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Assessment 4 Instructions: Final Care Coordination Plan

May 15, 2023 | Nursing | Capella FlexPath | FPX4050 | 33
Question:
For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. NOTE: You are required to complete this assessment after Assessment 1 is successfully completed. Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life. This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem. You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment. Demonstration of Proficiency 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. Design patient-centered health interventions and timelines for a selected health care problem. Competency 2: Collaborate with patients and family to achieve desired outcomes. Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. Competency 3: Create a satisfying patient experience. Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document. Competency 4: Defend decisions based on the code of ethics for nursing. Consider ethical decisions in designing patient-centered health interventions. Competency 5: Explain how health care policies affect patient-centered care. Identify relevant health policy implications for the coordination and continuum of care. Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Course Navigation Assessment 4 Instructions: Final Care Coordination Plan &ndash... Preparation In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030. Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback. Instructions Note: You are required to complete Assessment 1 before this assessment. For this assessment: Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan. Document Format and Length Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA- formatted paper, 5–7 pages in length, not including title page and reference list. Supporting Evidence Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources. Grading Requirements The requirements, outlined below, correspond to the grading criteria in the Final 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. Design patient-centered health interventions and timelines for a selected health care problem. Address three health care issues. Design an intervention for each health issue. Identify three community resources for each health intervention. Consider ethical decisions in designing patient-centered health interventions. Consider the practical effects of specific decisions. Include the ethical questions that generate uncertainty about the decisions you have made. Identify relevant health policy implications for the coordination and continuum of care. Cite specific health policy provisions. Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. Clearly explain the need for changes to the plan. Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document. Use the literature on evaluation as guide to compare learning session content with best practices. Align teaching sessions to the Healthy People 2030 document. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. 5/11/2021 Assessment 4 Instructions: Final Care Coordination Plan &ndash... Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Additional Requirements Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final
Answer:
Final Care Coordination Plan Care coordination is undertaking patient care activities through several healthcare professionals who collaborate to offer quality services to a patient. All the health professionals that are assigned to a particular patient share information about themselves about their roles to ensure a smooth transition of care. For a long time, health care systems have always been disjointed as the practices carried out in different health centres varying from time to time. Many patients have minimal information why they are being referred to a specialist. At the same time, the specialist has no adequate information why the patient was referred to them or what they have gone through in the previous meetings. All these instances, no matter their degree, lead to less efficient care. Through the incorporation of ethical decisions, policy interventions, and other priorities, care coordination becomes a great process that improves healthcare outcomes. Patient-Centred Health Interventions and Timelines for Care Three Patient Health Issues Mr. Shadrack is a retired truck driver who has worked in the job for more than 40 years. With his current age of 70 years, he has type 2 diabetes and heart failure. Mr. Shadrack lives with his wife, who is aged 65 years. In addition to these conditions, Mr. Shadrack walks with a cane, and he recently has been having some memory problems. After visiting the hospital, he was confirmed to be having Dementia. The three patient health issues that will be addressed will be congestive heart failure, type 2 diabetes, and Dementia. Interventions for the Heath Issues The interventions for heart failure include pharmacological, non-pharmacological, and invasive strategies to lower the condition's manifestations. There need to have good care for the condition as it has many comorbidities that can cause increased risks on the patient. Such comorbidities include coronary artery disease, valvular heart disease, sleep apnea, Anemia, cardiorenal syndrome, and Atrial fibrillation (Dumitru, 2021). The non-pharmacologic therapy that can be offered to the patient includes improving diet, nutrition, and exercise. A certified nutrition specialist should offer the right advice on what the patient should take to improve the heart condition. Dietary sodium should be strictly restricted to minimal amounts. A medical exercise specialist is also crucial to help to identify the right exercises to promote physical conditioning. There should be close supervision, and patient education should be done to ensure that the patients adhere to the current plan. This also helps to identify issues such as weight gain and any primary symptom. Pharmacologic therapy includes the use of diuretics which lowers blood volume hence lowering any risk of edema. Angiotensin-converting enzyme inhibitors help greatly in vasodilation and improving the left ventricular ejection fraction (LVEF). Nitrates and hydralazine help improve exercise capacity and also improve various symptoms. Digoxin is also helpful in improving cardiac output. Other pharmacological interventions can be used depending on how the patient expresses various symptoms (Dumitru, 2021). Type 2 diabetes interventions for Mr Shadrack would include both pharmacological and non-pharmacological interventions. The main pharmacologic treatment is offering the patient insulin therapy to help keep the sugar at manageable levels. Some of the non-pharmacologic intervention that can be applied includes having a healthy diet. A healthy diet means eating a lot of fruits and vegetables while avoiding sugary foods (Raveendran, 2018, p. 31). The exercise plan used in the management of heart failure should help to keep the body active. The interventions for Dementia include providing medications that can improve the patient's conditions as well as therapies that reduce the rate of progression of the condition. As there is no cure for the condition, medications can only slow down the disease progression. Many of the drugs offered to play the role of acetylcholine in the brain. They assist in improving the communication between nerve cells. These drugs are often referred to as acetylcholine inhibitors. They include Aricept, Exelon, and Rimynl (DSiDC, 2020). As Dementia progresses, Memantine can also be used as it helps in blocking the chemical glutamate. Non-pharmacological interventions involve the use of an occupational therapist. This specialist can help the patient cope with home activities better and avoid accidents at home. Other therapies include Reminiscence therapy, validation therapy, and cognitive stimulation therapy (CST). Community Resources Community resources for Dementia in California include Alzheimer's Association which has a 24hr toll-free helpline and offers support and education. WISE and Healthy Aging and Senior Concerns are other resources that help dementia patients manage their problems. Community resources for heart attack include the American Heart Association, which ensures people in California manage their heart conditions better. Cedars-Sinai medical centre and UCLA Medical centre provide great services for various heart conditions. The California Hospital Medical Center helps in the management of type 2 diabetes. Other hospitals that offer great programs for the disease include Providence Mission Hospital-Mission Viejo, and UCSF Medical Centre, San Francisco. Ethical Decisions in Designing Patient-centered Health Interventions Health interventions involve a lot of interaction and communication for patients to adopt the right health practices. In the process, there are many preferences, beliefs, social norms, divergent views, and other issues that lead to dilemmas and ethical issues. In response to this, there are ethical principles that should govern decision-making to ensure that everyone is satisfied with the outcome. Ethical decisions should be founded on autonomy, beneficence, non-maleficence, and justice. Non-maleficence obligates the healthcare staff not to harm their patients. This can be interpreted as not causing pain to the patient, killing, or offending. Therefore, before any decisions are made, the healthcare practitioners should weigh the burden of the treatment options to come up with the best option (Varkey, 2020, p. 18). Beneficence, on the other hand, calls for the doctors to do everything to benefit the patient. Not only avoiding harm, but they should support all the moral rules. Interventions should always respect the autonomy of the patient. Adult patients have the right to decide what they want to be done to their bodies. Patient interventions may involve certain therapies or medications that can lower the effects of a certain condition. A patient can decide that he/she only want some particular non-pharmacologic interventions. Even if the doctor knows that they might not help much, all he can do is offer his advice and respect the patients' decisions. Justice is another principle that should be observed during interventions. Treatment approaches should be fair and equitable. Practitioners should not seem to favour certain practices with other people and deny some the same (Varkey, 2020, p. 21). Fairness helps improve the treatment processes as patients have a positive attitude hence more satisfied. Relevant Health Policy Implications for the Coordination and Continuum of Care Care coordination has a great potential for the reduction of costs in the healthcare system. This was obvious as the balanced budget Act of 1997 requested a review of the care coordination activities. Care coordination gained support and saw the programs evaluated in the Medicare fee to allow service setting. This early legislation approved the continued adoption of demonstration elements that were proven to lower overall Medicare costs or improve the efficiency of medical care and beneficiary satisfaction without rising costs. The healthcare reform of 2010 saw the inclusion of some care coordination policies in the Affordable Care Act and Patient protection. Efforts have been observed in the creation of offices within Medicare and Medicaid centres. This was done to increase the continuity of care and ensure there is a better transition of care. A network of community-based Collaborative Care Programs will also be developed to help consortiums of healthcare providers that plan and incorporate medical services people with low incomes, those with no insurance, and those underinsured (AHRQ 2016). HIPPA policies also help in protecting patients against any breach of their data. This protects the information as it moves in the continuum of care. Priorities that should be Established when Developing a Plan with Patients or Family Members The first priority that a care provider should do is to establish accountability and agree on responsibility. This is important as one is able to agree with their role and develop a positive attitude for it. They can also identify the patient that it is their responsibility to improve their health as much as they are provided with help from the community. Another priority that should be established is that of the culture or background of the patient and family. Changes should be made to align with the background of the patient. This will assist in delivering care more effectively. The plan should link with the community resources that surround the patient. This will make it easier for them to access them at any time. Another priority should be developing a plan that incorporates periodic monitoring of the patient. These priorities will guarantee a smooth process of engagement, minimizing conflicts that may occur among the involved parties. Comparison of Learning sessions with Best Practices There has been a great connection between the learning sessions content with the best practices in the literature. Much of the literature has touched on the importance of care coordination which has effectively been covered in the class sessions. The healthy people 2030 objectives cover many of the conditions that have been analyzed in previous sessions. It talks about the general improvement of health across every single person in America. With the right practices, this can be achieved. Improvement of the current policies as identified in the literature will ensure everyone can access healthcare without much struggle. Conclusion Care coordination is crucial to ensure a healthy nation. It is the role of all health practitioners to adopt this practice as it improves the outcomes of various conditions. In addition to this, ethical practices should be adhered to as it promotes better interaction between the patient and the provider. Governments and hospitals should ensure the necessary resources are accessible at all time for the continuity of care coordination. References AHRQ. (2016). Priorities in focus–care coordination. Agency for Healthcare Research and Quality. https://www.ahrq.gov/workingforquality/reports/priorities-in-focus/care-coordination.html#:~:text=The%20Affordable%20Care%20Act%20created,care%20quality%20and%20reduced%20spending.&text=Care%20coordination%20also%20is%20facilitated,use%20of%20health%20information%20technologies DSiDC. (2020). Interventions. Dementia Services Information and Development Centre. https://dementia.ie/interventions/ Dumitru, L. (2021, March 2). Heart failure treatment & management: Approach considerations, Nonpharmacologic therapy, pharmacologic therapy. Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/163062-treatment#d1 Raveendran, A. V. (2018). Non-pharmacological treatment options in the management of diabetes mellitus. European Endocrinology, 14(2), 31. https://doi.org/10.17925/ee.2018.14.2.31 Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17-28. https://doi.org/10.1159/000509119100
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