Final Care Coordination Plan Essay

Final Care Coordination Plan Essay

Heart disease is the leading cause of increased mortality rates, comorbidities, prolonged hospitalization, high rates of readmissions, compromised quality of life, and a steady increase in care costs. According to Roth et al. (2020), cardiovascular diseases like heart disease, stroke, and heart failure accounted for approximately 19.7 million deaths in 2019. Similarly, the global trends for disability-adjusted life years (DALYs) and years of life lost doubled from 17.7 million to 34.4 million from 1990 to 2019. The modifiable and non-modifiable risk factors for heart disease include physical inactivity, smoking, unhealthy diet, obesity, poor stress management, family history of cardiovascular disease, age, and genetics. When developing a care plan for people with heart disease, it is vital to address modifiable risk factors to prevent complications and improve disease management approaches. Therefore, this final care coordination plan focuses on issues facing people with heart disease, patient-centered interventions, ethical considerations for individualized care approaches, relevant health policy implications for coordinating care, and the priorities for the care coordination plan.

Patient-centered Health Interventions

Patient-centered care entails interventions that uphold patients’ health needs, values, and preferences. In the context of heart disease management, individualized care approaches should focus on addressing factors that exacerbate the disease, including smoking, physical inactivity, obesity, and unhealthy diets. Mesana (2019) proposes multiple team-based measures for managing heart disease. These approaches include ensuring dietary compliance, optimizing guideline-directed medical therapy, facilitating cardiac rehabilitation, and enhancing patient education. Further, it is essential to involve individuals with heart disease in supervised physical exercises to ensure healthy weight management. Educating patients on healthy diets can promote sustainable lifestyle changes necessary for heart disease management (Halatchev et al., 2019). Equally, patient education promotes other elements of self-management, including medication adherence and compliance with smoking cessation interventions and physical exercise schedules. Interprofessional team collaboration between heart failure specialists, cardiac surgeons, dieticians, social workers, nurses, pharmacists, palliative care physicians, and patients can promote implementing and sustaining these patient-centered approaches to heart disease management.

Issues Facing People with Heart Disease

People with heart disease face various issues and challenges, including unfamiliarity with self-management interventions, limited access to timely care, and unawareness of early vital sign identification, reporting, and monitoring. According to Jaarsma et al. (2020), self-management approaches for heart disease entail pharmacologic and non-pharmacologic interventions like adherence to prescribed medications, engaging in physical activity, complying with healthy diet plans, and self-care monitoring competencies. Patient-centered interventions for improving patients’ self-management competence include educating them on disease management activities, linking them to community resources, incorporating technology like telehealth to promote remote monitoring, and fostering effective communication. Equally, patients with heart disease can leverage community resources, including community-based health organizations, expert offices, and online databases like the American Heart Association (AHA) to improve self-management competencies.

Secondly, limited access to timely and convenient care exacerbates heart disease complications. According to White-Williams et al. (2020), poor social determinants of health, including poverty, low-level education attainment, health illiteracy, uninsurance, and infrastructure deficiencies, are the profound causes of limited access to quality, timely care for people with heart disease. It is possible to address these issues by educating people about the causes, effects, and management approaches for heart disease, collaborating with local authorities to modify the environment, and providing infrastructures like accessible sidewalks, gymnasia, and other public opportunities for physical activity. Equally, it is possible to utilize community resources like recreational parks, community amenities for physical activity, and health institutions that provide information regarding heart disease management and prevention.

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Thirdly, people with heart disease grapple with the challenge of unawareness of early vital sign detection, reporting, and management. According to Conn et al. (2019), in-home vital sign monitoring can transform the healthcare system by facilitating care transition from reactive to proactive and preventive care. It is possible to improve individual awareness of vital sign monitoring by strengthening the use of mHealth and telehealth technology to foster communication, educating people on how to use these technologies, and coordinating care with community-based organizations to ensure timely response in the case of deteriorating signs. In this sense, individuals with heart disease and other cardiovascular conditions can utilize community resources like healthcare institutions, expert offices, and free-access databases to gain insights into appropriate interventions for vital sign monitoring.

Ethical Decisions in Designing Patient-centered Health Interventions

Patient-centered interventions for improving heart disease management and control should rely massively upon ethical considerations. Tomaselli et al. (2020) contend that patient-centered care entails respecting patients’ demands, preferences, and principles. This care dimension results in patient empowerment and enhanced individual decision-making competencies for influencing care trajectories. Varkey (2021) states that healthcare professionals are responsible for benefiting patients, preventing harm, ensuring justice and fairness, and respecting values, preferences, and decisions. The four bioethical principles of beneficence, non-maleficence, autonomy, and justice enshrine these moral obligations by requiring healthcare professionals to provide care consistent with individual needs and interests. When designing and implementing patient-centered interventions to improve the health of people with heart disease, it is vital to involve them, understand their learning priorities, empower them to make decisions, and ensure that the subsequent approaches are consistent with established collective goals and objectives.

Health Policy Implications for Coordination and Continuum of Care

Developing a care coordination plan for managing heart disease and improving the health of people grappling with this disease is consistent with the Affordable Care Act (ACA) 2010 provision, which requires hospital and healthcare professionals to prevent avoidable readmissions. According to the Centers for Medicare and Medicaid Services [CMS] (2022), the Hospital Readmissions Reduction Program (HRRP) is a value-based program that encourages hospitals to improve communication and enhance care coordination to reduce avoidable readmissions perpetrated by various diseases, including acute myocardial infarction (AMI), Chronic Obstructive Pulmonary Disease (COPD). Further, this program enables CMS to track hospital readmission rates (HRRs) and determine benefits and penalties based on the organizational ability to reduce preventable readmissions. In this sense, CMS can provide incentives for hospitals that reduce avoidable readmissions to acceptable benchmarks while reducing Medicare payments to institutions with high readmission rates. Gai & Pachamanova (2019), the HRRP program proposes various interventions for reducing preventable readmissions, including coaching patients on discharge instructions and self-management, improving care coordination and care setting transition planning, and performing medication reconciliation. These approaches align with the proposed patient-centered interventions for improving the health and wellness of people with heart disease.

Priorities for Care Coordination

Notably, it is essential to communicate the plan with patients and family members before embarking on its enactment. Making changes consistent with patients’ feedback, external evidence, and contextual issues is vital. For example, patients with heart disease may fail to adhere to the 150 to 300 minutes of physical exercise per week requirement due to the underlying complications associated with the disease. Therefore, altering the intervention schedule should be consistent with patients’ preferences, needs, and values. The care coordinator should emphasize various priorities when discussing the plan with patients and family members and making changes based on evidence-based practice. These priorities include improving patients’ health literacy, enhancing their self-management competencies, and bolstering their knowledge of appropriate technologies for care coordination and effective communication.

Learning Sessions

The learning sessions for improving the health and wellness of people with heart disease contain various topics, including practices of a healthy diet, recommended measures and length of physical exercise, smoking cessation approaches, and strategies for vital sign monitoring. These sessions align with the evidence from the current scholarly literature that supports improving patients’ self-management competencies and enabling them to prevent disease progression by addressing modified risk factors for heart disease. According to Podvorica et al. (2021), education sessions for people with heart disease should focus on increasing patients’ knowledge in improving modifiable factors like nutrition, physical activity, body mass index (BMI) monitoring, glycemia, and cholesterol. Undoubtedly, focusing on these themes is fundamental in improving self-management competencies, enhancing the quality of life, reducing readmissions, and minimizing eventual complications associated with heart disease.

Equally, the proposed patient-centered interventions for improving the health and wellness of people with heart disease are consistent with Healthy People 2030’s objectives. For instance, Healthy People 2030 targets to reduce cholesterol in adults to about 186.4 mg/dL by emphasizing physical activities and healthy weight management approaches (Healthy People 2030, n.d.). Other Healthy People 2030 objectives for heart disease include reducing the proportion of adults with high blood pressure, increasing aspirin use for secondary prevention of atherosclerotic cardiovascular disease, and enhancing control of high blood pressure in adults.

Conclusion

While heart disease is the leading cause of increased mortality rates, comorbidities, prolonged hospitalization, increased care costs, and compromised quality of life, implementing patient-centered interventions and ensuring care coordination can improve people’s health and wellness. Examples of patient-centered approaches for addressing the disease include emphasizing physical activity sessions, educating patients on self-management interventions, linking patients to community resources, improving their health literacy, and coordinating with community-based organizations to foster communication, timely care delivery, information transfer, and consultations. When implementing these approaches, it is vital to incorporate ethical considerations, align them with external evidence, and make changes consistent with patients’ preferences, needs, and values. Finally, it is crucial to uphold the Hospital Readmissions Reduction Program (HRRP) provisions and evaluate the Healthy People 2030 objectives to ensure consistency with the final care coordination plan.

References

Centers for Medicare and Medicaid Services. (2022). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Conn, N. J., Schwarz, K. Q., & Borkholder, D. A. (2019). In-Home cardiovascular monitoring system for heart failure: Comparative study. JMIR MHealth and UHealth, 7(1), e12419. https://doi.org/10.2196/12419

Gai, Y., & Pachamanova, D. (2019). Impact of the Medicare hospital readmissions reduction program on vulnerable populations. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4645-5

Halatchev, I. G., McDonald, J. R., & Wu, W.-C. (2020). A patient-centered, comprehensive model for the care for heart failure: The 360° heart failure center. Open Heart, 7(2), e001221. https://doi.org/10.1136/openhrt-2019-001221

Healthy People 2030. (2020). Heart disease and stroke. https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke

Jaarsma, T., Hill, L., Bayes‐Genis, A., La Rocca, H. B., Castiello, T., Čelutkienė, J., Marques‐Sule, E., Plymen, C. M., Piper, S. E., Riegel, B., Rutten, F. H., Ben Gal, T., Bauersachs, J., Coats, A. J. S., Chioncel, O., Lopatin, Y., Lund, L. H., Lainscak, M., Moura, B., & Mullens, W. (2020). Self‐care of heart failure patients: Practical management recommendations from the heart failure Association of the European Society of Cardiology. European Journal of Heart Failure, 23(1). https://doi.org/10.1002/ejhf.2008

Mesana, T. (2019). Heart teams for treatment of cardiovascular disease: A guide for advancing patient-centered cardiac care (1st ed.). Springer International Publishing.

Podvorica, E., Bekteshi, T., Oruqi, M., & Kalo, I. (2021). Education of the patients living with heart disease. Materia Socio Medica, 33(1), 10. https://doi.org/10.5455/msm.2021.33.10-15

Roth, G. A., Mensah, G. A., Johnson, C. O., Addolorato, G., Ammirati, E., Baddour, L. M., Barengo, N. C., Beaton, A. Z., Benjamin, E. J., Benziger, C. P., Bonny, A., Brauer, M., Brodmann, M., Cahill, T. J., Carapetis, J., Catapano, A. L., Chugh, S. S., Cooper, L. T., Coresh, J., & Criqui, M. (2020). Global burden of cardiovascular diseases and risk factors, 1990-2019: Update from the GBD 2019 study. Journal of the American College of Cardiology, 76(25), 2982–3021. https://doi.org/10.1016/j.jacc.2020.11.010

Tomaselli, G., Buttigieg, S. C., Rosano, A., Cassar, M., & Grima, G. (2020). Person-Centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: A scoping review. Frontiers in Public Health, 8(44). https://doi.org/10.3389/fpubh.2020.00044

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

White-Williams, C., Rossi, L. P., Bittner, V. A., Driscoll, A., Durant, R. W., Granger, B. B., Graven, L. J., Kitko, L., Newlin, K., & Shirey, M. (2020). Addressing social determinants of health in the care of patients with heart failure: A scientific statement from the American Heart Association. Circulation, 141(22). https://doi.org/10.1161/cir.0000000000000767

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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 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.

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.

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

VIEW SCORING GUIDE