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.

Final Care Coordination Plan

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, 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, 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.


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.


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