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.
Full Answer Section
As a staff nurse at a community care center, I am concerned about the impact of low health literacy on our patients. In the absence of dedicated case management staff, I am taking on the responsibility of coordinating care for these individuals, ensuring they receive appropriate and accessible information and support. This preliminary care coordination plan outlines my approach to managing patients with low health literacy.
- Health Concern: Low Health Literacy
2.1. Physical Considerations:
- Poor health outcomes: Individuals with low health literacy are more likely to experience chronic diseases, complications from existing conditions, and hospital readmissions due to inadequate self-management.
- Difficulty managing chronic conditions: Understanding medication regimens, dietary restrictions, and treatment plans can be challenging, leading to non-adherence and poor disease control.
- Increased vulnerability to misinformation: Individuals with low health literacy may be more susceptible to inaccurate or misleading health information, leading to inappropriate self-care practices.
2.2. Psychosocial Considerations:
- Anxiety and depression: Difficulty navigating the healthcare system, understanding diagnoses, and making informed decisions can be stressful and overwhelming, leading to anxiety and depression.
- Social isolation and stigma: Individuals with low health literacy may feel embarrassed or ashamed to ask questions or seek help, leading to social isolation and hindering their ability to access needed resources.
- Loss of autonomy and control: Dependence on others for understanding health information and making healthcare decisions can be disempowering and lead to feelings of loss of control.
2.3. Cultural Considerations:
- Language barriers: Limited English proficiency or reliance on interpreters can create communication difficulties and impede effective care delivery.
- Cultural beliefs and practices: Traditional healing practices and cultural beliefs about health and illness may conflict with conventional medical recommendations, requiring cultural sensitivity and patient-centered care.
- Socioeconomic disparities: Individuals from low-income and minority communities are disproportionately affected by low health literacy, highlighting the need for culturally competent and accessible healthcare services.
- Care Coordination Plan:
3.1. Assessment and Identification:
- Screening tools: Utilize validated screening tools like the Brief Health Literacy Screening Tool (BHLST) to identify patients with low health literacy.
- Patient interviews: Conduct open-ended interviews to understand patients' preferred learning styles, language needs, and cultural beliefs about health.
- Collaboration with providers: Partner with physicians, nurses, and other healthcare providers to identify patients with medication non-adherence, poor disease control, or difficulty understanding diagnoses.
3.2. Intervention and Education:
- Clear and concise communication: Avoid medical jargon and use plain language, visuals, and culturally relevant materials to explain diagnoses, treatment options, and self-management strategies.
- Patient-centered education: Tailor educational materials and interventions to individual needs and learning styles, incorporating interactive activities and hands-on demonstrations.
- Medication adherence support: Utilize medication reminder systems, pillboxes with pictograms, and culturally appropriate medication counseling to improve adherence.
- Technology and telehealth: Leverage technology like video consultations, online educational resources, and text message reminders to improve access to information and support.
3.3. Community Resources:
- Health literacy programs: Partner with local libraries, community centers, and public health agencies that offer health literacy workshops and educational programs.
- Patient navigators: Utilize trained patient navigators who can help individuals navigate the healthcare system, access necessary resources, and advocate for their health needs.
- Multilingual resources: Ensure access to translated materials, interpreters, and culturally competent healthcare providers to address language barriers.
- Social support groups: Connect individuals with peer support groups or community organizations that offer emotional support and information sharing for those facing similar challenges.
- Evaluation and Monitoring:
- Track intervention outcomes: Monitor medication adherence, disease control markers, and healthcare utilization to assess the effectiveness of interventions.
- Patient satisfaction surveys: Regularly collect feedback from patients to identify areas for improvement and ensure their needs are met.
- Data analysis and refinement: Analyze data to identify trends and patterns, refine interventions, and continuously improve the care coordination plan.
- Conclusion:
Low health literacy presents a significant challenge for healthcare providers and individuals alike. This preliminary care coordination plan outlines a comprehensive approach to addressing this issue by focusing on patient-centered education, community resources, and ongoing evaluation. By implementing these strategies, we can empower individuals with low health literacy to navigate the healthcare system effectively, make informed decisions, and achieve better health outcomes.
Sample Answer
1. Introduction:
Low health literacy is a significant public health issue, affecting millions of individuals globally. It is defined as the limited ability to understand, interpret, and use health information effectively. This can lead to a plethora of challenges, including poor health outcomes, inadequate medication adherence, inappropriate utilization of healthcare services, and increased healthcare costs.