Develop a 3-4 page preliminary care coordination plan for a selected 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.
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Introduction
The first step in any effective project is planning. This assessment 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.
NOTE: You are required to complete this assessment before Assessment 4.
Preparation
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.
Scenario
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.
Full Answer Section
- Potential Complications:Pulmonary edema, arrhythmias, hospital readmission.
Psychosocial Considerations:
- Depression and Anxiety:Heart failure can lead to depression and anxiety due to limitations in daily activities and fear of complications.
- Social Isolation:Physical limitations and fatigue can lead to social isolation, impacting mental well-being.
- Support System:Assess the patient's support system (family, friends) and their ability to assist with daily needs.
- Mental Health Resources:Provide referrals for counseling or support groups if needed.
Cultural Considerations:
- Beliefs about Illness:Explore the patient's cultural beliefs about heart failure and treatment options.
- Dietary Practices:Consider cultural preferences and adapt the low-sodium, low-fat diet to accommodate them.
- Language Barriers:If English is not the primary language, identify a translator or culturally appropriate resources.
- Religious Practices:Be mindful of religious practices that might impact dietary restrictions or medication adherence.
Community Resources:
- Cardiologist:Regular follow-up appointments for monitoring and medication adjustments.
- Heart Failure Clinic:Specialized clinic providing education, support groups, and disease management programs.
- Nutritionist:Develop a personalized low-sodium, low-fat diet plan considering cultural preferences.
- Home Health Nurse:Provide education on medication management, monitoring vital signs, and activities of daily living.
- Mental Health Services:Referral for individual therapy or support groups to address depression and anxiety.
- Transportation Services:Assist with transportation to medical appointments or grocery shopping.
- Meals on Wheels:Home-delivered meals for patients who have difficulty preparing healthy meals.
- Senior Center:Socialization opportunities, exercise programs, and educational workshops on managing chronic conditions.
- Faith-Based Organizations:Provide social support, spiritual counseling, and potential meal assistance programs (depending on the organization).
Care Coordination Plan:
- Initial Assessment:
- Conduct a comprehensive assessment of Mr. Doe's physical health, including medication adherence, dietary habits, activity level, and symptom management.
- Assess his mental health status, including signs of depression or anxiety.
- Explore his cultural beliefs and preferences related to illness and treatment.
- Develop a Plan of Care:
- Develop a collaborative plan of care with Mr. Doe, his physician, and other healthcare providers involved.
- Outline medication schedule, dietary plan, and activity recommendations.
- Set specific and measurable goals for managing symptoms and improving quality of life.
- Identify the primary care provider responsible for coordinating care and communication between specialists.
- Implementation:
- Refer Mr. Doe to appropriate community resources such as a nutritionist, home health nurse, and mental health services.
- Facilitate communication between healthcare providers to ensure continuity of care.
- Educate Mr. Doe and his support system on managing heart failure, medication management, and recognizing complications.
- Monitoring and Evaluation:
- Schedule regular follow-up appointments to monitor Mr. Doe's progress towards goals.
- Monitor vital signs, medication adherence, and symptom management.
- Conduct periodic assessments of mental health and well-being.
- Evaluate the effectiveness of the care plan and make adjustments as needed.
- Communication:
- Maintain open communication with Mr. Doe and his support system.
- Facilitate communication between healthcare providers involved in Mr. Doe's care.
- Document all interactions and updates in the patient's medical record.
Conclusion:
This care coordination plan provides a framework for managing Mr. Doe's heart failure in a community setting. By addressing physical, psychosocial, and cultural considerations, this plan aims to improve his health outcomes, quality of life, and reduce the risk of complications and hospital readmission. Utilizing available community resources ensures a comprehensive and coordinated approach to managing chronic heart failure.