Final Care Coordination Plan Essay

Final Care Coordination Plan Essay

Final Care Coordination Plan Essay

The optimal possible treatment for individuals’ health issues requires careful planning and coordination of care. Numerous facets of care coordination have been explored in detail in the three prior evaluations, with an emphasis on the principles and healthcare standards that have been developed to guarantee that they fulfill their goals. This final care plan will be based on the preliminary care coordination framework. The final care plan will include ethical and regulatory considerations, cultural values, quality care, and physiological requirements (Kuipers et al., 2021). This paper will serve as Mr. X’s ultimate care coordination plan while he recovers from a stroke.

Patient-Centered Intervention

Patient-centered care prioritizes the needs of the individual receiving medical treatment. Because of this, the patient is an integral component of the treatment coordination team and the center of attention. A stroke is a potentially fatal medical disorder, and people who have had the disease before are at greater risk of having it reoccur (Skeels & Leung, 2019). Mr. X, who is 46 years old, has had hypertension for the past few years. He knew this increased his risk of having a stroke. He is also obese, which is associated with a higher risk of stroke. His vitals are as follows: blood pressure 156/92, heart rate 99, temperature 35.9, and respiratory rate 19.

Health issues

1. Stroke recurrence

The patient had a stroke, but signs indicate a high recurrence rate. As was said before, a stroke occurs when brain tissue is damaged because a portion of the brain does not receive enough blood supply. All efforts should be made to prevent a stroke from happening again (Skeels & Leung, 2019). Improved nutrition and diet instruction for stroke patients is one form of intervention. The patient can also improve his health by increasing their amount of physical exercise, maintaining a healthy body weight, and controlling their blood sugar levels. It is important that he learns to regulate his blood pressure. Community resources include community stroke patient groups, gyms, and rehabilitation centers. These facilities help the patient recover better and offer emotional and psychological support.

1. Depression

The individual’s health problems have severely limited his daily activities, and his left-sided paralysis has contributed to his clinical depression. The state of his health has had an impact on his relationships, ability to work, and state of mind. It is caused the client a lot of anxiety and unhappiness, particularly when he is left alone. A common patient-centered solution for depression is to provide the individual with a distraction or activity that will help him focus on anything other than his negative emotions. The patient may also benefit from establishing routines that will allow him to feel more in charge of his own life. Medication for depression and instruction in self-care strategies can both make a big difference in a client’s health and quality of life. Community resources include rehabilitation centers and support groups. These groups in the community aid the patient in overcoming their issue as they feel they are not alone.

• Hypertension

Elevated blood pressure is a major risk factor for cardiovascular disease and stroke. The condition known as high blood pressure occurs when arterial blood flows at a pressure greater than normal. Mr. X has hypertension, and it is important to remember that it is a chronic condition, so he will likely continue to have hypertension and accompanying symptoms intermittently throughout his life. He risks having a stroke if his hypertension is not managed. Patient-centered hypertension care entails addressing Mr. X’s nutritional status, reducing his salt intake, helping him keep his weight in check (particularly given that he is obese), enhancing his physical activity, and treating his anxiety and despair. In addition, the following are some of the community resources that could be helpful to Mr. X, including a gym that will enable him to do physical activity. Sidewalks in the community are also essential to ensure the client is physically fit. Lastly, community hypertension groups are essential for hypertension patients to help each other.

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Ethical Decisions

The formulation of health therapies that put the patient at the center requires thoughtful consideration of ethical considerations. Delivering treatment in an ethical manner is essential. As it pertains to medical treatment, it entails making the correct decisions. Ethical concerns must be considered while planning healthcare interventions with the patient in mind. Indeed, the aforementioned actions are vital for both the patient’s health and the development of treatment, which is an ethical consideration (Kuipers et al., 2021). The individual will be better equipped to self-manage their condition, which may improve their chances of a successful outcome and a long, healthier lifestyle as an outcome of the choices taken.

Moreover, they have viewed the use of pharmaceuticals and other therapies with adverse side effects as a last choice, which suggests well for their prospects (Epp et al., 2021). As a healthcare practitioner, it is essential to ask yourself if you would be comfortable using the same methods on yourself if you were in the patient’s position. One may also wonder if the chosen solutions to the health problems the greatest possible option are, or if other options have been overlooked. Does having access to superior resources outside of what a community provides make a difference? Will the patient improve, and will the decisions that arise from this improve their chances of success? A person’s morality and ethics should not be called into doubt by their responses.

Relevant Health Policy Implications

Affordable Care Act was a landmark piece of healthcare legislation that has had far-reaching effects on coordinated care. The Affordable Care Act is a piece of healthcare legislation that has been on the books since 2010 (Zhao et al., 2020). Access to coordinated care is emphasized in the legislation as a crucial method for lowering healthcare expenses while guaranteeing the quality of medical care is maintained. Care coordination has improved greatly after its implementation because of the new possibilities for establishing and evaluating healthcare strategies that improve both service and financing (Epp et al., 2021). The health insurance portability and transparency Legislation of 1996 has significantly influenced care coordination and the care continuum. With this legislation in place, it is now possible for members of the American population to maintain their healthcare coverage even if they relocate to a different state. Care coordination among healthcare professionals should also prioritize the protection of sensitive patient data during data transmission.

Medicare and Medicaid are two types of health insurance whose primary goals are to make medical care financially accessible. In 1945, Medicare was created to serve those over 65 years old, while in 1965, Medicaid was created to serve low-income persons of all ages (Wadhera et al., 2020). These insurance policies cover the collaboration of care for patients with chronic illnesses. Care coordination is essential to expanding patients’ healthcare availability, and as coverage has grown, more and more people have been able to afford it (Zhao et al., 2020). The Hospital Readmissions Reduction Program is a policy initiative included in ACA that aims to improve patient’s ability to receive timely medical care. While lowering the number of patients who need to be readmitted to the hospital is a goal shared by all of the aforementioned care plans. Improved patient outcomes and fewer hospitalizations are made possible through better care coordination made possible by strategy. According to the Affordable Care Act of 2010, Medicare and Medicaid are responsible for lowering readmission payments. The key to avoiding unnecessary readmissions is ensuring that patients receive effective care coordination.

Priorities That a Care Coordinator Would Establish

Education seminars like these are essential for developing a better care coordination strategy. Care coordination plans rely on regular meetings to make sure everybody engaged is aware of what is required of them (Kuipers et al., 2021). Our time with the client yielded a wealth of insights. After attending the workshops, I understood the individual’s expectations regarding the care coordination strategy. He seemed genuinely thrilled about his future plans for dealing with the issue. As a bonus, he disclosed that the educational seminars taught him things about his disease that he had never known before, such as self-intervention strategies that were crucial to his health but which he had never learned before.

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Further explanation and changes were necessary for certain spots. For one, the client stated that the present number of sessions was insufficient and that he required more because the information was so crucial. As it was affecting the whole family, he said they should all be involved in the therapy sessions. Also, I observed that certain sessions necessitated a more interdisciplinary strategy for explaining particular approaches to the patient. Experts in nutrition and dietary habits, respiratory therapy, psychotherapy, and training were essential for this purpose. They were left out of the initial draft but made it into the final version because they were deemed necessary for better patient comprehension and care coordination.

Evaluation And Healthy People 2030

Evaluating the effectiveness of care coordination is essential for learning what works and what does not so that future plans can incorporate the lessons learned. Care coordination success can be measured in large part through the use of learning sessions (Epp et al., 2021). Care coordination assessment tools such as surveys were also distributed to healthcare practitioners and patients to gauge the program’s overall effectiveness. The progress made toward the shared objectives is evaluated, and any problems that have arisen are documented (Epp et al., 2021). Care coordination and patient-centered programs did not take into account the involvement of the client’s family in this meeting, but that will change in the future. The reviews also highlighted the importance of telehealth, particularly during this covid-19 phase, to improve patient care. The finalized treatment plan incorporates these details, and all the highlighted problems are anticipated to be resolved.

Training for individuals and their family members is essential to providing good care coordination. Care coordination will be improved, and these educational opportunities will support Healthy People 2030. The Healthy People 2030 program aims to enhance healthcare quality in the United States (Pronk et al., 2021). This calls for collaboration from professionals in healthcare, state officials, and others involved in the healthcare industry. Learning meetings will ensure that everyone who participates in care coordination is working to achieve a common goal. Targets and health outcomes under Healthy People 2030 have been narrowed in on purpose to better reflect the full scope of the most immediate concerns in the medical system today (Pronk et al., 2021). The importance of these healthcare outcomes and goals should be highlighted during the training program, and the goals offered should be consistent with the training. The medical services, psychology, ecology, genetic predisposition, and, most importantly, social variables should all be considered in the educational sessions. Successful patient and community outcomes and achievement of Healthy People 2030 targets hinge on these conditions being met during the sessions.

Conclusion

The ultimate goal of care coordination is to cater to each patient’s individual needs. Stroke is a severe disorder that can cause result in mortality or paralysis in its victims. Ethical, legislation and patient-specific factors are all considered to ensure the best possible outcome. More consideration has been given to Healthy People 2030 and how these discussions may help in the effort to reach that goal. The importance of the training session in gauging the plan’s performance has been established. In the end, the proposal’s effectiveness and improved patient outcomes depend on its users’ capacity to concentrate on the health of their patients.

References

Epp, J., Cutler, H., Heather-Reid, R., Lewis, P., Critchley, A., Bishop, M., & Gazzard, T. (2021). Commissioning for coordinated care services using an outcomes-based funding model: Insights from a process review. International Journal of Integrated Care, 20(S1). https://doi.org/10.5334/ijic.s4140

Kuipers, S. J., Nieboer, A. P., & Cramm, J. M. (2021). Easier said than done: Healthcare professionals’ barriers to the provision of patient-centered primary care to patients with multimorbidity. International Journal of Environmental Research and Public Health, 18(11), 6057. https://doi.org/10.3390/ijerph18116057

Pronk, N. P., Kleinman, D. V., & Richmond, T. S. (2021). Healthy People 2030: moving toward equitable health and well-being in the United States. Clinical Medicine, 33. https://doi.org/10.1016/j.eclinm.2021.100777

Skeels, K., & Leung, L. Y. (2019). Transitional Care Matrix to Improve the Coordination of Stroke Care Between Inpatient and Outpatient Care Settings. Stroke, 50(Suppl_1), https://doi.org/10.1161/str.50.suppl_1.WMP109

Wadhera, R. K., Figueroa, J. F., Maddox, K. E. J., Rosenbaum, L. S., Kazi, D. S., & Yeh, R. W. (2020). Quality measure development and associated spending by the Centers for Medicare & Medicaid Services. JAMA, 323(16), 1614-1616. https://doi.org/10.1001/jama.2020.1816

Zhao, J., Mao, Z., Fedewa, S. A., Nogueira, L., Yabroff, K. R., Jemal, A., & Han, X. (2020). The Affordable Care Act and access to care across the cancer control continuum: a review at 10 years. CA: A Cancer Journal for Clinicians, 70(3), 165-181. https://doi.org/10.3322/caac.21604

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Final Care Coordination Plan

Professional Context

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.

In this assignment, you will evaluate the preliminary care coordination plan you developed in Unit 3, using best practices found in the literature.

To prepare for your assignment, 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.

Scenario

In this assignment, you will evaluate the preliminary care coordination plan you developed in Unit 3 and communicate the plan in a professional, culturally sensitive, and ethical manner.

Instructions

Note: For this assignment: Evaluate the comprehensive care coordination plan developed in Unit 3, making changes based upon comparison to evidence-based practice.

Document Format and Length

Evaluate the preliminary plan you created in Unit 3. 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 patient health care issues.

Design an intervention for each health issue.

Identify three community resources for each health intervention.

Consider the 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 the priorities that a care coordinator would establish when discussing the plan with a patient and family members, making changes based upon evidence-based practice.

Clearly explain the need for the 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 a guide to compare learning session content with best practices.

attached is the unit 4 prelim care plan and the scoring guide