Preliminary Care Coordination Plan

Healthcare systems face various challenges that compromise care delivery and necessitate the leveraging of nursing informatics to inform quality improvement initiatives. Examples of concerns in the current healthcare systems include a high prevalence of chronic diseases, patient falls, medication errors, nursing staff shortages, and increased incidences of preventable readmissions.

Preliminary Care Coordination Plan

Healthcare professionals should track information regarding these nursing-sensitive indicators and implement evidence-based strategies to address their causal factors and avert adverse consequences. As a result, this preliminary care coordination plan focuses on heart disease as a profound healthcare concern, the best practices for addressing the problem, goals, and objectives, and community resources for a safe and effective care continuum.

An Overview of the Problem

Heart disease encompasses conditions that affect the heart and its anatomy, including blood vessel disease (coronary artery disease), irregular heartbeat (arrhythmias), heart failure, heart valve disease, and pericardial disease. According to Gaspar et al. (2022), cardiovascular diseases like heart disease and stroke are prevalent due to various modifiable and non-modifiable factors, including physical inactivity, obesity, poor stress management, smoking, unhealthy diet, overweight (body mass index 25-30 kg/m²), and sedentary lifestyle.

Age, gender, family history of cardiovascular disease, and genetics remain non-modifiable factors of heart disease. Undoubtedly, the knowledge of modifiable risk factors for heart disease promotes evidence-based practices for preventing, treating, managing, and controlling the disease.

Heart disease and its sequelae pose significant health concerns by leading to increased mortality and morbidity rates, increased care costs, prolonged hospitalization, age-adjusted mortalities, disability-adjusted life years (DALYs), and compromised quality of life.

The Centers for Disease Control and Prevention (2022) contend that heart disease is the leading cause of death in the United States. In this sense, one person dies every 34 seconds from cardiovascular disease in the country. In the same breath, the disease accounted for 1 in 5 deaths in 2020. Besides increased mortalities, the United States incurred about $229 billion in 2017 and 2018 as the financial burden of heart disease. This financial burden accounted for healthcare services, medicines, and loss of productivity due to health.

Although everybody is susceptible to heart disease, its prevalence and effects are disproportionate to people with poor social determinants of health (SDOH), including poverty, limited access to quality care, low-level education attainment, and ethnic minorities.

Best Practices for Health Improvement

Although heart disease poses a challenge to the current healthcare systems, it is preventable and manageable by implementing proven interventions for addressing the disease’s risk factors and progression. According to Mayo Clinic (2022), it is possible to prevent and manage heart disease by implementing approaches for lifestyle modification, including smoking cessation, maintaining a healthy weight through physical activities, adhering to healthy diet plans that have low salt and saturated fat, reducing and managing stress through non-pharmacologic interventions like meditation, and good sleep. Also, controlling high blood pressure, cholesterol, and early screening are fundamental approaches to preventing and managing heart disease.

Besides non-pharmacologic approaches, patients with heart disease can collaborate with healthcare professionals in adhering to various medication interventions to prevent the disease’s progression and its subsequent complications like sudden cardiac arrest, heart attack, heart failure, and aneurysm.

According to the World Health Organization (2021), people with cardiovascular diseases should access appropriate medications, including beta-blockers, angiotensin-converting enzyme inhibitors, and statins. Equally, clinical procedures like coronary artery bypass surgery, Ballin angioplasty, heart transplant, valve repair, and artificial heart operations can enable patients to manage the disease. However, it is essential to focus on preventive mechanisms instead of treatment and management approaches.

Goals and Objectives

The preliminary care coordination plan for heart disease aims to achieve various goals and objectives, including;

  • Adhering to 150 to 300 minutes of physical exercise per week
  • Maintaining a blood pressure of <120/80 mm Hg
  • Maintaining fasting glucose of <100 mg/dL
  • Tracking blood pressure every week using a phone app and wearable devices

Community Resources

A safe and effective care continuum promotes positive outcomes by ensuring that patients benefit from timely and convenient care services. As a result, community resources are drivers of quality care, including local healthcare organizations, care providers, infrastructure, and support systems. In this sense, these resources act as the major source of information, data, medication, and psychological, and social support to reduce the prevalence and effects of heart disease. Also, community resources should support preventive interventions like physical activity and smoking cessation.

Local community resources, including non-government organizations (NGOs), clinics, support groups, and expert offices provide knowledge and awareness of self-care interventions. Also, the availability of gymnasia, accessible sidewalks, and recreation parks can promote preventive approaches like cycling, jogging, and strolling. Besides these resources, access to online databases and government websites can improve knowledge acquisition and influence the application of evidence-based practices for self-management.

Examples of online databases that provide credible information and resources for people with heart disease are the American Heart Association (AHA), the Centers for Disease Control and Prevention, National Heart, Lung, and Blood Institute. These databases provide information about effective heart disease management, vital signs monitoring, adherence to medications, and maintaining a healthy weight.

References

Preliminary Care Coordination Plan

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.

Introduction

NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular 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.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Preparation

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.

To prepare for this assessment, you may wish to:

Instructions

Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan

Complete the following:

Document Format and Length

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.

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.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.

Allow plenty of time to plan your chosen health care concern.

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:

Stroke.

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.

Trauma.

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

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.

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.

Competency 1: Adapt care based on patient-centered and person-focused factors.

Analyze a health concern and the associated best practices for health improvement.

Competency 2: Collaborate with patients and family to achieve desired outcomes.

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

Competency 3: Create a satisfying patient experience.

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

Competency 6: Apply professional, scholarly communication strategies to lead patient-centered 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.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

**Please follow guidelines for a Distinguished** on the scoring guide