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Final Care Coordination Plan

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Final Care Coordination Plan

Ischemic stroke is a serious condition. According to the World Health

Organization (n.d), yearly, 16% of all deaths are attributed to ischemic heart disease.

Cardiac diseases are closely associated with ischemic stroke. Moreover, another 11% of

all deaths are attributed to ischemic stroke. In this case, the patient is a 67-year-old

African American woman with a history of type II diabetes mellitus. The patient is

admitted to the hospital and diagnosed with ischemic stroke. The patient’s family has a

history of diabetes mellitus that runs in the family.

Additionally, the patient is at a greater risk of developing hypertension and other

related cardiovascular conditions. Family support plays the most significant role in this

patient's care as she has a daughter who takes care of her and ensures she is on a healthy

diet, exercise and proper adherence to medication. Care coordination is crucial for the

recovery of this patient. It is essential to coordinate with the family to ensure that the

patient is facilitated in-home recovery.

Care coordination is properly organizing and planning patient care activities

through effective information sharing with involved parties and families to ensure that the

patient receives quality care that fosters better outcomes. According to AHRQ (n.d), it is

essential to outline the underlying conditions and risk factors, essentially the patient’s

history of diabetes, ischemic stroke, and family history of diabetes. Involving the family

in the care coordination is the basis for effective recovery. Family plays the most

important role in care coordination by facilitating the patients to keep a proper diet,

exercise, health behaviours, routines, adherence to medication and avoiding potential

dangers to patient’s health. However, the receptiveness of family and patient towards care
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coordination depends on the effective patient and family education efforts to inform them

about the importance of family involvement in care coordination and its benefits.

Informing and educating the patients on diabetes mellitus and ischemic stroke

empowers them to control their health actively. Care coordination effectively promotes

positive and quality care outcomes by reducing the number of hospital admissions,

especially for patients with diabetes mellitus and ischemic stroke. Given the patient’s

family history and underlying conditions, there is a great risk of developing fatal

cardiovascular conditions (Maida et a., 2022). Healthcare education should also address

these underlying conditions and risk factors, therefore, its importance in ensuring a

wholesome recovery.

Care Interventions And Timelines

Effectively coordinated care is essential for preventing stroke fatalities. The CDC

(2020) estimates that one person in the US has a stroke every forty seconds and dies an

average of 3.5 minutes later. The CDC identified potential risk factors such as

hypertension, overweight, diabetes and tobacco use as leading causes of fatal conditions

such as stroke that take many lives. An estimated one in four out of 185,000 stroke case

patients has had a previous attack. Therefore, previous history of stroke is a greater risk

factor for stroke that could lead to loss of lives. Keeping physically active can

significantly reduce the risk of stroke. The care plan for this patient should entail physical

activity such as cycling, walking, swimming and doing cardio exercises for at least two

hours a week.

Additionally, less saturated fats and food rich in omega-3 fatty acids and fibre are

encouraged. Diet plays a significant role in managing diabetes, hypertension and other
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potential cardiac risk factors the patient is vulnerable to. The care plan also entails

education on tobacco and alcohol cessation, as they are a potential risk to the patient's

health. Alcohol and tobacco consumption are associated with poor health outcomes.

Regular consultation and coordination with specialists such as cardiologists and

neurologists is essential for improving therapy efficiency of home care. Two weeks of

consultation and visits with a cardiologist are part of the care plans for this patient to

monitor progress and improve patient outcomes. Consultation would facilitate the

patient's in-home therapy to facilitate home care activities such as medication

management and medication interaction.

Ethical Decisions and Healthcare Intervention

Ethical practice entails acceptable nursing practice that fosters justice,

beneficence, non-maleficence and autonomy. When making ethical decisions, it's

important to foster cultural competence so that patient's needs can be adequately

addressed to increase their satisfaction with care. Quality care delivery must ensure that

the nurses stick to the nursing codes of ethics when making decisions. The principles of

nursing practice, such as justice, autonomy, beneficence and non-maleficence, play the

most significant role in facilitating patient safety and the quality of their healthcare

outcomes. In the care plan for the patient in this case, giving the patient the freedom to

choose to adhere to medication, therapies and other interventions to improve her health

condition should foster autonomy.

Additionally, being culturally competent when addressing her healthcare needs

fosters justice. The patient should be allowed to choose appropriate community

resources, such as community centres and support groups, that she thinks would
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significantly accelerate her healing process. The patient is also allowed the choice of

neurology and cardiology specialist without being forced. By doing what is right for the

patients, nurses would promote beneficence and non-maleficence, ensuring that the

patient’s safety needs are well addressed regardless of nurses' opinions over the patient’s

healthcare plans.

Implications of Healthcare Policies

Healthcare policies are essential for improving patient safety and promoting the

quality of healthcare outcomes. Quality care is essential for minimizing hospital

readmission rates. According to Hosp. readmission reduction (2022), the hospital

Readmission Reduction Program (HRRP) is a crucial policy in healthcare delivery

because it helps reduce hospital readmission rates by providing healthcare professionals

with effective instructions and communication that empowers them to reduce hospital

readmissions. HRRP program fosters care coordination, leading to quality and improved

healthcare outcomes. The HRRP program has become effective at connecting care to

payment; hence reduction of readmissions has significantly reduced healthcare costs.

This stroke case patient could benefit from this policy through reduced healthcare costs,

improved safety, and quality care, leading to better outcomes.

The Affordable Care Act (ACA) is a federal healthcare policy that protects

patients and improves healthcare quality by making it affordable for low-income families.

The Act has significantly benefitted millions of patients and reduced the percentage of

uninsured persons by 8.6%(Affordable Care Act, n.d). The patient could benefit from this

policy by having affordable and easy access to healthcare services, improving care

outcomes.
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Care Coordination Priority Evaluation

Effective care coordination for managing the patient’s conditions requires

effective information sharing among the teams involved in the care coordination and

treatment process. The teams involved in this care coordination are healthcare

professionals and family members. Effective information sharing between these parties

would significantly improve the healthcare conditions of the patient. Additionally,

applying nursing ethics, cultural competence and addressing patients' needs would

significantly improve healthcare outcomes and patient satisfaction with care (Care

coordination AHRQ., n.d.). Additionally, patient education has been established to play

a significant role in care coordination to improve care outcomes.

Patient Satisfaction And Patient Experience.

Quality care delivery is essential for facilitating patient experience and

satisfaction with care. Patient experience is gained from interaction with healthcare

providers and the healthcare system (Larson et al., 2019). According to Patient

Management HIT (2018), the patient experience could be determined by assessing

satisfaction, loyalty, and behavioural intentions. HCAHPS (2021) assessed patients'

perspective of care is a survey. This survey aimed to determine patients' perspectives on

care satisfaction and help hospitals promote accountability in patient satisfaction by

comparing different hospitals and their performance. The survey contained 27 survey

questions on patient experience regarding medical care. The findings of this study can

inform decision-making to foster accountability in healthcare delivery and quality

outcomes. Based on the findings of this study, it is essential to identify and address

patient needs to achieve good patient experience and satisfaction.

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Healthy people 2030

The goal of healthy people 2030 is to provide appropriate interventions that would

significantly improve healthcare outcomes. The policy provides a framework that is

evidenced based and resources to facilitate the creation of awareness of chronic diseases,

their causes, associated risk factors and diagnosis and treatment. Such interventions are

meant to prevent preventable deaths by eliminating risk factors that cause complications

that cause loss of lives.

Conclusion

An effective care coordination plan is essential for quality care delivery. However,

effective care plans should foster healthcare policies and nursing ethics that facilitate

quality care outcomes. Evidence-based approaches are essential for managing stroke,

cardiovascular conditions and diabetes. These conditions are associated with numerous

underlying factors that can be fatal. Therefore, comprehensive care plans should address

all these care plans. Fostering care coordination significantly facilitates quality outcomes.
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References

Affordable care act (ACA) - glossary. Glossary | HealthCare.gov. (n.d.).

https://www.healthcare.gov/glossary/affordable-care-act/

Care coordination. AHRQ. (n.d.).

https://www.ahrq.gov/ncepcr/care/coordination.html#:~:text=Care%20coordination

%20involves%20deliberately%20organizing,safer%20and%20more%20effective

%20care

Centres for Disease Control and Prevention. (2021, August 10). Education and support.

Centres for Disease Control and Prevention.

https://www.cdc.gov/diabetes/managing/education.html

Centres for Disease Control and Prevention. (2020, May 25). Stroke facts. Centres for

Disease Control and Prevention. https://www.cdc.gov/stroke/facts.htm

HCAHPS: Patients' perspectives of care survey. (2021). CMS.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/HospitalQualityInits/HospitalHCAHPS

Hosp. readmission reduction. (2022). CMS. https://www.cms.gov/Medicare/Quality-

Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/

Hospital-Readmission-Reduction-Program

Larson, E., Sharma, J., Bohren, M. A., & Tunçalp, Ö. (2019). When the patient is the

expert: measuring patient experience and satisfaction with care. Bulletin of the

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World Health Organization, 97(8), 563–569.

https://doi.org/10.2471/BLT.18.225201

Maida, C. D., Daidone, M., Pacinella, G., Norrito, R. L., Pinto, A., & Tuttolomondo, A.

(2022). Diabetes and ischemic stroke: An old and new relationship an overview of

the close interaction between these diseases. International Journal of Molecular

Sciences, 23(4), 2397. https://doi.org/10.3390/ijms23042397

Patient Engagement HIT, (2018, February 8). What is the difference between patient

experience and satisfaction? Patient Engagement HIT.

https://patientengagementhit.com/news/what-is-different-between-patient-

experience-satisfaction