Assessment 4: Final Care Coordination Plan Essay

 

Final Care Coordination Plan

The care approach has shifted from disease-centered to patient-centered, where each patient is handled individually, addressing their needs and ensuring that their preferences are considered in plans of care. Care coordination is one of the aspects of patient-centered care that focuses on addressing the patient’s needs. Care providers such as nurses facilitate coordination by planning patient care activities and sharing information with the other team members and the patient/family members. Coordinated care plans require specific interventions and timelines customized to fit individual patient needs. Ethical decisions and health policy implications should also be considered in care coordination and the care continuum. Priorities are established and discussed with a patient/family, and necessary changes to the care plan are made based on the patient’s concerns and needs. This essay presents a care coordination plan for trauma and trauma-related health issues.

Patient-Centered Health Interventions and Timelines

The selected health problem for this assessment is trauma. The three health issues related to trauma that will be addressed in this assessment include Post-Traumatic Stress Disorder, depression (Major Depressive Disorder), and alcohol use disorder. The three healthcare issues related to trauma significantly impact the community’s health. Trauma impacts the mental and physical health of individuals of all ages across health populations. Developing patient-centered care coordination interventions with timelines for these health issues helps promote individual patient outcomes and provide safer and more effective care.

Post-Traumatic Stress disorder is a mental health condition triggered by exposure to a terrifying event and characterized by the inability to recover after experiencing or witnessing a life-threatening or terrifying event. Major depressive disorder is a mood disorder characterized by a persistent feeling of sadness and loss of interest, thus interfering with their daily life by negatively impacting how they think, feel and behave. Alcohol use disorder is a chronic disease characterized by uncontrolled drinking and preoccupation with alcohol. It is caused by physical and emotional dependence on alcohol, which results in the inability to control drinking.

As mentioned earlier, patient-centered interventions contribute to better health outcomes and address patients’ needs. The patient-centered intervention used for the PTSD patient is Cognitive Behavioral Therapy (CBT). Psychotherapies are some of the most effective interventions for mental health conditions. CBT is a form of psychotherapy focusing on behavior to treat short-term and long-term PTSD. Trauma-focused cognitive behavioral therapy uses the traumatic event(s) as the center of treatment. In 12-16 weeks, the Cognitive Behavioral Therapy sessions will be used to help the patient identify, understand, and modify behavior and thinking patterns. According to Peters et al. (2021), CBT employs weekly sessions to teach the patient skills that can be applied to deal with the symptoms and practice the skill repeatedly throughout the sessions to improve symptom improvement. One of the community resources that can be used to facilitate this intervention is community counseling centers.

For a Major Depressive Disorder (MDD) patient, the patient-centered care intervention is interpersonal therapy, also known as interpersonal psychotherapy. Interpersonal psychotherapy is a time-limited, evidence-based approach to treating mood disorders (Lemmens et al., 2020). It can also be used effectively for MDD by focusing on symptom relief by improving interpersonal functions. Depression considerably affects an individual’s interpersonal functions. Focusing on improving interpersonal problems, therefore, assists in symptom recovery. The timeline for this intervention is 12-16 weeks, after which an evaluation will be done to determine the effectiveness and recommend further actions. The community resource that can be used in the intervention is mental health support groups.

The patient-centered intervention for the patient with alcohol use disorder will be a medical intervention using Naltrexone administration for two weeks. Research and clinical experiments show that the medication effectively reduces heavy drinking, manages cravings, and supports abstinence (Han et al., 2021). After two weeks, a review will determine whether the medication should be changed or incorporate a behavioral therapy intervention into the plan. The community resource that will be used is a mutual aid group, such as alcoholic anonymous, to enhance mutual support as the patient undergoes medical treatment.

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Ethical Decisions in Designing Patient-Centered Care Interventions

It is a nurse’s responsibility to maintain high standards of ethics in practice. Designing patient-centered care interventions are one of the actions that should maintain ethics and use ethical decisions. It is worth noting that patient-centered care is offered based on the patient’s needs, beliefs, and preferences. However, sometimes engaging patients in intervention decisions to enhance patient-centered care may raise certain ethical questions.

Patient-centered care is driven by the ethical principle of autonomy, considering the patient’s cultural traditions, preferences, values, and lifestyle (Delgado, 2021). One of the ethical decisions in designing patient-centered care interventions is involving the patient in setting goals for the care intervention. It is essential to consider the patient’s needs, preferences and values when setting the goals of the intervention, thus enhancing autonomy. However, patient involvement in decision-making may raise ethical questions when the patient’s input leads to a decision that will cause harm to them. For instance, patients may decline medication use in their care intervention due to their preferences. The decision might lead to poor patient outcomes if the condition management required medication intervention, thus raising an ethical question.

Another ethical decision in patient-centered care is providing the patient with all the information required on their options before making decisions to ensure they make informed decisions. One of the ethical principles in nursing is informed decision-making. It is, therefore, vital to provide all the information about intervention options before the patient makes a decision.

The practical effects of involving patients in decision-making, goal setting, and providing all the relevant information before they make decisions involving their care have different positive implications. First, the ethical decisions enhance patient adherence and active participation in the intervention since they feel that their input is important. Secondly, it contributes to positive patient outcomes since patients are more likely to follow the intervention guidelines when their needs and preferences are considered.

Relevant Health Policy Implications on the Coordination and Continuum of Care

Health and government policies and guidelines guide healthcare practice. These policies impact the various aspects of care in one way or another. The health policy that affects care coordination and the continuum of care is the US Self-Determination Act of 1990.

According to Teoli and Gassemzadeh (2022), the patient self-determination act stipulates that the patient should be informed of their right in decision-making regarding the medical care they are receiving. It also maintains that patients should be asked about advanced directives and their wishes documented, including what they want or do not want about care and advanced directives. The act considerably impacts care coordination and continuum since it enhances patient-centered care. Additionally, patients are more likely to seek healthcare services when their input is considered, thus enhancing the continuum of care in the community. For instance, mental health care services are usually surrounded by the stigma that influences the care continuum. Increasing patient involvement would enhance trust in mental healthcare services, improve help-seeking behavior, and therefore enhance the care continuum.

Priorities in Care Coordination

There are different priorities that a care coordinator should discuss with the patient and their family while discussing the plan of care or communicating changes to the plan. The priorities in care coordination include the development of a therapeutic relationship with the patient/family, collaboration, and individual needs and preferences.

A therapeutic nurse-patient relationship should be developed to enhance care coordination. A therapeutic relationship helps build trust between the patient/family and the care provider, thus enhancing care coordination. Additionally, a therapeutic relationship enhances openness and enables the patient to share information freely, thus easing coordination and enhancing better care provision and development of interventions. Patients can also seek clarification and more information on various related issues when a therapeutic relationship is maintained. Therefore, creating a therapeutic relationship is crucial.

Collaborating with the patients/family is another priority in care coordination since it enhances successful intervention implementation. According to Grondahl et al. (2019), collaborating with patients includes helping patients identify a specific goal, brainstorming activities to accomplish the goal, selecting activities, focusing the activities, selecting a timeline for achieving the goals, and considering any barriers to achieving the goal. Effective collaboration eases the care coordination process and enhances better outcomes, thus a priority in care coordination.

Care coordination is the backbone of patient-centered care, which maintains that patient needs and preferences should be the basis of care. Therefore, considering the patient’s needs and preferences and incorporating them into the care plan is a priority in care coordination.

Learning Session Evaluation Against Best Practices outlined by Healthy People 2030

Some of the best practices in trauma management, identified in the literature evaluation of the previous assessment, include trauma-focused cognitive behavioral therapy, immediate management of the physical effects of trauma, psychoeducation, and psychological first aid. The learning session best practices, as outlined by Healthy People (2030), include empathetic care as opposed to sympathetic care and patient empowerment. The learning session for the care coordination plan will consider the use of patient education to facilitate psychoeducation. The patient education will be facilitated using individual and group sessions. Additionally, patient education will empower the patient to take up the desired behavior and adhere to the intervention. More so, the learning sessions will be developed and delivered empathetically. Therefore, based on this evaluation, the learning sessions to implement care coordination interventions meet the best practices. However, revision can be done to the coordinated care plans to include evaluation intervals and change incorporation.

Conclusion

Care coordination is a complex process that requires the input of all players in the care delivery process, working in collaboration with the patients/family. Ethical decisions and policy implications should be considered in care coordination plans. The nurse should identify priorities in care coordination, including collaboration and developing a therapeutic nurse-patient relationship. Developing learning lessons in line with best practices and practice guidelines is essential.

References

Delgado, J. (2021). Vulnerability as a key concept in relational patient-centered professionalism. Medicine, Health Care, and Philosophy, 24(2), 155-172. https://doi.org/10.1007/s11019-020-09995-8

Gröndahl, W., Muurinen, H., Katajisto, J., Suhonen, R., & Leino-Kilpi, H. (2019). Perceived quality of nursing care and patient education: a cross-sectional study of hospitalized surgical patients in Finland. BMJ Open, 9(4), e023108. https://doi.org/10.1136/bmjopen-2018-023108

Han, B., Jones, C. M., Einstein, E. B., Powell, P. A., & Compton, W. M. (2021). Use of medications for alcohol use disorder in the US: results from the 2019 National Survey on drug use and health. JAMA Psychiatry, 78(8), 922-924. https://doi.org/10.1001/jama.2020.2012

Healthy People 2030 (n.d.). https://health.gov/healthypeople/patient-education

Lemmens, L. H., van Bronswijk, S. C., Peeters, F. P., Arntz, A., Roefs, A., Hollon, S. D., Derubeis, R. & Huibers, M. J. (2020). Interpersonal psychotherapy versus cognitive therapy for depression: how they work, how long, and for whom—key findings from an RCT. American Journal of Psychotherapy, 73(1), 8-14. https://doi.org/10.1176/appi.psychotherapy.20190030

Peters, W., Rice, S., Cohen, J., Murray, L., Schley, C., Alvarez-Jimenez, M., & Bendall, S. (2021). Trauma-focused cognitive–behavioral therapy (TF-CBT) for interpersonal trauma in transitional-aged youth. Psychological Trauma: Theory, Research, Practice, and Policy, 13(3), 313. https://psycnet.apa.org/doi/10.1037/tra0001016

Teoli, D. & Ghassemzadeh, S. (2020). Patient Self-Determination Act. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK538297/

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Assessment 4 Instructions: Final Care Coordination Plan

 

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

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.

 

 

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.

 

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

 

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
  • Address three health care
  • Design an intervention for each health
  • Identify three community resources for each health
• Consider ethical decisions in designing patient-centered health

« Consider the practical effects of specific decisions.

• Include the ethical questions that generate uncertainty about the decisions you have

• 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
  • Align teaching sessions to the Healthy People 2030
• Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA
• 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.

 

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
  • Design patient-centered health interventions and timelines for a selected health care
• Competency 2: Collaborate with patients and family to achieve desired
  • 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
• 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
  • Consider ethical decisions in designing patient-centered health
• Competency 5: Explain how health care policies affect patient-centered
  • Identify relevant health policy implications for the coordination and continuum of
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

 

 

SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluated.