Nurs FPX 4050 Assessment 4 Final Care Coordination Plan

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Assessment 4: Final Care Coordination Plan
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Student Name
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Capella University
Course Name
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Prof Name
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FEB 6, 2023
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Final Care Coordination Plan rv
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The care coordination plan initially outlined in Assessment 1 will undergo rigorous evaluation,
integrating evidence-based best practices from scholarly references to develop a comprehensive
and conclusive care coordination plan. This plan is dedicated to addressing the healthcare issue
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of Chronic Obstructive Pulmonary Disease (COPD) and is structured around patient-centered

health interventions, ethical considerations, the influence of health policy, care coordinator
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priorities, and alignment with the Healthy People 2030 strategy.

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Timelines and Interventions for Patient-Centered Healthcare

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Patient-centered health interventions for Chronic Obstructive Pulmonary Disease (COPD)

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require a holistic approach encompassing symptom management, lifestyle modifications,

educational initiatives, and robust support systems. Timelines for interventions may vary
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depending on disease severity and individual patient requirements. The following interventions
can be seamlessly integrated into COPD management to ensure patient-centered care delivery
within appropriate timelines.
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● Awareness and Education: The primary patient-centered intervention involves raising
awareness about COPD, its symptoms, causes, and progression. Patient education,
spanning topics such as smoking cessation, physical activity, and medication use, has
been shown to reduce hospital visits by up to 85% (Boyer, 2023). The optimal timeline
for COPD education is the initial three months, utilizing community resources like
community centers, non-profit organizations (e.g., American Lung Association), and
healthcare professionals.
● Medication Adherence: Ensuring patients adhere to medications is crucial. Healthcare
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practitioners can organize sessions emphasizing the significance of adherence and
addressing potential obstacles. Utilizing smartphones for medication reminders is also
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effective. The recommended timeline is 3-6 months, with annual sessions thereafter, and
community resources include mobile application specialists, support groups, and
telemedicine services.
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● Pulmonary Rehabilitation: This intervention, enhancing lung capacity and overall quality
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of life, should be implemented within 6-12 months after diagnosis (Barata et al., 2022).
Community resources include fitness centers, rehabilitation support groups, and
hospital-based programs.
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Ethical Considerations in Formulating Patient-Oriented Health Interventions
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Developing interventions for COPD necessitates ethical considerations, including fairness in
information delivery, stigma reduction, and addressing cultural factors. Patient education,
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medication adherence, and pulmonary rehabilitation should all incorporate ethical values, such as
long-term patient wellness, non-maleficence, beneficence, patient autonomy, and informed
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consent (Woo et al., 2021; George & Bender, 2019; Martinez-Martin et al., 2021).
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Implications of Health Policy for Care Coordination and Continuity of Care

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Effective patient-centered health interventions must align with relevant health policy provisions.
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The Affordable Care Act (ACA) and the Family Smoking Prevention and Tobacco Control Act
play significant roles in supporting COPD patients. ACA's expansion of Medicaid programs aids
those with economic constraints, covering crucial aspects like prescription drugs, hospital stays,
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and pulmonary rehabilitation. Smoke-free policies under the Tobacco Control Act contribute to
reducing hospitalizations (Bhadra et al., 2021; Stallings-Smith et al., 2019).
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Priorities and Evidence-Based Changes in Care Coordination
COPD patients' care coordination priorities include literacy about the disease, cultural
competence, and optimal care plans. Evidence-based changes involve tracking symptoms,
medication compliance, and lung function through telehealth monitoring. Changes are also
necessitated by new information or worsening patient conditions, emphasizing patient
involvement in decision-making.
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Align Learning Sessions with Best Practices and Healthy People 2030
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Learning sessions should align with Healthy People 2030 objectives, focusing on evidence-based
interventions. Patient education, medication adherence, and pulmonary rehabilitation are key
interventions aligned with Healthy People 2030 goals. Evaluations and adjustments to learning
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sessions should be made in line with program goals, addressing the specific needs of the target
audience (Aliakbari, 2022).
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Conclusion
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This study underscores the importance of developing patient-centered health therapies for COPD
care coordination, considering ethical standards and relevant health policies. By establishing
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priorities and making evidence-based improvements, care coordinators can enhance the quality
of care for COPD patients and their families. Aligning educational sessions with best practices
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and Healthy People 2030 objectives ensures ongoing relevance and effectiveness of
interventions.
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References
Aliakbari, F., Tavassoli, E., Alipour, F. M., & Sedehi, M. (2022). Promoting health literacy and
perceived self-efficacy in people with chronic obstructive pulmonary disease. Iranian Journal of
Nursing and Midwifery Research, 27(4), 331.
https://doi.org/https://doi.org/10.4103%2Fijnmr.ijnmr_34_21
Barata, P. I., Crisan, A. F., Maritescu, A., Negrean, R. A., Rosca, O., Bratosin, F., Citu, C., &
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Oancea, C. (2022b). Evaluating Virtual and Inpatient Pulmonary Rehabilitation Programs for
Patients with COPD. Journal of Personalized Medicine, 12(11), 1764.
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https://doi.org/10.3390/jpm12111764
Bhadra, R., Bhattacharya, S., D’Souza, G. A., Schols, A. M. W. J., & Sambashivaiah, S. (2021).
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Pulmonary rehabilitation in the management of chronic obstructive pulmonary disease among
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asian indians- current status and moving forward. COPD: Journal of Chronic Obstructive
Pulmonary Disease, 1–6.
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https://doi.org/10.1080/15412555.2021.1962267
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Boyer, P. (2023). What are the benefits of using self-management plans for COPD patients in the
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community: a critical review of the literature. British Journal of Community Nursing, 28(1),
22–32.
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https://doi.org/10.12968/bjcn.2023.28.1.22
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George, M., & Bender, B. (2019). New insights to improve treatment adherence in asthma and
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COPD. Patient Preference and Adherence, 13, 1325–1334. https://doi.org/10.2147/ppa.s209532

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Guerra-Paiva, S., Dias, F., Costaa, D., Santos, V., & Santos, C. (2021). DPO2 Project: Telehealth
to enhance the social role of physical activity in people living with COPD. Procedia Computer
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Science, 181, 869–875.
https://doi.org/10.1016/j.procs.2021.01.241
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Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – A scoping
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review of strategies implemented in healthcare organizations and a model of culturally

competent healthcare provision. PLOS ONE, 14(7), 1–24.
https://doi.org/10.1371/journal.pone.0219971
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Health.gov. (n.d.). Reduce deaths from COPD in adults — RD‑05 – Healthy People 2030 |
Health.gov.
https://health.gov/healthypeople/objectives-and-data/browse-objectives/respiratory-disease/reduc
e-deaths-copd-adults-rd-05
Martinez-Martin, N., Luo, Z., Kaushal, A., Adeli, E., Haque, A., Kelly, S. S., & Milstein, A.
(2021). Ethical issues in using ambient intelligence in health-care settings. The lancet digital
health, 3(2), e115-e123.
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https://doi.org/10.1016/S2589-7500(20)30234-9.
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Stallings-Smith, S., Hamadi, H. Y., Peterson, B. N., Apatu, E. J. I., & Spaulding, A. C. (2019).
Smoke-Free Policies and 30-day readmission rates for Chronic Obstructive Pulmonary Disease.
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American Journal of Preventive Medicine, 57(5), 621–628.
https://doi.org/10.1016/j.amepre.2019.06.008
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Woo, S., Zhou, W., & Larson, J. L. (2021). Stigma experiences in people with Chronic
Obstructive Pulmonary Disease: An integrative review. International Journal of Chronic
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Obstructive Pulmonary Disease, 16, 1647–1659.
https://doi.org/10.2147/copd.s306874
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of Chronic Obstructive Pulmonary Disease (COPD) and is structured around patient-centered

priorities, and alignment with the Healthy People 2030 strategy.

Timelines and Interventions for Patient-Centered Healthcare

Patient-centered health interventions for Chronic Obstructive Pulmonary Disease (COPD)

require a holistic approach encompassing symptom management, lifestyle modifications,

Implications of Health Policy for Care Coordination and Continuity of Care

COPD. Patient Preference and Adherence, 13, 1325–1334. https://doi.org/10.2147/ppa.s209532

Science, 181, 869–875.

review of strategies implemented in healthcare organizations and a model of culturally

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