Final Care Coordination Plan
The matter of stroke was mentioned in the background in the preliminary care coordination plan. As with other acute problems in health care, there are specific existing measures that need to be set in place and orchestrated for the survivors of stroke. Moreover, NURS FPX 4050 Assessment 4 Final Care Coordination Plan
measures activities are also put in place for those patients who have at greater chance of having a stroke. In the words of the author, “Stroke ranks second as a leading cause of death globally with an estimated death rate of approximately 5.5 million annually” (Donker, 2018, pg. 5). The greater the death rate is around the world for stroke, the acute the case is for chronic illnesses towards the survivors of the disability. Reff: Final Care Coordination
The final care coordination plan is expected to deliver interventional strategies directed toward healthy patients with a pecific focus on the timeline and the three major health problems and community services that include stroke, heart disease, and diabetes. This plan will also incorporate ethical considerations of the patient-centered health interventions design, health policies for the coordination and the continuum of care, and predetermined major concerns for the coordinator to effectively implement the plan, determine best practices, and synchronize the plans to Healthy People 2030.
Patient-Centered Health Interventions, Timelines and Community Resources
The chosen illness is stroke, but there are two prominent health conditions that greatly raise the probability of stroke occurring. These two prominent health conditions are heart disease and diabetes. All of these healthcare problems will include patient-centered health interventions with a timeline and community resources that need to be explained.
Stroke
According to the World Health Organization, strokes rank as the second leading cause of mortality globally. The consequences that follow can put a strain on one’s life, as the remnants of strokes can be burdensome. This includes difficulty with speaking, ambulating, and other activities of daily living (Mejia et al., 2016, pg. 630). In addition, a person suffering a stroke is at a greater risk of experiencing another stroke. Under Healthy People 2030, strokes are the result of unbeneficial cardiovascular health (Health People 2030, n.d.). This summarizes that strokes are the outcome of impactful cardiovascular health. Notably, there are many forms of strokes, and it is vital that the proposed patient-centered care strategies targets the type of stroke the patient has suffered. Knowing the reason behind the stroke, it is possible to help prevent, manage, and treat it.
NURS FPX 4050 Assessment 4 Final Care Coordination Plan
Different modalities are taken into account, considering that various factors need to be addressed in these interventions. These do include the patient’s overall health, culture along with the primary reason for the stroke. The systemic changes will first aid in lifestyle management using dietary approaches and cardiovascular exercises (Wafa et al., 2020, pg. 17). The next step is to have a consultation with a cardiologist to assess the condition of the blood vessels and the potential for occlusion. Patients with an ischemic stroke will require examinations through the field of neurology. Education and training sessions will be required for healthcare professionals to make an accurate and timely diagnosis of a stroke. In the attempt to quickly intervene, the correct diagnosis may save the patient’s life. How a person shifts emotionally after the event will play a role in the stigma associated with stroke and recovery (Merriman et al., 2019, pg. 9).
To commence, nurses along with other health professionals will be trained and educated in the first month. NURS FPX4050 Assessment 4 Final Care Coordination training and education can increase the success rate of patient-centered interventions. This plan will be carried out over a period of three months, and the success of the plan will be evaluated based on the results of the interventions. There are also available resources that will assist in helping implement the plan.
Cardiovascular Diseases
One of the major contributors to the risk of having a stroke is Cardiovascular Disease, and this is so because the latter heightens the chances of clot formation in the blood vessels. As mentioned by the CDC, this disease contributes to over 655,000 deaths each year in the United States alone, and out of these, one in every four deaths is attributed to cardiovascular disease (CDC, 2021). Since cardiovascular diseases is associated with clotting which can cause strokes, stroking risk mitigation measures will be put in place. Health People 2030 outlines patient interventions in bypassing risks of strokes from cardiovascular diseases or in managing the disease as a condition. Measures for prevention and control include performing exercises and diet.
To attempt to mitigate or solve the problem of having cardiovascular disease, proper diet and lifestyle changes should be part of the NHS FPX4050 Assessment 4 final care-coordination plan to be assigned along with interprofessional collaboration for patient-centered care (Brandhorst & Longo, 2019, pg. 953). Such diet and lifestyle changes should focus on the patient’s culture, and implement the right care techniques. This can be done by implementing proper culture diet plans alongside other measures such as moderate exercise for one hour each day.
Related Assessment: NURS FPX4050 Assessment 1
With the correct adjustments to lifestyle and exercise, it is possible to manage or even prevent cardiovascular diseases. It is important, however, to follow up with physicians to assess these changes. Integrating the patients’ culture into the patient-centered health intervention is important, especially in dealing with specific communities where obesity and cardiovascular disease prevalence is higher (Brandhorst & Longo, 2019, pg 954). Stress management and many other therapeutic and psychological interventions can certainly be useful in the plan. Psychotherapy and meditation are ultimately needed when a patient’s diet and exercise are altered, as it can be very stressful.
A drastic change like this plan suggests is unrealistic to expect anything significant to result from it. Therefore, the evaluation of it will be a month-long process, completed at the 3-month mark. The accuracy of the intervention’s effectiveness can only be figured out after the three to six months it is expected to properly implement changes of diet and lifestyle. To assist in this three-month plan, community resources such as the American Heart Association, the Eat for a Healthy Heart program, local nutritional clubs, and the U.S. Food and Drug Administration can certainly be useful.
Diabetes
Another potent health issue that poses a great threat to the risk of stroke is diabetes. There is CDC data showing that there is a growing percentage of diabetes patients, mapping to 34.2 million diabetic patients along with 7.3 million undiagnosed cases in the world which is on a progressive increase every year (CDC, 2021). The vast statistics call for immediate intervention and proactive measures pertaining to prevention and management. Diabetes self-care begins with the understanding that diabetes is a disease, and with it comes the need for proper management, which is precisely why people having diabetes are more prone to cardiovascular diseases, like heart diseases themselves. Furthermore, Healthy People 2030 advises and sets standards for intensive nutritional and lifestyle change interventions coupled with self-management as self-care best practices (Health People 2030, n.d).
Diabetes Self Management
People with diabetes, or those who are prediabetic, and are at risk due to his genetics, wind up needing education to self-manage their illness. Diabetes self-management education (DSME) is where a diabetic patient participates in an organized program to learn a self-managed diabetes care plan as it’s developed through a teamwork process with a nurse, physician, nutritionist, and other para-medical personnel (Lepard et al., 2017, pg. 15). Alongside taking proper medications prescribed by healthcare providers, patients who monitor their blood sugar daily find themselves more in control of the situation. Effective self-management includes giving the person the feeling of having some sort of control.
NHS FPX4050 Assessment 4 Final Care Coordination Plan
This plan can be implemented in a timeframe of three months. The first month will be allocated for patient education regarding the adoption of a healthier lifestyle. Some examples would include dietary changes and low-intensity exercise incorporated into their daily activities. Thereafter, the last two months will be geared towards executing the plan developed during the educational session of the first month. Socioeconomic-based, culturally appropriate, patient centered interventions need to be designed and implemented for effective diabetes management and prevention in the community (Health People 2030, n.d.). Some of the community resources that can facilitate self-management include nutritionists and dietitians as well as local nutrition firms and medical clinics that do yearly blood work for A1C monitoring.
Ethical Decisions in Designing Patient-Centered Health Interventions
The effort of putting together a care coordination plan that helps treat, prevent, or manage a particular condition is advantageous for the patient. It is possible for people to not be willing or interested in patient-centered health interventions. This has the potential to cause ethical dilemmas concerning the care coordination plans, which would then require ethical decision-making. The responsibility to provide quality care is a must. An example of a need for an ethical decision in a designed patient-centered intervention is two different methods of dealing with a stroke. A patient can use either a thrombolytic treatment or an endovascular approach.
The next scenario concerns highly active patients who have started exercising regularly in their lives. However, certain patients suffering from comorbidity, such as particular lung diseases, are unable to carry out such prescribed exercises. At this point, considerations have to be made as to whether to change or to try out this intervention without modification, despite the known adverse consequences. Having said this, the fact that there is a greater chance of achieving desired outcomes creates a dilemma in ethical consideration (DeCamp et al., 2017, pg 371). Another ethical dilemma which can pertain to this case is decision making one that can be culture-specific for the patient. As some religions such as Hinduism, Islam, and Judaism have, do, and will prescribe certain diets, they tend to have foods that are meat-dependent. The consumption of red meat is associated with heart problems that may increase the chances of a stroke. There are challenges that come into play with the application of a diet with little or no protein. This poses an ethical challenge which leads to where respect for the patient’s religion and freedom of choice for high consumption of meat (Lulé et al., 2019, pg. 1).
Relevant Health Policy Implications for The Coordination and Continuum of Care
Activities related to the continuum of care and its coordination can be both directly and indirectly influenced by healthcare policies. The Agency for Healthcare Research and Quality (AHRQ) suggests a policy that ensures identity protection, healthcare accessibility, and affordability. The first policy that has a bearing on the coordination of care is the HIPPA Act. While the coordination of care refers to the integration of various health providers in regard to a patient’s treatment, that poses a challenge in terms of exposure of sensitive health information to people who are not part of the patient’s treatment team. Care providers have a responsibility to ensure that during the coordination of care, the patients’ identities and other relevant information are safeguarded (Renee Holt, 2020, pg. 1).
Another policy, the Affordable Care Act (ACA) also made provisions for health diseases and structured Medicaid and treatment, and cost containment measures (Khullar & Chokshi, 2018, pg. 17). Self-management interventions require assistance from patients, and therefore, affordable health care is important. ACA is also known to affect some economic aspects of health care, including costs, coordination, and the continuum of care. Telemedicine and telehealth policies also regulate patient access to resources in the online community. All these health policies affect the coordination and continuum of care for the Patient.
Priorities a Care Coordinator Would Establish When Discussing the Plan
There’s a requirement for the consideration coordinator to lay out needs while discussing the plan with the patient and relatives. A few laid-out needs can be the prosperity, security, and nature of care given to the patient. Be that as it may, needs can change depending on evidence-based practice (EBP). At the point when there’s a need to execute a change-based EBP, the patient’s clinical history, culture, and autonomic choice will be thought of. Other needs a consideration coordinator would lay out is the expense of medical services and training meetings for the patient and the relatives. NURS FPX4050 Assessment 4 is fundamental to think about those two viewpoints, as training for the patients and families will feature the counteraction of a stroke. Further, the requirement for a change ought to be pointed out as there’s an inability to forestall, treat, or manage as this will bring about mortality, grimness, and other confusions (Zhao et al., 2018, pg. 208).
Evaluating The Best Practice and Healthy People 2030
The causes of stroke, cardiovascular diseases, and diabetes are all linked to each other, as one causes the other. Effective patient-centered intervention would need to be used to prevent, treat, or manage the current health issues to reduce the risk of a stroke. The best evidence-based practice (EBP) solution during a stroke is to perform carotid interventions (Morris et al., 2017, pg. 24). Health People 2030 focuses on patient-centered care and adopting new EBP in care to provide a better treatment outcome and recovery (Health People 2030, n.d). The best practice for stroke is the combination of stress management, vascular interventions, thrombolytic, and patient care based on psychosocial, social, and cultural aspects (Lindekleiv et al., 2018, pg. 11). The best EBP to treat, prevent, and manage cardiovascular disease can be educated on the alternation of the diets and incorporation of moderate exercise. In addition, the best EBP to prevent and manage diabetes can be exercise, diet alternations, and continuous check-ups to monitor the A1C from the bloodwork.
Readmission Rates and Cost
Healthy People 2030 has identified some key aspects that reduce the mortality rate of stroke occurrence. Their objectives aim to reduce hospital stays, readmission rates, and cost of care. In addition, they aim to increase the quality of care through care coordination plans and collaboration with other healthcare professionals. Educational sessions for the patient on the best EBP to treat, prevent, and manage their health diseases to prevent or reduce the risk of a stroke aligns with Healthy People 2030. Thus, the care coordination plan should include healthy people’s objectives as revisions. Failure of the best EBP in the care coordination plan to achieve the aim of Healthy People 2030 listed above would need revisions to accomplish those objectives.
References
Brandhorst, S., & Longo, V. D. (2019). Dietary restrictions and nutrition in the prevention and treatment of cardiovascular disease. Circulation Research, 124(6), 952–965. https://doi.org/10.1161/circresaha.118.313352 Centers for Disease Control and Prevention. (2022, February 7). Heart disease facts. Centers for Disease Control and Prevention.
DeCamp, M., Pomerantz, D., Cotts, K., Dzeng, E., Farber, N., Lehmann, L., Reynolds, P. P., Sulmasy, L. S., & Tilburt, J. (2017). Ethical issues in the design and implementation of population health programs. Journal of General Internal Medicine, 33(3), 370–375. https://doi.org/10.1007/s11606-017-4234-4
Donkor, E. S. (2018). Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life. Stroke Research and Treatment, 2018, 1–10. https://doi.org/10.1155/2018/3238165