# Final Care Coordination Plan
## Title Page
**Title**: Comprehensive Care Coordination Plan for Hypertension Management
**Name**: [Your Name]
**Institution**: [Your Institution]
**Date**: [Date]
## Introduction
Effective care coordination is essential for managing chronic conditions like hypertension. This plan builds on the preliminary care coordination plan developed in Assessment 1, integrating best practices from the literature to design patient-centered interventions. The plan addresses three critical health care issues, proposes specific interventions, identifies community resources, considers ethical implications, and aligns with Healthy People 2030 objectives.
## Patient-Centered Health Interventions and Timelines
### Health Care Issue 1: Medication Adherence
**Intervention**:
– Educate patients on the importance of medication adherence through personalized counseling sessions.
– Implement a reminder system using phone apps or text messages to prompt patients to take their medication.
**Community Resources**:
1. Local pharmacies offering medication synchronization services.
2. Support groups for patients with hypertension.
3. Mobile health apps designed for medication reminders (e.g., Medisafe).
**Timeline**:
– Initiate education and counseling sessions within the first week of diagnosis.
– Set up the reminder system within the first month.
– Review adherence and adjust strategies during monthly follow-ups for six months.
### Health Care Issue 2: Lifestyle Modifications
**Intervention**:
– Develop a tailored exercise program in collaboration with a physiotherapist.
– Provide nutritional counseling to encourage a heart-healthy diet.
– Organize community-based workshops on stress management techniques.
**Community Resources**:
1. Local gyms or community centers offering exercise classes.
2. Dietitians and nutritionists available for individual consultations.
3. Mental health professionals and stress management workshops.
**Timeline**:
– Initiate exercise and nutritional counseling within the first month.
– Begin stress management workshops by the second month.
– Evaluate and adjust the program during bi-monthly follow-ups for one year.
### Health Care Issue 3: Regular Monitoring
**Intervention**:
– Equip patients with home blood pressure monitors and train them on proper usage.
– Schedule regular virtual check-ins to review blood pressure readings.
– Encourage patients to maintain a blood pressure diary to track trends and identify triggers.
**Community Resources**:
1. Medical supply stores providing affordable blood pressure monitors.
2. Telehealth services for regular virtual consultations.
3. Patient portals for easy communication and data sharing with healthcare providers.
**Timeline**:
– Distribute blood pressure monitors and provide training within the first week.
– Schedule virtual check-ins starting the second week.
– Review blood pressure diaries during monthly visits for six months.
## Ethical Considerations in Patient-Centered Health Interventions
Designing patient-centered interventions requires considering ethical principles such as autonomy, beneficence, non-maleficence, and justice. Practical effects include ensuring informed consent, respecting patient preferences, and avoiding potential harm from interventions.
### Ethical Questions
1. How can we ensure that patients fully understand the importance and potential side effects of their medication regimen?
2. What measures can be taken to respect patient autonomy while encouraging lifestyle changes?
3. How do we address disparities in access to community resources?
## Health Policy Implications
### Relevant Health Policy Provisions
1. **Affordable Care Act (ACA)**: Ensures patients have access to preventive services without cost-sharing, which includes hypertension screening and counseling.
2. **HIPAA**: Protects patient privacy, especially when using telehealth and mobile health apps for monitoring and reminders.
3. **Medicare and Medicaid Services**: Provide coverage for blood pressure monitors and telehealth services for eligible patients.
These policies support the coordination and continuum of care by ensuring access to necessary resources and protecting patient rights.
## Priorities for Care Coordination
### Establishing Priorities
1. **Medication Adherence**: Ensure patients understand their treatment regimen and the importance of adherence.
2. **Lifestyle Modifications**: Provide education and resources to support sustainable lifestyle changes.
3. **Regular Monitoring**: Equip patients with tools and knowledge to monitor their blood pressure effectively.
### Changes Based on Evidence-Based Practice
1. **Enhanced Education**: Utilize multimedia resources (videos, brochures) to reinforce verbal instructions.
2. **Technology Integration**: Implement mobile health apps to facilitate communication and monitoring.
3. **Community Engagement**: Partner with local organizations to increase access to resources and support networks.
## Evaluation and Alignment with Healthy People 2030
### Best Practices
– **Literature Review**: Studies show that patient education, technology integration, and community support are critical for effective hypertension management (Aycock et al., 2017).
– **Healthy People 2030**: Aligns with objectives to improve cardiovascular health, increase health literacy, and enhance access to preventive services.
### Teaching Sessions
– **Content**: Focus on medication adherence, lifestyle modifications, and self-monitoring techniques.
– **Methods**: Use interactive workshops, digital tools, and personalized counseling to engage patients.
– **Evaluation**: Regular feedback and outcome measurements to adjust and improve teaching strategies.
## Conclusion
A comprehensive care coordination plan for hypertension management requires a multifaceted approach addressing medication adherence, lifestyle modifications, and regular monitoring. Integrating community resources, considering ethical implications, and aligning with health policies and Healthy People 2030 objectives ensure a patient-centered and effective plan. Ongoing evaluation and adaptation based on evidence-based practices will optimize patient outcomes and enhance the quality of care.
## References
– Aycock, D. M., Clark, P. C., Thomas-Seaton, L., Lee, S.-Y., & Moloney, M. (2017). Simple tools to facilitate project management of a nursing research project. *Western Journal of Nursing Research*, 39(3), 430–443. https://doi.org/10.1177/0193945916656605
– Centers for Disease Control and Prevention. (2015). Develop SMART objectives—evaluate a CoP. https://www.cdc.gov/phcommunities/resourcekit/evaluate/smart_objectives.html
– Healthy People 2030. (2020). *Office of Disease Prevention and Health Promotion*. https://health.gov/healthypeople
By addressing these criteria, this final care coordination plan demonstrates proficiency in the competencies required to provide patient-centered care, collaborate effectively, create a satisfying patient experience, defend ethical decisions, and understand health policy implications.
Assessment 4
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.
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.
INSTRUCTIONS
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.
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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