Description
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 2020 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. 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 2020. 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 2020 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 2020 document. Use the literature on evaluation as guide to compare learning session content with best practices. Align teaching sessions to the Healthy People 2020 document. 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.
Assessment 1
Preliminary Care Coordination Plan
In health care in the community and at the health care facility, initial patient assessments and planning of the best possible outcomes are the crucial in formulating a care coordination plan. The preliminary care plan formulation depends on the assessment data, available community resources, and other client-centered specifications, which could influence the quality of care. High competency and precision are essential aspects that influence the preliminary care coordination plan (Pont & Alhawassi, 2016).
Let’s begin our discussion by developing a care coordination plan for a hypertensive patient. Hypertension is usually associated with chronic, elevated blood pressure. Risk factors for developing hypertension are age, smoking, obesity, alcohol abuse, race and the disease’s genetic preference, as well as other factors (Crittenden et al., 2017).
In order to manage hypertension, it is important to obtain accurate vital signs and to evaluate the type of hypertension the particular patient is suffering from. The type of hypertension diagnosed is managed by hypertension management guidelines and protocols which are specific to the patient’s disease process. Priority is given to critical symptoms, particularly those involving the airway, breathing, or the cardiovascular system.
The nursing interventions which are going to be appropriate in the care coordination plan include strategies to reduce elevated blood pressure, provide nutritional counseling to the patient to reduce hypertension. Lifestyle modification counseling will emphasize the importance of diet and exercise, drug regimen compliance, and review administration of the patient’s prescribed antihypertensive medications. The patient will closely monitor their vital signs, especially within two hours after therapeutic management, which is an essential component of preliminary care for our coordination plan. Preventing the development of other complications associated with hypertension is also a critical step in the patient’s nursing care plan.
Collaboration with our patient and their family helps the patient and care plan have the best chance at success. Health improvement and promotion interventions should feel to the patient like something they decided to do themselves. They need an active role in their care. This is because many of the proposed goals specific to hypertension include lifestyle modifications, nutritional considerations, compliance with their treatment regimen, among other realistic goals. They’ve got to be involved to accomplish these changes. Nutritional advice to take foods rich in green and leafy vegetables, plenty of fruits, and low-fat content diets are key steps in combating the hypertension crisis. There may be cultural barriers, especially when it comes to the modification of an established diet which is contraindicated for their condition. The patient may need to consume moderate white meat intake such as fish and poultry and emphasize whole-grain meals and restrict the sodium content in the meals they take, but they be used to an entirely different diet. They may also have family which are reliant on them to eat, and modifying their diet means modifying everyone else’s diet in the family. It may be pertinent to ask the family to participate in lifestyle modification, counseling, planning and education.
Encouraging the patient to engage in regular exercise is crucial to lowering blood pressure and reducing the levels of high-density lipoproteins, which contribute to the deposition of cholesterol in blood vessels and the development of obesity. Both increase risk factors for our patient developing hypertension. Family members need to be willing to help the patient achieve realistic and achievable goals set to enable them to enhance their health status, in order for them to have the highest chance of success in controlling hypertension (Ali & Bakris, 2019).
It is also important to realize that compliance with the patient’s medication is of great significance, especially when it comes to preventing a hypertensive crisis or rebound hypertension associated with a sudden withdrawal from antihypertensives. A satisfying and positive patient experience is crucial for managing hypertension.
A useful community resource in the management of hypertension which promotes care is the local community health center, which can be an effective hypertension screening, diagnosis, and treatment option and help in dispensing of hypertensive medication. It is also important to conduct community outreach services and offer free screening, diagnosis, treatment, and health education to the community members would be involved in meeting with the patient.
Encouraging family members and the patient to play a central role in designing achievable goals that they deem best suited for them is crucial in ensuring that the suggested health interventions are implemented while in community settings (Ali & Bakris, 2019). Developing a realistic care plan will improve and promote the easy implementation of interventions, especially if the patient and their family members are involved in the initial step of designing the care plan.
Effective communication with the patient is another crucial step in the creation and implementation of a nursing care plan. From the initial step of planning for the provision of care, to creating a good rapport with the patient, it all helps build an effective and therapeutic patient-nurse relationship with bound trust between the two. (Brownie et al., 2016)
Trusting a healthcare provider can enable the patient to be free and open to the health care suggestions, get more detailed assessments, diagnosis, planning of care, and better implementation of the care plan. It is important that health workers avoid medical lingo when communicating with clients. The use of appropriate and professional communication skills is essential in nursing practice to offer high-quality care. Caregivers want to create a common but professional environment where patient and provider can freely interact on a level field. It is through the utilization of these techniques that quality patient care and safety can be improved.
References
Ali, W., & Bakris, G. (2019). The management of hypertension in 2018: what should the targets be? Current Hypertension Reports, 21(6), 41. https://link.springer.com/article/10.1007/s11906-019-0946-7
Brownie, S., Scott, R., & Rossiter, R. (2016). Therapeutic communication and relationships in chronic and complex care. Nursing Standard, 31(6), 54. http://ecommons.aku.edu/cgi/viewcontent.cgi?article=1087&context=eastafrica_fhs_sonam.
Crittenden, D., Seibenhener, S., & Hamilton, B. (2017). Health coaching and the management of hypertension. The Journal for Nurse Practitioners, 13(5), e237-e239. https://www.sciencedirect.com/science/article/pii/S1555415517301307.
Pont, L., & Alhawassi, T. (2016). Challenges in the management of hypertension in older populations. In hypertension: from basic research to clinical practice (pp. 167-180). Springer, Cham. https://link.springer.com/chapter/10.1007/5584_2016_149.
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