Assignment; Preliminary Care Coordination Plan Essay

Assignment; Preliminary Care Coordination Plan Essay

Assignment; Preliminary Care Coordination Plan Essay

Assignment; Preliminary Care Coordination Plan Sample Essay

Hypertension is a cardiovascular condition diagnosed based on a systolic blood pressure (BP) at or above 140 mm Hg and/or a diastolic BP at or above 90 mm Hg. The relationship between high BP and cardiovascular events is direct and independent of other risk factors. A person’s BP increases the risk of developing cerebral, coronary, renal, and peripheral vascular disease. The purpose of this paper is to develop a preliminary care coordination plan for hypertension and identify goals to address the problem and available community resources.

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Health Concern

Hypertension is a major health concern not only in the US but also globally and contributes to a great healthcare burden. Almost half of all adults globally have high blood pressure or are on hypertension medications. According to the CDC, hypertension primarily contributed to approximately 691,095 deaths in the US. Hypertension predisposes Americans to vascular diseases, stroke, myocardial infarction, and chronic kidney disease (Jaeger et al., 2023). Hypertension also contributes to pregnancy-related complications like eclampsia, placental abruption, and DIC, as well as maternal mortality. Statistics reveal that hypertensive disorders of pregnancy (HDP) are the leading underlying cause of pregnancy-related mortalities and account for 7% of US maternal mortalities from 2017-2019 (Ford et al., 2022). Hypertension not only has physical effects on individuals but also a significant economic burden on patients and the healthcare system. For instance, it costs the US healthcare system approximately $131 to $198 billion annually. This includes the cost of health care services, medications, and loss of productivity.

Associated Best Practices for Health Improvement of Hypertension

Best practices for hypertension seek to maintain optimal BP (SBP< 140 and DBP<90) and prevent complications. Both pharmacological and non-pharmacological practices are used for health improvement in hypertension. After patients are diagnosed with hypertension, they are initiated on treatment to help control and reduce cardiovascular complications. The 2017 ACC/AHA BP guideline recommends initiating non-pharmacological interventions for all hypertensive adults (Whelton et al., 2018). Most hypertensive adults in the US are recommended for lifestyle modification to lower BP. They are advised to lower their dietary sodium intake, increase physical activity, lose weight, and minimize alcohol consumption.

A diet composed of whole grains, vegetables, and fruits is usually recommended to lower BP. Other recommendations are consuming low‐fat dairy products, fish, poultry, legumes, non‐tropical vegetable oils, and nuts, as well as minimizing intake of sweets, red meat, and sugar‐sweetened beverages (Carey et al., 2018). Additionally, individuals should engage in moderate to vigorous aerobic physical activity for at least 120 minutes weekly to lower BP. Furthermore, pharmacological antihypertensive treatment is used in persons with SBP > 140 mm Hg or DBP > 90 mm Hg who fail to control BP with lifestyle modification. Patients are started one a single drug like ACE, ARB, CCB, or thiazide diuretic (Carey et al., 2021). However, a second drug is added if BP is not adequately controlled with a single agent.

Goals That Should Be Established to Address Hypertension

The first goal to address hypertension is to achieve optimal BP< 140/90 within six months. An optimal BP will significantly lower the risk of complications like stroke or CKD. The second goal is for hypertensive patients to adopt and adhere to a healthy diet to help lower BP within three months. Examples of these diets include the Mediterranean and DASH diets. Verma et al. (2021) explain that both diets are relatively easy to adhere to and palatable. They are high in vegetables, fruits, whole grains, nuts, and unsaturated oils and low in sugar‐sweetened beverages, sweets, and red meat.

Thirdly, each hypertensive patient will adopt a tailored physical exercise program within three months. The program will include at least 40 minutes of moderate to vigorous aerobic physical activity five days a week and two days of strength-training exercises. The fourth goal will be to attain tobacco cessation among smokers with hypertension within six months. Tobacco increases the risk of cardiovascular disease by raising heart rate, BP, and myocardial contractility (Carey et al., 2018). Another goal will be to attain medication adherence in at least 80% of hypertensive patients within two months. Adherence to prescribed treatment is key to achieving an optimal BP.

Available Community Resources for A Safe and Effective Continuum of Care

Available community resources to help address hypertension include community sporting facilities like gymnasiums to promote active lifestyles. The American Heart Association, the Red Cross, or local community pharmacies can be used for free BP checks for patients who cannot afford personal BP machines. Community health fairs are also available in most places to educate individuals on the prevention and self-management of hypertension.

Conclusion

Hypertension predisposes individuals to complications like stroke, heart disease, kidney failure, and pregnancy-complication. Adults with high BP are usually recommended to adopt non-pharmacological approaches to lower their BP. These interventions have been linked with a higher likelihood of achieving controlled BP. The goals of the care coordination plan include attaining optimal BP, enabling patients to adopt a diet and physical activity program, promoting smoking cessation, and fostering medication adherence.

References

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. https://doi.org/10.1016/j.jacc.2018.07.008

Carey, R. M., Wright, J. T., Jr., Taler, S. J., & Whelton, P. K. (2021). Guideline-Driven Management of Hypertension: An Evidence-Based Update. Circulation Research, 128(7), 827–846. https://doi.org/10.1161/CIRCRESAHA.121.318083

Ford, N. D., Cox, S., Ko, J. Y., Ouyang, L., Romero, L., Colarusso, T., … & Barfield, W. D. (2022). Hypertensive disorders in pregnancy and mortality at delivery hospitalization—United States, 2017–2019. Morbidity and Mortality Weekly Report, 71(17), 585. http://dx.doi.org/10.15585/mmwr.mm7117a1

Jaeger, B. C., Chen, L., Foti, K., Hardy, S. T., Bress, A. P., Kane, S. P., Huang, L., Herrick, J. S., Derington, C. G., Poudel, B., Christenson, A., Colantonio, L. D., & Muntner, P. (2023). Hypertension Statistics for US Adults: An Open-Source Web Application for Analysis and Visualization of National Health and Nutrition Examination Survey Data. Hypertension (Dallas, Tex.: 1979), 80(6), 1311–1320. https://doi.org/10.1161/HYPERTENSIONAHA.123.20900

Verma, N., Rastogi, S., Chia, Y. C., Siddique, S., Turana, Y., Cheng, H. M., Sogunuru, G. P., Tay, J. C., Teo, B. W., Wang, T. D., Tsoi, K. K. F., & Kario, K. (2021). Non-pharmacological management of hypertension. Journal of Clinical Hypertension (Greenwich, Conn.), 23(7), 1275–1283. https://doi.org/10.1111/jch.14236

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.

BUY A CUSTOM PAPER HERE ON; Assignment; Preliminary Care Coordination Plan Essay

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.

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Introduction

The first step in any effective project is planning. This assessment 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.

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

Preparation

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.

Scenario

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:

• 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.

Instructions

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

Develop the Preliminary Care Coordination Plan

Complete the following:

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

Document Format and Length

• 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.

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.

• 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.

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. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

Course Competencies

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

• 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.

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Scoring Guide

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

View Scoring Guide

Use the resources linked below to help complete this assessment.

Care Coordination Fundamentals

You may review the following:

• Improving Chronic Illness Care. (n.d.). Care coordination: Background. http://www.improvingchroniccare.org/index.php?p=Background&s=350
  • This resource provides background information of care coordination. Think about how this information applies to your community and patients as you read the case study of Ms. G., which highlights the importance of care coordination.
• McGee, B. T., & Breslin, S. E. (2020, May). The Affordable Care Act 10 years in: What nursing leaders should know.Nurse Leader.
• Cleveland, K. A., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses.The Online Journal of Issues in Nursing, 24(19). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-24-2019/No2-May-2019/Affordable-Care.html

Academic Resources

A variety of writing resources are available in the NHS Learner Support Lab, linked in the courseroom navigation menu.

Scholarly Writing and APA Style

Use the following resources to improve your writing skills and find answers to specific questions.

• Academic Honesty & APA Style and Formatting.
• APA Module.

Library Research

Use the following resources to help with any required or self-directed research you do to support your coursework.

• BSN Program Library Research Guide.
• Capella University Library.
• Journal and Book Locator Library Guide.
• Library Research and Information Literacy Skills.
• NURS-FPX4050: Coordinating Patient-Centered Care Library Guide.

Writing SMART Goals for Care Coordination

During care coordination, nurses should ensure that they are creating patient-centered goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable, Relevant, Timely) goals. SMART goals provide direction for patient-centered care coordination.

SMART goals must be effective, meaningful, achievable, and collaborative in nature. Key stakeholders (such as the individual, group, or community; possibly significant others; and you, the nurse) must be taken into account.

Often the best way to patient-centered functional goals is simply to ask the target group, “What are your goals?” Doing this will help you to improve adherence, satisfaction, and outcomes. Consider the following when developing SMART goals:

• Specific: Goals will specify who will be responsible, what is to be achieved, where the activity is located, and why it is important or beneficial.
• Measurable: Goals must specify criteria for measuring progress against them. This helps you to stay on track, reach milestones, and motivate the stakeholders.
• Attainable: Setting attainable goals serves to motivate the individual or group.
• Relevant: Key stakeholders must see how a specific goal is relevant to them.
• Timely: To be most effective, goals must be structured around a specific time frame to motivate individuals to begin working on their goals.

After developing a mutually agreed-upon goal, SMART objectives are developed to help guide activities. Objectives help to determine whether the goals have been achieved and if revisions need to be made for future educational sessions.

SMART objectives must be:

• Specific: Objectives need to be concrete, detailed, and well-defined so that you know what exactly is going to occur and what to expect.
• Measurable: A way to determine how the goal was met or if it needs revision.
• Achievable: The objective must be appropriate and feasible for those involved. Ask: What’s the patient’s learning style? For example, does the patient prefer reading printed materials, viewing audiovisual materials, or watching demonstrations?
• Realistic: It must take into consideration constraints such as resources, personnel, cost, education level, learning style, reading level and comprehension level. What language do they speak? How much does the individual or group like to know? Ask: Can the patient read or comprehend instructions or follow directions? Do they prefer reading printed materials, viewing audiovisual materials, or demonstrations?
• Time-bound: A time frame helps set boundaries around the objective. Ask: How long will it take to obtain the objective? Objectives may be process- or outcome-oriented.

Outcome objectives can be short-term, intermediate, or long-term:

• Short-term objectives can be achieved after implementing certain activities or interventions. Change may be in cognitive (knowledge), psychomotor (demonstration), and values (attitude).
• Intermediate outcome objectives provide a sense of progress toward reaching long-term objectives. This could be behavior and policy change.
• Long-term objectives occur after the program has been implemented. It may take more than a month. These can be changes in mortality, moribundity, and quality of life.

Example of a SMART goal:

• Walk for 30 minutes a day, seven days a week.

Example of a SMART objective:

• By the end of the week, patient will have walked 3.5 hours.

Example of an evaluation of a SMART objective:

• The patient will complete a daily log of miles each week.

Additional Resources

The following additional resources will help you in establishing SMART goals and objectives in collaboration with educational session participants:

• Centers for Disease Control and Prevention. (n.d.) Develop SMART objectives. https://www.cdc.gov/publichealthgateway/phcommunities/resourcekit/evaluate/develop-smart-objectives.html
• Centers for Disease Control and Prevention. (n.d.) Resources. https://www.cdc.gov/publichealthgateway/phcommunities/resourcekit/resources-2-2.html
  • This site has a template for you to use as a guide.
• L. (2012). Making SMART goals smarter. Physician Executive, 38(2), 68–70.

Additional Resources for Further Exploration

You may use the following optional resources to further explore topics related to the competencies.

• Improving Chronic Illness Care. (n.d.). Care coordination: Family Care Network: Developing agreements between primary care and specialty groups. http://www.improvingchroniccare.org/index.php?p=Family_Care_Network&s=344
  • The Family Care Network case study highlights the importance of care coordination. Look for similarities with your own practice and community.
• Improving Chronic Illness Care. (n.d.). Care coordination: San Francisco General Hospital: Connectivity through electronic referral. http://www.improvingchroniccare.org/index.php?p=San_Francisco_General_Hospital&s=347
  • The San Francisco General Hospital case study addresses how care coordination can change patient outcomes. This is a great resource as you think about care coordination in your community.