Stroke: Final Care Coordination Plan

Stroke is a cardiovascular and neurological disease whose underlying pathophysiology is a compromise of perfusion to a region of the brain resulting from ischemia or bleeding. Most cases of stroke are linked with an underlying cardiovascular disease or risks. While heart disease is the leading cause of mortality in the United States, stroke is the sixth leading of death, according to Benjamin et al. (2019) and Murphy et al. (2018).

Stroke: Final Care Coordination Plan

Nursing care for stroke involves handling various issues relating to patient outcomes and quality. Some of these issues include recurrence of stroke, mortality from stroke, and return of activities of daily living. The purpose of this paper is to plan nursing interventions and provide relevant community resources for these interventions, incorporate decision-making and relevant policy implications, and explain priorities for the care coordinator during communication of this plan with the family.

Patient-Centered Health Interventions for Stroke

Quality of Life

Stroke causes predictable neurological deficits in survivors that limit their performance of activities of daily living. Complications such as dysphagia, urinary tract infections, pneumonia, thromboembolism, and poor bladder or bowel control lead to poor quality of life. These complications lead to dependence on family members and caregivers for activities of daily living.

In general, nursing and medical care should aim to prevent these complications to improve the patient’s quality of life. Specific nursing interventions are applicable in the hospital and community settings. Nursing assessment is a strategy that will detect these complications early through physical examination and monitoring before discharge to home care.  During this timeline, the nurse gets a better objective understanding of the patient’s risk of developing such complications.

This assessment is still insufficient to salvage the outcomes of the patients presenting with stroke. An interprofessional approach will improve outcomes through collaboration and early detection of stroke or its complications. For example, collaboration with the emergency medical services ensures that emergency interventions such as thrombolysis and thrombectomy are initiated early to avoid extensive permanent neuronal death.

Community resources can also be utilized in perverting complications. Comprehensive stroke centers, primary stroke centers, and community clinics are community resources that can help detect stroke and related complications early to prevent poor outcomes. Prevention of adverse outcomes of stroke starts with stroke prevention and emergency care.

The early phase of stroke management is time-dependent, and delays in the decision for care, reaching care, and accessing care should be prevented to prevent adverse outcomes. Therefore, these community resources are important in reducing these delays.

Recurrence of Stroke and Mortality

Stroke is a disease that, in more than 90% of cases, occurs in patients with identifiable risk factors. According to Benjamin et al. (2019), these risk factors are majorly modifiable and include but are not limited to elevated blood pressure, obesity, overweight, and persistently elevated blood sugar levels as seen in diabetes mellitus, dyslipidemia, and renal disease. These risk factors are highly associated with the occurrence of stroke, and their persistence in stroke survivors can lead to a recurrence of stroke.

Specific nursing interventions include assessing and managing blood pressure, lipid levels, blood sugar, obesity, and renal function in patients with a history of stroke or known risk factors. These interventions are done as long as the patient is still alive and as regular as possible to maximize risk factor reductions. Therefore, no specific timelines are set for these interventions.

Community resources that can help achieve this goal include but are not limited to primary care clinics, comprehensive stroke centers, nursing care homes, personal care homes, and home care services (Sasso, 2021). These resources can be useful in screening these risk factors and their management in long-term centers. Therefore, the risk of stroke recurrence can be minimized by managing the main known risk factors.

Activities of Daily Living

Stroke survivors can develop deficit and conative and neuromuscular functions that make them dependent on caregivers. This dependence is associated with caregiver stress and survivor’s mental health deterioration (Prasanna & Forshing, 2022). Nursing care must incorporate these dimensions of holistic care that would improve their quality.

Nursing interventions encompass stroke rehabilitation centers such as Rehab Without Walls, an organization that provides personalized stroke rehabilitative care, including physical, psychological, and cognitive care to restore the general health of the stroke survivor.

Other community resources such as respite care, adult day care services, home care services, and homemaker assistance can help in relieving caregiver stress and anxiety by offering short-term relief to caregivers. Patient-centered nursing care focuses on offering the patient education on the need for utilization of these services. This education is offered to both the stroke survivor and the caregiver (Sasso, 2021).

Additional referral to organizations such as American Stroke Foundation, American Stroke Association, and Stroke Support Association is also essential to provide caregivers and survivors with social support and education that would improve their coping with activities of daily living.

Ethical Decisions in Designing Patient-Centered Health Interventions

Nursing care and care coordination decision made based on ethical principles and the code of ethics for nurses by the American Nurses Association ensures that the decision-makers are committed to promoting the welfare of the patients (Potter et al., 2020). Considering ethical decisions benefits patient safety and quality of care.

The first nursing decision is to ensure that the nurse modifies the patient care and coordination to meet the assessed needs. Ethically, this decision has a practical impact on social justice in that the nurse will connect the patients with specific community resources based on their needs, thus fair resource distribution and utilization. Beneficence will also be ensured by executing this decision for all stroke survivors and at-risk patients. The second decision to screen risk factors will prevent a recurrence, thus preventing harm to the patient.

Harm to the patient may come from complications of stroke or poor risk factor control. This is practical in promoting patient safety and care quality. Patient education empowers patients to understand why some interventions and care coordination steps are made (Agency for Healthcare Research and Quality, 2018).

Therefore, they will feel involved in their care; thus, patient autonomy will be ensured. These three decisions and nursing interventions are only practical in a well-managed setting. Sometimes, health disparities that these decisions aim at minimizing still impact the outcomes of these decisions. The socioeconomic status of various patients can make the affordability of some community resources impossible. Therefore, uncertainty lies in the access to these resources and, ultimately, their utilization to promote patient outcomes.

Relevant Health Policy Implications

A health policy that is of great significance and relevance to stroke management is the Stroke Systems Of Care (SSOC). This policy has more than 19 provisions and has been adopted by all states in improving stroke patients’ care (Adeoye et al., 2019). Some of the provisions of this policy that impact care coordination require the utilization of emergency medical services assessment tools and transportation protocols in the community & acute settings and tiered stroke centers based on national standards.

Implementing SSOC policies in stroke care coordination improves stroke outcomes (CDC, 2022). Care providers should access the mentioned community resources and tools in a timely and fair manner to offer ethically efficient care. Interfaculty transfer agreements, transport protocols, care quality improvement data reporting, and tiered stroke center systems are some of the policy provisions that reduce delays in care, minimize complications, and enhance coordinated care.

Priorities to be Considered by a Care Coordinator

When communicating this care coordination plan to the patient and their families, a care coordinator must consider the social determinants of the family’s health. Factors such as income level will affect the affordability of community resources. The availability of caregiver and respite care services is important for seamless care coordination and reduction of caregiver burden.

The availability of communication strategies that will keep caregivers and care coordination up to date with the progress of care must also be considered by the care coordination. When these priorities are not favorable, the coordinator may need to adjust the plan to meet the socioeconomic status of the patient and their family or seek other affordable community resources. This will ensure compliance and better patient outcomes.

Literature Comparison

This care plan has been based on the best available recent pieces of evidence. The sources have been deemed credible because they are recent, relevant, and scholarly. The goals of the care plans are appropriately aligned with the healthy people 2030 objectives on heart disease and stroke. Broadly, the healthy people 2030 goals aim to improve care for patients with cardiovascular disease and reduce mortality from these diseases, including stroke (Office of Disease Prevention and Health Promotion & U.S. Department of Health and Human Services, n.d.).

Some of the healthy people 2030 goals aim at increasing referral to a rehabilitation program, reducing stroke deaths, increasing blood pressure control among adults, and improving emergency preparedness. The policy aforementioned has worked to improve preventive and promotive health through coordination. The specific decisions in this plan have also aimed at improving rehabilitative health. Therefore, the teachings, this plan, and healthy people 2030 goals are well aligned. In case this care coordination plan is well executed, more patient-centered and safe care will be ensured.


This final care coordination plan has addressed three issues around care for stroke patients: quality of life, preventive health, and activities of daily living. Key interventions with undefined timelines suggested are needs assessment, interprofessional collaboration,  risk factor management, and patient education. Key community resources identified are respite care services, adult day care services, social support organizations, primary care clinics, and comprehensive stroke centers.

Identified ethical implications are patient autonomy and social justice. The stroke systems of care policy are identified to impact care coordination and delivery. Priorities to the coordinator during the communication of this plan are health disparities and social determinants of care.

Stroke: Final Care Coordination Plan References

Stroke: Final Care Coordination Plan Instructions

Week 10 Case 1: Stroke (LAST NAME BEGINNING A-M)


Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office where he works part-time. One of his co-workers called 911. On the way to the hospital, the advanced squad team evaluated Mario’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient.

Upon Mario’s arrival at the hospital, the ER nurse practitioner proceeded to gather the patient’s medical history from his wife, Lucinda, who accompanied him in the ambulance. She tells the nurse practitioner that Mario has a history of uncontrolled hypertension (and was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted, as well as the oral hypoglycemic agents he was taking.

The wife states that both of Mario’s parents died from myocardial infarctions in their late 60s.

Smoking history: Mario is a smoker, usually smoking about a pack and a half daily.

Exercise history: Mario leads a sedentary lifestyle that has contributed to his excess weight.

At 5’5” inches, Mario weighs 255 pounds. BMI of: ____

What other family history, social history, and vital signs will you obtain from the wife and the patient?

What diagnostic tests will you order for Mario to determine what type of stroke he is having? List at least four diagnostic tests you would order and explain the rationale of each test.

The CT scan indicated a diagnosis of stroke. However, the lab tests and CT scan performed on Mario told there was no hemorrhage or early signs of ischemia. What education can you provide the family about the CT scan results to diagnose a brain stroke?

You tell Mario’s wife that it is crucial to recognize the signs of an impending stroke. Describe at least four symptoms and signs of stroke you will educate the patient and family to look for.

You also discuss the RISK factors for stroke with Mario’s family. Lucinda realizes that Mario meets the criteria for all of them. List at least four risk factors for having a stroke:

List at least three differential diagnoses for the symptoms listed above:

What referrals will you make for Mario after his stroke? List at least three.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

  • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
  • Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
  • Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential is in or out. Explain the critical thinking process that led you to your chosen primary diagnosis. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, patient disposition, caregiver support, and any planned follow-up visits. Discuss health promotion and disease prevention for the patient, considering patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
  • Provide at least three evidence-based peer-reviewed journal articles or evidence-based guidelines related to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

Stroke Final Care Coordination Plan Example 2

The optimal possible treatment for individuals’ health issues requires careful planning and coordination of care. Numerous facets of care coordination have been explored in detail in the three prior evaluations, with an emphasis on the principles and healthcare standards that have been developed to guarantee that they fulfill their goals. This final care plan will be based on the preliminary care coordination framework. The final care plan will include ethical and regulatory considerations, cultural values, quality care, and physiological requirements (Kuipers et al., 2021). This paper will serve as Mr. X’s ultimate care coordination plan while he recovers from a stroke.

Patient-Centered Intervention

Patient-centered care prioritizes the needs of the individual receiving medical treatment. Because of this, the patient is an integral component of the treatment coordination team and the center of attention. A stroke is a potentially fatal medical disorder, and people who have had the disease before are at greater risk of having it reoccur (Skeels & Leung, 2019). Mr. X, who is 46 years old, has had hypertension for the past few years. He knew this increased his risk of having a stroke. He is also obese, which is associated with a higher risk of stroke. His vitals are as follows: blood pressure 156/92, heart rate 99, temperature 35.9, and respiratory rate 19.

Health issues

  •   Stroke recurrence

The patient had a stroke, but signs indicate a high recurrence rate. As was said before, a stroke occurs when brain tissue is damaged because a portion of the brain does not receive enough blood supply. All efforts should be made to prevent a stroke from happening again (Skeels & Leung, 2019). Improved nutrition and diet instruction for stroke patients is one form of intervention. The patient can also improve his health by increasing their amount of physical exercise, maintaining a healthy body weight, and controlling their blood sugar levels. It is important that he learns to regulate his blood pressure. Community resources include community stroke patient groups, gyms, and rehabilitation centers. These facilities help the patient recover better and offer emotional and psychological support.

  •  Depression

The individual’s health problems have severely limited his daily activities, and his left-sided paralysis has contributed to his clinical depression. The state of his health has had an impact on his relationships, ability to work, and state of mind. It has caused the client a lot of anxiety and unhappiness, particularly when he is left alone. A common patient-centered solution for depression is to provide the individual with a distraction or activity that will help him focus on anything other than his negative emotions. The patient may also benefit from establishing routines that will allow him to feel more in charge of his own life. Medication for depression and instruction in self-care strategies can both make a big difference in a client’s health and quality of life. Community resources include rehabilitation centers and support groups. These groups in the community aid the patient in overcoming their issue as they feel they are not alone.

  • Hypertension

Elevated blood pressure is a major risk factor for cardiovascular disease and stroke. The condition known as high blood pressure occurs when arterial blood flows at a pressure greater than normal. Mr. X has hypertension, and it is important to remember that it is a chronic condition, so he will likely continue to have hypertension and accompanying symptoms intermittently throughout his life. He risks having a stroke if his hypertension is not managed. Patient-centered hypertension care entails addressing Mr. X’s nutritional status, reducing his salt intake, helping him keep his weight in check (particularly given that he is obese), enhancing his physical activity, and treating his anxiety and despair. In addition, the following are some of the community resources that could be helpful to Mr. X, including a gym that will enable him to do physical activity. Sidewalks in the community are also essential to ensure the client is physically fit. Lastly, community hypertension groups are essential for hypertension patients to help each other.

Ethical Decisions

The formulation of health therapies that put the patient at the center requires thoughtful consideration of ethical considerations. Delivering treatment in an ethical manner is essential. As it pertains to medical treatment, it entails making the correct decisions. Ethical concerns must be considered while planning healthcare interventions with the patient in mind. Indeed, the aforementioned actions are vital for both the patient’s health and the development of treatment, which is an ethical consideration (Kuipers et al., 2021). The individual will be better equipped to self-manage their condition, which may improve their chances of a successful outcome and a long, healthier lifestyle as an outcome of the choices taken.

Moreover, they have viewed the use of pharmaceuticals and other therapies with adverse side effects as a last choice, which suggests well for their prospects (Epp et al., 2021). As a healthcare practitioner, it is essential to ask yourself if you would be comfortable using the same methods on yourself if you were in the patient’s position. One may also wonder if the chosen solutions to the health problems are the greatest possible options or if other options have been overlooked. Does having access to superior resources outside of what a community provides make a difference? Will the patient improve, and will the decisions that arise from this improve their chances of success? A person’s morality and ethics should not be called into doubt by their responses.

Relevant Health Policy Implications

The Affordable Care Act was a landmark piece of healthcare legislation that had far-reaching effects on coordinated care. The Affordable Care Act is a piece of healthcare legislation that has been on the books since 2010 (Zhao et al., 2020). Access to coordinated care is emphasized in the legislation as a crucial method for lowering healthcare expenses while guaranteeing the quality of medical care is maintained. Care coordination has improved greatly after its implementation because of the new possibilities for establishing and evaluating healthcare strategies that improve both service and financing (Epp et al., 2021). The Health Insurance Portability and Transparency Legislation of 1996 has significantly influenced care coordination and the care continuum. With this legislation in place, it is now possible for members of the American population to maintain their healthcare coverage even if they relocate to a different state. Care coordination among healthcare professionals should also prioritize the protection of sensitive patient data during data transmission.

Medicare and Medicaid are two types of health insurance whose primary goals are to make medical care financially accessible. In 1945, Medicare was created to serve those over 65 years old, while in 1965, Medicaid was created to serve low-income persons of all ages (Wadhera et al., 2020). These insurance policies cover the collaboration of care for patients with chronic illnesses. Care coordination is essential to expanding patients’ healthcare availability, and as coverage has grown, more and more people have been able to afford it (Zhao et al., 2020). The Hospital Readmissions Reduction Program is a policy initiative included in ACA that aims to improve patient’s ability to receive timely medical care. While lowering the number of patients who need to be readmitted to the hospital is a goal shared by all of the aforementioned care plans. Improved patient outcomes and fewer hospitalizations are made possible through better care coordination, which is made possible by strategy. According to the Affordable Care Act of 2010, Medicare and Medicaid are responsible for lowering readmission payments. The key to avoiding unnecessary readmissions is ensuring that patients receive effective care coordination.

Priorities That a Care Coordinator Would Establish

Education seminars like these are essential for developing a better care coordination strategy. Care coordination plans rely on regular meetings to make sure everybody engaged is aware of what is required of them (Kuipers et al., 2021). Our time with the client yielded a wealth of insights. After attending the workshops, I understood the individual’s expectations regarding the care coordination strategy. He seemed genuinely thrilled about his future plans for dealing with the issue. As a bonus, he disclosed that the educational seminars taught him things about his disease that he had never known before, such as self-intervention strategies that were crucial to his health but which he had never learned before.

Further explanation and changes were necessary for certain spots. For one, the client stated that the present number of sessions was insufficient and that he required more because the information was so crucial. As it was affecting the whole family, he said they should all be involved in the therapy sessions. Also, I observed that certain sessions necessitated a more interdisciplinary strategy for explaining particular approaches to the patient. Experts in nutrition and dietary habits, respiratory therapy, psychotherapy, and training were essential for this purpose. They were left out of the initial draft but made it into the final version because they were deemed necessary for better patient comprehension and care coordination.

Evaluation And Healthy People 2030

Evaluating the effectiveness of care coordination is essential for learning what works and what does not so that future plans can incorporate the lessons learned. Care coordination success can be measured in large part through the use of learning sessions (Epp et al., 2021). Care coordination assessment tools such as surveys were also distributed to healthcare practitioners and patients to gauge the program’s overall effectiveness. The progress made toward the shared objectives is evaluated, and any problems that have arisen are documented (Epp et al., 2021).

Care coordination and patient-centered programs did not take into account the involvement of the client’s family in this meeting, but that will change in the future. The reviews also highlighted the importance of telehealth, particularly during this COVID-19 phase, in improving patient care. The finalized treatment plan incorporates these details, and all the highlighted problems are anticipated to be resolved.

Training for individuals and their family members is essential to providing good care coordination. Care coordination will be improved, and these educational opportunities will support Healthy People 2030. The Healthy People 2030 program aims to enhance healthcare quality in the United States (Pronk et al., 2021). This calls for collaboration from healthcare professionals, state officials, and others involved in the healthcare industry. Learning meetings will ensure that everyone who participates in care coordination is working to achieve a common goal. Targets and health outcomes under Healthy People 2030 have been narrowed in on purpose to better reflect the full scope of the most immediate concerns in the medical system today (Pronk et al., 2021).

The importance of these healthcare outcomes and goals should be highlighted during the training program, and the goals offered should be consistent with the training. The medical services, psychology, ecology, genetic predisposition, and, most importantly, social variables should all be considered in the educational sessions. Successful patient and community outcomes and achievement of Healthy People 2030 targets hinge on these conditions being met during the sessions.


The ultimate goal of care coordination is to cater to each patient’s individual needs. Stroke is a severe disorder that can result in mortality or paralysis in its victims. Ethical, legislation and patient-specific factors are all considered to ensure the best possible outcome. More consideration has been given to Healthy People 2030 and how these discussions may help in the effort to reach that goal. The importance of the training session in gauging the plan’s performance has been established. In the end, the proposal’s effectiveness and improved patient outcomes depend on its users’ capacity to concentrate on the health of their patients.

Stroke: Final Care Coordination Plan References

Epp, J., Cutler, H., Heather-Reid, R., Lewis, P., Critchley, A., Bishop, M., & Gazzard, T. (2021). Commissioning for coordinated care services using an outcomes-based funding model: Insights from a process review. International Journal of Integrated Care, 20(S1).

Kuipers, S. J., Nieboer, A. P., & Cramm, J. M. (2021). Easier said than done: Healthcare professionals’ barriers to the provision of patient-centered primary care to patients with multimorbidity. International Journal of Environmental Research and Public Health, 18(11), 6057.

Pronk, N. P., Kleinman, D. V., & Richmond, T. S. (2021). Healthy People 2030: Moving toward equitable health and well-being in the United States. Clinical Medicine, 33.

Skeels, K., & Leung, L. Y. (2019). Transitional Care Matrix to Improve the Coordination of Stroke Care Between Inpatient and Outpatient Care Settings. Stroke, 50(Suppl_1),

Wadhera, R. K., Figueroa, J. F., Maddox, K. E. J., Rosenbaum, L. S., Kazi, D. S., & Yeh, R. W. (2020). Quality measure development and associated spending by the Centers for Medicare & Medicaid Services. JAMA, 323(16), 1614-1616.

Zhao, J., Mao, Z., Fedewa, S. A., Nogueira, L., Yabroff, K. R., Jemal, A., & Han, X. (2020). The Affordable Care Act and access to care across the cancer control continuum: a review at 10 years. CA: A Cancer Journal for Clinicians, 70(3), 165-181.

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