Assessment 4: Final Care Coordination Plan Essay

Care Coordination Plan

Care coordination is an effective tool for delivering optimum outcomes in nursing practice. nurses adopt care interventions such as interprofessional collaboration in care coordination to select the best treatments that address the prioritized and potential health needs of their patients. Chronic conditions such as heart failure have immense burden to patients and their significant others. Often, patients and families suffer from the high cost of healthcare services, loss of productivity, poor quality of life, and premature mortality. Care coordination enables the delivery of patient-centered and continuous care that enables heart disease patients to live a healthy life. Therefore, this paper explores healthcare issues, interventions, community resources, and effects of specific decisions adopted to meet the care needs of heart failure patients. It also explores the priorities the nurse must consider and policy implications to care coordination and continuum of care.

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Three Health Care Issues, Interventions and Community Resources

Heart failure patients experience a range of health issues that affect the disease management process and outcomes. One of the health care issues that heart failure patients experience is frequent hospital visits and hospitalizations. Heart failure patients often experience complications such as liver damage, reduced ejection fraction, and arrythmias. These complications increase the need for close monitoring of the patients to identify and alleviate any potential risks. Frequent emergency department visits and hospitalizations increase the costs that patients and their families incur, hence, the disease’s impact on the population. An effective intervention that can be adopted to address the issue of frequent hospitalization and emergency department visits is the incorporation of telehealth into heart disease management (Fedson & Bozkurt, 2022). The community resources that patients can utilize to address the problem include community social support groups for individuals with chronic illnesses, the American Heart Association, and Centers for Disease Control and Prevention (CDC).

The second healthcare issue that heart disease patients and their families experience is emotional distress from the disease. Heart disease patients are increasingly predisposed to mental health problems such as depression and anxiety disorders. The disease’s complex needs act as a source of stress to patients and significant others. In addition, the loss of productivity in social and occupational roles affect their mental health. An effective intervention to promote mental health and wellbeing of heart failure patients is by providing them with counselling services to help them cope with the demands of the disease (Son et al., 2020). Some of the community resources to promote mental health include social support groups, CDC, and heart safe community within the patient’s locality.

The third health care issue that heart disease patients experience is challenges in managing the condition. As noted above, heart failure is a complex disease that requires patient involvement in its management. Issues such as low level of understanding by patients about its management lower the treatment outcomes. An effective intervention to address patient-related challenges in heart failure management is patient education (Son et al., 2020). Some of the community resources to enhance patient’s understanding of heart disease management include social support groups for chronic disease management, heart safe communities and information from organizations such as the American Heart Association.

Practice Effects of Specific Decisions

The above health interventions have positive outcomes on heart failure management. Health education is an effective tool used to raise awareness among the patients on the management of their condition. The increased awareness level stimulates patients to adopt healthy lifestyles and behaviors that will minimize complications in heart failure management (Son et al., 2020). Increased level of knowledge among patients will also result in better treatment adherence, hence, better outcomes.

Heart failure has a negative effect on the mental health and wellbeing of patients and their significant others. It predisposes them to conditions such as major depression, which worsen the health outcomes further. Counseling helps patients to identify effective strategies to cope with the complex needs of their conditions. It also empowers patients to explore the available resources they can utilize to achieve the desired outcomes in heart disease management (Son et al., 2020). Telehealth is a technology that has largely been incorporated into chronic disease management, including heart failure. The technology allows virtual interaction between patients and their healthcare providers. Telehealth facilitates care interventions such as patient assessment, planning, implementation, monitoring, and evaluating care plans. Its effective use has been shown to reduce healthcare costs and complications since it is possible to detect and manage complications earlier (Fedson & Bozkurt, 2022). In addition, it reduces the costs incurred by patients for unnecessary hospital visits for assessment.

The above decisions raise some ethical questions that should be considered in heart failure management. First, the use of health technologies require healthcare providers to adopt measures that will protect privacy and confidentiality of the patients’ data. Secondly, the provision of health education and counseling services should ensure the promotion of patients’ autonomy. Interventions such as active patient involvement should be considered. Therefore, the arising questions from the interventions focus on the promotion of data integrity and patient autonomy in the disease management process.

Relevant Health Policy Implications for the Care Coordination and Continuum of Care

Healthcare policies influence care coordination and continuum of care for patients with heart failure. One of such a policy is the Affordable Care Act (ACA). The ACA was adopted with the aim of increasing the proportion of the American citizens with a medical insurance coverage. The policy addresses the challenges associated with health care access such as costs for the vulnerable. ACA ensures increased access to coordinated care for patients with heart failure. The other policies are Medicare and Medicaid. They reduce the potential out-of-pocket spending by the patients in purchasing the medications they need and health care services for managing comorbid conditions in heart failure. The other policy is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a policy that was adopted to safeguard safe and efficient use of health information technologies in disease management and ensuring efficiency in healthcare organizations (THOMAS, 2022). The policy guides health organizations in selecting and effective technology that will enhance outcomes in heart disease management while ensuring data integrity in care coordination.

Priorities

The developed care plan for heart disease management may require changes to ensure the realization of the desired outcomes. Nurses should prioritize several issues when discussing the plan with patient and family members and changing the care plans. They should ensure that the changes align with the values and expectations of their patients. The alignment ensures increased adherence and minimal resistance. Patients and their families should also be involved in making the changes to promote ownership of the new interventions. Nurses should seek feedback from the patients and their families with the aim of ensuring their engagement and satisfaction with the care that they received (Nilsson et al., 2019). The need for changes to the plan may arise from the lack of realization of the set outcomes. Patient’s experiences with the selected interventions may also necessitate the need for a change in the plan. Lastly, the changes may be necessary if the adopted plan has safety, quality, and efficiency issues in heart disease management.

Comparison of Learning Session Content with Best Practices

The learning session content aligned with best practices. The content was obtained from sources of evidence-based information such as peer-reviewed journals. The content was also appropriate to the chosen health problem. This ensured relevance of the interventions taught to the audience. The content matched with the characteristics of the audience to ensure its relevance and potential for changing their lifestyles and behaviors.

Alignment with Healthy People 2030 Document

The learning session align with the Health People 2030 document. The session addresses social determinants of health for patients suffering from heart failure. It raises awareness about the needs of these patients and interventions that can be adopted to improve their health outcomes. The session also aims at reducing disease burden among health failure patients by examining efficient ways to ensure patient-centered and continuity in care. Lastly, it raises awareness about the need for preventive care against lifestyle diseases such as heart failure, obesity, and diabetes (health.gov, n.d.).

Conclusion

In summary, heart failure patients face several issues that affect their health. Nurses should adopt interventions that address prioritized and potential issues among their patients. Health policies affect care coordination and continuum of care. Making changes in care plans should prioritize patient and family needs. The session utilized best practices and aligned with Healthy People 2030 document.

References

Fedson, S., & Bozkurt, B. (2022). Telehealth in Heart Failure. Heart Failure Clinics, 18(2), 213–221. https://doi.org/10.1016/j.hfc.2021.12.001

health.gov. (n.d.). Home of the Office of Disease Prevention and Health Promotion—Health.gov. Retrieved March 23, 2023, from https://health.gov/

Nilsson, M., From, I., & Lindwall, L. (2019). The significance of patient participation in nursing care – a concept analysis. Scandinavian Journal of Caring Sciences, 33(1), 244–251. https://doi.org/10.1111/scs.12609

Son, Y.-J., Choi, J., & Lee, H.-J. (2020). Effectiveness of Nurse-Led Heart Failure Self-Care Education on Health Outcomes of Heart Failure Patients: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health, 17(18), Article 18. https://doi.org/10.3390/ijerph17186559

THOMAS, M. D. (2022). 2023 Healthcare Reform Facts. National Underwriter Company.

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For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

Introduction

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed. ( THis is related to order # 241391

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Instructions

Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

• Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Final 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.

• Design patient-centered health interventions and timelines for a selected health care problem.
  • Address three health care issues.
  • Design an intervention for each health issue.
  • Identify three community resources for each health intervention.
• Consider ethical decisions in designing patient-centered health interventions.
  • Consider the practical effects of specific decisions.
  • Include the ethical questions that generate uncertainty about the decisions you have made.
• Identify relevant health policy implications for the coordination and continuum of care.
  • Cite specific health policy provisions.
• Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
  • Clearly explain the need for changes to the plan.
• Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
  • Use the literature on evaluation as guide to compare learning session content with best practices.
  • Align teaching sessions to the Healthy People 2030 document.
• Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
• Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.