Final Care Coordination Plan
Care coordination in the care continuum requires efforts from all professionals and is based on knowledge and collaboration between all healthcare professionals and patients. The professionals collaborate to provide much-needed care from admission to discharge of patients.
Addressing ethical issues along the care continuum increases patient and care provider collaboration, achieving the desired outcomes. Pain management is the focus of this care coordination plan and should be addressed with attention to ethical, economic, and legal implications.
Patient-centered health interventions and timelines for Pain Management
Health issues associated with pain management include the desire for effective patient control despite patient differences. An evidence-based health intervention is a personalized care plan. Welch-Coltrane (2021) notes that pain management requires a keen assessment of patients and considering their differences and underlying conditions before implementing interventions.
Pain can compromise collaboration and severely limit the care provider-patient relationship. Using pharmacologic and non-pharmacologic interventions to manage pain are prioritized in these individualized care plans.
Another major health issue is patient and family collaboration in care delivery. Their efforts are necessary for the success of healthcare interventions. A specific health intervention for this issue is patient education during discharge. Luther et al. (2019) notes that educated patients feel supported, have better knowledge, and are more likely to collaborate in the care process. Educators empower patients and ensure they collaborate and take charge of their health in their homes.
Ensuring care continuity is integral to effective pain management. Care continuity at home will entail referral to vital community resources besides patient education. Depending on the resources’ nature, these community resources can offer assistance in pain education, social support, and pain management education. Healthcare providers should refer patients to community resources before discharge to enhance care continuity, reduce readmissions, and ensure holistic patient care.
The Pain Community is one such community resource that enhances care continuity. The Pain Community is an ideal community resource that can be utilized in the three healthcare decisions. The community resource, as mentioned earlier, participates in health research to determine the best care interventions and thus helps providers and researchers find effective pain control. It can thus be a reference to care providers who wish to develop individualized care plans for their patients in pain.
In addition, support groups within The Pain community encourage patients and their families to seek care and seek care and hence improve care collaboration among patients and their families. These support groups also ensure care continuity by educating members on care at home, the best medications, and when to seek medical attention. Thus, the Pian Community is an ideal community resource.
Ethical decisions in designing patient-centered health interventions
Pain significantly affects the quality of life and nurse-patient interactions; thus, pain management requires extensive ethical decision-making. The first ethical decision to consider is strengthening nurse-patient relationships through extensive education. The first ethical decision is to strengthen the patient-care provider relationship. Xue and Hefferman (2021) note that therapeutic relationships occur through quick and easy access to information and patient education.
Personalized care plans require mutual decision-making. Having common goals and objectives in care delivery is vital. Involving patients in care decisions and explaining the reasons for findings is vital in ensuring patient compliance in care delivery.
Patients adhere to decisions when they are involved. Patients are crucial individuals in providing information for healthcare decisions. They explain the need and reasons for decisions, such as demonstrating drugs’ self-experienced effectiveness and side effects. Hence, shared decision-making and mutual goals and objectives are critical ethical decisions in care provision.
Prioritizing pain, especially in chronic illnesses and palliative care, is vital, yet it raises many ethical issues. Many researchers argue that pain is a symptom and the underlying condition should receive priority in management, and focusing on the pain shows failure in the healthcare system in managing the cause. Cohen et al. (2020) state that pain is often ignored and given less priority than the patient’s healthcare condition.
While this may be true, some underlying conditions, such as cancer and cardiovascular conditions, may not be controlled effectively over a short time and could be severe pain for prolonged periods. Prioritizing pain management is thus vital for patient comfort and quality outcomes.
Considering underlying clinical conditions allows the care provider to treat patients effectively. The decision raises ethical concerns, with many arguing that pain management in certain conditions is often overmanaged or undermanaged based on the underlying conditions.
Assumptions that cancer pain can only be treated with opioids and other drugs with similar efficacy may lead to the over management of mild pain. Carvalho et al. (2020) argue that patients respond differently to different interventions, and physical assessment and history taking are usually the first and most important steps in managing pain.
The caregiver’s care participation raises ethical concerns in care delivery. Ghoshal et al. (2019) note that patients have control over their personal information and care interventions. They determine who should access their care and health information and limit access.
Sharing information with caregivers and healthcare team members is vital as it enhances their ability to care for the patients effectively. However, care providers cannot share the information without the patient’s consent, and they often seek the patient’s approval before sharing information despite the sharing being beneficial to the patients.
Relevant health policy implications for the coordination and continuum of care
Various policies impact the care continuum and care coordination. The opioid analgesics use policy, different in each state, is the most prevalent policy affecting pain management, according to Schuler et al. (2020). States have created laws governing the administration of opioid analgesics for the treatment of chronic pain. The policy provisions aim to prevent addiction relapse in patients while ensuring they deliver high-quality care.
Depending on the state, the policy stipulates conditions like lifting restrictions on opioid analgesics. To prevent tolerance and addiction, it also necessitates that healthcare professionals conduct careful patient assessments for side effects and regular therapy adjustments. The policy guarantees efficient care coordination, high-quality care, and the avoidance of medication side effects.
The US self-determination policy significantly impacts care coordination. According to Hall and Kadetz, in 2020, the policy grants patients ultimate control over decision-making, enabling them to accept or reject choices regardless of how they will affect their health. The policy significantly impacts patients’ health outcomes and care coordination, particularly for uncooperative patients and those with limited knowledge.
The policy makes an exception for some conditions, including COVID-19, mental health issues, and tuberculosis, due to public health and safety. Decisions made by the healthcare provider may be decisive in these situations and may be final and protected by the law.
Several ACA provisions have an impact on care coordination. Saloner et al. (2018) note that the Medicaid Part D Drug Prescription Act, a part of the ACA, ensures that prescription medications are affordable and that best practices are used. The prescription drug coverage clause ensures that at least one drug in any class is covered, increasing access to medications. Consequently, the act broadens access to medications and successful pain relief. Prescription medications are essential for treating acute pain as it occurs, increasing the efficiency of pain management.
Priorities in Care Coordination
Collaboration between patients and healthcare professionals is a top priority in care coordination. Effective interventions may be ineffective when the patient and the primary caregiver are not involved in the care delivery process. According to Manaf et al. (2018), care providers should prioritize patient collaboration, such as patient education and therapeutic relationships with the patient and their family.
The patient and the family determine the care collaboration interventions’ success, and creating a rapport is the priority in care. There is a need for this change because establishing patient and care provider collaboration first improves the effective implementation of care interventions, aids in creating shared goals and objectives, and promotes better patient outcomes.
Considering the patient and family perspectives is another priority. Changes must be made to ensure that interventions align with family processes to be effective because some interventions, like dose frequencies, may not be compatible with all family processes.
According to Healthy People 2030, a key component of care coordination is considering the compatibility of patients with the care interventions (Healthy People 2030.gov, n.d.). Patient and family factors include culture (influencing care perspectives), economic factors (influencing care decisions), and knowledge.
The most effective intervention to help accomplish these goals is patient education. The Healthy People 2030 initiative strongly emphasizes providing top-notch patient education. It recognizes it as a useful preventive measure for many acute and chronic health conditions, such as depression and arthritis pain (Healthy People 2030.gov, n.d.). Instead of empathic care, the Healthy People 2030 initiative emphasizes patient empowerment and empathetic care. Thus, patient education should cover topics like accessing local resources to aid healing and pain-management processes.
Conclusion
Cate coordination is a complicated process with numerous requirements. The care continuum spans from admission to discharge, and care providers must also ensure care continuity even at patients’ homes. Pain management faces many ethical problems primarily because of the policies and ethics surrounding it.
Ethical interventions include considering the clinical indication into account, creating personalized care plans, and collaborating with and educating patients and their caregivers. Priorities in care make sure that patients collaborate and take caregivers’ and patients’ perspectives into account when planning care.
The overall goal n patient management is to develop common interventions with a likelihood of patient collaboration and improve the patient’s quality of life. The care providers must also consider policies such as Medicaid expansion. The US self-determination act and opioid policies help manage patients effectively.
References
Carvalho, A. S., Pereira, S. M., Jácomo, A., Magalhaes, S., Araújo, J., Hernández-Marrero, P., Gomes, C. C., & Schatman, M. E. (2018). Ethical decision making in pain management: a conceptual framework. Journal Of Pain Research, 11, 967. https://dx.doi.org/10.2147/JPR.S162926
Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, B. C., Chen, Y., Hooten, W. M., Laker, S. R., Wasan, A. D., Kennedy, D. J., Sandbrink, F., King, S. A., Fowler, I. M., Stojanovic, M. P., Hayek, S. M., & Phillips, C. R. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine, 21(7), 1331-1346. https://doi.org/10.1093/pm/pnaa127
Ghoshal, A., Salins, N., Damani, A., Chowdhury, J., Chitre, A., Muckaden, M. A., Deodhar, J., & Badwe, R. (2019). To tell or not to tell: exploring the preferences and attitudes of patients and family caregivers on disclosure of a cancer-related diagnosis and prognosis. Journal of Global Oncology, 5, 1-12. https://dx.doi.org/10.1200/JGO.19.00132
Hall, B., & Kadetz, P. (2020). Finding the subject in the objectified: Problematizing the dependence on metrics for patient care in the United States. In The Routledge Companion to Health Humanities (pp. 196-203) (1st Ed.). Routledge.
Luther, B., Wilson, R. D., Kranz, C., & Krahulec, M. (2019). Discharge processes: What evidence tells us is most effective. Orthopaedic Nursing, 38(5), 328-333. https://doi.org/10.1097/NOR.0000000000000601
Saloner, B., Levin, J., Chang, H. Y., Jones, C., & Alexander, G. C. (2018). Changes in buprenorphine-naloxone and opioid pain reliever prescriptions after the Affordable Care Act Medicaid expansion. JAMA Network Open, 1(4), e181588-e181588. https://doi.org/1001/jamanetworkopen.2018.1588
Schuler, M. S., Heins, S. E., Smart, R., Griffin, B. A., Powell, D., Stuart, E. A., Pardo, B., Smucker, S., Patrick, S. W., Pacula, R. L., & Stein, B. D. (2020). The state of the science in opioid policy research. Drug and Alcohol Dependence, 214, 108137. https://doi.org/10.1016/j.drugalcdep.2020.108137
Sholjakova, M., Durnev, V., Kartalov, A., & Kuzmanovska, B. (2018). Pain relief is an integral part of palliative care. Open access Macedonian Journal Of Medical Sciences, 6(4), 739. https://dx.doi.org/10.3889/oamjms.2018.163
Welch-Coltrane, J. L., Wachnik, A. A., Adams, M. C., Avants, C. R., Blumstein, H. A., Brooks, A. K., & Hurley, R. W. (2021). Implementation of individualized pain care plans decreases the length of stay and hospital admission rates for high-utilizing adults with sickle cell disease. Pain Medicine, 22(8), 1743-1752. https://doi.org/10.1093/pm/pnab092
Xue, W., & Heffernan, C. (2021). Therapeutic communication within the nurse-patient relationship: A concept analysis. International Journal of Nursing Practice, 27(6), e12938.
Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes. Federal Practitioner, 36(6), 284. https://www.ncbi.nlm.nih.gov/pubmed/31258322
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.
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.
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.
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.