NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan Essay

Preliminary Care Coordination Plan

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Care coordination is defined as the process in which the care protocols and information regarding the treatment of a certain patient is shared among all the personnel involved in the recovery process (“Care Coordination,” 2014). An example of such coordination is the collaboration between different doctors regarding certain aspects about the treatment of a specific patient. 

The importance of proper care coordination can be understood just by its definition. The progress that a previous doctor has made on the condition of a patient has to be efficiently relayed and delineated to the professional who is taking over. If the previous doctor fails to actively convey the status of the patient, the following professional can make changes, prescribe medications or perform activities that could have been previously performed, hence proving detrimental. Poor care coordination planning can lead to devastating results and can cost the patients financially as well as emotionally. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

In this paper, the purpose is to explain a health concern and then come up with some rational goals which can be achieved by the healthcare sector in the bid to improve the standard of care given to the patients suffering from said health concern. The community resources shall also be enumerated as a part of the solution. 

Stroke

Strokes are among the leading causes of death worldwide. When ranked in numbers, stroke falls in second place with a mortality rate of 5.5 million persons annually (Donkor, 2018). The danger of strokes is not only portrayed by the mortality rate, but also by the aftereffects manifested on those who survive it. 50% of all survivors were seen to become chronically disabled (Donkor, 2018).

Strokes are categorized into two major types. These include ischemic strokes and hemorrhagic strokes. The former is caused by the obstruction of the blood flow to a part of the brain. The interruption of the blood flow causes the loss of functioning. Hemorrhagic stroke, on the other hand, is caused by the bursting or rupturing of a blood vessel (Donkor, 2018).

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Identification of Best Practices for Stroke

Thus concludes the identification of the health concern. When it comes to the best practices that can be applied for stroke patients, there are a few which are enumerated thus.

The patients who are seen to have a large vessel occlusion are to be examined for endovascular intervention (Khaki & Tadi, 2021). The patients who are suspected of having a severe ischemic stroke should be taken in for a neurological workup. 

Aside from the specific and particular measures taken for the care and management of strokes, antiplatelet and statins are the primary constituents that serve as the mainstay of the said management (Khaki & Tadi, 2021).

There are different other factors that play a part in the treatment and accommodation of a stroke patient. The cultural, social and psychosocial needs have to be incorporated and included in the treatment in order to facilitate a recovery process devoid of trauma and undeterred by mental discomfort. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

The needs referred to can include the accommodation and consideration of the various idiosyncrasies that come with a person’s cultural background etcetera. People of different cultures tend to react differently to treatments and the various stages of the recovery process.

Similarly, the needs from the social and psychosocial aspect can entail giving proper mental support to the patient during treatment. The presence of friends and family members can help along with the treatment, and this is a psychosocial dynamic because it relates to social factors viz. the people, and the psychological factors viz. the effects on the mental state of the patient. The importance of psychosocial factors in medications treatments is unequivocal (Xu, Mercury, Zhang, & Xu, 2008), hence the need to address these three areas.

Goals to be established to address Stroke Care

In order to make sure that the care for strokes is carried out properly, there are certain goals that can be established that the professionals or the institute have to meet. There are different strategies that have been put forward in a bid to improve the quality of the care given to stroke patients. By utilizing these strategies, we can formulate goals and objectives that can be set as a standard for all to meet. For example, a certain strategy put forward in a medical journal (Baatiema et al., 2020) was the computerization and digitization of medical practices. Utilizing this strategy, we can create a goal for the organization. It can be said that the hospital, or the professional, must digitally enter and save the information and important details of a certain stroke patient in order to facilitate better care coordination among professionals and transitions between different places. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Apart from this goal viz. the computerization of the medical practice, a few others can be enumerated as well. Increasing the workforce and the number of professionals is another goal that is necessary to address the treatment of strokes. While the exact number will be different for each institution, it is necessary to have an adequate number of professionals to tend to the patients (Baatiema et al., 2020). 

Furthermore, another goal that can be established is the development of a standardized set of clinical guidelines and treatment protocols for all professionals to follow in a certain institution (Baatiema et al., 2020). The standardization of protocols leads to better collaboration and care coordination since all the professionals are on the same plane as far as the treatment steps are concerned.

Community Resources

Community resources can play a major in the passive recovery of stroke patients. After a stroke, the recovery of the patient and the transition to the normal style of living can be a difficult process. However, in this study, the reason for enumerating these community resources is to explain how care can be continued even after the transition from hospital to home. In other words, the various community resources help in the recovery process of the patient even after they have left the hospital or the medical institution. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

One of the reasons for prescribing community resources to a patient is the deracination of any trauma that might linger. Hence, it was seen that walking groups (White & South, 2012) and other exercising activities with other people is a good way to help patients recover from their potentially depressive state. The community resources in play here are the parks and gardens which are accessible to the public.

Similarly, cooking and eating sessions (White & South, 2012) are another example of treatment based on community resources. Doing these activities with other people can be helpful for the patients. People are also a part of community resources, hence such activities are justifiably a part of community resource-centered treatment.

Literacy classes (White & South, 2012) are also a type of community resource that can help patients in their recovery process. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

References

Baatiema, L., de‐Graft Aikins, A., Sarfo, F. S., Abimbola, S., Ganle, J. K., & Somerset, S. (2020). Improving the quality of care for people who had a stroke in a low‐/middle‐income country: A qualitative analysis of health‐care professionals’ perspectives. Health Expectations, 23(2), 450–460. https://doi.org/10.1111/hex.13027

Donkor, E. S. (2018). Stroke in the21stCentury: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Research and Treatment, 2018, 1–10. https://doi.org/10.1155/2018/3238165

Khaki, A. S., & Tadi, P. (2021). Cerebrovascular Disease [Statpearls]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430927/

White, J., & South, J. (2012). Health together: how community resources can enhance clinical practice. British Journal of General Practice, 62(602), 454–455. https://doi.org/10.3399/bjgp12x653804

Xu, J., Mercury, J., Zhang, Z., & Xu, F. (2008). Psychological, social and behavioural factors that influence drug efficacy: a noteworthy research subject in clinical pharmacology. British Journal of Clinical Pharmacology, 66(6), 901–902. https://doi.org/10.1111/j.1365-2125.2008.03300.x

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan Essay

NURS-FPX4050 Assessment 2

NURS-FPX4050 Assessment 2

Free Example of Free Example of SOAP Analysis Essay

Proper intervention in a patient’s condition depends on a number of issues, which include the relation between doctor and patient, availability of medical facilities, and the skills that the medical specialist possesses. In this regard, the patient’s information must be documented and kept safe without encroachment by unauthorized people. Documentation and record-keeping carried out by nurses concerning the patient’s clinical condition are very important as they will help in proper evaluation and monitoring of the patient’s progress.

With regard to this, the SOAP nursing framework that includes subjective data, objective data, assessment, and the plan is appropriate in the sense that it facilitates proper documentation of the patient’s information basing on his/her condition for easier supervision and medical intervention.

Using this framework, the attending doctor and nurse are able to give their impressions of the patient (Robinson & Ava, 2015). Moreover, the physician is able to report the behaviors and conducts of the patient as a result of their interaction. Medical specialists will also be in a position to define the performance of the patient as a result of the interaction with him/her and they will finally prescribe the type of treatment plan that is appropriate for the patient with regard to the kind of information collected as a result of the doctor’s examination and socialization process (Goldman, 2011). Therefore, this essay focuses on SOAP analysis concerning the case of Mr. L. S.

My SOAP nursing documentation for the patient will be as follows:

S (Subjective Data)

Chief Complaint: Mr. L. S.

History of Present Illness

Location: Stomach.

Quality: Low.

Severity: High.

Duration: 5 days.

Timing: Severe chest pain during day time.

Context: Body weakness.

Relieving Factors: Pain relievers.

Exacerbating Factors: Smoking.

Associated Symptoms: Fever, nausea, headache, and dizziness among others. 10% off with word count difference (300 words instead of 270 words per page at other services) + 15% off for first time order = 25% off on every page! with code: writers15

Review of Systems

Constitutional: Weight loss, severe chest pain, chilling at times, and general body weakness.

Head: Light hair on the head.

Face: Brownish.

Eyes: Blurred vision (cannot see properly).

Ears: No sign of hearing loss.

Nose: Neither sneezing nor running nose.

Mouth/Throat/Neck: Sore throat.

Respiratory: Shortness of breath.

Cardiovascular: Severe chest pain.

Breast: Large.

GI (Gastrointestinal): Not detected.

GU (Genitourinary): Not detected.

Reproductive: Not affected.

Musculoskeletal: Occasional back pain.

Skin/Integument: Small rash is seen.

Psychiatric: No history.

Neurological: Slight headache and dizziness.

Endocrinologic: High body temperature leading to sweating.

Hematologic: No signs of anemia.

Lymphatics: No history.

Allergies: No history.

Diagnostic results: No records.

Past History (include dates)

PMH: N/A

PSH: N/A

Past Psychiatric Hx: N/A

Obstetrical History: N/A

Hospitalizations: Was hospitalized 5 years ago.

Medications: Dosage: 4 tablets of Nitroglycerin as of 25/02/2011.

Route: 4/2.

Frequency: Twice daily

Allergies: N/A

Dietary Hx: Average.

Immunizations: Fully immunized.

Health Promotion: Newsletters.

Functional Status: : ADLs Functional.

Family History: Alive, deceased, age, diseases, health conditions that place patient at risk (ages).

Grandparents: Deceased at the age of 78 years.

Parents: Deceased at the age of 66 years.

Siblings: 3, one suffering heart problems.

Children: 2, none affected

Social History

Cultural Background: African American.

Spiritual History/Religious Affiliation and Practices: Protestant.

Activities of Daily Living/Hobbies/Interests: Tennis.

Type of Family: Nuclear.

Marital Status: Married.

Parental Status: A father of 2 children.

Work History: Full time employed.

Financial History: Financially stable.

Sexual History/Orientation: Bi-sexual.

Use of Alcohol, Smoking, or Recreational Drugs: Smokes a pack of cigarettes a day.

Living Arrangements: He lives an average life.

Travel History: Travels a lot.

Social Support: From a community health volunteer.

Level of History

Expanded HPI (1-3 Findings); ROS – 2; PFSH N/A

O (Objective Data)

Physical Exam

Vital Signs: Body weakness.

Oxygen Saturation: 95% (this is slightly below normal range).

Ht: 198cm.

Wt: 95kg.

BMI: 0.479798.

Constitutional: Weight loss, severe chest pain, chilling at times, and general body weakness.

Head: Light hair on the head.

Face: Brownish.

Eyes: Blurred.

Ears: Clear (he hears well).

Nose: Often sneezes.

Mouth/Throat/Neck: Sores detected.

Respiratory: Suffocating.

Cardiovascular: Narrow veins.

Breast: Large.

GI (Gastrointestinal): N/A

GU (Genitourinary): N/A

Reproductive: Not affected.

Musculoskeletal: Node on the back.

Skin/Integument: Rashes on some parts.

Psychiatric: N/A

Neurological: Lump on the neural vein.

Endocrinologic: Temperature (400C).

Hematologic: N/A

Lymphatics: N/A

Allergies: No allergic reactions.

Diagnostic Results: The patient may be suffering from cholecystectomy.

Determine Billing Level of Physical Objective Examination:

Expanded: problem-focused (2-4 body parts or organ system (6-11 elements). This can help determine the specific problem that the patient is suffering from to be able to come up with comprehensive medical intervention using the laboratory data below.

Mouth/Throat/Neck: Sores detected.

Respiratory system: Suffocating.

Cardiovascular: Narrow veins.

Breast: Large.

Musculoskeletal: Node on the back

Skin/Integument: Rashes on some parts.

A (Assessment)

Main Diagnosis

Based on my assessment of the patient, the diagnosis from the history and physical exam is given below.

i. Cholecystectomy.

Additional Health Problem/Dx

i. Alpha-1-antitrypsin deficiency.

The clinical findings above, which are based on the assessment, show that the patient might be resistant to certain medical practices that are prescribed to him with an aim of ensuring his enhanced welfare.

Differential Diagnoses

The probability of the patient suffering from cholecystectomy is higher than the chances of Alpha-1-antitrypsin deficiency. Cholecystectomy is a surgical operation that involves the removal of the gallbladder. It is mainly done in human beings in cases when gallbladder diseases cause severe complications and problems that may demand its removal. Gallstones have always been the main reason why this type of procedure should be carried out in the sense that they cause pain that is intolerable by people.

The gallbladder is a very vital organ in the body of human beings as it stores bile which is produced by the liver. Bile plays an important role when it comes to the digestion process, especially breaking down fats into simple substances that can easily be absorbed in the bloodstream without any problem.

Risk Factors

1. Digestion failure

The failure of digestion of fats may lead to serious problems in the body of an individual.

1. Surgery consequences

Laparoscopy is a type of surgical operation in human beings that involves small incisions in the body as opposed to the normal open surgery that is very painful and takes a long period of time to heal (Marks, 2013). This kind of operation is less painful and takes a short period of time to close. Any surgical operation involves blood loss as patients bleed and, as a result of this, blood transfusion is mandatory to facilitate life during the surgical procedure and afterward for normal functioning of the body.

1. Blood transfusion problems

The patient may require blood transfusion as there will be loss of blood as a result of the surgical procedure he will probably be subjected to (Goldman, 2011).

P (Plan)

On arrival at the hospital, the patient was physically examined and tested to diagnose his condition and be able to plan for intervention.

Diagnostics

the following are additional laboratory tests necessary for the patient:

1. Electrocardiogram (ECG);
2. Chest X-ray;
3. Blood tests.

Pharmacologic Management (Rx)

1. Nitroglycerin;
2. Over-the-Counter Antacids.

Non-Pharmacologic Management

1. Hot packs;
2. Position changes.

Complementary Therapies

1. Physical exercises;
2. Diet control.

Education

The patient has to be educated about his disease in terms of the possible causes, signs to watch, treatment plan, and the process of education would include:

• pamphlets;
• medical newsletters;
• medical journals;
• trained nurses;
• trained volunteer community workers (Goodlin, 2009).

Referrals: N/A

Follow up/Appointment: the patient should return to the clinic after two weeks for a follow-up checking and if this is not possible, then the nurse will visit him at home.

Final Level of Decision Making

Moderate Complexity: based on Hx, even though the patient is not psychologically affected, he smokes a pack of cigarettes daily, his cardiovascular veins are narrow, he has a node on the musculoskeletal back, and has rashes on some parts of the body, meaning that his current and anticipated future condition would be complex to manage.

Billing Level

Patient Status: Level II.

Level of History: Level III.

Level of Physical Exam: Level II.

Level of Medical Decision Making: Level I.

Subjective and Objective Data

Looking at the subjective and objective data, Mr. L. S. has got the following characteristics:

1. Bp = 139/94, Wt = 60kg, T = 36.4c, pH6, P = 105, Ht = 198cm.
2. He is very resistant to drugs, but he has to take them due to the need for surgery to correct his worsening medical condition.
3. Mr. L. S. should agree with the idea of blood transfusion.
4. Proper treatment should be given to him basing on his attitude and clinical condition (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
5. There should be proper communication delivered to him.
6. As Ball et al., (2015) noted, the patient’s background, problem, and the doctor’s/nurse’s recommendations contribute to the success of treatment.
7. For instance, Mr. L. S.’s situation includes sore throat, suffocation, narrow cardiovascular veins, large breast, the node on the musculoskeletal back, and rashes on some parts of the skin.
8. Decisions like the need for laparoscopy as opposed to the normal open operation are done to ensure the well-being of the patient (Ball et al., 2015).
9. Laparoscopy is selected due to the shorter period of time one needs to heal the operated part as well as reduced pain to be felt during the operation (Spry, 2010).

Plan

In terms of the plan, it is true that appropriate nursing interventions should be implemented so as to deal with certain medical problems that are critical and require special attention. For instance, in the case of any surgical operation, proper preoperational and post-operational care should be enhanced in the sense there is no loss of lives before, during, and after the surgical process. Surgeons should be careful during surgeries to ensure that the welfare of the patient is well catered for without any limitation (Kaewprom, Curtis, & Deane, 2011).

In the case scenario, preoperational care was well-provided and this is one of the nursing interventions that are employed in the case scenario. Preoperational care involves all the interventions that are taken prior, during, and after any surgical operation are done (Spry, 2010).

At the stage before surgery, the patient is thoroughly examined in terms of his or her general health to ensure that the surgical process does not affect him/her negatively in any given circumstances. This involves checking the amount of blood required before one is subjected to surgery, the pressure of one’s blood, and many other vital issues are checked upon after which the necessary conditions are created that enable the surgery process to be successful without any loss of lives.

In the case scenario, Mr. L. S. was examined after which a prescription was done that recommended that a blood transfusion would be necessary for him. Intra-operational care is provided during the operation in the sense that the individuals carrying out the operation ensure that the patient does not die during the process. This is always achieved if the surgical guidelines are properly observed without any neglect.

Post operational care is provided after the surgical operation has been finished. This is done to ensure that the patient does not develop other complications after he/she has undergone any operation in his/her body. Surgeons or nurses have to follow and monitor the progress of the patient. Preoperational care is one of the nursing interventions that have been observed in the case scenario where Mr. L. S. is expected to undergo cholecystectomy.

Conclusion

In summary, SOAP analysis is important because it ensures that proper information is documented by the medical experts with regard to any treatment or procedure they may want the patient to undergo as this will help prevent any resistance to medical treatment.

NURS-FPX4050 Assessment 2

NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

Final care coordination plan on a 65 y/o Hispanic female patient with a recent stroke. HX of hypertension, high cholesterol, heart failure, non-compliant with medications. NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

Assessment 4 Instructions: Final Care Coordination Plan

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.

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Demonstration of Proficiency – NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

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
  • Design patient-centered health interventions and timelines for a selected health care
• Competency 2: Collaborate with patients and family to achieve desired
  • 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
  • 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
• Competency 4: Defend decisions based on the code of ethics for
  • Consider ethical decisions in designing patient-centered health

• Competency 5: Explain how health care policies affect patient-centered
  • Identify relevant health policy implications for the coordination and continuum of
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and

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 – NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

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

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
  • Address three health care
  • Design an intervention for each health
  • Identify three community resources for each health
• Consider ethical decisions in designing patient-centered health interventions.

• Consider the practical effects of specific
• Include the ethical questions that generate uncertainty about the decisions you have

• Identify relevant health policy implications for the coordination and continuum of
  • 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
• 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
• Align teaching sessions to the Healthy People 2020

• 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

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.

Sample NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

Final Care Coordination Plan

Jane Doe is a 77year old, African American, female, who is a recent widower and has no children, was admitted to the hospital due to complaints of shortness of breath, chest pain, and fatigue. She was diagnosed with Congestive Heart Failure (CHF) during this admission and we are creating a care coordination plan for Jane Doe to control signs and symptoms of CHF and prevent further admissions to the hospital. NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

Three Health Care Issues

1. CHF

The interprofessional team, this includes physicians, nurses, specialists, case management, the patient, and family if available, to create a care plan to improve signs and symptoms of CHF that is individualized. Jane Doe will be educated on CHF, follow-ups, medication adherence, low-sodium diet and fluid restrictions, and maintain weight by self- management as these elements are known to improve patient outcomes. Self-management is an intervention that puts the patient in control. The patient is required to have CHF knowledge, meaning they understand the disease and signs of symptoms, how to eat a low sodium diet, fluid restrictions, and be able to recognize fluid overload and when to seek additional health care (Zakrisson, A., Arne, M., Hasselgren, M., Lisspers, K., Ställberg, B., & Theander, K, 2019). To make behavioral changes support groups are key element in success. Support groups allow patients to see that they are not alone and can be persuaded by trustworthy people to see and accept positive changes. There are many community resources available. There are many online support groups and information such as, https://www.heartfailurematters.org, but for the older population it may be difficult to use technology. The American Heart Association also offers support groups online and in person for patients and caregivers. They also have print out educational pamphlets available such as care sheets for Self- check management and about the disease itself.

2.  Physical Activity and Nutrition

Poor physical activity and nutrition is linked to increase risk of CHF. Several reviews have found that sedentary behavior consistently increases the risk of both non-fatal and fatal cardiovascular diseases and CHF in the general adult population. As patients are educated on an exercise program following a cardiovascular event, preventative care works too. CHF patients should partake in an exercise program to improve quality of life (Tan, M. K. H., Wong, J. K. L., Bakrania, K., Abdullahi, Y., Harling, L., Casula, R., . . . Jarral, O. A, 2019). Nutrition is also linked to heart conditions. The African American culture tends to eat a “southern diet.” These are foods that include fruits and vegetables but are prepared in an unhealthy fashion. This diet is high in added fats, sugars, and sodium, with prominent use of high-fat meats for main dishes and the use of deep frying and other cooking techniques that add excess calories and sodium (Mercedes R. Carnethon, Jia Pu, George Howard, Michelle A. Albert, Cheryl A.M. Anderson, Alain G. Bertoni, Mahasin S. Mujahid, Latha Palaniappan, Herman A. TaylorJr, Monte Willis, and Clyde W. Yancy, 2020). Jane Doe must be educated on how to prepare the foods she likes in a healthier fashion. Jane Doe can meet with a Dietician to obtain the resources to learn how to cook foods she likes. She is an elderly woman and may need help obtaining groceries and preparing meals. Transportation, affordability of food, and physical activity has to be examined. There are community resources to help with physical activity and nutrition. Occupational or physical therapist can be prescribed to help improve physical activity. Home care can help will activities of daily living such as grocery shopping, cooking, and cleaning. And there are organizations such as meals on wheels that will bring healthy meals to the patient’s home.

3.  Access to Health Care

According to the American Heart Association, an estimated 7.3 million Americans with cardiovascular disease (CVD) are currently uninsured. As a result, they are far less likely to receive appropriate and timely medical care and often suffer worse medical outcomes, including higher mortality rates (AHA, 2018). Efforts are being made to extend health care coverage to all Americans; so that patient have a continuum of care and better outcomes. The Affordable Care Act has expanded on rural and urban populations. The patient also needs to be able to go to appointments. If transportation is an issue, there are community resources such as senior citizens transportation. There are bus services available to transport senior citizens places they need to go. If Jane Doe lives in a rural community transportation can be more of a barrier. Telemedicine is on the rise. This is where patients can grant access to health services through telephone or video conferencing. This will help with follow up visits and continued monitoring with Jane Doe’s health care team.

Health Policy Provisions

The Affordable Care Act, also known as OBAMACARE, is an act signed into law in 2010, which allowed persons to have an increase in access to health care, lowered costs, and incentivized care coordination to decrease gaps in care (ACA, n.d). This expanded Medicaid program to cover all adults in the poverty level. What this means is that more people have been granted easier access to health services. It allows for people to be able to seek care and afford treatments available to improve health outcomes.

According to the US department of Health and Human Resources, Health Insurance Portability and Accountability Act (HIPAA) establishes national standards that protect individuals’ medical records and other personal health information. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients’ rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections (HHS.gov, 2020). This allows the patient to be involved and in control of where and with who their health information is being shared. Paving the way for efficient care coordination.

Healthy People 2020

According to Healthy People 2020, it is important to recognize the impact that social determinants have on health outcomes of specific populations. Over the past two decades Healthy People has been focusing on health disparities and how to eliminate them while providing equity of healthcare and improve the health of all groups. In order to accomplish this goal, Healthy People have been performing ongoing studies; which examine American influential factors of availability and access to healthcare. These include: high-quality education, nutritious food, decent and safe housing, affordable and reliable public transportation, culturally sensitive health care providers, health insurance coverage, and clean water and non-polluted air (Healthy People, 2020). Healthy People 2020 promote preventative measures to improve people’s lives. For example, the Community Preventative Services Task Force is working to reduce costs for patient medications, improving patient-provider interaction and patient knowledge, such as team-based care with medication counseling, and patient behavioral and nutritional counseling (Healthy People, 2020). Costs for services can be reduced by eliminating out of pocket expenses such as copayments or deductibles. NURS-FPX 4050 Assignment 4 Final Care Coordination Plan

Ethical Decisions

As the interprofessional health care team, the care coordination plan must address the needs and wants of Jane Doe and the ethical responsibilities of care. What the health care team thinks may be right for the patient may not line up with what the patient believes or wants. The patient has the right to refuse medications or treatments. It is the health care team’s job to inform and educate the patient on all aspects of their disease and treatments. It is important to act in best practice to ensure the safety and cause no harm to the patient. As the care plan is implemented it is also important to make sure that the wishes and goals of the patient are being met. Everyone comes from different backgrounds and morals or beliefs but in health care, the healthcare team must respect the patient’s beliefs and values in order to have a successful care plan. In a study data was collected and implied that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-manager to reduce conflicting interests and ethical dilemmas (Tønnessen, S., Ursin, G., & Brinchmann, B. S,2017).

Priorities of Care Coordination

The priorities of planning care coordination are as follows. The nurse and physician must have open communication and speak with the patient and family to obtain insight on their values, beliefs, and wants. The patient and families knowledge of the disease process must be evaluated and reinforced. Then from there, coordinating services and other disciplines can be implemented. Health care is ongoing; even after discharge from hospitals or other facilities such as rehabilitation centers or nursing homes. Continued evaluation of the patient is essential to improve patient outcomes; through follow-ups and implementing the proper interventions to reach patient specific goals. For Jane Doe, her home needs to be accessed. It is the healthcare team’s job to figure out how she will obtain the right nutrition, exercise, transportation, medications, weight-management, and resources. Along with being able to afford care and lifestyle.

References

American Heart Association (AHA). (2018). Access to Care. Retrieved from https://www.heart.org/en/get-involved/advocate/federal-priorities/access-to-care

Healthcare.gov. Affordable Health Care Act. N.d. Retrieved from https://www.healthcare.gov/glossary/affordable-care-act/

Healthy People 2020. (2020). Healthypeople.gov. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities#5

HHS.gov. Health Information Privacy. 2020. Retrieved from https://www.hhs.gov/hipaa/for-

professionals/privacy/index.html

Mercedes R. Carnethon, Jia Pu, George Howard, Michelle A. Albert, Cheryl A.M. Anderson, Alain G. Bertoni, Mahasin S. Mujahid, Latha Palaniappan, Herman A. TaylorJr, Monte Willis, and Clyde W. Yancy. (2020). Cardiovascular Health in African Americans: A Scientific Statement from the American Heart Association. Circulation. Retrieved from https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000534

Tan, M. K. H., Wong, J. K. L., Bakrania, K., Abdullahi, Y., Harling, L., Casula, R., . . . Jarral, O. (2019). Can activity monitors predict outcomes in patients with heart failure? A systematic review. European Heart Journal. Quality of Care & Clinical Outcomes, 5(1), 11-21. doi:10.1093/ehjqcco/qcy038. Retrieved from https://search-proquest-com.library.capella.edu/docview/2303856022?pq-origsite=summon

Tønnessen, S., Ursin, G., & Brinchmann, B. S. (2017). Care-managers’ professional choices: ethical dilemmas and conflicting expectations. BMC health services research, 17(1), 630. https://doi.org/10.1186/s12913-017-2578-4. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590170/

Zakrisson, A., Arne, M., Hasselgren, M., Lisspers, K., Ställberg, B., & Theander, K. (2019). A complex intervention of self‐management for patients with COPD or CHF in primary care improved performance and satisfaction with regard to own selected activities; A longitudinal follow‐up. Journal of Advanced Nursing, 75(1), 175-186. doi:10.1111/jan.13899. Retrieved from https://onlinelibrary-wiley-com.library.capella.edu/doi/full/10.1111/jan.13899 NURS-FPX 4050 Assignment 4 Final Care Coordination