Final Care Coordination Plan Essay

Final Care Coordination Plan Essay

Final Care Coordination Plan

Heart disease is one of the health problems with increasing prevalence in the USA and other global states. Disease burden due to heart disease affects the health and quality of life for patients and their significant others. Nurses play crucial roles in ensuring the provision of care that addresses the needs of heart disease patients. They utilize care interventions such as care coordination to ensure optimum outcomes for their patients. In addition, they explore other practice interventions that include interprofessional collaboration to develop care plans that address both the actual and potential health needs of heart disease patients. Therefore, the purpose of this paper is to explore patient-centered interventions and timelines, priorities for care coordination, and ethical decisions in developing care for heart disease patients.

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Patient-Centered Interventions and timelines

Patient-centered interventions are needed to achieve optimum outcomes in patients suffering from heart disease. One of the patient-centered health interventions for these patients is health education. Heart disease patients should be educated about the causes, effects, risks, and management of the condition. Health education raises their level of awareness towards the required interventions to achieve optimum outcomes (Chiang et al., 2018). The other patient-centered intervention in heart disease patients is the prevention of complications. Heart disease patients are at an increased risk of complications that include stroke, heart attack, heart failure, and stroke. Patients should be educated about the methods of minimizing complications, including treatment adherence, lifestyle and behavioral modifications, and engaging in self-management interventions (Lindman et al., 2020).

The other patient-centered intervention in heart disease patients is reducing healthcare costs. Often, heart disease patients incur significant costs due to frequent hospitalizations, emergency department visits, and the purchase of the needed medications. Nurses involved in care coordination should explore ways of reducing healthcare costs patients incur. Interventions that include the incorporation of health technologies such as telehealth may help lower the treatment costs(Poitras et al., 2018). The other patient-centered intervention in heart disease patients is ensuring shared decision-making. Shared decision-making is a practice concept that requires patient involvement in the treatment process. The decision-making should consider the patient’s values, beliefs, and preferences. The outcomes of shared decision-making include in caring for heart disease patients include patient satisfaction, empowerment, and holism in disease management(Chiang et al., 2018). The interventions should be implemented before the patient’s discharge from the hospital. Nurses involved in the care coordination process should ensure that patients understand their roles in chronic disease management. They should also ensure the availability of resources for use in care coordination.

Priorities for Care Coordination

Nurses involved in care coordination will prioritize the realization of some outcomes when discussing the plan with a patient and family member on the effective management of heart disease. One of the priorities is patient education and understanding of the disease process. Effective educational methods should be used to raise the patients’ understanding of the effective management of heart disease (Rutledge et al., 2018). Patient education also empowers patients to embrace effective lifestyles and behaviors that will minimize the risk of adverse outcomes in heart disease management.

The other priority in the care coordination is patient and family engagement. The effective management of heart disease depends largely on the collective roles that patients and their families play. Family members should provide patients with the social, emotional, physical, and psychological support they require for effective disease management(Chiang et al., 2018). Therefore, nurses involved in the care coordination should ensure that patients and their families are optimally engaged in assessment, planning, implementation, monitoring, and evaluating the adopted care interventions.

The other nurses’ priority in care coordination involving heart disease patients is incorporating health information technology to enhance access to care. Health information technologies enhance care outcomes that include safety, quality, and efficiency in care coordination. Patients have enhanced access to health information whenever they need it when health information technologies are incorporated into the care process. As noted above, technologies that include mobile health and telehealth may be incorporated into the treatment plan to ensure continuity in care after the patient’s discharge from the hospital l(Rutledge et al., 2018). Therefore, nurses involved in care coordination will prioritize incorporating health information technologies into the treatment process to ensure optimal treatment outcomes.

Comparison of Learning Session with Best Practices

The learning session throughout this cause aligns with best healthcare practices. The session also underpins the realization of the Healthy People 2030 goals. One of the ways in which the session aligns with best healthcare practices is that it incorporated the ethical and legal aspects of patient care in the learning process. It exposed the students to different ethical considerations in care coordination such as autonomy, beneficence, non-maleficence, and justice. The session content also exposed the students to evidence-based interventions that are important in care coordination. Evidence-based practice interventions have been shown to contribute to outcomes that include safety, quality, and efficiency in the care coordination process. As a result, the session underpinned the realization of care outcomes following the utilization of best practices in healthcare. The session also instilled in students the principles of teamwork in exploring issues in healthcare. Teamwork improves students’ understanding of the applications of different concepts in the patient care process for optimum outcomes.

The session also contributed to the realization of Healthy People 2030 goals. Care coordination aims at improving the health outcomes of patients suffering from health problems, including heart disease. It explores interventions that can be used to enhance patient engagement, empowerment, and satisfaction with the care process. Nurses involved in the process utilize care interventions that address barriers to care such as costs and geographical location in chronic disease management(Healthypeople.gov, n.d.). Therefore, the session increased nurses’ understanding of their contributions towards the realization of the Healthy People 2030 goals.

Ethical Decisions in Designing Patient-Centered Health Interventions

Nurses should consider ethical requirements in the designing of patient-centered health interventions for heart disease. One of the ethical decisions is the patient’s autonomy. Nurses involved in the care coordination process should seek informed consent from the patients. Patients should make independent decisions about their participation in the care coordination. Nurses should also ensure safety in the care coordination process. Patients should not be exposed to any form of harm in the care coordination process. Ethical principles such as beneficence should also be considered to ensure that nurses strive to do good to the patients. An example in the selected condition is incorporating health information technologies into the care process to minimize adverse events that patients may develop following their discharge from the hospital. The incorporation of health information technologies into heart disease management should also ensure the protection of data privacy and confidentiality. The adopted health information technologies should protect unauthorized access to patients’ data(Vijn et al., 2018). Therefore, the consideration of the above issues contributes to safety, quality, and efficiency in the care coordination process.

Health Policy Implications

Healthcare policies affect patient-centered care in care coordination. One of the policies is the Affordable Care Act. The Affordable Care Act is a policy that was adoptedto increase care by the American population. The act addresses the barriers to healthcare due to issues such as cost and health insurance coverage. The act increased the population with medical insurance coverage. An increase in this population translates into enhanced access to care due to the elimination of cost-related barriers. The Affordable Care Act increases patient-centeredness in the care process and care continuum by ensuring that patients have access to their needed care irrespective of their backgrounds. The act also providers nurses and other healthcare providers the opportunities to develop and implement new care models to achieve optimum care outcomes(Ruggiero et al., 2019). An example can be seen in the incorporation of healthcare technologies into care coordination due to enhanced affordability of care by the patients.

The other policy that affects care coordination and continuum of care in heart disease patients is Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a federal law that was adopted in the USA to promote and protect the use of health information technologies in the patient care process. The act emphasizes the need for healthcare organizations to adopt interventions that will protect the integrity of the patients’ data. It also requires them to seek informed consent from the patients before sharing their private and confidential data with third parties, including insurance payers. HIPAA has promoted patient-centeredness by increasing the need for the adoption of interventions that protect the patients’ interests. It has also streamlined the meaningful use of health information technologies to advance care outcomes in healthcare. An example can be seen from the use of telehealth technology to increase access to healthcare services to patients. The technology has also enhanced the safety, quality, and efficiency of healthcare services(Ezell et al., 2021). Therefore, through HIPAA, heart disease patients receive their needed care irrespective of their distance from the healthcare providers, hence, care continuum and patient-centeredness in the care process.

Conclusion

Care coordination in heart disease patients is important in promoting optimum care outcomes. Care coordination should focus on the prioritized health needs of heart disease patients. Patient engagement, understanding, and use of health information technologies in heart disease are some of the prioritized care outcomes. The learning session content aligns with best practices and supports the realization of Healthy People 2030 goals. Ethical decisions should be made in care coordination involving patients with heart disease. Ethical principles that include autonomy, justice, beneficence, and non-maleficence inform the decisions made in the care coordination process. Healthcare policies that include the Affordable Care Act and HIPAA affect care coordination and continuum of care. Therefore, nurses need to understand the different policies that influence their care interventions in patients under the care coordination program.

References

Chiang, C.-Y., Choi, K.-C., Ho, K.-M., & Yu, S.-F. (2018). Effectiveness of nurse-led patient-centered care behavioral risk modification on secondary prevention of coronary heart disease: A systematic review. International Journal of Nursing Studies, 84, 28–39. https://doi.org/10.1016/j.ijnurstu.2018.04.012

Ezell, J. M., Hamdi, S., &Borrero, N. (2021). Approaches to Addressing Nonmedical Services and Care Coordination Needs for Older Adults.Research on Aging, 01640275211033929. https://doi.org/10.1177/01640275211033929

Healthypeople.gov. (n.d.).Healthy People 2030 Framework | Healthy People 2020. Retrieved February 1, 2022, from https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

Lindman, B. R., Arnold, S. V., Bagur, R., Clarke, L., Coylewright, M., Evans, F., Hung, J., Lauck, S. B., Peschin, S., Sachdev, V., Tate, L. M., Wasfy, J. H., & Otto, C. M. (2020). Priorities for Patient‐Centered Research in Valvular Heart Disease: A Report From the National Heart, Lung, and Blood Institute Working Group. Journal of the American Heart Association, 9(9), e015975. https://doi.org/10.1161/JAHA.119.015975

Poitras, M.-E., Maltais, M.-E., Bestard-Denommé, L., Stewart, M., & Fortin, M. (2018). What are the effective elements in patient-centered and multimorbidity care? A scoping review.BMC Health Services Research, 18(1), 446. https://doi.org/10.1186/s12913-018-3213-8

Ruggiero, K., Pratt, P., &Antonelli, R. (2019).Improving outcomes through care coordination: Measuring care coordination of nurse practitioners.Journal of the American Association of Nurse Practitioners, 31(8), 476–481.

Rutledge, G. E., Lane, K., Merlo, C., &Elmi, J. (2018).Coordinated Approaches to Strengthen State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke.Preventing Chronic Disease, 15, E14. https://doi.org/10.5888/pcd15.170493

Vijn, T. W., Wollersheim, H., Faber, M. J., Fluit, C. R. M. G., & Kremer, J. A. M. (2018). Building a patient-centered and interprofessional training program with patients, students and care professionals: Study protocol of a participatory design and evaluation study.BMC Health Services Research, 18(1), 387. https://doi.org/10.1186/s12913-018-3200-0

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

Introduction
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.

Preparation
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: Remember that you can submit all, or a portion of, your 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.

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.

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.
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.