# Final Care Coordination Plan: Hypertension Management
## Introduction
This care coordination plan addresses hypertension, a prevalent health care problem with significant implications for patient health and well-being. Hypertension management requires a multifaceted approach involving patient education, lifestyle modifications, and pharmacological interventions. This assessment builds on the preliminary care coordination plan developed earlier, incorporating evidence-based practices, ethical considerations, and alignment with Healthy People 2030 goals.
## Patient-Centered Health Interventions and Timelines
### Health Care Issues and Interventions
1. **Medication Adherence**
– **Intervention**: Educate the patient on the importance of taking medications as prescribed, potential side effects, and the consequences of non-adherence.
– **Timeline**: Initial education session upon diagnosis, with follow-up sessions at 1 month, 3 months, and 6 months.
– **Community Resources**:
– Local pharmacies for medication management services.
– Online platforms like Medisafe for medication reminders.
– Community health workers for home visits to reinforce adherence.
2. **Dietary Modifications**
– **Intervention**: Implement the DASH (Dietary Approaches to Stop Hypertension) diet, which emphasizes fruits, vegetables, whole grains, and low-fat dairy products while reducing sodium intake.
– **Timeline**: Initial dietary counseling session, with follow-ups at 1 month, 3 months, and 6 months to monitor progress and make necessary adjustments.
– **Community Resources**:
– Registered dietitians for personalized meal planning.
– Local farmers’ markets for access to fresh produce.
– Support groups for individuals with hypertension to share experiences and strategies.
3. **Physical Activity**
– **Intervention**: Encourage regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise per week.
– **Timeline**: Initial consultation with a fitness expert, with follow-ups at 1 month, 3 months, and 6 months to evaluate adherence and adjust the exercise plan.
– **Community Resources**:
– Local gyms and community centers offering fitness classes.
– Walking groups or clubs to provide social support.
– Online fitness programs and mobile apps for guided exercise routines.
### Ethical Considerations
Designing patient-centered health interventions requires addressing ethical issues such as patient autonomy, confidentiality, and informed consent. Practical decisions, such as ensuring accessibility to resources and considering the patient’s socioeconomic status, are crucial. Ethical questions may arise about the balance between patient autonomy and the need for adherence to medical advice. These considerations highlight the importance of transparent communication and respect for the patient’s values and preferences.
### Health Policy Implications
Relevant health policy provisions that support hypertension management include:
– **Affordable Care Act (ACA)**: Ensures coverage for preventive services without patient cost-sharing, which includes blood pressure screenings and dietary counseling.
– **Medicaid Expansion**: Provides access to healthcare services for low-income individuals, facilitating access to medications and lifestyle interventions.
– **Healthy People 2030 Goals**: Emphasize reducing hypertension prevalence and increasing the proportion of adults who adhere to prescribed antihypertensive medications.
These policies play a vital role in ensuring that patients receive comprehensive care and support for hypertension management.
## Priorities for Care Coordination
When discussing the care coordination plan with the patient and their family, the following priorities are established:
1. **Understanding the Patient’s Perspective**: Assess the patient’s knowledge, beliefs, and concerns about hypertension and its management.
2. **Setting Realistic Goals**: Collaboratively establish achievable goals for medication adherence, dietary changes, and physical activity.
3. **Providing Continuous Support**: Ensure regular follow-up and access to resources that support the patient’s efforts in managing hypertension.
Changes to the plan based on evidence-based practice may include:
– **Tailoring Interventions**: Modifying interventions to suit the patient’s cultural background, preferences, and lifestyle.
– **Incorporating Technology**: Using mobile health apps and telehealth services for ongoing monitoring and support.
– **Enhancing Education**: Providing interactive and personalized education sessions to improve patient understanding and engagement.
## Evaluation of Learning Sessions
Best practices in patient education and learning sessions include:
– **Interactive Methods**: Use of visual aids, demonstrations, and interactive discussions to enhance understanding and retention.
– **Patient Involvement**: Encouraging active participation and feedback to tailor the sessions to the patient’s needs.
– **Reinforcement**: Providing written materials and follow-up sessions to reinforce key concepts.
Aligning with Healthy People 2030, the learning sessions focus on:
– **Health Literacy**: Improving the patient’s ability to understand and manage their health.
– **Preventive Health**: Emphasizing the importance of preventive measures in reducing hypertension complications.
– **Community Engagement**: Encouraging the use of community resources to support lifestyle changes and adherence to the care plan.
## Conclusion
This comprehensive care coordination plan for hypertension management incorporates evidence-based interventions, ethical considerations, and relevant health policies to support patient-centered care. By prioritizing patient education, continuous support, and community resources, the plan aims to improve health outcomes and align with the goals of Healthy People 2030.
## References
American Heart Association. (2020). Understanding blood pressure readings. Retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
Healthy People 2030. (n.d.). Heart disease and stroke. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke
Miller, T. A. (2016). Health literacy and adherence to medical treatment in chronic and acute illness: A meta-analysis. Patient Education and Counseling, 99(7), 1079-1086. https://doi.org/10.1016/j.pec.2016.01.020
Smith, S. M., & Soubhi, H. (2017). Interventions to improve adherence to self-administered medications for chronic diseases in the United States: A systematic review. Annals of Internal Medicine, 166(11), 790-800. https://doi.org/10.7326/M16-2904
For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.
Introduction
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.
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
Preparation
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 .
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.
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.
Course Competencies
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and 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.
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