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.
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.
• Allow plenty of time to plan your chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
• 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
Health Concern: Heart Failure (HF)
HF is a chronic condition where the heart's ability to pump blood effectively is impaired. This leads to a buildup of fluid in the body, causing shortness of breath, fatigue, and swelling in the legs. HF is a significant public health issue, with a high prevalence and mortality rate.
Physical Considerations:
- Medication Management: Patients with HF require a combination of medications to manage symptoms and prevent complications, such as diuretics, ACE inhibitors, and beta-blockers. Adherence to medication regimens is essential.
- Dietary Management: A heart-healthy diet low in sodium and saturated fat is crucial for managing HF and preventing further cardiovascular events.
- Fluid Restriction: Fluid intake may need to be monitored to prevent fluid overload and worsening symptoms.
- Physical Activity: Regular, low-impact exercise can improve physical function and overall well-being in patients with HF.
- Symptom Monitoring: Patients need to be educated about recognizing and reporting worsening symptoms like shortness of breath, fatigue, or weight gain.
Psychosocial Considerations:
- Emotional Distress: HF can significantly impact a person's quality of life, leading to anxiety, depression, and social isolation.
- Social Support: Social support networks are crucial for coping with the challenges of chronic illness.
- Mental Health Care: Addressing anxiety and depression is essential for overall well-being and treatment adherence.
- Financial Concerns: The cost of medications, treatments, and transportation can create financial strain.
Cultural Considerations:
- Health Beliefs: Cultural beliefs about illness and treatment may influence healthcare utilization.
- Language Barriers: Language barriers can hinder communication and understanding of instructions.
- Dietary Practices: Dietary adaptations may be necessary to accommodate cultural preferences while adhering to heart-healthy dietary recommendations.
- Religious Practices: Religious beliefs may influence dietary restrictions or acceptance of certain treatments.
Care Coordination Plan:
- Assessment:
- Conduct a comprehensive assessment on admission to the community care program, including physical, psychosocial, and cultural needs.
- Utilize culturally appropriate assessment tools and translation services if necessary.
- Plan of Care:
- Develop a personalized care plan addressing physical limitations, medication management, dietary restrictions, and activity level.
- Consider cultural preferences and address any language barriers.
- Involve the patient and their family in developing the plan for better adherence.
- Implementation:
- Collaborate with a healthcare team, including physicians, dietitians, social workers, and mental health professionals, to implement the care plan.
- Coordinate medication management and schedule follow-up appointments with specialists.
- Work with community resources to provide support services, like transportation or meal delivery.
- Monitoring and Evaluation:
- Monitor adherence to medication regimens, dietary recommendations, and activity goals.
- Regularly assess patient well-being, including physical symptoms, emotional status, and social functioning.
- Modify the care plan as needed based on patient progress and changing needs.
Community Resources:
- American Heart Association (AHA): Provides educational resources, support groups, and advocacy for patients with heart disease (www.heart.org).
- National Heart, Lung, and Blood Institute (NHLBI): Offers information and resources for patients with HF (www.nhlbi.nih.gov/health-topics/heart-failure).
- Local Support Groups: Connect with others managing HF for peer support and information sharing.
- Nutritional Counseling Services: Dietitians can provide personalized guidance on heart-healthy eating.
- Mental Health Services: Address emotional concerns and manage mental health conditions associated with chronic illness.
- Transportation Services: Help ensure reliable transportation to appointments and medication pickups.
- Home Delivered Meals: Provide access to nutritious meals for individuals struggling to cook independently.
Conclusion:
Effective care coordination is crucial for managing HF in a community setting. This preliminary plan emphasizes the importance of addressing physical, psychosocial, and cultural needs while leveraging available community resources. Through collaboration, communication, and ongoing monitoring, this approach aims to improve patient outcomes and quality of life for individuals living with HF.
.
Sample Answer
Preliminary Care Coordination Plan: Heart Failure
Introduction:
This preliminary care coordination plan addresses heart failure (HF) in a community setting. Following budget cuts that eliminated dedicated case management staff, the responsibility for coordinating care now falls to nurses. This plan outlines a comprehensive approach for managing patients with HF, considering physical, psychosocial, and cultural factors. Effective care coordination is crucial for optimizing patient outcomes and ensuring a safe and effective continuum of care.