NURS4050 Assessment 4: Final Care Coordination Plan Essay

NURS4050 Assessment 4: Final Care Coordination Plan Essay

Chronic Obstructive Pulmonary Disease (COPD) Final Care Coordination Plan

Chronic Obstructive Pulmonary Disease is a debilitating irreversible chronic lung inflammatory disease that causes functional and physical limitations to the patient. Management of COPD patients is affected by various challenges because it requires a multifaceted, multidisciplinary, and well-coordinated approach. Planning care for COPD patients must therefore account for various dimensions of wellness, such as physical, social, emotional, intellectual, spiritual, and occupational wellness. Utilization of community resources can help the patient and the care provider achieve some care goals. Self-care deficit, risk of infection, and activity intolerance are some of the healthcare issues that COPD patients face. The purpose of this paper is to discuss these healthcare issues, propose interventions to solve these issues, set goals and timelines for the achievement of these goals, and propose relevant local community resources that can be utilized to achieve these goals.

Self-care Deficit

Self-care among COPD patients enables them to look after themselves. It involves a process of decision-making that requires physical, emotional, spiritual, and mental fitness to conveniently and efficiently that results take care of oneself. Self-care drift among patients with COPD results from various disabilities and deficiencies. According to Matarese et al. (2020), disabling somatic and psychological symptoms lead to poor self-care. Somatic symptoms include dyspnea, fatigue, and cough. These symptoms and associated limitations can lead to depression or anxiety that further worsens the quality of life.

Intervention

A nursing intervention such as health coaching on self-care activities can improve self-management. This health coaching should not be limited to patients with severe symptoms of COPD. A nurse can deliver health coaching for self-care by telephone. In a study by Jolly et al. (2018), telephone-based health coaching delivered by a nurse improved behavior change leading to self-care for patients with mild COPD symptoms. According to Kermelly & Bourbeau (2022), digital approaches to self-care and self-management can improve the quality of life for COPD patients. The desired outcome of self-care health coaching is that the patient will exhibit the ability to take care of themselves and reduce dependence on activities of daily living. Self-management and self-care plans are best discussed collaboratively with the patient or their caregiver at the point of diagnosis (Jolly et al., 2018). Considerations for self-care can include self-hygiene and risk reduction through lifestyle strategies.

Community resources

Home-based care services for COPD patients with self-care needs can improve the outcome of care. Home care services can provide activities of self-care that can improve mobilizations, bowel habits, and nutrition. For bedbound or wheelchair-bound COPD patients, home care services can provide temporary relief for family caregivers and sometimes link them with any necessary hospital care services. In the process, the risk of caregiver burnout and stress is reduced by utilizing these community resources. Additionally, these home-based care services proved services such as patient education, physical therapy, occupational therapy, breathing exercises, and general nursing care. Assisted living facilities can also be useful in some cases where the condition of the patient dictates.

Risk of Infection

COPD patients are at increased risk of infection due to various reasons. The increasing severity of the disease is a risk of infections among COPD patients. The risk of infection among COPD patients is also related to the choric nature of the disease, malnutrition in COPD, stasis of secretions, and decreased ciliary function. Most infections affect the respiratory tract. Pneumonia, common cold, flu, and bronchitis are some of the infections for which COPD patients are at risk (Lopez-Campos et al., 2020). Most infections are viral and bacterial in etiology. Therefore, airborne means of transmission routes are good common points for disease prevention.  Infections are a major cause of COPD exacerbations that lead to readmissions, higher costs of care, and even mortality (Ritchie & Wedzicha, 2020). Therefore, there is a need to address this risk with every COPD patient.

Intervention

Teaching hand hygiene is an affordable and sustainable nursing intervention that would aim at infection risk reduction. In this intervention, the goal is that the patient will verbalize the correct reasons for regular handwashing and demonstrate the correct hand-washing techniques and frequency. A more specific invention will involve monitoring daily body temperature, septum color, consistency and teaching patients about adequate nutritional intake. These interventions will be completed after the first encounter with the patient and during follow-up visits.

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Community Resources

Nutrition and hygiene are important accessible interventions that reduce infection risk. Common community resources that would benefit these patients are adult daycare services. These resources will provide debilitated patients with daily daytime monitoring and referrals. The centers for disease control and prevention recommends an annual flu vaccine for COPD patients older than 65 years. Therefore, primary care centers providing these services will be important community resources that will cut costs and improve service access. However, there have been various controversies about the efficacies, effectiveness, and necessities of these vaccines among COPD patients. Their use is thus determined by local and national guidelines.

Activity Intolerance

Activity intolerance among COPD is an outcome of the limitations that this respiratory disease exerts on the functionality of the patients. Physical exercise is a recommended intervention among COPD patients, but some cannot tolerance some levels of active exercise. Activity intolerance in COPD patients is associated with insufficient physiological or psychological energy that can enable these patients to complete required daily activities. This intolerance is related to impaired oxygen supply-demand balance, a sedentary lifestyle, and physical deconditioning. Activity intolerance can be evidenced by variability in heartbeat, exertional discomfort, dyspnea during exercise, fatigue, and weakness.

Intervention

A key intervention in improving somatic and psychological health is physical exercise. Physical exercise and mobilization for COPD patients aim at improving physical and psychological health. More specific goals for physical exercise and mobilization are that the patient will be able to complete at least 20 minutes of passive exercise every day or as tolerated, maintain adequate oxygen saturation at any time, and tolerate exercise well. These interventions will also include passive mobilizations in cases where patients are debilitated. Another intervention related to this issue is oxygen therapy. Oxygen therapy can prolong life and alleviate dyspneic symptoms (Ackley & Ladwig, 2022). For ambulant patients, the goal is that they will report reduced rates of exertional dyspnea and lower scores of self-ratings of exertional after the first month of therapy.

Community Resources

Pulmonary rehabilitation programs are useful community resources that would benefit COPD patients with self-care needs due to respiratory compromise. In pulmonary rehabilitation programs, patients can receive services such as physical exercise, breathing techniques, and respiratory muscle training. Dyspnea management skills can be acquired by COPD patients in these community resources (Matarese et al., 2020). These programs train the patients to be able to perform these self-care behaviors at home to ensure disease stability (Ackley & Ladwig, 2022). Disease stability is associated with lighter benefits, such as readmission reductions.

Ethical Decisions in Designing Patient-Centered Health Interventions

These healthcare interventions have been based on ethical considerations and determinants of healthcare quality. Specific decisions are made to promote interest and well-being and achieve measurable outcomes. The specific decision to improve self-care, and use telephone technologies to provide self-care coaching, was made with the goals of life quality in mind. Practically, this was expected to be a low-cost intervention that would eliminate health disparities in care access. The second decision, physical exercise, was a productive evidence-based strategy but could produce ethical challenges in COPD patients. Patients with activity intolerance would not benefit from this strategy. Therefore, ethically, only tolerable amounts will do no harm to the patient. Infections are health safety risks to patients and early prevention through handwashing are less costly intervention. These interventions would require collaborative patient engagement to ensure respect for patient autonomy.

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Relevant Health Policy Implications for the Coordination and Continuum of Care

The COPD National Action Plan by the national institute of health (NIH) and centers for disease control and prevention (CDC) advocated for policies that aimed at achieving five goals. One of these goals was to facilitate the translation of national health policies and educational programs in the primary care of COPD patients. One of the relevant national policies that must be considered in care coordination for COPD is the Health Insurance Portability and Accountability Act which ensures the protection of sensitive patient information during information sharing. Another effective policy is the affordable care act that requires patients to access information about institutional health services and is not denied insurance services based on their preexisting COPD. Therefore, at any level of care, coordinators must adhere to these policies to ensure care affordability, information security, and privacy.

Care Coordination Priorities

While discussing these plans with the patient or their families, a care coordinator must prioritize cost, safety, and quality. The affordability of community services and specific interventions will promote adherence. The safety of the intervention will ensure a good patient experience. The quality outcomes will ensure patient satisfaction. Any intervention leading to increased costs, poor quality, or jeopardizing patient safety would necessitate change that would be communicated to the patient and their caregivers in time.

Relevance to Healthy People Goals and Literature Evaluation

The interventions align well with healthy people’s objectives on respiratory diseases and COPD. Reduction of readmission rates, emergency hospitalization, and mortality from COPD are three specific Healthy People 2030 goals that were considered in the development of the intervention. Reduction of risk of infection would reduce chances of exacerbations and hospitalizations (Ackley & Ladwig, 2022). Promoting the health safety of the patient through infection prevention and self-care would improve the quality of life that can reduce mortality risks. The overall goal of these interventions in this plan is to improve the respiratory health of COPD patients, similar to the healthy people 2030 objectives. Cost of care has been a major determinant in the access and utilization of resources. The nursing interventions proposed in this plan considered costs and benefits to the patients.

Conclusion

COPD is a disabling disease that is progressive, and every intervention must aim at improving respiratory health and quality of life. This plan documentation utilized care coordination strategies, including ethical and policy considerations, to develop a care plan for COPD patients. Key issues identified were self-care deficit, risk of infection, and activity intolerance. Proposed interventions considered cost, safety, access, and quality to incorporate community resources. The healthy people 2030 goals played a crucial role in this plan to improve COPD patients’ respiratory health.

References

Ackley, & Ladwig. (2022). Ackley and Ladwig’s nursing diagnosis handbook Elsevier eBook on vitalsource (retail access card): An evidence-based GUI (13th ed.). Elsevier Science Publishing.

Cravo, A., Attar, D., Freeman, D., Holmes, S., Ip, L., & Singh, S. J. (2022). The importance of self-management in the context of personalized care in COPD. International Journal of Chronic Obstructive Pulmonary Disease, 17, 231–243. https://doi.org/10.2147/COPD.S343108

Jolly, K., Sidhu, M. S., Hewitt, C. A., Coventry, P. A., Daley, A., Jordan, R., Heneghan, C., Singh, S., Ives, N., Adab, P., Jowett, S., Varghese, J., Nunan, D., Ahmed, K., Dowson, L., & Fitzmaurice, D. (2018). Self-management of patients with mild COPD in primary care: a randomized controlled trial. BMJ (Clinical Research Ed.), 361, k2241. https://doi.org/10.1136/bmj.k2241

Kermelly, S. B., & Bourbeau, J. (2022). EHealth in self-managing at distance patients with COPD. Life (Basel, Switzerland), 12(6), 773. https://doi.org/10.3390/life12060773

Lopez-Campos, J. L., Miravitlles, M., de la Rosa Carrillo, D., Cantón, R., Soler-Cataluña, J. J., & Martinez-Garcia, M. A. (2020). Current challenges in chronic bronchial infection in patients with chronic obstructive pulmonary disease. Journal of Clinical Medicine, 9(6), 1639. https://doi.org/10.3390/jcm9061639

Matarese, M., Clari, M., De Marinis, M. G., Barbaranelli, C., Ivziku, D., Piredda, M., & Riegel, B. (2020). The self-care in Chronic Obstructive Pulmonary Disease Inventory: Development and psychometric evaluation. Evaluation & the Health Professions, 43(1), 50–62. https://doi.org/10.1177/0163278719856660

Ritchie, A. I., & Wedzicha, J. A. (2020). Definition, causes, pathogenesis, and consequences of chronic obstructive pulmonary disease exacerbations. Clinics in Chest Medicine, 41(3), 421–438. https://doi.org/10.1016/j.ccm.2020.06.007

Wedzicha, J. A. (2022). Vaccines for COPD exacerbation prevention: do they work? The Lancet. Respiratory Medicine, 10(5), 422–423. https://doi.org/10.1016/S2213-2600(22)00007-8

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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.

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.