Final Care Coordination Plan

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.

Design patient-centered health interventions and timelines for a selected health care problem.

Competency 2: Collaborate with patients and family to achieve desired outcomes.

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

Competency 3: Create a satisfying patient experience.

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document.

Competency 4: Defend decisions based on the code of ethics for nursing.

Consider ethical decisions in designing patient-centered health interventions.

Competency 5: Explain how health care policies affect patient-centered care.

Identify relevant health policy implications for the coordination and continuum of care.

Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

Instructions

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Design patient-centered health interventions and timelines for a selected health care problem.

Address three health care issues.

Design an intervention for each health issue.

Identify three community resources for each health intervention.

Consider ethical decisions in designing patient-centered health interventions.

Consider the practical effects of specific decisions.

Include the ethical questions that generate uncertainty about the decisions you have made.

Identify relevant health policy implications for the coordination and continuum of care.

Cite specific health policy provisions.

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

Clearly explain the need for changes to the plan.

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document.

Use the literature on evaluation as guide to compare learning session content with best practices.

Align teaching sessions to the Healthy People 2020 document.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Sample paper 

Final Diabetic Care Coordination Plan Care coordination can be defined in many ways, such as, deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This also means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient (Care Coordination | Agency for Healthcare Research & Quality, 2018). Regardless of the definition, the goals of care coordination are to meet the patients needs, assist with transferring patient information to the appropriate people, improving the patients overall health outcome and aiding them in being in control of their health care decisions. Currently, diabetes is the seventh leading cause of death in the United States, it affects over 34 million Americans (CDC, 2020). There has been a downward trend of adults being diagnosed with diabetes, but an upward trend has been seen in the number of youth (ages 10-19) diagnosed with both type 1 and type 2 diabetes. Certain ethnic groups, such as American Indians and Alaska Natives, are more susceptible to diabetes and have the highest percentage of existing cases. Patient-Centered Health Interventions and Timelines for Care Along with the diagnosis of diabetes, there also comes the potential of several other health concerns such as high blood pressure, high cholesterol which can lead to heart disease, stroke, blindness, kidney failure, limb amputations and premature death. Having diabetes also puts a person at an increased risk of certain types of cancers including liver, breast, pancreas, uterine and bladder cancer (CDC, 2019). One of the main goals for diabetic control is obtaining good blood sugar management: the target range for fasting blood sugars is 70-100 and A1C is less than 5.6%. Keeping blood sugar readings within the target range can be achieved through healthy eating, such as following the American Diabetes Association diet, and exercise, at least 10 minutes with a goal of 30 minutes most days of the week (Colberg et al., 2016). Checking blood sugars at home should be done four times per day, fasting first thing in the morning, before the noon and evening meal, and before bedtime, this schedule could change per the physicians discretion. Checking the A1C should be done every three months or as directed by the provider. Blood pressure management can help reduce the risk of heart disease, stroke and kidney failure. The ideal range for blood pressure is less than 140 for the systolic and less than 90 for the diastolic. This can be achieved through a heart healthy diet that is low in sodium and meeting the exercise goal of 10 30 minutes most days of the week. Having ones blood pressure checked at every doctors appointment is an important piece to monitoring, and if available to have an in home blood pressure machine to further monitor the readings. Medication compliance can also be a health care issue when treating a patient with diabetes. Diabetic medication is very expensive and at times not covered by medical insurance or Medicare. Honest conversations with the provider/care coordination and the patient need to happen so that the patient is aware of the potential for no coverage and the provider is aware that this could derail the treatment regimen. The patient needs to be honest with the providers if they are taking the medication as prescribed, a different way, or not at all, the provider is not able to properly treat if they are not made aware of how medication is being used or if at all. These conversations need to happen at every visit and sooner if problems arise. Community Recourses One community resource to utilize for the overall health of a diabetic is working with the Chronic Care Management team (CCM) at the clinic. Patients meet individually, in person or via telephone, with a registered nurse and a health coach to work on personal goals, ways to achieve them, and ways to overcome any potential barriers. The CCM team also works with the patients primary care physician to ensure compliance with medications, appointments, and blood draws. They also are able to assist with financial situations, such as assisting with medication programs when cost is an issue. Meeting with the clinics diabetic educator and dietician is another resource that is available to aide in managing target blood sugar and blood pressure readings. They can assist with healthy meal planning and ways to modify ones diet as to not have to eliminate all unhealthy foods. The wellness center is another community option to work on meeting the recommended fitness goals. The wellness center has an onsite athletic trainer that is able to work individually to set goals and to also demonstrate proper use of the machines as to not cause injury. Another resource is the Better Choices Better Health Diabetic Self-Management program. The BCBH program is a six week group centered program that is led by healthcare workers to assist the person with ways to self-manage their diabetes. Some of the topics include healthy eating, meal planning, coping with stress and difficult emotions, exercise, and how to communicate with ones provider. All of these community resources (with the exceptions of the BCBH program) are individually tailored to the patient and their needs. Their cultural and family beliefs can be incorporated into the plan to increase the best potential outcome. Ethical Decisions in Designing Patient-Centered Health Interventions There are four main principles that make up the nurses code of ethics, they include autonomy, beneficence, justice, and non-maleficence. These principles should be the foundation of every healthcare workers daily practice (Gaines, 2020). Autonomy is allowing every patient the right to self-determination and decision making: this is one of the main goals to care coordination. It is the care coordinators responsibility to ensure that the patient has all the information, education, risks, benefits, and options regarding their diagnosis and treatment to be able to decide what their best option is. It is important that the care coordinator support the patients decisions while still providing any needed education along the way. Beneficence is acting for the good and welfare of the patient, actions guided by compassion (Gaines, 2020). It is the care coordinators responsibility to be the patients advocate and have their plan of care in the best interest of their health. Justice deals with fairness in decisions and care. The care coordinator must care for all patients with the same level of fairness despite factors such as race, gender, religious beliefs, and financial abilities. Non-maleficence is to do no harm. This ensures the safety of the patient in the delivery of their care. The care coordinator needs to be aware of all the treatment options and assist in choosing those that will cause the least amount of harm to attain beneficial outcomes. Health Policy Implications for the Coordination and Continuum of Care According to the Centers for Medicare & Medicaid Services (CMS) website, Chronic Care Management (CCM) requires at least 20 minutes of clinical staff time by either a physician or other qualified healthcare professional per calendar month. The following requirements need to be met to be in the CCM program: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, having a comprehensive care plan established, implemented, revised and/or monitored. Some qualifying chronic conditions include arthritis, asthma, atrial fibrillation, COPD, cardiovascular disease, depression, diabetes, and hypertension. The CCM program is the foundation for the care coordination program and gives the healthcare facility the ability to make the program a billable service. The hospital readmissions reduction program is a part of the patient protection and affordable care that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. The program supports the national goal of improving health care for Americans by linking payment to the quality of hospital care (Centers for Medicare and Medicaid Services, 2016). The goal is to be able to treat the patients healthcare needs without readmission to the hospital. Change Management Change happens in all areas of healthcare and care coordination is not immune. The best plan of care will require change at some time, as the patient progresses or regresses. Change will have to be made in order to allow for improvement to happen or continue. When working with patients and their family members on care plan changes, it is beneficial to use a change management model for guidance on how to initiate and support the change. The Lewins ThreeStep Model for Planned Change consists of three stages: Unfreezing: creating problem awareness, making it possible for people to let go of old ways and undo the current behavior. This is done by educating, challenging the status quo, and demonstrating issues or problems Changing or seeking alternatives: demonstrating benefits of change, and decreasing the things that affect change negatively. This is done by brainstorming, role modeling new ways, coaching, and training. Refreezing: integrating and stabilizing a new change so it becomes habit and resists relapse. This is done by celebrating success and re-training (A Case Review: Integrating Lewins Theory with Leans System Approach for Change, 2016). Healthy People 2020 The goals of Healthy People 2020 include: attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieving health equity, eliminate disparities, and improve the health of all groups; creating social and physical environments that promote good health for all; and promoting quality of life, healthy development, and healthy behaviors across all life stages. (About Healthy People | Healthy People 2020, 2020). Some of their diabetic objectives include reducing the number of new diabetes diagnosis, improve glycemic control among persons with diabetes, increase the proportion of persons with diagnosed diabetes whose blood pressure is under control, improve lipid control among persons with diagnosed diabetes, and increase the proportion of persons with diagnosed diabetes who have at least an annual dental examination (About Healthy People | Healthy People 2020, 2020). These goals align with the literature discussing some of the best practices for treatment of diabetes and diabetes related incidences. A 2019 article published in the British Dental Journal looked at some best practices for diabetics and oral care. It looked at three recommended clinical behaviors for improvement. These behaviors included informing patients with diabetes about the links between diabetes and periodontitis, considering the impact of periodontitis treatment on the patients glycemic control, as opposed to treating periodontitis in isolation from the diabetes, and contacting the doctor with regard to the management of patients who have periodontitis and poorly controlled diabetes (Bissett, Presseau, Rapley, & Preshaw, 2019). By more providers, not just medical, being aware of best practices and outcome goals, patients have an increased chance of not falling off the radar for their health diagnosis. Conclusion Care coordination is continuously gaining momentum and will continue to be the cornerstone to quality patient care. Care coordination can not only assist patients but also family members with navigating through the healthcare system to help alleviate the burden of being overwhelmed by their diagnosis. Care coordination puts the patient and their healthcare decisions at the forefront and its the care coordinators duty to provide support and education along the way