Assessment 4: Final Care Coordination Plan Paper

Assessment 4: Final Care Coordination Plan Paper

Assessment 4: Final Care Coordination Plan Paper

Care coordination is one of the strategies that healthcare professionals have continually and increasingly applied to improve patient care outcomes. The implication is that healthcare professionals should formulate relevant care coordination plans that can be used to help improve patient care outcomes. An effective care coordination plan requires that the health care professional share the necessary patient information with the right and authorized individuals involved in the care coordination to ensure that they use the same information to timeously make relevant definitions for a timely care plan (McLendon et al.,2019). Timeous planning implies that the professionals have enough time to consider patient needs and preferences so as to offer effective and acceptable care to the patients. The previous assignment entailed a preliminary care coordination plan for individuals with diabetes. As such, the purpose of the current assignment is to formulate a final care coordination plan based on the guidelines provided by the literature.

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Patient-Centered Interventions and Timeline

Diabetes is among the most common conditions impacting populations; hence has attracted much attention from healthcare professionals and researchers. The condition can lead to other unwanted health outcomes such as stroke, heart disease, kidney failure, and organ damage if not well managed or if left unmanaged (Cole & Florez, 2020). Patients living with diabetes usually have preferences and needs when it comes to the management of the condition. The implication is that healthcare professionals involved in the management of the condition need to embrace and adopt a patient-centered care approach. Healthcare issues known to accompany diabetes include high blood pressure, raised HbA1c levels, and kidney damage

Raised HbA1c: The use of a patient-centered care approach is particularly important since the glycemic targets for every patient need to be individualized to help address the individual needs and characteristics which impact the risk and intervention for each patient. One of the intervention strategies is managing the patient blood glucose levels by using continuous glucose monitoring gadgets (Harding et al., 2019). Such an approach can be key in limiting the possibility of neuropathic and vascular complications development. Part of this management approach involves ensuring the patients achieve fasting blood glucose levels of less than 140 mg/dL, HgA1c levels lower than seven percent, and blood glucose levels lower than 180 mg/dL. The timeline require for the blood glucose monitoring is twelve weeks

High blood pressure: It is important to adopt an approach for high blood pressure. Recent research also indicates that lifestyle modifications have a huge role to play in improving care outcomes for a patient living with diabetes. Hence this is another management approach that the care team should consider as part of the plan (Sigal et al., 2018). The lifestyle modification approach can help patients to have better care outcomes due to lifestyle and behavior changes. Modification of the patient’s diet and encouraging physical exercise should form a core part of lifestyle modifications. As part of the physical exercise plan, the patients should undertake a forty-minute physical activity, such as walking every day, accomplished in sessions. Such physical exercise can be key in managing the blood pressure to the expected levels (Naci et al., 2019). This intervention is also expected to take a period of twelve weeks before evaluating its impact.

Kidney damage: It is important to protect the patients from potential kidney damage as a health complication associated with diabetes. Dietary modifications such as lowering the amount of sodium intake can also help patients in lowering the chances of kidney damage and kidney disease. The intervention of dietary modification is projected to go for twelve weeks before an evaluation can be done. These interventions can be reinforced using an education intervention. Education can be important in training the patients and their family members regarding adherence to glucose monitoring, the formulated physical exercise plan, and the proposed dietary adjustments.

Community Resources

It is important to explore community resources that can be used for each of the proposed health interventions. The community resources can be important in the control of HbA1c levels. One of the community resources that can be used to support glucose monitoring is individuals with information technology knowledge. These individuals can be family members or other community members who are able to help the patients by reading the glucose monitors from the instruments and reporting the same (Sigal et al., 2018). The other resources include community library and community online support.

Community resources should also be used to help protect patients control their blood pressure. As such, pamphlets and newsletters with information on diabetes management through physical exercises and lifestyle modifications will also be used as part of the community resources. These pamphlets and newsletters will be accessed by the patients so that they can have more information regarding the management of diabetes through physical exercises (Sigal et al., 2018). The other resources is community gyms for physical exercise

As highlighted earlier kidney damage can be reduced by dietary adjustments. One of the resources that will be used for dietary adjustments is professional nutritionists found in the community. They will help individual patients to come up with foods that can be used to help control the chances of kidney damage and kidney diseases. The other resources include community library with information on kidney damage prevention and support groups. The use of these resources will all depend on how effective the care coordination strategy and plan is.

The Ethical Decisions in Designing the Patient-Centered Interventions

It is important to consider various ethical implications and decisions which surround the designing of patient-centered interventions. There can be practical effects of the care decisions taken. For example, by ensuring that the patients engage in regular exercise, one of the practical effects can be improved weight control and well as appropriate glycemic control. However, these care decisions should consider various ethical aspects. The decisions have to be guided by the principles of non-maleficence, beneficence, respect for persons, and justice (Greaney& Flaherty, 2020). Therefore, the plan is to show respect to patients and ensure that the conditions do not lead to increased unwanted outcomes.

The care aspects should also consider integrating patients’ views and preferences since the patients have a right to make decisions regarding the path that their care should take. The implication is that the care plan should focus on respect and not control. Another consideration is the potential moral tension that could be experienced due to the treatment and management strategies. For example, while the healthcare professionals could be focusing on the effectiveness of the medical treatment approach, the patient may be more concerned about the impacts of the condition on the day-to-day activities and overall well-being. Therefore, the healthcare team should strive to reach a common ground to enhance the chances of the interventions succeeding.

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

Existing healthcare policies can greatly impact the coordination of care and the continuum of care. The implication is that the healthcare professionals participating in the care coordination should possess adequate knowledge regarding these policies. Example of health policies that can affect the coordination of care and the health continuum is Accountable Care organizations, Medicare, and the Affordable Care Act. These policies have played a key role in improving Medicare eligibility for patients with diabetes hence improving care outcomes. The patients hence can have increased participation in programs dealing with diabetes prevention and management. As such, if a patient is to miss out on a program because of a lack of funds, then Medicare covers the costs; hence the patient can take part in the programs hence improving health (McCoy et al., 2021). Medicaid has also enhanced the rates of diagnosis of diabetes and the use of medication for the condition. As part of the policy, the government requires that individuals at high risk of diabetes should be registered for better care coordination and outcomes. The registration information is used as part of decision support for diabetes prevention, and the clinical information and feedback are used as part of planning to improve the coordination of care.

The Affordable Care Act also impacts the coordination of care. As part of the policy, there are provisions that require health insurance plans to offer free diabetes screening to people who are at a high risk of diabetes. In addition, this policy prompts the health insurance provider to desist from putting requirements for cost-sharing for evidence-based items or services. This policy has also put in place provisions that help enhance access to care. This is achieved by ensuring that those in health plans of small groups as well as individual markets are offered some diabetes care coverage as an essential benefit (Casagrande et al., 2018). Various reforms were also proposed and implemented to help improve healthcare delivery and coordination for patients living with diabetes. For example, through the Accountable Care Organization and the Comprehensive Primary Care Initiative, the Affordable Care Act has helped improve the coordination of care for patients living with diabetes.

The Priorities that a Care Coordinator Would Establish

Formulating an appropriate and effective care plan needs the healthcare coordinator to explore various factors or aspects which underline the importance of bringing along the patients and their family members. Such collaboration leads to the establishment of priorities. When the healthcare coordinator discusses the proposed care plan with patients and their families, they are able to jointly determine if there is a need to make adjustments to the existing care plan. Among the priorities are the need to enhance the use of pharmacological approaches in case the patient falls short of meeting the expected glucose levels, blood pressure control, and acceptable lipid level control (Harding et al., 2019). The next priority is making decisions on whether the patients should undergo intensified lifestyle change or adjustment therapies to help improve the chances of better outcomes. As part of the priority, it would also be important to establish if the patients are adhering to the physical exercise plan, diet plan, and medications as appropriate.

A Comparison between Learning Session Content and Best Practices

From the earlier discussion, it is conceivable that education is part of the strategies for managing these patients with diabetes. The educational content to be used during the learning sessions is magazines and pamphlets which have information regarding diabetes care and management (Harding et al., 2019). The pamphlets have images of the foods to be used as part of the diet, information on when to see a specialist and strategies for glucose monitoring, and the importance of physical exercise. Healthy People 2030 underline the importance of having healthy American citizens.  It aims to reduce the burden of diabetes and improve quality of life for individuals at risk of or have diabetes. As such, the teaching content to be used as part of the education program has been deliberately designed to promote the health of individuals living with diabetes, in line with Healthy People 2030.

As compared to the best practices that exist in the literature, the discussed education content to be used during the learning sessions is well in sync. As part of the most current interventions in literature, healthcare professionals use smartphones to deliver educational content to patients since it enables uniform access to relevant information even from remote locations as opposed to face-to-face meetings, which require traveling. Therefore, smartphones can be used to access information such as the types of physical exercise, medication adherence, and the right diet to use (Doupis et al., 2020). Professionals also use phone messaging services for short messages to patients and their family members to improve care outcomes. Therefore, these evidence-based approaches are well comparable to the proposed education sessions as they all seek to deliver content on diabetes care and management.

Conclusion

An appropriate care coordination plan is important for better outcomes among patients living with various chronic conditions such as diabetes. The plan needs to integrate patient choices and preferences. In addition, the care team needs to consider other factors, such as healthcare policies that can impact the coordination of care, such as ACA, before formulating a care coordination plan.

 References

Casagrande, S. S., McEwen, L. N., & Herman, W. H. (2018). Changes in health insurance coverage under the Affordable Care Act: a national sample of US adults with diabetes, 2009 and 2016. Diabetes Care, 41(5), 956-962. https://doi.org/10.2337/dc17-2524

Cole, J. B., & Florez, J. C. (2020). Genetics of diabetes mellitus and diabetes complications. Nature Reviews Nephrology, 16(7), 377-390. https://doi.org/10.1038/s41581-020-0278-5

Doupis, J., Festas, G., Tsilivigos, C., Efthymiou, V., & Kokkinos, A. (2020). Smartphone-based technology in diabetes management. Diabetes Therapy, 11, 607-619. Doi: 10.1007/s13300-020-00768-3

Greaney, A. M., & Flaherty, S. (2020). Self‐care as care left undone? The ethics of the self‐care agenda in contemporary healthcare policy. Nursing Philosophy, 21(1), e12291. https://doi.org/10.1111/nup.12291

Harding, J. L., Pavkov, M. E., Magliano, D. J., Shaw, J. E., & Gregg, E. W. (2019). Global trends in diabetes complications: a review of current evidence. Diabetologia, 62(1), 3-16. Doi: 10.1007/s00125-018-4711-2

McCoy, R. G., Van Houten, H. K., Deng, Y., Mandic, P. K., Ross, J. S., Montori, V. M., & Shah, N. D. (2021). Comparison of diabetes medications used by adults with commercial insurance vs. Medicare Advantage, 2016 to 2019. JAMA network open, 4(2), e2035792-e2035792. Doi: 10.1001/jamanetworkopen.2020.35792

McLendon, S. F., Wood, F. G., & Stanley, N. (2019). Enhancing diabetes care through care coordination, telemedicine, and education: Evaluation of a rural pilot program. Public Health Nursing, 36(3), 310-320. https://doi.org/10.1111/phn.12601

Naci, H., Salcher-Konrad, M., Dias, S., Blum, M. R., Sahoo, S. A., Nunan, D., & Ioannidis, J. P. (2019). How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure. British Journal of Sports Medicine, 53(14), 859-869. http://dx.doi.org/10.1136/bjsports-2018-099921

Sigal, R. J., Armstrong, M. J., Bacon, S. L., Boule, N. G., Dasgupta, K., Kenny, G. P., & Riddell, M. C. (2018). Physical activity and diabetes. Canadian Journal of Diabetes, 42, S54-S63. https://doi.org/10.1016/j.jcjd.2017.10.008

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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.

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.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

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.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

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.
  • Design patient-centered health interventions and timelines for a selected health care problem.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
  • 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.
• Competency 3: Create a satisfying patient experience.
  • 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.
• Competency 4: Defend decisions based on the code of ethics for nursing.
  • Consider ethical decisions in designing patient-centered health interventions.
• Competency 5: Explain how health care policies affect patient-centered care.
  • Identify relevant health policy implications for the coordination and continuum of care.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
  • 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.