Preliminary Care Coordination Plan Example

Preliminary Care Coordination Plan Example

The Agency of Healthcare Research and Quality (AHRQ) defines care coordination as an intentional formulation of care activities and distribution of relevant information among healthcare providers participating in patient care to enhance efficiency, effectiveness, safety, and outcome (Karam et al., 2021). A vast majority of patients have complex needs that extend beyond the capability of a typical healthcare system.

Subsequently, integration of care helps the patient circumvent their own initiated navigation across services and providers. Care coordination assumes several attitudes, including case management, medication management, teamwork, disease management, patient navigation, and chronic care model. Irrespective of the approach, the inculpation of the multidisciplinary care team that operates as a cohesive and cooperative entity to provide the right care in the right place at the right time is crucial (Izumi et al., 2018). This writing will develop a preliminary care coordination plan for hypertension, after which available community resources shall be listed.



According to the Journal of American College of Cardiology, hypertension refers to a condition in which the systolic blood pressure is 140 mm Hg or more and or diastolic blood pressure is 90 mmHg or more (Carey et al., 2018). This condition can be essential or secondary to another pathology. Its prevalence is rising globally, and currently, it is estimated at 26% (Carey et al., 2018 Preliminary Care Coordination Plan Example).

However, in the United States, one-third to one-half of the US adults have the condition, with its incidence directly proportional to age (Carey et al., 2018). This condition is multifactorial and complex, encompassing both modifiable and nonmodifiable risk factors. Modifiable risk factors include physical activity, overweight, obesity, psychological stress, excessive alcohol intake, uncontrolled diabetes, smoking, and a diet rich in sodium and low potassium. On the other hand, a positive family history, advanced age, race, and ethnicity make up the nonmodifiable risk factors.

Hypertension is usually asymptomatic until complications of end-organ damage or hypertensive crisis develop. Consequently, best practices for this health concern have been developed, including prevention, screening, risk factor modification, and pharmacologic therapy (Cheung et al., 2020). Several strategies have been set up to prevent and control hypertension, creating an informed, activated patient and prepared, proactive practice team.

Meanwhile, screening is recommended annually for individuals aged 40 years and above or adults of any age with risk factors for hypertension (Cheung et al., 2020). On the other hand, screening every 3 to 5 years is done for individuals 18-39 years of age or previously normotensive adults with no risk factors.

Risk factor modification includes health education on weight loss strategies, dietary approaches to stop hypertension, aerobic exercises, smoking cessation, and reduction of alcohol intake. Additionally, pharmacologic treatment is recommended depending on the stage and coexisting comorbidities and involves first-line and second-line antihypertensive drugs. Finally, follow-up and monitoring are recommended.

Consequently, my care coordination plan will involve identifying hypertensive individuals, diagnosis, assessment for comorbidities, staging of hypertension, risk factor modification, pharmacotherapy, and follow-up. Hypertensive individuals shall be identified through screening as aforementioned, followed by a detailed history and physical assessment to establish the diagnosis.

Subsequently, underlying conditions such as diabetes, renal problems, heart problems, asthma, and gout, among others, will be evaluated to design the appropriate therapy. Hypertension will then be staged, followed closely by treatment using both nonpharmacological and pharmacological methods.  Nonpharmacological methods will include patient education on risk factors and the importance of lifestyle modifications. Finally, routine patient follow-up and blood pressure monitoring shall sum up the care coordination plan for hypertensive patients.

The assumption made during the analysis is that most individuals are hypertensive, although they remain undiagnosed until symptoms of end damage or hypertensive crisis develop. Secondly, hypertension is a multifactorial condition with devastating effects that require patient participation in care to be effectively controlled. Finally, hypertension is rare before the age of eighteen years.

As a result, specific goals have to be established to address this health concern. For instance, to diagnose hypertension as early as possible. Early diagnosis of hypertension is associated with few complications and effective treatment.

Another goal is to maintain systolic pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg. This correlates to well-controlled hypertension with good health outcomes. Finally, another goal is to involve patients in their care. Patient participation is crucial as this is a long-term condition that requires medication adherence, self-monitoring of blood pressures, and lifestyle modifications which can only be possible with patient involvement in care.


Several resources will be deployed in this care coordination plan which will be highlighted listed comprehensively in the resource list document. They include rehabilitation services, hospitals, social services, nutritional services, pharmacies, endocrinologists, health educational services, mental health providers, blood pressure and glucose monitoring equipment, laboratory services, skilled nurse services, community services, transportation services, transition services, and hourly nursing services.


A care coordination plan is elemental for transition and continuity of care. The plan should take care of the physical, psychosocial, and cultural needs of the patient. For effectiveness, the coordination plan should be multidisciplinary with a proactive healthcare team, with informed and activated patients.

Preliminary Care Coordination Plan Example Resources

Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Prevention and control of hypertension: JACC health promotion series. Journal of the American College of Cardiology, 72(11), 1278–1293.

Cheung, B. M. Y., Or, B., Fei, Y., & Tsoi, M. F. (2020). A 2020 vision of hypertension. Korean Circulation Journal, 50(6), 469–475.

Izumi, S., Barfield, P. A., Basin, B., Mood, L., Neunzert, C., Tadesse, R., Bradley, K. J., & Tanner, C. A. (2018). Care coordination: Identifying and connecting the most appropriate care to the patients. Research in Nursing & Health, 41(1), 49–56.

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 16.

Preliminary Care Coordination Plan Instructions

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.


Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

Develop the Preliminary Care Coordination Plan

Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:


Heart disease (high blood pressure, stroke, or heart failure).

Home safety.

Pulmonary disease (COPD or fibrotic lung disease).

Orthopedic concerns (hip replacement or knee replacement).

Cognitive impairment (Alzheimer’s disease or dementia).

Pain management.

Mental health.


Identify available community resources for a safe and effective continuum of care.

Document Format and Length

Your preliminary plan should be an APA scholarly paper, 3-4 pages in length.

Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.

In your paper include possible community resources that can be used.

Be sure to review the scoring guide to make sure all criteria are addressed in your paper.

Study the subtle differences between basic, proficient, and distinguished.

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

Analyze your selected health concern and the associated best practices for health improvement.

Cite supporting evidence for best practices.

Consider underlying assumptions and points of uncertainty in your analysis.

Describe specific goals that should be established to address the health care problem.

Identify available community resources for a safe and effective continuum of care.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Write with a specific purpose with your patient in mind.

Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents. Preliminary Care Coordination Plan Example

Community Resources

  • Rehabilitation services
  • Hospitals
  • Social services
  • Nutritional services
  • Pharmacies
  • Endocrinologists
  • Health educational services
  • Mental health providers
  • Blood pressure and glucose monitoring equipment
  • Laboratory services
  • Skilled nurse services
  • Community services
  • Transportation services
  • Transition services
  • Hourly nursing services
  • Specialists including neurologist, cardiologist, ophthalmologist, urologist and nutritionist.