., Espeland, M. A., Hewston, L., & O’Connor, C. M. (2021). Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. New England Journal of Medicine, 385(3), 203–216. https://doi.org/10.1056/NEJMoa2026141

Rao, B. R., Dickert, N. W., Morris, A. A., Speight, C. D., Smith, G. H., Shore, S., & Moore, M. A. (2020). Heart Failure and Shared Decision-Making: Patients Open to Medication-Related Cost Discussions. Circulation: Heart Failure, 13(11), e007094. https://doi.org/10.1161/CIRCHEARTFAILURE.120.007094

Shaw, S. E., Seuren, L. M., Wherton, J., Cameron, D., A’Court, C., Vijayaraghavan, S., Morris, J., Bhattacharya, S., & Greenhalgh, T. (2020). Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction. Journal of Medical Internet Research, 22(5), e18378. https://doi.org/10.2196/18378

Vogel, B., Acevedo, M., Appelman, Y., Bairey Merz, C. N., Chieffo, A., Figtree, G. A., Guerrero, M., Kunadian, V., Lam, C. S. P., Maas, A. H. E. M., Mihailidou, A. S., Olszanecka, A., Poole, J. E., Saldarriaga, C., Saw, J., Zühlke, L., & Mehran, R. (2021). The Lancet women and cardiovascular disease Commission: Reducing the global burden by 2030. The Lancet, 397(10292), 2385–2438. https://doi.org/10.1016/S0140-6736(21)00684-X

Zhao, Q., Chen, C., Zhang, J., Ye, Y., & Fan, X. (2021). Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials – Reprint. International Journal of Nursing Studies, 116, 103909. https://doi.org/10.1016/j.ijnurstu.2021.103909

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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 assignment 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.

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 health care concern.

Instructions

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, 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.

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.