Final Care Coordination Plan Sample Paper

Final Care Coordination Plan Sample Paper

Patient-Centered Health Interventions and Timeliness

Patients with chronic illnesses and multimorbidity have complex healthcare requirements that make healthcare delivery difficult and costly. Additionally, the fragmented nature of the US healthcare system tremendously accentuates these difficulties. As a result, patient-centered care and care coordination are elemental to ensuring quality patient care, especially in individuals with chronic illnesses and multimorbidity.

Patient-centered care is an evidence-practice that involves tailoring healthcare delivery to the needs of the patient (Kuipers et al., 2019 Final Care Coordination Plan Sample Paper). This practice has been correlated with immense patient satisfaction as well as improved quality of life. Meanwhile, care coordination which encompasses the intentional organization of healthcare activities of a patient among healthcare providers is a crucial component to the realization of patient-centered healthcare.


Subsequently, this paper will focus on integrating care coordination to achieve patient-centered care. The paper will be based on Mr. Collins, a 68-year-old Caucasian male, and a newly diagnosed hypertensive. A care coordination plan will be drafted that will be tailored to his and his family’s needs. Similarly, ethical considerations and policies affecting the designing of the coordination plan will also be highlighted.

Hypertension describes a condition of persistently elevated systolic blood pressure of more than 140 mmHg and a diastolic pressure of more than 90 mmHg (DeGuire et al., 2019). According to DeGuire et al. (2019), this condition has been found to increase with age, with an estimated prevalence of between one-third and one-half of adults in the US. Hypertension is usually asymptomatic until target organ damage or hypertensive crisis arises.

Thus, early diagnosis of this condition prevents an optimal window to treat the condition and prevent subsequent complications. The management of this condition is complex and multifactorial and involves a multidisciplinary approach that combines both pharmacological and nonpharmacological approaches that are individualized.

Mr. Collins’s hypertension diagnosis was established after two consecutive out-of-office blood pressure measurements of 155/95 mmHg and 152/98, respectively, on two separate clinical visits.  According to Kitt et al. (2019), a newly diagnosed hypertensive patient should be evaluated for target organ damage and atherosclerotic cardiovascular disease risk assessment.

Therefore Mr. Collins was clinically examined, and further investigations were conducted such as thyroid function tests, basic metabolic panel, complete blood count, fasting blood glucose, lipid profile, and liver chemistries, to mention but a few. The results were noncontributory except for a BMI of 28.

Surprisingly, Mr. Collins was already aware of this condition after having read much about it. He has willingly accepted to take part in coordinating his care and has also requested the involvement of his family in this plan. He acknowledges that the care coordination plan will assist him in avoiding subsequent complications, reducing hospitalizations, reducing medical expenses, thus allowing him to live a healthy lifestyle. Mr. Collins and his family identified the following goals;

  • To maintain a healthy weight and diet. This was the first objective as Mr. Collins was already worried about his weight and diet and wanted to be assisted. Realizing his BMI of 28, his target was to achieve an ideal BMI, which means at least a 2-pound weekly weight loss. According to Kitt et al. (2019), weight loss is the most effective lifestyle change with an estimated reduction of systolic blood pressure of 1 mmHg per Kg weight loss. Meanwhile, a dietician will help him adhere to a DASH diet that includes fruits, vegetables, and whole grains.
  • The second goal was daily physical activity. Mr. Collins and his family agreed on a cumulative aerobic exercise of at least 150 minutes per week. Kitt et al. (2019 Final Care Coordination Plan Sample Paper) highlight the importance of exercise in hypertension as it contributes to weight reduction in addition to lowering blood pressures.
  • To prevent complications and improve the quality of life. Mr. Collins emphasized the need to continue living a healthy lifestyle. He agreed to comply with the prescribed current pharmacological agents. Similarly, he conformed to daily blood pressure measurements at home. The target blood pressure was less than 130/80 mmHg to be achieved within three months.
  • Monthly follow-up. During these visits, Mr. Collins requested full clinical evaluation, including fundoscopy and laboratory tests to assess the functioning of various organs. As elaborated by DeGuire et al. (2019), he was informed of the side effects of the drugs and warned of the red flags for hypertension. Mr. Collins was advised to see his primary healthcare provider or notify any healthcare professional in such events.

The community resources for the above plan include a community dietician, a hypertension support group that meets monthly, Clark Pharmacy where he will access his medications and monitor the blood pressure, hypertension communications kit, library, Roadside Church to address spiritual needs, a fitness center for physical activity, primary care physician for prompt consultations, community health centers, and hypertension educational handouts.

Ethical Decisions in Designing Patient-Centered Health Interventions.

Patient-centered interventions are driven by ethical principles including autonomy, beneficence, non-maleficence, justice, equity, and other ethical considerations such as privacy and confidentiality. Allowing Mr. Collins to participate in his care plan ensures that autonomy is maintained. The principles of justice and equity are achieved by ensuring that patients can access healthcare resources as well as treatment options regardless of their diversity.

For instance, Mr. Collins accessed the standard of care for managing hypertension comprising of both pharmacological and nonpharmacological options. Finally, allowing the participation of his family members was in the best interest of Mr. Collins. Shayo et al. (2020), in their study, concluded that an ethically based patient-centered intervention has greater chances of prosperity as patients’ interests are respected.

Health Policy Implications for Care Coordination

Health care policies such as Medicare will ensure that Mr. Collins is covered for his chronic condition and can access specialist services. Meanwhile, Health Insurance Portability and Accountability Act ensures that Mr. Collins’ information is kept private. The World Health Organization policies regarding health ensure that an individual’s health is more than physical well-being. Consequently, the care coordination plan should be comprehensive, including physical, mental, and social well-being. The aforementioned care coordination plan was based on ethical principles and tailored to Mr. Collins’ needs, including his family’s involvement and patient satisfaction.

Priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice

Priorities for Mr. Collins’s care coordination plan are autonomy in decision making, patient-centered care, involvement of his family, and shared decision making, among others. Uncertainties arose after a detailed elaboration of the plan with Mr. Collins and his family. For instance, what should be the ideal blood pressure? What should Mr. Collins consume? How do I exercise? What is the ideal weight that I should achieve? How long should I take the medications?

Together we spent a considerable amount reviewing each concern and adjusting the goals as needed. I was also able to provide Mr. Collins with evidence-based educational materials on hypertension. Furthermore, I linked Mr. Collins to a dietician as well as a hypertension support group. To increase the prosperity of this plan, I further scheduled a monthly meeting to review the goals and make any adjustments based on the level of control and tolerability.

Finally, Mr. Collins was equipped with contacts of every member of the coordination plan. Together with his family, they attested that they are satisfied with the plan and look forward to leading long and healthy lifestyles.

Healthy People 2030 Teaching Sessions

The care coordination plan goals correlate with the data-driven national objectives to improve the health and well-being of the United States citizens over the next decade. The physical activity and heart disease and stroke healthcare policies of the Healthy People 2030 stress the importance of physical activity and control of blood pressure in the prevention of cardiovascular diseases and events (Pahigiannis et al., 2019). In addition, Healthy People 2030 emphasizes screening for hypertension as key to preventing associated complications (Pahigiannis et al., 2019). Thus, screening Mr. Collins’ family members for hypertension will be considered.


Patient-centered and timely interventions are crucial for the management of chronic illnesses. A care coordination plan should always be individualized, ethically based, and should be in line with the healthcare policies and objectives. This ensures patient satisfaction and quality patient care.

Final Care Coordination Plan Sample Paper References

DeGuire, J., Clarke, J., Rouleau, K., Roy, J., & Bushnik, T. (2019). Blood pressure and hypertension. Rapports Sur La Sante [Health Reports], 30(2), 14–21.

Kitt, J., Fox, R., Tucker, K. L., & McManus, R. J. (2019). New approaches in hypertension management: A review of current and developing technologies and their potential impact on hypertension care. Current Hypertension Reports, 21(6), 44.

Kuipers, S. J., Cramm, J. M., & Nieboer, A. P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Services Research, 19(1), 13.

Pahigiannis, K., Thompson-Paul, A. M., Barfield, W., Ochiai, E., Loustalot, F., Shero, S., & Hong, Y. (2019). Progress toward improved cardiovascular health in the United States: Healthy People 2020 Heart Disease and Stroke objectives. Circulation, 139(16), 1957–1973.

Shayo, E., Van Hout, M. C., Birungi, J., Garrib, A., Kivuyo, S., Mfinanga, S., Nyrienda, M. J., Namakoola, I., Okebe, J., Ramaiya, K., Bachmann, M. O., Cullen, W., Lazarus, J. V., Gill, G., Shiri, T., Bukenya, D., Snell, H., Nanfuka, M., Cuevas, L. E., … Sewankambo, N. K. (2020). Ethical issues in intervention studies on the prevention and management of diabetes and hypertension in sub-Saharan Africa. BMJ Global Health, 5(7), e002193.

Final Care Coordination Plan Assignment Instructions

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. Final Care Coordination Plan Sample Paper
    • 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.