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Health Concern and Associated Best Practices

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Health Concern and Associated Best Practices

Care coordination is composed of deliberate organization of patient care activities as well as sharing of information among every participant concerned with the care of the patient in order to attain more effective and safer care. The main goal of care coordination is to meet the patient’s preferences and needs in delivering high-value and high-quality health care. A multidisciplinary team is often required in the care of patients with various, often chronic diseases. In this case, the care coordination plan will focus on caring for heart disease patients.

Healthy People 2020 (2020) reveals that heart disease is the leading mortality cause in the US, and stroke takes fifth place. Together with other cardiovascular illnesses, heart disease results in a total of £320 billion spent on health care and other expenses yearly. The common risk factors of heart disease include: diabetes, obesity and overweight, high cholesterol, high blood pressure, physical inactivity, unhealthy diet, and cigarette smoking. Addressing these risk factors at an early stage is essential. Heart disease risk can be lessened if individuals indulge in regular physical activity, a proper and nutritional diet, control their cholesterol and sodium intake, and quit smoking. This paper aims to outline a care coordination plan that addresses heart disease patients’ psychosocial, physical, and cultural needs and identifies the community resources available for an effective and safe continuum of care.

Goals for Addressing Heart Disease

Heart diseases are a common cause of mortality in the US. Research shows that care coordination after a patient with heart disease has been discharged from the hospital helps reduce readmissions, reduce mortality, and enhance patient satisfaction (Halatchev, McDonald & Wu, 2020). The care coordinator needs to be familiar with the patient’s financial, social, mental, and medical condition and must work with multidisciplinary support staff such as a dietician, social worker, primary care physician, and clinical pharmacist to help in the recovery of the patient. The goal of the care coordination plan is to: ensure the client eats a healthy diet, the client indulges in regular physical activity, maintains a healthy weight, and also the client limits or quits intake of alcohol and tobacco.

In order to meet these goals, having a multidisciplinary team that will help address the patient’s various physical, psychosocial, and cultural needs will be important. For instance, a registered dietician will be needed to address the diet modifications of patients based on their cultural and individual needs and beliefs. A physical therapist will be needed to help patients in supervised workouts. A social worker can address the social support and resources the client needs. A psychologist will be required to cater to the patient’s psychological needs, such as anxiety and depression. A clinical pharmacist will be needed for proper medication. A nurse will be needed to ensure proper care coordination and a physician will be needed to assess the patient’s condition regularly.

Cultural considerations should be taken into account when designing diet modifications. In some cultures, being plump is considered a sign of good health, so such body size perceptions should be considered when evaluating diet modifications. Research by Moholdt, Lavie, and Nauman (2018) shows that regular physical activity and not weight loss reduces mortality risk among heart disease patients. Having background and lifestyle information about the patient can be important in counseling about reducing the risks of cardiovascular diseases.

Available Community Resources

New Jersey at Heart is a community resource that works to generate a world free of stroke and heart disease and where individuals can attain the best health possible. The organization collaborates with city leaders to support more biking routes, walking and drive initiatives that make healthier food options accessible to individuals, and offering children the opportunity to stay active in school. The organization also works with emergency care professionals, hospitals, and communities for efficient and effective care systems to improve and save lives (New Jersey at Heart, 2020).

Healthy Lives Program

Healthy Lives Program is an added service at the Community Medical Center in New Jersey. This facility helps individuals understand everything needed to help them lead a healthy life. Programs that support proper lifestyle choices and monitoring to enhance the quality of life and patient outcomes are available. Participation in this program could begin during one’s in-patient stay at the Community Medical Center, or a physician could refer one to the program as an outpatient. The program works with a multidisciplinary team of professionals to help with symptom monitoring, management, and lifestyle education (Healthy Lives Program, 2020).

Deborah Heart and Lung Center

This community resource aims to provide free speakers and health screenings to the public on cardiovascular disease risk factors and help them lead a healthy lifestyle. The organization distributes information on managing cholesterol and blood pressure, heart-healthy cooking and recipes, and eating tips. The organization works with members from other organizations to provide necessary information on reducing heart disease risks (Deborah Heart and Lung Center, 2020). Working with these community resources will play a major role in enhancing and coordinating the care of patients with heart disease.

References

Deborah Heart and Lung Center. (2020). Community Outreach. Retrieved from https://demanddeborah.org/patients-and-visitors/community-resources/community-outreach/

Halatchev, I. G., McDonald, J. R., & Wu, W. C. (2020). A patient-centred, comprehensive model for the care for heart failure: the 360° heart failure centre. Open Heart, 7(2), e001221.

Healthy Lives Program. (2020). Heart Failure Intervention. Retrieved from https://www.rwjbh.org/community-medical-center/treatment-care/heart-and-vascular-care/programs-and-specialties/healthy-lives-program/

Healthy People 2020 (2020). Heart Disease and Stroke. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke

Moholdt, T., Lavie, C. J., & Nauman, J. (2018). Sustained physical activity, not weight loss, associated with improved survival in coronary heart disease. Journal of the American College of Cardiology, 71(10), 1094-1101.

New Jersey at Heart. (2020). Home. Retrieved from https://www.heart.org/en/affiliates/new-jersey/new-jersey

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Question 

Health Concern and Associated Best Practices

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.
NOTE: You are required to complete this assessment before Assessment 4.
The first step in any effective project is planning. This assignment 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.
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.

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.
Analyze a health concern and the associated best practices for health improvement.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe specific goals that should be established to address a selected health care problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Organize content so ideas flow logically with smooth transitions; contains few errors in
grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA
format.

Preparation
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:

Allow plenty of time to plan your chosen healthcare concern.
Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring for feedback,
before you submit the final version for this assessment. If you plan on using this free service, be mindful of the
turnaround time of 24–48 hours for receiving feedback.

Instructions

Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical,
psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:

Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
Remember to use active voice, this means being direct and writing concisely; as opposed to passive
voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.

Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your
preliminary plan.
Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.
Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the health care problem.
Identify available community resources for a safe and effective continuum of care.

Health Concern and Associated Best Practices

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation,
word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list
to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your
plan. Be sure to submit both documents.
Portfolio Prompt: Save your presentation to your ePortfolio.

SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.

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