Care Coordination Plan Essay

Care Coordination Plan Essay

Care Coordination Plan

Care coordination is an essential approach to promoting optimum healthcare outcomes in the patient care process. The process facilitates efficiency in resource utilization to achieve optimum outcomes, including safety and quality in nursing and health care. Healthcare providers, including nurses, play critical roles in ensuring the realization of the desired outcomes in the care coordination process. They explore multidisciplinary interventions that can be used to address both patients’ actual and potential needs. Therefore, the purpose of this paper is to examine the application of care coordination in addressing the needs of heart disease patients by exploring the healthcare issue, goals that should be met, and available community resources that can be used for a safe and effective continuum of care.


Analysis of Healthcare Concern

Heart disease is a leading cause of morbidity and mortality in the United States of America. Statistics from the Center for Disease Control and Prevention (CDC) show that one person dies due to heart disease every 36 seconds in the USA. The annual mortality rate due to heart disease in the USA is estimated to be 659,000, accounting for 1 in every 4 mortalities in the state. The costs of treating heart disease in the state are high. For example, the CDC reports that about $363 billion was spent annuallyon heart disease between 2016 and 2017. The costs included those for healthcare services, drugs, and productivity lost due to heart disease-related deaths. The most common types of heart diseases diagnosed among Americans include coronary artery disease and heart attack. Statistics show that coronary artery disease contributed to 360,900 deaths in the USA in 2019. About 6.7% of adults aged 20 years and above have coronary artery disease. Conversely, approximately 805,000 people in the USA develop heart attacks yearly (CDC, 2021).

Populations are predisposed to heart disease due to several risk factors. They include physical inactivity, excessive alcohol use, unhealthy diet, overweight and obesity, and diabetes. Conditions such as obesity and overweight causes thickening of blood vessels and adiposity, which increase the risk of heart diseases such as hypertension and coronary artery disease. Physical inactivity increases the risk of diabetes, overweight, and obesity due to poor metabolism and unhealthy weight gain (Benjamin et al., 2019). The prevalence of heart disease is highest among individuals from ethnic minorities. For example, heart disease contributes to 18.3% of deaths in American Indians, 21.4% in Asian Americans, 23.5% in African Americans, and 20.3% among Hispanic Americans (CDC, 2021). Therefore, interventions that reduce the population’s risk of developing heart disease should be implemented.

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Best practice interventions should be adopted to promote the health and wellbeing of heart disease patients and populations at risk. One of the interventions is the provision of health education. The affected and populations at risk of heart disease should be educated about its risk factors, effects, prevention, and management. Nurses and other healthcare providers should participate in assisting patients to learn how to optimize treatment outcomes using self-management interventions (De Backer et al., 2019). Health education should also focus on raising the population’s awareness towards the adoption of health interventions such as engaging in physical activity, healthy dietary habits, and utilizing screening services.

There is also a need to incorporate evidence-based interventions into the treatment of heart disease patients. Healthcare providers should utilize practice recommendations from studies with the incorporation of the patients’ preferences and provider expertise. Evidence-based practice in heart disease management would result in care outcomes that include efficiency, quality, and safety. Multidisciplinary collaboration is also needed as part of the best practices in heart disease management and prevention. Healthcare providers should collaborate in assessing, planning, implementing, monitoring, and evaluating the care interventions adopted for heart disease. The outcomes of multidisciplinary collaboration include enhanced patient satisfaction, engagement, and empowerment with the care process (Zipes, 2018). Therefore, adopting the above best practice interventions in care coordination will enhance the treatment outcomes in heart disease.


Some goals should be established to address heart disease in the American population. One of them is the need for raising awareness among the population about heart disease and prevention using public health initiatives within six months to promote behavioral change. Interventions that include health education are effective in raising the desired awareness. The second goal is to increase the uptake of screening services for heart disease by the American population within six months. The screening will facilitate early identification of those at risk and affected and initiation of treatment to prevent disease progression. The last goal entails increasing access to healthy diets and spaces for engaging in physical activity for the population. The availability of these resources will enhance the adoption of healthy lifestyles and behaviors by the population.

Available Community Resources

Community resources are essential for the provision of a safe and effective continuum of care for heart disease patients. The resources help them in coping with the disease demands and effect on their quality of life. Several community resources can be used to achieve optimum care outcomes in heart disease patients. One of them is the social support from family members, friends, and the community as a whole. Social support from these individuals helps heart disease patients develop effective coping strategies with their health needs. It also addresses issues that affect their health, including social isolation and stigma that they may experience due to their diagnoses (Su et al., 2018). Heart disease patients can benefit from social support groups for patients with heart disease. They get social, emotional, and psychological support from other patients and survivors on how to live and manage heart disease effectively. Patients also learn from other effective interventions in optimizing treatment outcomes in heart disease (Rasmussen et al., 2021). Patients can also get their desired social support from professional organizations that include the American College of Cardiology and the American Society for Preventive Cardiology where they can access the resources they need for managing their conditions. The organizations provide educational resources, links to social support communities, and healthcare provider support needed by heart disease patients.


Care coordination in heart disease management is an important intervention for optimizing treatment outcomes. Nurses play crucial roles in leading the implementation of best practice interventions that include patient-centeredness, interprofessional collaboration, and the use of evidence-based interventions in the care of heart disease patients. Social support is important for heart disease patients. Sources of social support such as family, friends, and community members should be explored to facilitate the effective management of heart disease in the affected populations. Therefore, nurses and other healthcare providers should explore the available social support resources in the patients’ settings for utilization in achieving optimum care outcomes.


Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., & Das, S. R. (2019). Heart disease and stroke statistics—2019 update: A report from the American Heart Association. Circulation, 139(10), e56–e528.

CDC. (2021, September 27). Heart Disease Facts | for Disease Control and Prevention.

De Backer, G., Jankowski, P., Kotseva, K., Mirrakhimov, E., Reiner, Ž., Rydén, L., Tokgözoğlu, L., Wood, D., De Bacquer, D., & De Backer, G. (2019). Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries. Atherosclerosis, 285, 135–146.

Rasmussen, A. N., Guise, A., & Overgaard, C. (2021).The role of social support in the experience of life with ischemic heart disease for socially disadvantaged patients: A qualitative study.Chronic Illness, 17423953211065004.

Su, S.-F., Chang, M.-Y., & He, C.-P.(2018). Social support, unstable angina, and stroke as predictors of depression in patients with coronary heart disease. Journal of Cardiovascular Nursing, 33(2), 179–186.

Zipes, D. P. (2018).Braunwald’s heart disease: A textbook of cardiovascular medicine.BMH Medical Journal-ISSN 2348–392X, 5(2), 63–63.


Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem.

Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen health care concern.
Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.

Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan
Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
Heart disease (high blood pressure, stroke, or heart failure).
Home safety.
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
Pain management.
Mental health.
Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3-4 pages in length.
Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the health care problem.
Identify available community resources for a safe and effective continuum of care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

Competencies Measured
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 factors.
Analyze a health concern and the associated best practices for health improvement.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe specific goals that should be established to address a selected health care problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

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