Program Name, Institution
COURSE CODE: Course Title
Final Care Coordination Plan
When it comes to providing healthcare services in today’s environment, care coordination is a crucial part of the process. It is being done in an attempt to resolve the difficult problems that the experts in this sector are experiencing. Poor patient outcomes, Cost of service provision and substandard quality are all issues that need to be addressed. These shortcomings lead to an increase in medical mistakes, as well as an increase in human suffering and resource consumption. Therefore, care coordination offers the community an opportunity to gain from a recovery-focused and collaborative service delivery model to address these issues (World Health Organization, 2018). This cooperation is the result of a purposeful arrangement of a client’s care plan with two or more partners in order to provide suitable, coordinated, and sufficient service provision to the patient in question. The care coordination team in this case would include the patient, nurse, physician, and the caregiver. Care coordination guarantees that a comprehensive approach to care is taken as a result of this coordinated treatment that includes a multidisciplinary approach to care (World Health Organization, 2016).
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Providing patient-centered care in chronic obstructive pulmonary disease (COPD) is a complex effort that entails more than simply appropriate diagnosis and management of the illness. To offer the best possible treatment, it is necessary to have a multidisciplinary connection amongst health care professionals. This cooperation is concerned with the patient’s objectives to meet the patient’s requirements. It takes into account both emotional and physical requirements in order to enhance the overall quality of care
Patient Health Issues
Smoking is one of the most common triggers of COPD. Aside from being the source of severe flare-ups, the habit causes damage to the lining of the lung, air sacs, and the airways themselves .It is hard for the lungs to move air in and out as a result of this damage, which causes breathing to be a major difficulty(Johansson et al., 2019). About 650 million individuals, or half of the world’s smokers, will die as a result of their tobacco usage. Mr. X’s health is very concerned as a result of this situation. Individuals who smoke cigarettes have a higher chance of dying from any cause. However, there is a great deal of potential for affecting the natural history of the disease after treatment has been discontinued (Bai et al., 2017).
Smokers are rapidly being denied treatment by doctors on the grounds that they are ethically accountable for their illnesses, which is becoming more and more widespread. The ethical responsibility that practitioners have to provide just and inclusive care to all clients cannot also be overstated. Whenever a patient fails to carry out medical decisions for improved health, the care coordination team, which includes the nurse, physician, patient and caregiver, is morally obligated to provide the care and resources that are required to restore health. According to Gratziou (2017), quitting smoking has been shown to improve results in COPD patients. The World Medical Association clarifies that every health practitioner has the legal right to offer the treatment without regard to race, gender, or ethnicity (Senderovich, 2016). A smoking cessation approach, as it pertains to the ethical perspective, is needed as a key step on the road to rehabilitation, and this is why it is necessary.
The participation of the patient’s family is essential in developing a treatment plan for him or her. My initial plan of care is to encourage the client to tell his family and friends of his or her decision to stop smoking. The patient has already shown the willingness to stop smoking, and I am set to help him in this endeavor by providing him with applicable health teachings. These health teachings would include encouraging him to avoid triggers, engage in physical activity to get distracted, practice relaxation techniques, and remind himself the benefits of tobacco cessation. He will also be required to put down the grounds for his decision to quit smoking to enable him become goal-driven to maintain his healthy and balanced way of living. It is also advisable to tell him that it is Okay to try to stop more than once, even if they do not manage on the first effort to quit. When it comes to protecting others from secondhand smoking, he will make certain that his house and vehicle are smoke-free zones and that any ashtrays are removed from the premises. If at all possible, he is obliged to frequent smoke-free establishments such as public places and restaurants. Mr. X will also get medicines for his addiction and to assist alleviate the symptoms of withdrawal from his main care physician via the primary care physician.
The American Lung Association is a valuable resource that also gives telephone counseling on how to successfully stop smoking. In order to fulfill this function, the patient will join a support group and make use of this resource. Quitting smoking may not be simple, but with the introduction of new medicines to the market and the implementation of helpful programs, it is feasible.
Depression and Anxiety
Anxiety and depression are also conveyed by the client, and this could take a toll on his health. Delay in recognizing and treating depression and anxiety has a negative impact on the social interaction and physical capabilities of those who suffer from these conditions (Majid & Nadeem, 2017). Workout regimens are essential in the treatment of anxiety and depression, and they should be included in everyone’s daily routine.
In addition, the client will be given tricyclic antidepressants by his or her primary care physician or specialist (Tselebis et al., 2016). The client’s treatment and development will be monitored by the care manager, who will work with the physician to ensure that the patient recovers in six months. According to a study published in the European Respiratory Journal, this strategy leads to a decrease in depression symptoms and dyspnoea-related impairment (Tselebis et al., 2016).
With the help of pulmonary rehabilitation, patients may get the most knowledge about their lungs and the illness they are dealing with. With the possibility for peer support provided by the program, the emphasis is placed on exercising with less breathlessness, which results in greater effectiveness overall. The patient will feel better and more comfortable with the treatment of the illness as a result of this education and skill development. The opportunity to live a healthy lifestyle and participate in more physical activities allows the patient to spend more time with friends and family as a result of the treatment plan. According to research, pulmonary rehabilitation is associated with a reduction in the number of hospitalizations for flare-ups (Özmen et al., 2018).
Care coordination is based on the principles of ethical conduct. This is a key component of my patient-centered treatment strategy. This strategy is inconsistent with the ethical repercussions of all actions done when it comes to the supply of resources and the development of a plan of care. It also ensures conformity to the priorities and inclinations of the client with a view to attaining optimal COPD management. It harmonizes with the ideals of empathy, tolerance, autonomy and respect that are commonly acknowledged. This enables the client to engage in the care coordination plan and concentrates more on accomplishing the health goals that were set. Engagement of the patient’s family also offers an opportunity for the patient to express issues and discuss the treatment plan.
The Patient Protection and Affordable Care Act not only works to reduce the percentage of uninsured people but has also achieved major advances in the enhancement of healthcare quality and access (Vincent & Reed, 2018). The poor will have greater access to health care services as a result of this program, which is being implemented. This care coordination strategy has achieved considerable success since it has reduced the financial burden associated with the management of COPD. Besides that, it offers the advantage of guaranteeing timely delivery of treatment while also providing high-quality care and making medicines readily available. Healthy workplaces, clean air, and Tobacco control are all policies that are in existence in addition to the Affordable Care Act .It enables the COPD patient to strive towards attaining a nicotine-free body.
Learning Session Outcomes: Final Care Coordination Plan Essay Assignment Paper
During the training session, the patient demonstrated an open mind to the treatment of COPD in cooperation with the care team and with the help of his or her family members. Aside from that, by concentrating on the ethical point of view, he was receptive to putting down reasons to stop smoking as well as reaching a mutually agreed-upon health objective. He also committed to participate in support and fitness programs as part of his rehabilitation. In subsequent sessions, it will be necessary to provide specific information on educational programs that the patient has participated in as part of prior plans. If care coordination measurement can be made accessible in an electronic format, it would be very beneficial for improved record-keeping and service delivery. It would go a long way toward enhancing the quality of care provided to COPD patients in future programs.
Patient Satisfaction with the Care Coordination Plan
Among the primary goals of care coordination is to accommodate clients’ requirements and desires in the delivery of high-quality, high-value health care, thereby reducing the risk of premature fatalities associated with chronic obstructive pulmonary disease (COPD). It is in accordance with Healthy People 2030’s vision of a healthy society, the effectiveness of the person-centered approach is almost guaranteed.
The care coordination process was carried out in the most efficient manner feasible, right up to the point of developing the final coordination plan. Ample information was provided to the healthcare team during in-person interactions with the client, which was useful in moving the healthcare process forward. As part of the meetings, numerous problems were discussed, and some suggestions were made that will be incorporated into a finalized care coordination plan. In addition, the importance of ethical standards in the patient care was discussed, as well as the relevance of health policies in the accomplishment of healthcare objectives, as well as the value of Healthy People 2030 in the overall operation. I anticipate that the client’s life would be improved as a result of this care coordination plan. It also serves as a framework for formulating care coordination plans for those who have comparable health problems in the future, should they arise.
Bai, J., Chen, X., Liu, S., Yu, L., & Xu, J. (2017). Smoking cessation affects the natural history of COPD. International Journal of Chronic Obstructive Pulmonary Disease, Volume 12, 3323-3328.
Gratziou, C., Florou, A., Ischaki, E., Eleftheriou, K., Sachlas, A., Bersimis, S., & Zakynthinos, S. (2016). Smoking cessation effectiveness in smokers with COPD and asthma under real- life conditions. Respiratory Medicine, 108(4), 577-583.
Johansson, H., Berterö, C., Berg, K., & Jonasson, L. L. (2019). To live a life with COPD–the consequences of symptom burden. International journal of chronic obstructive pulmonary disease, 14, 905.
Majid, H., & Nadeem, T. (2017). Anxiety and Depression in COPD Patients. Depression and Anxiety in Patients with Chronic Respiratory Diseases, 57-72.
Özmen, İ., Yıldırım, E., Öztürk, M., Ocaklı, B., Yıldız, R., Aydın, R., … & Aksoy, E. (2018). Pulmonary rehabilitation reduces emergency admission and hospitalization rates of patients with chronic respiratory diseases. Turkish thoracic journal, 19(4), 170.
Senderovich, H. (2016). How Can We Balance Ethics and Law When Treating Smokers? Rambam Maimonides Medical Journal, 7(2), e0011.
Tselebis, A., Pachi, A., Ilias, I., Kosmas, E., Moussas, G., Tzanakis Nikos, N., & Bratis, D.
(2016). Strategies to improve anxiety and depression in patients with COPD: a mental health perspective. Neuropsychiatric Disease and Treatment, 297.
For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.
Note: You are required to complete Assessment 1 before this assessment.
For this assessment:
• Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.
Document Format and Length
Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.
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.
o Address three health care issues.
o Design an intervention for each health issue.
o Identify three community resources for each health intervention.
• Consider ethical decisions in designing patient-centered health interventions.
o Consider the practical effects of specific decisions.
o 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.
o 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.
o 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 2030 document.
o Use the literature on evaluation as guide to compare learning session content with best practices.
o Align teaching sessions to the Healthy People 2030 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.
Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.
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.
o Design patient-centered health interventions and timelines for a selected health care problem.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
o 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.
o 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 2030 document.
• Competency 4: Defend decisions based on the code of ethics for nursing.
o Consider ethical decisions in designing patient-centered health interventions.
• Competency 5: Explain how health care policies affect patient-centered care.
o Identify relevant health policy implications for the coordination and continuum of care.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
o Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
o Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
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- Patient Care Coordination Plan PCCP
- Fundamental principles of care coordination
- Preliminary Care Coordination Plan
- Care for Individuals and Families
- Ethical And Policy Factors In Care Coordination
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