NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
Preliminary Care Coordination Plan
Taking the role of care coordination as an RN in the community care center, it is essential to acknowledge age-related and elder care health issues. Aging encompasses numerous physical, psychosocial, and cultural issues, which together make it very demanding and, therefore, require a multi-faceted approach to achieve optimum health for our elderly citizens. This initial plan for care coordination has HF as the focus when it comes to elderly patients in a community care context.
The staff shortage in the dedicated care management area prompts the development of a different approach, where the functions of the nurses predominate in care coordination. The plan below encompasses physical, psychosocial, and cultural considerations for elderly patients with HF, as well as community resources that can provide a safe and effective continuum of care.
Analysis of Health Concerns and Best Practices
Heart failure (HF) is a chronic condition that results from the weakening of the heart’s pumping function; thus, the blood flow becomes insufficient throughout the body. It becomes more common with age, making it a significant problem in older adults (Hajouli & Ludhwani, 2022). The established guidelines for managing HF connotes drug adherence, lifestyle changes, and patient education.
Examples of drug treatment include diuretics, angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers (Hajouli & Ludhwani, 2022). Lifestyle modifications aim at advancing a healthy diet, weight management, regular physical activity, and quitting smoking. Education for patients is one of the main pillars that enable HF patients to competently manage their conditions, among them identification of the symptoms associated with deterioration of heart failure (Allida et al., 2020).
While the introduction of these best practices for elderly patients into a community setting has some distinctive challenges, they provide significant advantages. The elderly frequently experience polypharmacy, where multiple drugs are used, thereby complicating the task of medication adherence (Unlu et al., 2020). Moreover, age-related cognitive decline, a frequently occurring occurrence in older persons, can interfere with the mastery of educational materials and the application of self-management approaches (Yang et al., 2022).
Specific Goals
The following specific goals are intended to address the issues experienced by older individuals with HF in a community care setting:
- Increase drug adherence by 80% within three months. Implement medication reminders, educate patients on the purpose of medications, and simplify prescription regimens to improve adherence.
- Increase participation in an appropriate exercise program by 70% within two months. Collaborate with physical therapists and provide transportation to encourage older people to participate in personalized exercise regimens.
- Increase patient education by 60% in one month: Use more straightforward materials, include family members in education sessions, and provide educational resources in preferred languages to improve good comprehension and self-management of HF.
- Reduce hospital readmission rates by 50% in 6 months: Focus on early detection of increasing symptoms and prompt communication with healthcare providers to avoid unnecessary hospitalizations.
Physical Considerations
Physical limitations, such as fatigue, shortness of breath, and low exercise tolerance, are highly prevalent among elderly patients with heart failure. Such restrictions may prohibit everyday activities, and they could make falling more likely or increase crash skills. The care coordination plan addresses these needs through:
- Working together with physical therapists to formulate proper and safe exercise regimens aimed at increasing mobility and muscle strength.
- Assessment for devices, such as crutches and walkers that support the body’s strength and take away the risk of slipping.
- Nutritional counseling to ensure a well-balanced diet enriched in weight management that lowers cardiovascular risk factors.
Psychosocial Considerations
Social isolation and depression are recurring problems for the elderly suffering from HF (Goodlin & Gottlieb, 2023). Psychosocial factors that are concerned with the well-being of both body and mind often have a negative impact on self-care and health results. The plan addresses these needs by:
- Working on creating a social support group exclusively for individuals who have HF as one of the main objectives to foster social engagement and ward off loneliness.
- Examination of depression symptoms and placement of assistance with either referral to mental health professionals.
- Providing emotional support and taking care of the fears related to the chronic nature of HF.
Cultural Considerations
Cultural beliefs and values affecting health and illness can determine the decision to seek medical help, as well as the exact level of medication compliance in elderly patients (Kwame & Petrucka, 2021). The plan addresses these needs through:
- Patient-centered communication that is culturally sensitive and acknowledges patients’ personalities and attitudes toward their health.
- Using interpreters whenever needed to make sure that the communication is clear and the decisions are informed.
- Developing educational resources that pay attention to cultural sensitivity and do a critical job of addressing the issues of culture in relation to HF.
Available Community Resources
The establishment of a resilient network of community resources is critical in guaranteeing a seamless and efficient progression of care for elderly individuals afflicted with heart failure (HF). Through the utilization of these resources, it is possible to improve the overall well-being and quality of life of the geriatric demographic. The following community resources are essential for geriatric HF patients and are tailored to their specific needs:
- Senior Centers: These facilities function as indispensable centers for senior adults’ fitness activities, health education programs, and social interaction. Through active involvement in these programs, geriatric patients with heart failure can cultivate social bonds, partake in activities that improve health, and counteract sentiments of seclusion.
- Transportation Services: To attend healthcare appointments, join exercise programs, or obtain any of the necessary services, then transportation becomes essential for geriatric HF patients.
- Mental Health Services: The role that mental health services play in the treatment of depression and anxiety among individuals with advanced heart failure is undoubtedly pivotal (Goodlin & Gottlieb, 2023). These services are designed to alleviate the burden of depression, anxiety, and psychological health issues in general, with the objective of improving quality of life and physical health.
- Programs for Nutritional Counseling: Providing a proper kind of nutrition becomes a necessity both for cardiac failure prevention and the reduction of cardiovascular risk factors. Nutritional counseling programs initiate the process of patient education on heart-healthy routine diets and enable older persons with heart failure to make rational decisions concerning their diet, minimizing the general negative impact on the quality of life.
- Support Groups: Sharing burden is a role of peers that helps patients of geriatric heart failure to deal with difficulties of managing a chronic illness. Support groups provide a forum for fellow people to exchange private histories, receive emotional assistance, as well as to get linked to others who are grappling with the same struggles as them. The presence of this feeling of being understood and bonded has the possibility of not only amplifying coping mechanisms but also improving psychological well-being as a whole.
Through availing the community resources, the community will be able to build an environment boosting individuals’ mental and physical well-being for those with senior heart failure, and this will allow them to manage the ailment competently, which will have an impact on their overall wellness and flourishing in our local community.
Conclusion
A comprehensive strategy that incorporates the physical, social, and cultural aspects of a patient is required to improve care for the elderly with heart failure. By strategically establishing objectives and leveraging community resources, it is possible to create a series of services that guarantee a secure and empathetic progression of healthcare for the most susceptible members of our community. By means of collaborative efforts and the pursuit of culturally sensitive treatment provision, it is possible to achieve the intended result of optimizing the well-being and healthcare services of geriatric patients diagnosed with heart failure.
NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED References
Allida, S., Du, H., Xu, X., Prichard, R., Chang, S., Hickman, L. D., Davidson, P. M., & Inglis, S. C. (2020). MHealth education interventions in heart failure. Cochrane Database of Systematic Reviews, 7. https://doi.org/10.1002/14651858.cd011845.pub2
Goodlin, S. J., & Gottlieb, S. H. (2023). Social isolation and loneliness in Heart Failure. JACC: Heart Failure. https://doi.org/10.1016/j.jchf.2023.01.002
Hajouli, S., & Ludhwani, D. (2022, December 23). Heart failure and ejection fraction. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553115/
Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(158), 1–10. https://doi.org/10.1186/s12912-021-00684-2
Unlu, O., Levitan, E. B., Reshetnyak, E., Kneifati-Hayek, J., Diaz, I., Archambault, A., Chen, L., Hanlon, J. T., Maurer, M. S., Safford, M. M., Lachs, M. S., & Goyal, P. (2020). Polypharmacy in older adults hospitalized for heart failure. Circulation: Heart Failure, 13(11). https://doi.org/10.1161/circheartfailure.120.006977
Yang, M., Sun, D., Wang, Y., Yan, M., Zheng, J., & Ren, J. (2022). Cognitive impairment in heart failure: Landscape, challenges, and future directions. 8. https://doi.org/10.3389/fcvm.2021.831734
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NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan Instructions
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.
Introduction
The first step in any effective project is planning. This assessment 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.
NOTE: You are required to complete this assessment before Assessment 4.
Preparation for NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
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.
Scenario to use in NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
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:
Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF] Download Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
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 for NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.
Grading Requirements for NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
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.
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 to Complete NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
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.
Course Competencies in NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and 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.
NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
Criterion 1
Analyze a health concern and the associated best practices for health improvement.
Distinguished
Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis.
Proficient
Analyzes a health concern and the associated best practices for health improvement.
Basic
Attempts to analyze a health concern and the associated best practices for health improvement.
Non Performance
Does not analyze a health concern and the associated best practices for health improvement.
Criterion 2
Describe specific goals that should be established to address a selected health care problem.
Distinguished
Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable.
Proficient
Describes specific goals that should be established to address a selected health care problem.
Basic
Attempts to describe undefined goals that should be established to address a selected health care problem.
Non Performance
Does not describe specific goals that should be established to address a selected health care problem.
Criterion 3
Identify available community resources for a safe and effective continuum of care.
Distinguished
Identifies significant and available community resources for a safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health.
Proficient
Identifies available community resources for a safe and effective continuum of care.
Basic
Attempts to identify available community resources.
Non Performance
Does not identify available community resources.
Criterion 4
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Distinguished
Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.
Proficient
Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Basic
Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.
Non Performance
Does not organize content for ideas. Lacks logical flow and smooth transitions.
Criterion 5
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Distinguished
Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.
Proficient
Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Basic
Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes and/or paraphrasing.
Non Performance
Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.
NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED Example 2
Nurses are vital to care coordinators. Patient care is holistic and requires the collaboration of various healthcare providers, nurses, patients, and their families. One of the prerequisites for accurate coordination is extensive knowledge of care coordination. The care providers then relay the information to other stakeholders and outline their care coordination roles. The care provider’s ability to manage the problems effectively determines the success of their community interactions and health. This essay analyzes care coordination concepts in pain management.
Selected Health Concern and the Associated Best Practices for Health Improvement
Pain management is an area that has many problems and ethical issues surrounding it. Pain accompanies most healthcare conditions, and the intensity, severity, and duration differ based on personal characteristics and the pain etiology. Pain management faces many issues due to tolerance and opioid addiction, affecting all health domains.
McCabe (2018) notes that physical pain can be disabling and limit daily activities, cause psychosocial pain, and affect the social interaction of individuals. Pain aggravates the management of conditions such as cancer when patients take many medications with various side effects, such as nausea and vomiting. Yet, they do not feel their therapeutic effectiveness because the pain does not cease. Thus, pain management needs to be addressed owing to the many issues associated with the problem.
Various institutions have come together to manage the issue of pain. The WHO developed the pain management ladder to assess the pain level, which outlines the management interventions for the specific pain level (McGuire & Slavin, 2020). WHO developed the ladder to manage cancer pain, but it can be used to manage all other health conditions.
Patient pain assessment tools for all populations have been developed over time. They help healthcare providers assess pain from patient reports and even from their facial expressions (Gregory, 2019). The tools have helped ensure quality care delivery. The primary assumption in pain management is that it refers to physical pain because the pain in other domains may present as other symptoms, such as fear and depression.
The prescription drug monitoring program (PDMP) is a national program that was developed to manage prescription drugs. The technology helps care providers to trace prescription drugs, especially opioids and benzodiazepines (Manders & Abd-Elsayed, 2020). The care providers also use the technology to determine the include and rates of opioid addiction and enroll them in management programs. Scholars argue that the technology has helped predict and prevent opioid use addiction in patients with prolonged opioid analgesics use.
Another integral evidence-based strategy is the management algorithm supported by clinical decision support systems. Care providers assess patients to determine their needs and then manage them depending on the algorithm’s instructions. Pangarkar et al. (2020) note that various clinical pain management algorithms have been developed to help manage pain in cancer, ballistic injuries (in veterans), and other chronic diseases such as acute renal injury. Patient assessment (using current tools) is integral to their management hence the need for patient clinic visits and assessment.
Specific Goals That Should be Established to Address Pain
There are various goals when addressing the healthcare problem. The first goal is to ensure pain control and relief while taking the lowest possible medication doses. Meaningful pain control increases functional abilities and the quality of life. Adequate pain control requires care collaboration between patients and their primary care providers.
Moreover, the goal is based upon continuous assessment and therapy change for effective pain management. The second goal is medication and other interventions adherence. Poor medication adherence is associated with many factors, such as perceived effectiveness, negligence, forgetfulness, and medication side effects (Swarm et al., 2019).
The third goal is utilizing pharmacologic and non-pharmacologic pain management interventions for effective pain management. Pain management should entail corresponding and effective pain management interventions. Some duos have been found more effective than single therapies using medications or non-pharmacologic pain interventions. For example, massage can be used in musculoskeletal pain in addition to pharmacologic interventions. The two methods used together produce superior effects. Other interventions include acupuncture and yoga for back pain.
The fourth goal is the holistic care of patients. Pain management, especially chronic and severe pain, requires opioid analgesic interventions. This goal aims to ensure that pain management interventions do not affect other aspects of patient health (Cohen et al., 2020). These include addiction and dependence, and undesirable side effects. The goals will also entail social support for patients to promote their psychological welfare. Holistic care affects the effectiveness of other interventions, such as medication adherence. These goals are vital in pain management and will help ensure all interventions and efforts are in tandem with population needs.
Community Resources
Various society groups focus on patients and support them in patient management. Groups such as cancer (Cancer Care) and veteran affairs support groups (Veterans In Pain) help patients recover from the pain and painful experiences. The groups offer social support to individuals with pain and underlying medical condition. These institutions enhance care continuity at home. Most of these organizations are accessible online, and they provide online resources that help in decision-making.
Other non-profit organizations have been developed in communities to aid in pain management. Organizations such as US Pain Foundation and The Pain Community help individuals with pain conditions access medical care and effective prescriptions (Savoy, 2022). They also support them financially and emotionally to increase their utilization of pain management interventions and thus improve their quality of life. Other organizations, such as the Pelvic Pain Society, offer care specific to their target population. These organizations provide evidence-based strategies and pain management interventions to their target populations.
They provide online resources where they teach patient interventions such as addiction assessment and best prescription practices. They also offer room for social support when individuals interact and share their experiences. Community centers and parks are essential community resources, often underrated for their effectiveness in pain management and mental health stability (Savoy, 2022). Community centers increase access to other individuals, especially the elderly population, and helps these patients meet social needs.
Conclusion
Pain management is surrounded by many ethical and legal issues surrounding medications and other interventions. Nurses play a significant role in care coordination and ensuring patients receive the care they need. Care coordination also ensures care continuity in the community. Community resources such as pain management organizations and support groups are integral in meeting patients’ cultural and social needs, hence managing the holistic patient. Care coordination is a vital nurse’s role, and succeeding in the role enhances the success of care interventions.
NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED References
Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, B. C., Chen, Y., Hooten, W. M., Laker, S. R., Wasan, A. D., Kennedy, D. J., Sandbrink, F., King, S. A., Fowler, I. M., Stojanovic, M. P., Hayek, S. M., & Phillips, C. R. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine, 21(7), 1331-1346.7. https://doi.org/10.1093/pm/pnaa127
Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard, 34(9), 70-4. https://doi.org/10.7748/ns.2019.e11308
Manders, L., & Abd-Elsayed, A. (2020). Mandatory review of prescription drug monitoring programs before issuance of a controlled substance results in overall reduction of prescriptions including opioids and benzodiazepines. Pain Physician, 23(3), 299. https://pubmed.ncbi.nlm.nih.gov/32517396/
McCabe, M. J. (2018). Ethical issues in pain management. Ethics in Hospice Care: Challenges to Hospice Values in a Changing Health Care Environment, 25-32. https://doi.org/10.4324/9781315809823-4/
McGuire, L. S., & Slavin, K. (2020). Revisiting the WHO analgesic ladder for surgical management of pain. AMA Journal of Ethics, 22(8), 695-701. https://doi.org/10.1001/amajethics.2020.695
Pangarkar, S. S., Kang, D. G., Sandbrink, F., Bevevino, A., Tillisch, K., Konitzer, L., & Sall, J. (2019). VA/DoD clinical practice guideline: diagnosis and treatment of low back pain. Journal of General Internal Medicine, 34(11), 2620-2629. https://doi.org/10.1007/s11606-019-05086-4
Savoy, M. L. (2022). Systems-Based Practice in Chronic Pain Management. Primary Care: Clinics in Office Practice, 49(3), 485-496. https://doi.org/10.1016/j.pop.2022.01.004
Swarm, R. A., Paice, J. A., Anghelescu, D. L., Are, M., Bruce, J. Y., Buga, S., & Gurski, L. A. (2019). Adult cancer pain, version 3.2019, NCCN clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network, 17(8), 977-100 https://doi.org/10.6004/jnccn.2019.0038
