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.

Preliminary Care Coordination Plan Example

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 Example 2

More often than not, the management of chronic diseases and other conditions leading to chronic disability requires more than one health professional. Therefore, there is a need for care coordination to ensure that care continuity for these patients is not interrupted. In this project, chronic obstructive pulmonary disease (COPD) is the condition of choice for which care coordination will be planned. This paper aims to analyze COPD as a health concern, draft smart goals in the care for COPD, and identify community resources for patients with COPD.


Chronic Obstructive Pulmonary Disease

COPD is a respiratory disease with significant annual mortality and lifetime disability rates. This disease is progressive and is characterized by respiratory limitations that impair the quality of life of patients. COPD causes pathologic changes in the small and medium airways, leading to exaggerated inflammatory reactions.

The previous definition of COPD included chronic bronchitis and emphysema but currently, but these are separate entities now with clear diagnostic and management strategies. In the United States, more than 16 million people suffer from COPD, with this prevalence more in females than males (Hollier, 2018). COPD was the sixth leading cause of death among the general in the United States in 2019. Among persons aged 65 years and above, COPD was the third leading cause of death (Heron, 2021). Among the key risk factors are tobacco smoking, smoke exposure, air pollution, and advanced age.

Most common COPD symptoms include progressive dyspnea that is persistent, chronic cough, and chronic sputum production. The current practice promotes suspicion and evaluation of patients aged above 40 years who have these three symptoms of COPD. However, best practices recommend screening for COPD symptomatic patients or those with risk factors. Spirometry is the standard for the diagnosis of COPD.

Other studies are used to rule out other causes of chronic lung diseases. COPD causes acute illnesses due to exacerbations that are often due to viral infections. Therefore, preventive treatment involves risk factor reduction and minimizing exacerbators in already diagnosed patients. Influenza vaccinations and vaccines against pneumococcal bacteria are recommended in certain COPD patients.

Exercise, hygiene, nutrition, and pulmonary rehabilitation are critical nonpharmacological interventions for COPD. Medication treatment involves the use of bronchodilators, usually given through inhaler techniques, to alleviate symptoms, reduce exacerbation frequencies, improve exercise tolerance, and improve the quality of health of COPD patients. In acute exacerbations, bronchodilators are used adjunctively with corticosteroids to alleviate symptoms. As aforementioned, infections are a common cause of exacerbations. Antibiotic use, even though controversial, is sometimes used in acute management.

The point of assumption is that empiric infection treatment would reduce symptoms severity and disease exacerbations and promote recovery. Recurrent pneumonia, pulmonary hypertension, co-pulmonale, atrial fibrillation, lung malignancies, and respiratory failure are common complications that long-term care should focus on preventing. Regular follow-ups for stable and unstable diseases are recommended for COPD patients. Screening for acute respiratory infections during these follow-ups is impotent for preventing exacerbations. Annual spirometry can also be done where indicated.

Care Goals for COPD

Specific goals for COPD care are to prevent mortality, reduce the frequency of exacerbations, reduce the frequency of hospitalizations, and improve the quality of life for COPD patients. Acute respiratory failure is the commonest cause of death in COPD patients. Pulmonary infections, heart failures, arrhythmias, lung cancer, and pulmonary embolism are also notable mortality causes in COPD patients (Lindberg et al., 2021). These causes of death are prevented through primary, secondary, and tertiary prevention strategies such as patient education, screening, medication treatment, and palliative care. Dyspnea and chronic cough cause life discomfort and reduce the quality of life of COPD patients.

Alleviating these symptoms improves the quality of life for the patients. Exacerbations lead to emergency hospitalizations that have cost implications for the patient and their families. To ensure cost-effective care, addressing hospitalizations improves the quality of care by addressing safety concerns that lead to emergency visits. These specific goals are objectively measurable and achievable and contribute to the overall health system quality for COPD patients. These goals are also aligned with the healthy-people 2030 goals in respiratory disease care and are specific to COPD (U.S. Department of Health and Human Services, n.d.). To achieve these goals, an interprofessional approach and care coordination are required.

Community Resources

Community resource utilization is a means to achieving the above goals. There are various community resources for COPD patients that can be used to achieve certain specific goals. Adult daycare services are important for providing a reprieve for family caregivers of COPD patients. Home care services also serve the same function as adult daycare services but provide care to the patient in their homes.

Social support for COPD patients and their caregivers in the community can be acquired from friends and social organizations such as Living with COPD Community on Inspire, Better Breathers Clubs, and Better Breathers Club Network (American Lung Association, n.d.). Lung HelpLine is a community resource consisting of an organization of registered nurses, therapists, and other specialists that offer community care to enhance risk factor reduction and improve quality of life.


COPD can be debilitating to patients and sometimes require emergency medical attention. This irreversible disease is a significant mortality cause in the US. Management involves preventive and symptomatic care. Specific goals aim at peeving mortality, improving life quality, and cutting care costs. Community resources such as home care services can help achieve these goals.


Preliminary Care Coordination Plan Example 3

Nurses are vital to care coordinators. Patient care is holistic and requires the collaboration of various healthcare providers, nurses, patients, and their families. One of the prerequisites for accurate coordination is extensive knowledge of care coordination.


The care providers then relay the information to other stakeholders and outline their care coordination roles. The care provider’s ability to manage the problems effectively determines the success of their community interactions and health. This essay analyzes care coordination concepts in pain management.

Selected Health Concern and the Associated Best Practices for Health Improvement

Pain management is an area that has many problems and ethical issues surrounding it. Pain accompanies most healthcare conditions, and the intensity, severity, and duration differ based on personal characteristics and the pain etiology. Pain management faces many issues due to tolerance and opioid addiction, affecting all health domains.

McCabe (2018) notes that physical pain can be disabling and limit daily activities, cause psychosocial pain, and affect the social interaction of individuals. Pain aggravates the management of conditions such as cancer when patients take many medications with various side effects, such as nausea and vomiting. Yet, they do not feel their therapeutic effectiveness because the pain does not cease. Thus, pain management needs to be addressed owing to the many issues associated with the problem.

Various institutions have come together to manage the issue of pain. The WHO developed the pain management ladder to assess the pain level, which outlines the management interventions for the specific pain level (McGuire & Slavin, 2020). WHO developed the ladder to manage cancer pain, but it can be used to manage all other health conditions. Patient pain assessment tools for all populations have been developed over time.

They help healthcare providers assess pain from patient reports and even from their facial expressions (Gregory, 2019). The tools have helped ensure quality care delivery. The primary assumption in pain management is that it refers to physical pain because the pain in other domains may present as other symptoms, such as fear and depression.

The prescription drug monitoring program (PDMP) is a national program that was developed to manage prescription drugs. The technology helps care providers to trace prescription drugs, especially opioids and benzodiazepines (Manders & Abd-Elsayed, 2020). The care providers also use the technology to determine the include and rates of opioid addiction and enroll them in management programs. Scholars argue that the technology has helped predict and prevent opioid use addiction in patients with prolonged opioid analgesics use.

Another integral evidence-based strategy is the management algorithm supported by clinical decision support systems. Care providers assess patients to determine their needs and then manage them depending on the algorithm’s instructions.

Pangarkar et al. (2020) note that various clinical pain management algorithms have been developed to help manage pain in cancer, ballistic injuries (in veterans), and other chronic diseases such as acute renal injury. Patient assessment (using current tools) is integral to their management hence the need for patient clinic visits and assessment.

Specific Goals That Should be Established to Address Pain

There are various goals when addressing the healthcare problem. The first goal is to ensure pain control and relief while taking the lowest possible medication doses. Meaningful pain control increases functional abilities and the quality of life. Adequate pain control requires care collaboration between patients and their primary care providers.

Moreover, the goal is based upon continuous assessment and therapy change for effective pain management. The second goal is medication and other interventions adherence. Poor medication adherence is associated with many factors, such as perceived effectiveness, negligence, forgetfulness, and medication side effects (Swarm et al., 2019).

The third goal is utilizing pharmacologic and non-pharmacologic pain management interventions for effective pain management. Pain management should entail corresponding and effective pain management interventions. Some duos have been found more effective than single therapies using medications or non-pharmacologic pain interventions. For example, massage can be used in musculoskeletal pain in addition to pharmacologic interventions. The two methods used together produce superior effects. Other interventions include acupuncture and yoga for back pain.

The fourth goal is the holistic care of patients. Pain management, especially chronic and severe pain, requires opioid analgesic interventions. This goal aims to ensure that pain management interventions do not affect other aspects of patient health (Cohen et al., 2020).

These include addiction and dependence, and undesirable side effects. The goals will also entail social support for patients to promote their psychological welfare. Holistic care affects the effectiveness of other interventions, such as medication adherence. These goals are vital in pain management and will help ensure all interventions and efforts are in tandem with population needs.

Community Resources

Various society groups focus on patients and support them in patient management. Groups such as cancer (Cancer Care) and veteran affairs support groups (Veterans In Pain) help patients recover from the pain and painful experiences. The groups offer social support to individuals with pain and underlying medical condition. These institutions enhance care continuity at home. Most of these organizations are accessible online, and they provide online resources that help in decision-making.

Other non-profit organizations have been developed in communities to aid in pain management. Organizations such as US Pain Foundation and The Pain Community help individuals with pain conditions access medical care and effective prescriptions (Savoy, 2022).

They also support them financially and emotionally to increase their utilization of pain management interventions and thus improve their quality of life. Other organizations, such as the Pelvic Pain Society, offer care specific to their target population. These organizations provide evidence-based strategies and pain management interventions to their target populations.

They provide online resources where they teach patient interventions such as addiction assessment and best prescription practices. They also offer room for social support when individuals interact and share their experiences. Community centers and parks are essential community resources, often underrated for their effectiveness in pain management and mental health stability (Savoy, 2022). Community centers increase access to other individuals, especially the elderly population, and helps these patients meet social needs.


Pain management is surrounded by many ethical and legal issues surrounding medications and other interventions. Nurses play a significant role in care coordination and ensuring patients receive the care they need. Care coordination also ensures care continuity in the community.

Community resources such as pain management organizations and support groups are integral in meeting patients’ cultural and social needs, hence managing the holistic patient. Care coordination is a vital nurse’s role, and succeeding in the role enhances the success of care interventions.


  • 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 Medicine21(7), 1331-1346.7.
  • Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard34(9), 70-4.
  • Manders, L., & Abd-Elsayed, A. (2020). Mandatory review of prescription drug monitoring programs before issuance of a controlled substance results in overall reduction of prescriptions including opioids and benzodiazepines. Pain Physician23(3), 299.
  • McCabe, M. J. (2018). Ethical issues in pain management. Ethics in Hospice Care: Challenges to Hospice Values in a Changing Health Care Environment, 25-32.
  • McGuire, L. S., & Slavin, K. (2020). Revisiting the WHO analgesic ladder for surgical management of pain. AMA Journal of Ethics22(8), 695-701.
  • Pangarkar, S. S., Kang, D. G., Sandbrink, F., Bevevino, A., Tillisch, K., Konitzer, L., & Sall, J. (2019). VA/DoD clinical practice guideline: diagnosis and treatment of low back pain. Journal of General Internal Medicine34(11), 2620-2629.
  • Savoy, M. L. (2022). Systems-Based Practice in Chronic Pain Management. Primary Care: Clinics in Office Practice49(3), 485-496.
  • Swarm, R. A., Paice, J. A., Anghelescu, D. L., Are, M., Bruce, J. Y., Buga, S., & Gurski, L. A. (2019). Adult cancer pain, version 3.2019, NCCN clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network17(8), 977-100

Preliminary Care Coordination Plan Example 4

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.

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.