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.
- Before you complete the instructions detailed in the course room, first select one of the following health care problems or issues:
Health Literacy
• Physical considerations: Low health literacy can lead to poor health outcomes and difficulty managing chronic diseases.
• Psychosocial considerations: Low health literacy can cause emotional distress, anxiety, and depression.
• Cultural considerations: Cultural beliefs and practices may influence an individual.
• Community resources: Health literacy programs, patient education materials, and health navigators can provide resources and support for individuals with low health literacy.
Environmental Health
• Physical considerations: Environmental hazards such as air pollution, lead exposure, and toxic waste can cause physical health problems.
• Psychosocial considerations: Environmental hazards can cause emotional distress, anxiety, and depression.
• Cultural considerations: Cultural beliefs and practices may influence an individual's exposure to environmental hazards.
• Community resources: Environmental health clinics, community clean-up programs, and advocacy groups can provide resources and support for individuals affected by environmental hazards.
After you have selected one of the problems/issues from the list above, return to the detailed instructions in the course room to complete your assessment.
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.
Instructions
Develop the Preliminary Care Coordination Plan
Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF] Download Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
Identify available community resources for a safe and effective continuum of care.
Full Answer Section
- Physical Considerations:
- Symptoms: Fatigue, shortness of breath, edema, weight gain, coughing, palpitations, and dizziness.
- Diagnosis: Medical history, physical examination, echocardiogram, chest X-ray, blood tests.
- Treatment: Medications (diuretics, ACE inhibitors, ARBs, beta-blockers), lifestyle modifications (salt restriction, weight management, exercise, diet), device therapy (implantable devices), palliative care for advanced cases.
- Complications: Hospitalization, worsening symptoms, arrhythmias, kidney failure, and death.
III. Psychosocial Considerations:
- Depression and anxiety: Common due to diagnosis, physical limitations, and fear of death.
- Social isolation: Reduced participation in activities due to fatigue and fear of symptoms.
- Financial stress: Cost of medications, treatment, and potential loss of income.
- Family impact: Caregiving burden on family members.
- Cultural beliefs and practices: Understanding cultural views on illness and treatment is crucial for effective communication and care planning.
- Cultural Considerations:
- Dietary habits and preferences: Cultural diets may need Anpassung to adhere to heart-healthy recommendations.
- Language barriers: Access to culturally competent interpretation and health education materials is essential.
- Traditional medicine practices: Understanding and integrating these practices with conventional treatment can improve adherence and well-being.
- Religious beliefs: Addressing spiritual concerns and respecting religious practices can provide comfort and support.
- Care Coordination Plan:
- Interdisciplinary Team:
- Primary care physician
- Cardiologist
- Nurse practitioner
- Social worker
- Mental health therapist
- Nutritionist
- Pharmacist
- Home health care provider (if needed)
- Care Plan Components:
- Comprehensive assessment: Physical, psychosocial, spiritual, and cultural needs.
- Individualized treatment plan: Combining medication, lifestyle modifications, and psychosocial support.
- Patient education: Clear and culturally appropriate information about HF, medications, management strategies, and available resources.
- Regular follow-up appointments: Monitor progress, address questions, and adjust treatment as needed.
- Communication and collaboration: Between team members and with patients and their families.
- Discharge planning: Seamless transition from hospital to home with adequate resources and support.
- Crisis management plan: Plan for managing acute exacerbations and preventing hospital readmissions.
- Community Resources:
- Support groups: Provide peer support, education, and social connection.
- Meals on Wheels: Provides nutritious meals for individuals struggling with food preparation.
- Transportation assistance: Helps individuals access medical appointments and other essential services.
- Financial assistance programs: Help with the cost of medications and medical care.
- Home health care agencies: Provide in-home nursing care, physical therapy, and other services.
- Hospice care: Provides palliative care for individuals with advanced HF.
VII. Monitoring and Evaluation:
- Regular assessment of symptoms, functional status, and quality of life.
- Monitoring medication adherence and compliance with treatment plan.
- Evaluation of the effectiveness of care coordination interventions.
- Ongoing adjustments to the care plan as needed.
VIII. Conclusion:
Effective care coordination plays a crucial role in optimizing outcomes for individuals living with heart failure. This plan outlines a comprehensive approach that considers physical, psychosocial, and cultural factors, along with leveraging available community resources. By implementing this plan and continuously monitoring and evaluating its effectiveness, we can ensure that individuals with heart failure receive the coordinated care they need to live longer, healthier lives.
Sample Answer
Preliminary Care Coordination Plan for Heart Failure
Health Care Problem: Heart failure (HF)
Target Population: Adults diagnosed with heart failure, with a focus on individuals managing chronic HF at home.
I. Introduction:
Heart failure is a chronic condition where the heart cannot pump enough blood to meet the body's needs. It affects millions worldwide and significantly impacts quality of life, often leading to repeated hospitalizations. Effective care coordination is crucial for optimizing outcomes and reducing healthcare costs.