The Care Coordination Plan Discussion

The Care Coordination Plan Discussion

Assessment 4 Instructions: Final Care Coordination Plan PRINT 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 The Care Coordination Plan Discussion.

ORDER YOUR PAPER HERE

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 peerreviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources The Care Coordination Plan Discussion.

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 patientcentered 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 patientcentered 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 patientcentered 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 patientcentered 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. Running head: PRELIMINARY CARE COORDINATION PLAN Preliminary Care Coordination Plan Capella University NURS 4050- Coordinating Patient-Center Care July, 2021 1 2 PRELIMINARY CARE COORDINATION PLAN A care coordination plan has become a cornerstone that helps to promote quality healthcare. A care coordination plan helps research and promotes effective strategies that can be incorporated in healthcare facilities to ensure high-quality services and eliminate any medication errors that might arise (Vrijhoef, 2016). In nursing, care coordination plans help nurses create effective programs and focus on essential factors that help address health concerns. In contemporary times the nursing practice has become very complex due to the increasing number of diseases. The increasing numbers of diseases have become a very large and unbearable burden in healthcare, calling for a coordinated care plan that will help address them from an evidencebased perspective. It is paramount to understand the main cause of the diseases from both a patient-centered perspective and the environmental perspective. The care coordination plan will focus on heart disease, which has become a major health concern in the 21st century. Heart Disease as a Health Concern Heart diseases have become one of the most dangerous pandemics in the United States. The increasing rate at which heart diseases have continued to affect people in the United States is an issue that calls for an organized plan to help address the problem in society. Heart disease is the leading cause of death in the United States. The disease affects people from all races and genders, and hence it is a red flag that society needs to address. According to the CDC (2020)The Care Coordination Plan Discussion, the death rate caused by heart disease is alarming, and there is a need to ensure effective coordination.

One person dies every 36 seconds in the United States due to complications associated with the heart. The data indicates that more than 655,000 Americans die every year in the United States resulting comprising more than 25 percent of deaths nationally. The research indicates that heart diseases cost the United States about $219 billion every year. The health concern is the main cause of the increasing cost of healthcare in the United States. Addressing 3 PRELIMINARY CARE COORDINATION PLAN heart disease will be an important stride towards reducing the cost of healthcare in the United States economy. Heart disease is one of the most prevalent chronic diseases that have remained complex in terms of treatment. There has not been an approved standardized diagnosis to be the ultimate cure of heart disease. However, individuals can easily prevent the causes and risk factors that are associated with the health concern. The increment in the level of heart diseases is associated with people’s lifestyles. The lifestyles have contributed to the increase in heart disease by more than 50 percent (Katritsis et al., 2018). Eating habits in the 21st century have contributed to increasing cholesterol levels in the body, leading to heart complications. The second issue that leads to a high level of heart disease in the community is poor exercise due to the nature of lives that many people have adopted, such as living in urban areas and spending the largest part of their office life. Behaviors in the community also cause heart disease. Some of the most popular behaviors always associated with heart disease are smoking and drinking alcohol (Katritsis et al., 2018). The other behavioral factors that escalate the level of heart disease include issues like failure to check on the level of cholesterol and blood pressure. Most people have remained ignorant of the importance of regular check-ups on weight levels, blood pressure, and cholesterol levels, which have escalated heart disease. Best practices The current level of heart disease in the United States can be controlled and prevented successfully through the coordination of healthcare practitioners. One of the best measures to reduce the level of heart disease in the community is encouraging people to eat a healthy diet 4 PRELIMINARY CARE COORDINATION PLAN while avoiding consuming foods rich in cholesterol (Olivieri, 2019). Healthy eating will be a fundamental practice that will help reduce cholesterol levels in the body. The second intervention that is important in helping to reducing the occurrence of heart diseases is to encourage people to ensure that they are actively involved in physical exercises that are essential in burning the level of cholesterol in the body. Encouraging people to secure time for physical exercise will play an important role in reducing heart disease. The third important intervention is encouraging people to go for regular check-ups in the hospital to maintain their weight, blood sugars, and cholesterol at acceptable limits. Maintaining the level of weight and blood sugars will help reduce the risk factors associated with the increasing level of heart disease. The other important intervention that can be effective in helping to maintain a lower level of heart disease is to urge and educate people on the dangers associated with alcoholism and smoking pertaining to heart disease. Reducing the level of smoking and alcohol usage will help to improve population health while reducing the level of heart diseases in the community. Finally, practice promotes cultural competence care in healthcare facilities to encourage and motivate patients to go for check-ups The Care Coordination Plan Discussion.

Cultural competence plays a vital role in encouraging patients to attend health facilities and raise the quality of service provided (Karczewski, 2016). Promoting cultural competence will help improve the management of risk factors associated with increasing heart diseases. Goals for Addressing the Health Concern Addressing the health concern on the increased heart disease level in the community needs to be addressed efficiently by setting appropriate goals. The plan’s main goal is to create awareness and educate the population on the best practices fundamental in reducing heart disease. Creating awareness in the communities through such means as public address, calling up 5 PRELIMINARY CARE COORDINATION PLAN community meetings, and social media platforms will help reduce the ignorance of some community members. The awareness will also involve collaborating with families for individuals suffering from heart diseases and educating them on the best practices. The second goal that will be essential in helping to address the health concern is to create an open day where the local healthcare facility, in collaboration with other donors, can offer free check-up services for important factors that are fundamental in heart disease. Such measurements include cholesterol level, blood pressure, and weight. Creating an open day will reduce the stigma and fear that the community members might be having towards going for the check-ups. The third goal would be to make the heart disease department more efficient through promoting and encouraging interprofessional collaboration. Interprofessional collaboration is essential in helping to offer evidence-based care hence promoting quality. Improving the level of care given in the department concerned with heart disease will help create a good environment for managing heart disease (Vrijhoef, 2016). Available Community Resources The resources are very important in helping to promote an effective and safe continuum of care. The local community in New York has numerous resources that are fundamental in promoting quality care. The main resource that is available in the community is the richness of natural foods in society. Most of the locals are farmers, and there are plenty and various natural farm vegetables and fruits. Natural food is an essential resource in promoting quality healthcare. The second available resource in the community is recreational grounds and the terrain where people can engage in physical exercise. The environment is favorable to allow room for exercise. Last but not least is the availability of competent social workers in the community devoted to 6 PRELIMINARY CARE COORDINATION PLAN promoting a healthy population. Proper coordination with social workers will help promote quality services and eliminate a rising level of heart disease (Vrijhoef, 2016). 7 PRELIMINARY CARE COORDINATION PLAN References Cdc, (2020). Heart Disease Facts. Heart Disease in the United States. Retrieved from https://www.cdc.gov/heartdisease/facts.htm Karczewski, C. (2016). Enhancing cultural competence: Clinical settings, immersion experiences, service-learning, simulation, and nursing skills laboratory. Teaching Cultural Competence in Nursing and Health Care. https://doi.org/10.1891/9780826119971.0009 Katritsis, D. G., Anderson, M., & Webb-Peploe, M. M. (2018). Occupational risk factors for heart disease. ESC CardioMed, 31153118. https://doi.org/10.1093/med/9780198784906.003.0757 Olivieri, C. D. F.-B. C. (2019). The current state of heart disease: statins, cholesterol, fat and sugar. International Journal of Evidence-Based Healthcare, 17(3), 179–186. Vrijhoef, H. J. (2016). Care coordination and primary care: The inseparables. International Journal of Care Coordination, 19(3-4), 6364. https://doi.org/10.1177/2053434516684885 The Care Coordination Plan Discussion