NURS FPX 4020 Assessment 1: Preliminary Care Coordination Plan

NURS FPX 4020 Assessment 1: Preliminary Care Coordination Plan

NURS FPX 4020 Assessment 1: Preliminary Care Coordination Plan

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.

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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:
• 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:
o Stroke.
o Heart disease (high blood pressure, stroke, or heart failure).
o Home safety.
o Pulmonary disease (COPD or fibrotic lung disease).
o Orthopedic concerns (hip replacement or knee replacement).
o Cognitive impairment (Alzheimer’s disease or dementia).
o Pain management.
o Mental health.
o Trauma.
• 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.
o 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.
o 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.
o Cite supporting evidence for best practices.
o 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.
o Write with a specific purpose with your patient in mind.
o 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.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
• Competency 1: Adapt care based on patient-centered and person-focused factors.
o Analyze a health concern and the associated best practices for health improvement.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
o Describe specific goals that should be established to address a selected health care problem.
• Competency 3: Create a satisfying patient experience.
o Identify available community resources for a safe and effective continuum of care.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
o Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
o Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Preliminary Care Coordination Plan

A significant increase in the rate of chronic illnesses among community members is becoming a major public health concern. About 45% of the total population (133 million) of the total US population has been diagnosed with a minimum of one chronic illness, and this number is rising significantly (Raghupathi & Raghupathi, 2018). The most prevalent chronic illnesses in the United States include diabetes mellitus, cancer, hypertension, heart disease, stroke, respiratory diseases, obesity, arthritis, and oral diseases. These illnesses lead to hospitalization, long-term disability, reduced quality of life, and high mortality rates. According to Raghupathi and Raghupathi (2018), chronic diseases are one of the most common and costly health problems in the United States. Therefore, the medical community prioritizes the prevention and treatment of chronic illnesses. This paper presents a care coordination plan for addressing health needs associated with a chronic illness, namely high blood pressure, including an analysis of the health concern and best practices for health improvement, underlying assumptions and uncertainty, and specific goals that should be established while addressing this health care issue, and available community resources.

Analysis of the Selected Health Concern: High Blood Pressure

            High blood pressure or hypertension is one of the most prevalent chronic illnesses affecting US citizens. In the United States, hypertension is diagnosed in approximately 47% of the total population, or 116 million Americans (CDC, 2022). Hypertension is a condition that is characterized by blood pressure at or exceeding 130/80 mmHg (CDC, 2022). On the other hand, stage 2 hypertension is characterized by blood pressure of more than 140/90 mmHg (CDC, 2022). Having hypertension increases the risk of developing stroke or heart disease. This chronic illness is also associated with a high mortality rate. In 2020, hypertension was associated with over 670,000 deaths in the US (CDC, 2022). Thus, a care coordination plan for health improvement should be adopted to address physical, psychosocial, and cultural needs.

The plan should include evidence-based practice (EBP) for preventing and managing high blood pressure. A population health management approach for improved disease management and coordination of care should be implemented in preventing and controlling high blood pressure among the community member. According to Price et al. (2020), the population health management approach is a customizable and collaborative evidence-based approach, which allows health departments to initiate change locally by connecting practice to policy. This EBP allows medical professionals to address the healthcare needs of underserved communities, improving their health status and quality of life. Therefore, healthcare providers can adopt population health management approach physical, psychosocial, and cultural needs of people diagnosed with hypertension.

First, in addressing physical needs, the approach will enable healthcare providers to identify the lack of the required diet as the most significant need among people diagnosed with or at risk of hypertension. These individuals will then be provided with the recommended foodstuffs such as food with low salt, controlling their blood pressure. Secondly, by using the population health management approach clinicians will address psychosocial needs among people with hypertension. For instance, the approach will point out to low-income status among the minority groups as a significant factor hindering the management of blood pressure in this population. Consequently, the minorities and people with low-income status will be provided with providing subsidized hypertensive, resulting in blood pressure control in this population. Lastly, the approach will be applied in addressing cultural needs such as lack of awareness regarding hypertension risk factors, prevention, and control in some communities. The community members will then be educated about hypertension reducing the risk of developing hypertension among people at high risk and controlling blood pressure among people diagnosed with hypertension. The plan is associated with underlying assumptions, involving the willingness of the community members to accept healthcare services provided to address their healthcare needs. Addressing the community’s health needs is associated with some uncertainties, which might compromise the achievement of the targeted outcomes. For instance, proposed food components might contradict with cultural beliefs of the community members. In another example, cultural beliefs might be against the use of drugs. Consequently, community members will not comply with proposed interventions if they recommend the use of a particular food or drug in managing blood pressure. Failure to comply with guidelines will result in adverse outcomes such as high rates of hypertension-related deaths.

Goals for Addressing Hypertension

             The success of the care coordination plan in addressing this health issue will significantly depend on the set goals. Goals for addressing hypertension among the community members can be categorized into short- and long–term goals;

Short-Term Goals

• To identify the physical, psychosocial, and cultural needs of people diagnosed with hypertension.
• To establish adverse health impacts of hypertension on individuals and the entire community.
• To educate community members about the rising prevalence of hypertension.
• To create awareness concerning risk factors contributing to hypertension.
• To educate community members about hypertension preventive measures such as reducing salt intake.
• To educate community members about effective blood pressure control interventions.
• To inform community members about hypertension-related health complications including stroke and heart diseases.

Long-Term Goals

• To reduce the rate of hypertension in the community by 50% by August 2023.
• To lower hypertension-related deaths in the community by 30% by December 2023.

Available Community Resources for Hypertension

Resources and tools for supporting individuals with hypertension are available in the community. Interactive platforms allow people with hypertension to interact with healthcare professionals. These patients are educated on how to monitor blood sugar levels during the interactive program. Secondly, BP trackers are available, enabling community members with hypertension to monitor their blood pressure. Lastly, support groups enable people with hypertension to network amongst themselves, providing each other with the required psychological support and enhancing their understanding of hypertension and associated health complications. Thus, community resources provide people with hypertension with a safe and effective continuum of care.

            Overall, hypertension is a significant health concern facing community members. A care coordination plan for health improvement should be adopted to address physical, psychosocial, and cultural needs. The plan should include a population health management approach as an evidence-based practice (EBP) for preventing and managing high blood pressure. Incorporating this approach into the care plan will enable healthcare providers to address the physical, psychosocial, and cultural needs of all people with depression, including minorities. Resources and tools for supporting individuals with hypertension are available in the community.

References

CDC. (2022). Facts about Hypertension. National Center for Chronic Disease Prevention and Health Promotion. https://www.cdc.gov/bloodpressure/facts.htm

Price, J. D., Jayaprakash, M., McKay, C. M., Amerson, N. L., Jimenez, P. L., Barbour, K. E., & Cunningham, T. J. (2020). Peer Reviewed: Evidence-Based Interventions for High Blood Pressure and Glycemic Control Among Illinois Health Systems. Preventing Chronic Disease, 17. DOI: http://dx.doi.org/10.5888/pcd17.190058external icon

Raghupathi, W., & Raghupathi, V. (2018). An empirical study of chronic diseases in the United States: a visual analytics approach to public health. International journal of environmental research and public health, 15(3), 431. Doi: 10.3390/ijerph15030431.