Preliminary Care Coordination Plan Paper

Preliminary Care Coordination Plan Paper

Preliminary Care Coordination Plan Paper

Healthcare professionals fulfill the set healthcare goals by offering appropriate care and treatment to patients with different conditions. Nurses are usually at the center stage of offering care to patients to help achieve such goals. As such, they use various strategies to ensure and enhance effectiveness.  One of the strategies nurses usually use to ensure optimum care is care coordination. The implication is that the professionals have to come up with appropriate care coordination plans for specifically identified groups of patients living with the disease of focus (McLendon et al.,2019). Care coordination requires an organization of care activities and strategy and information sharing among the care team to foster safer and more effective care. The implication is that nurses need to have a grasp of patient preference and need before formulating an effective care coordination plan which can set the patients on the path of recovery. Therefore, the purpose of this assignment is to formulate a preliminary care coordination plan for patients with diabetes.

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The Chosen Health Care Problem

            The chosen or priority healthcare problem is diabetes. 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. Such an approach is key to the development of an effective care coordination plan.

Diabetes type 2 impacts more people as compared to diabetes type 1 as it impacts up to 95 % of all individuals with diabetes mellitus. Type 2 diabetes is a chronic condition when an individual experiences insufficient use of insulin hence difficulty in blood sugar regulation. The implication is that a person will experience raised glucose levels in the bloodstream leading to hyperglycemia. One of the risk factors for type 2 diabetes is age (Cole & Florez, 2020). The condition is known to be more prevalent in older populations in comparison to children and youths.

From the earlier discussion, diabetes is known to lead to various adverse effects if left uncontrolled. In addition to the health complications, diabetes also has serious impacts on a person’s economic productivity, as it can be disabling (McCoy & Theeke, 2019). Furthermore, the costs of treatment and management involved for the condition are usually high due to the need to buy appropriate medications, the need to use emergency care at times, and frequent hospitalizations. These aspects show the need to formulate an appropriate care coordination plan that can help improve care outcomes for patients living with this condition.

The Physical, Psychosocial, and Cultural Considerations

An effective care coordination plan should consider physical, psychosocial, and cultural considerations for the healthcare problem under consideration (McCoy & Theeke, 2019). Therefore, it is important to consider the physical, psychosocial, and cultural considerations for diabetes. The physical considerations for the condition usually come in the form of managing the diseases. It is well known that undertaking physical activity such as over two hours of walking every week and moderate-physical activity can help in controlling blood glucose levels hence better outcomes. Physical activities also help patients to reduce weight as appropriate, reduce cardiovascular risk factors and improve the overall well-being of the patients.

It is also important to consider the psychosocial considerations for diabetes. Psychosocial factors are known to impact the lives of those living with diabetes in terms of psychological well-being and obtaining satisfactory medical outcomes(McCoy & Theeke, 2019). As part of the psychosocial considerations, the professionals participating in the diabetes care and care coordination should assess symptoms of diabetes cognitive capacities, disordered eating, anxiety, depression, and distress using validated or standardized tools.

There are also cultural considerations for the condition, as diabetes affects individuals of all ethnicities, races, and cultures. Therefore, using various interventions such as diabetes self-management as part of care coordination requires that the care team consider various aspects, such as a person’s culture, as culture can impact how well the patient receives education. Meal planning, medication management, and daily living should all take the patient’s culture into account so that they effectively customize care plans as part of care coordination (Powers et al.,2020). The implication is that healthcare professionals such as nurses should be culturally sensitive to enable them to understand and acknowledge the patient’s different culture and cultural beliefs.

Best Practice For Diabetes

It is evident that diabetes has devastating effects on patient. However, with adequate blood sugar level management and working on the adverse impacts of the condition, there are higher chances of patients having better health outcomes (Powers et al.,2020). Due to research, there are current evidence-based treatment strategies for diabetes. Current management of diabetes involves both pharmacological and non-pharmacological approaches. Insulin treatment has widely been used in the treatment of patients with diabetes. The treatment leads to better control of the HbA1c levels among the patients. Non-pharmacological approaches include lifestyle modifications, dietary adjustments and engaging in physical activity (McLendon et al., 2019). The use of dietary adjustment such as reduction of sodium intake is important as it helps protect the patients from developing kidney complications. The use of exercise has also been associated with better control of blood pressure as patients with diabetes sometimes end up having high blood pressure, hence a need to control it.

The Specific Goals to be Addressed

            As part of the care coordination and treatment plan, various goals should be established. One of the goals should be to lower the neuropathic pain for better outcomes. For example, using appropriate strategies, the level of pain should be reduced to, at most, four on a scale of one to ten. The next goal is to ensure that the patients have a systolic pressure below 125 and a diastolic pressure below 90. The other goal is improved physical activity to reduce weight for normal BMI.

The Available Community Resources

As part of care coordination, it is important to identify relevant resources which can be used to support patients with diabetes for effective care. One such resource is community resources. Examples of community resources include pamphlets and newsletters which has diabetes information and education strategies. Community members participating in diabetes care activities are also important. There are also community groups where people meet and share their experiences regarding diabetes treatment and management. Such community groups also act as support groups hence helping individuals to have better outcomes.

Conclusion

            Effective treatment and management of chronic conditions such as diabetes can be achieved through various strategies, such as formulating a care coordination plan. Therefore, this write-up has explored the formulation of a preliminary care coordination plan for patients with diabetes. As part of the care coordination plan, physical, psychosocial, and cultural considerations for diabetes have all been explored.  In addition, various treatment and management goals have also been explored as appropriate.

References

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

McCoy, M. A., & Theeke, L. A. (2019). A systematic review of the relationships among psychosocial factors and coping in adults with type 2 diabetes mellitus. International Journal of Nursing Sciences, 6(4), 468–477. https://doi.org/10.1016/j.ijnss.2019.09.003

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

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., … & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care, 43(7), 1636-1649. https://doi.org/10.2337/dci20-0023

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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

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 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

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, 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.

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 family to achieve desired outcomes.
  • Describe specific goals that should be established to address a selected health care 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; 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.