Final Care Coordination Plan
QUESTION
For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. Please refer to Order #138712. I will upload the final draft of that order with this one.
RUBRIC
Final Care Coordination Plan Scoring Guide
CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Design patient-centered health interventions and timelines for a selected health care problem. Does not design patient-centered health interventions and timelines for a selected health care problem. Designs patient-centered health intervention for a selected health care problem. Designs patient-centered health interventions and timelines for a selected health care problem. Designs patient-centered health interventions and timelines for a selected health care problem that includes community resources.
Consider ethical decisions in designing patient-centered health interventions. Does not consider ethical decisions in designing health interventions. Considers ill-defined or ambiguous ethical decisions in designing patient-centered health interventions. Considers ethical decisions in designing patient-centered health interventions. Considers insightful ethical decisions in designing patient-centered health interventions. These decisions are supported by the literature.
Identify relevant health policy implications for the coordination and continuum of care. Does not identify relevant health policy implications for the coordination and continuum of care. Identifies health policy implications that are inconsistent with the goals and objectives for the coordination and continuum of care. Identifies relevant health policy implications for the coordination and continuum of care. Identifies relevant health policy implications for the coordination and continuum of care, based on precise and accurate interpretations of relevant policy provisions. Makes valid, insightful inferences.
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. Does not describe priorities that a care coordinator would establish when discussing the plan with a patient and family member. Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member but does not use evidence-based practice to make changes to the plan. Describes priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. 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 explains 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. Does not use the literature on evaluation as a guide to compare learning session content with best practices, and does not include how to align teaching sessions to the Healthy People 2030 document. Discusses evaluation but does not use the literature as a guide to compare learning session content with best practices, or does not include how to align teaching sessions to the Healthy People 2030 document. Uses 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. Uses 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. Clearly explains the need for any revisions.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly. Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes and/or paraphrasing. Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Does not organize content for ideas. Lacks logical flow and smooth transitions. Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling. Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.
Final Care Coordination Plan
ANSWER
Final Care Coordination Plan
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Final Care Coordination Plan
A care coordination plan entails the provision of a smooth and seamless care transition in the health continuum program. Since nurses are critical in the condition of necessary knowledge and communication in ensuring the seamless transition, they must be made aware of the available resources in the community, ethical considerations, safety, cultural norms, policy matters and patients’ psychological needs. The transition begins by drawing evidence-based practice in preventing disease prevention and health care hence creating a safe conducive environment for maintaining and improving patients’ health, their families and community (Poitras et al., 2018). A workable plan and adequate resources help achieve and maintain optimal health, benefiting the patient by creating a conducive environment for healing and good quality of life. This essay aims to design a patient-centered health intervention and timeline for older people suffering from heart diseases like stroke, high blood pressure, and heart failure. It describes the care coordination priorities in establishing the plan while creating a satisfying patient experience under ethical considerations and relevant health policies.
Patient-centered Health Intervention and Timeline
Optimal care for older adults suffering from heart diseases such as heart failure, stroke, and blood pressure is achieved through collaboration from patients, healthcare providers, and family members (Coffey et al., 2017). Cardiologists work with these parties by applying guiding principles in evaluating and managing elderly patients’ conditions. In cases of complex health issues coupled with psychological problems, the comprehensive evaluation is done by psychiatrists, home care providers, geriatricians, social workers and integrated care management programs become of help (Poitras et al., 2018). An intervention for patients at risk of heart failure would require close monitoring and the use of furosemide for treating fluid overload. A nurse would check the basic metabolic panel within a week. Spironolactone may reduce heart failure admissions even though the risk of deteriorating hyperkalemia and renal functioning may outweigh the benefits. However, using candesartan instead of lisinopril may reduce heart failure while offering Reno protective effects. Both carvedilol and furosemide are taken once daily as a dosage. The patient should get enrolled on a disease control program. Alternatively, a heart failure clinic would help too.
Final Care Coordination Plan
Intervention measures for patients at risk of stroke include switching from warfarin medications to improved oral anticoagulants. The reason for such a shift is because older patients’ annual risk of a stroke gets higher compared to those of significant bleeding, making a therapeutic anticoagulant effective. However, prescribing warfarin would require an adjustment to the oral anticoagulant for the proper functioning of the kidney. It would reduce the need for monitoring and reduce the drug-to-drug interaction risk while limiting dietary restrictions. In this case, aspirin gets discontinued since it lacks benefits and increases the chances of bleeding, especially when combined with warfarin (Poitras et al., 2018). High blood pressure intervention would require an increase in furosemide dosage. The patient should get enlightened about the dose coupled with close monitoring for orthostatic hypotension.
There are several heart disease resources across the country since the disease is the leading mortality cause globally. It occupies a spot as a pressing public health issue, and as a result, deaths related to the disease has drastically declined over the past decade, especially in the U.S. The decline raises hopes for further heart health improvements as seen through critical free resources such as the Centre for Disease Control, which has heart disease and stroke prevention division. The help got funds of approximately 50 million in 2011, and to date, it gathers data and carries research in the reduction of fatalities of stroke and heart disease all over the country (Coffey et al., 2017). The Cardiovascular Research Network receives funding from the National Health Blood and Lung Institute to reduce blood-pressure fatalities in the U.S. The Heart Failure Society of America offers voluntary benefit plans by financing medication for heart failure patients in the U.S.
Ethical Decisions
Heart disease patients have a moral right of getting informed about the benefits and demerits of taking particular treatments and medications. It is the responsibility of healthcare providers to ensure their patients get the information since diseases, especially heart failure, is among the leading causes of death. Some of the treatment options for heart failure include transplantation, implantable cardioverter, and resynchronization therapy. The use of ventricular devices creates a wide array of treatment options aside from medication. However, the treatments present various risks and impacts, which patients should know for adhering to proper patient-centered care. The Institute of Medicine acknowledges six quality pillars: respectful care, responsiveness to patients’ preferences, interpreting evidence, prognosis, clinical feasibility, and optimizing care plans.
The first ethical consideration for the treatment would include making a moral and shared decision during a treatment plan. The physician should hold an intimate dialogue with the patient to ensure the patient identifies the complex medical decisions regarding the patient’s wishes, values and goals. Questions such as what is the patient preference-sensitive decision? Does the nurse recognize the preferences, especially when it involves more than one medication option? The nurse should present numerical chances and risk reductions to clearly understand the benefits and risks involved (Brach and Harris, 2021). For patients who are unable to make decisions, a family member or surrogate decider should get involved.
Another ethical consideration is the interpretation of evidence to confirm the applicability of medication through literature review. The nurse needs to evaluate the patient’s conditions and their relevance to the general population, including any information which may negatively harm the patient. The consideration of the patient’s prognosis questions such as what is the life expectancy of the patient? What is their quality of life and functional status? Does it help prioritize the most pressing issue and make informed clinical decisions? Such decisions are made through validated tools such as cumulative deficit frailty index, functional limitation, health deficit etc. The other ethical consideration is clinical feasibility, a broad regimen connected with adverse drug occasions, caregiver stress, and economic burden. A discussion of the patient’s support system and preference is mandatory (Coffey et al., 2017). The last ethical consideration is aiming to minimize harm while minimizing benefits with the adherence to treatments.
Relevant Health Policy Implications in Treating Heart Disease Patients
Research about heart disease and health policy aims to provide an overview of current legislation and policy related to heart disease care. Some of the policies include; public reporting geared towards quality improvement. The peer pressure effect created pushes clinicians to perform and provide high-quality care. Another policy is paying for performance or value. High-quality physicians and hospitals get paid higher. In America, the Center of Medicine and Medicaid Services enrolled on a program in 2000 that pays bonuses to institutions recording high performance (Brach and Harris, 2021). The bundled payment model tested under care improvement is an innovation significant to heart disease medication. The program pays hospitals for each care, such as follow up checkup care which motivates quality performance. Another policy is Accountable care Organizations which asks hospitals to assume the risk of quality measures and the cost. They agree to care for heart disease patients under Medicaid programs to hit cost and quality targets.
Priorities a Care Coordinator Establishes when Discussing the Plan
Care coordinators should form a health care learning process by ensuring patients and their relatives become critical drivers for designing and operating the health care system. The priorities include outcome goals which the patient wants regarding their preferences for healthcare and sensitive communication with family. The full participation of both the patients, caregivers, families and the public leads to the active involvement of care hence sustaining and improving the economic outcome. The planned establishment requires other priorities such as active patient engagement to ensure correct care for personal characteristics, preferences, needs and circumstances (Brach and Harris, 2021). The clinician offers information through scientific evidence and potential outcomes for the treatment. Meaningful engagement is mandatory between the patient and clinician on all the available options rather than agreeing to everything the patient says to create Patient-centered care. In case of emerging problems, changes in the plan may happen after effective if they promote quality and safety of medication or save the cost.
Learning Session Content with Best Practices
There are ways of learning the health care system to fill the gap in coordinating and orienting the system around patients’ needs. The methods are considering the needs and preferences of the patients and summarizing the benefits of pushing forward with set visions. Learning to focus on the needs and preferences of the patient is crucial for patient-centered care as it ensures coordination. Such coordination leads to easy access to care or integrated care. The patient and his family should know simple information about the next step in treatment when to resume normal activities, side effects, or inquire about recovery. Necessary communication between the primary care and clinician reduces the patient’s stress on recalling recovery information. Learning the benefits of patient-oriented care by involving patients and their families reduces discomfort and boosts faster growth. The measures align with Healthy People 2030, which aims to improve the well-being and health of individuals in the U.S. (Kim et al., 2020). The initiative learns through past challenges and builds lessons for the development of health care.
References
Brach, C., & Harris, L. M. (2021). Healthy People 2030 health literacy definition tells organizations: make information and services easy to find, understand, and use. Journal of General Internal Medicine, 36(4), 1084-1085. Springer. Retrieved from https://link.springer.com/article/10.1007/s11606-020-06384-y
Coffey, M., Cohen, R., Faulkner, A., Hannigan, B., Simpson, A., & Barlow, S. (2017). Ordinary risks and accepted fictions: how contrasting and competing priorities work in risk assessment and mental health care planning. Health Expectations, 20(3), 471-483. Wiley Online Library. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/hex.12474
Kim DH, Rich MW. Patient-Centred Care of Older Adults With Cardiovascular Disease and Multiple Chronic Conditions. Can J Cardiol. 2016;32(9):1097-1107.NBCI. retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5003648/
Poitras, M. E., Maltais, M. E., Bestard-Denommé, L., Stewart, M., & Fortin, M. (2018). What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC health services research, 18(1), 1-9. Springer. Retrieved from https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3213-8#citeas