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NURS FPX 4050 Final Care Coordination Plan Assignment Example

NURS FPX 4050 Final Care Coordination Plan Assignment ExampleAssignment Brief: NURS FPX 4050 Final Care Coordination Plan

Assignment Overview:

The NURS FPX 4050 Final Care Coordination Plan assignment tasks students with formulating a detailed care coordination plan for a patient. This assessment explores patient-centered care, ethical dimensions, collaboration with community resources, and adherence to healthcare policies.

Assignment Objectives:

Students are tasked with assuming the role of a healthcare professional to craft a comprehensive care coordination plan. Objectives include developing a holistic plan, integrating ethical considerations, collaborating with community resources, understanding health policies, and ensuring patient satisfaction while aligning with broader health goals.

The Student’s Role:

The student assumes the role of a healthcare professional entrusted with crafting a care coordination plan. Drawing on knowledge about effective care, ethical considerations, and healthcare policies, the student will develop a comprehensive and practical plan.

Detailed Assessment Instructions for the NURS FPX 4050 Final Care Coordination Plan Assignment

  • 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 this assessment after Assessment 1 is successfully completed.

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.


In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected healthcare problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Note: Remember that you can submit all, or a portion of, your 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.


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, 6 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

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.
  1. Address three health care issues.
  2. Design an intervention for each health issue.
  3. Identify three community resources for each health intervention.

. Consider ethical decisions in designing patient-centered health interventions.

  1. Consider the practical effects of specific decisions.
  2. 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.

  1. 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.

  1. 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.

  1. Use the literature on evaluation as guide to compare learning session content with best practices.
  2. 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.

Additional Requirements

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.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Competencies Measured

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.

  1. Design patient-centered health interventions and timelines for a selected health care problem.

. Competency 2: Collaborate with patients and family to achieve desired outcomes.

  1. 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.

  1. 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.

  1. Consider ethical decisions in designing patient-centered health interventions.

. Competency 5: Explain how health care policies affect patient-centered care.

  1. Identify relevant health policy implications for the coordination and continuum of care.

. Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

  1. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
  2. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Resources: Managing Chronic Illnesses

  • Read through the following resources to identify the role of care coordination in managing chronic illnesses. Pay close attention to similarities between your community and the patient population.
  • Improving Chronic Illness Care. (n.d.). Care coordination: Reducing care fragmentation. s=326
  • Improving Chronic Illness Care. (n.d.). Reducing care fragmentation: A toolkit for coordinating care [PDF].

Resources: Additional Resources for Further Exploration

  • You may use the following optional resource to further explore topics related to the competencies. Consider how health care scientists assess and evaluate a diverse cultural setting and the impact on needed health care.
  • Quinn, M., Robinson, C., Forman, J., Krein, S. L., & Rosland, A. M. (2017). Survey instruments to assess patient experiences with access and coordination across health care settings: Available and needed measures. Med Care, 55(Supplement 7 1), S84-S91.

NURS FPX 4050 Final Care Coordination Plan Example Assignment

In the initial care coordination plan, stroke was identified as a significant healthcare concern, aiming to devise interventions and establish coordinated care for patients affected by or recovering from strokes, considering the high mortality rate of 5.5 million associated with strokes (Donkor, 2018). The final care coordination plan is designed to create patient-centered healthcare interventions with specific timelines, incorporating evidence from literature for three major health issues: stroke, heart disease, and diabetes in adults.

Stroke and Intervention Design

Stroke, a leading cause of global mortality, has profound effects on the quality of life, impairing speech, mobility, and daily activities, with a risk of recurrence (Mejia et al., 2017). Healthy People 2030 recognizes stroke as an outcome of poor cardiovascular health (, 2019), emphasizing the need to address cardiovascular conditions as a secondary key health issue. The coordinated intervention for strokes includes a multimodal approach, considering factors such as patient conditions, cultural aspects, type of stroke, and underlying causes.

The intervention comprises promoting a healthy lifestyle through improved diet and cardiovascular activities, implementing endovascular interventions, conducting neurological workups, and prioritizing urgent carotid interventions within 48 hours for moderate to severe strokes. Education and training for nurses to diagnose and apply suitable interventions, including percutaneous vascular interventions or intravenous thrombolytic treatments, are crucial. The plan incorporates stroke management interventions like the use of antiplatelet and statins and emphasizes the importance of psychosocial, social, and cultural support for successful recovery (Merriman et al., 2019).

Timeline and Resources

The implementation of the plan spans three months, allowing the first month for training and education of nurses and resource provision. Essential community resources include local support associations for stroke survivors, community health workers, and online support through the Internet Stroke Center (Stroke Support Association, 2021).

Cardiovascular Disease and Interventions

Selected due to its high mortality rate and its potential to lead to strokes, cardiovascular disease is a critical focus of the care coordination plan. To prevent and manage cardiovascular disease, the plan integrates diet and lifestyle-based interventions, therapeutic and clinical interventions, and emphasizes interprofessional collaboration to provide patient-centered care.

Diet and lifestyle-based interventions include culture-sensitive nutrition plans, moderate to high-intensity workouts, balanced diets, physician counseling, and BMI tracking. Therapeutic interventions involve stress management, cell-based therapies, stem cell therapies, nanomedicines, meditation, psychological well-being, and lifestyle choices based on individualized plans developed by healthcare professionals (Brandhorst & Longo, 2019).

Timeline and Resources

The implementation of the cardiovascular disease care plan takes three months, involving the creation of dietary plans and the promotion of a healthy lifestyle. A subsequent three to six-month evaluation period will assess the effectiveness of the integrated solutions. Community resources include the American Heart Association, the U.S. Food and Drug Administration’s “Eat for a Healthy Heart” initiative, and local nutritional clubs.

Diabetes and Interventions

Considering the increasing prevalence of diabetes globally, the care coordination plan addresses preventive and management interventions for diabetes, emphasizing its link to cardiovascular conditions. Healthy People 2030 recommends intensive lifestyle interventions with a focus on nutrition and self-management.

The intervention involves patient education, promoting a healthy lifestyle in the community, and implementing culture-based, patient-centered, and socioeconomic-based interventions to reduce obesity and diabetes. The plan collaborates with professionals from diverse fields, including nurses, physicians, nutritionists, to provide comprehensive diabetes self-management education (DSME), covering medication management, self-monitoring, diet, exercise, and appropriate healthcare utilization (Carpenter et al., 2019).

Timeline and Resources

The implementation of the diabetes care plan spans two months, with the first month dedicated to patient education and the promotion of a healthy lifestyle. The subsequent phase involves creating and implementing culture-based, patient-centered, and socioeconomic-based interventions. Community resources include the Academy of Nutrition and Dietetics, local health and nutrition services, and medical clinics.

Ethical Decisions in Designing Patient-Centered Health Interventions

The design and implementation of a final care coordination plan for treating, preventing, and managing health conditions present ethical challenges. Conflicts may arise due to differing patient preferences, evidence availability, and patient well-being. For instance, conflicts in stroke treatment options, the suitability of high-intensity workouts for certain patients, and cultural considerations in diabetes treatment pose ethical decision-making challenges. Addressing these requires an ethical decision-making process grounded in patient-centered, culture-based, high-quality, and affordable care, aligning with ethical principles of respect for persons, nonmaleficence or beneficence, and justice (DeCamp et al., 2017; Lulé et al., 2019).

Identifying Relevant Health Policy Implications for Coordination and Continuum of Care

Healthcare policies and acts play a crucial role in shaping coordinated care plans and the continuum of care. Key policy recommendations identified by the AHRQ, such as population identification, identity protection, service delivery, healthcare access, and cost of care, directly influence the care coordination plan (AHRQ, 2021). Policies like HIPAA ensure patient identity protection, while the Affordable Care Act (ACA) guides recommendations for identified diseases, Medicaid, treatment plans, and cost-effective care. Additionally, policies related to billing management and self-management, as well as telemedicine and telehealth policies, impact patient access to online community resources and organizational service provision while adhering to privacy regulations (Khullar & Chokshi, 2018; Bescos & Westerteicher, 2018).

Priorities for a Care Coordinator

When discussing the care coordination plan, the care coordinator prioritizes patient well-being, quality of care, and safety, aligning with evidence-based practice (Quinn et al., 2017; AHRQ, 2019). Consideration of medical history, cultural factors, and patient wishes or consent are essential aspects. Additionally, cost of care, patient and family education, and empowerment are prioritized to collaborate effectively with patients, families, and healthcare professionals. The urgency for change is highlighted, emphasizing the potential consequences of failing to prevent, treat, and manage health issues, including mortality and morbidity (Zhao et al., 2018).

Evaluating Best Practices and Healthy People 2030

The literature review underscores the interconnectedness of stroke, cardiovascular disease, and diabetes, emphasizing the need for effective interventions. Evidence-based practices, such as carotid interventions within 48 hours for stroke, are identified as solutions (Morris et al., 2017). Patient-centered care, advocated by Healthy People 2030, emphasizes the adoption of new evidence-based interventions to enhance treatment recovery (, 2019). Best practices for stroke involve a combination of interventions addressing psychosocial, social, and cultural aspects, stressing the importance of stress management, carotid interventions, percutaneous vascular interventions, and appropriate medication management (Lindekleiv et al., 2018).

Similarly, cardiovascular disease and diabetes are addressed through nutrition, therapeutic, and clinical interventions, coupled with education and community support. While Healthy People 2030 recognizes these aspects, there is a need for revisions to include telehealth services and culture-based care comprehensively (, 2019). Integrating these elements into the 2030 vision will enhance the effectiveness and inclusivity of proposed healthcare interventions.


AHRQ. (2019). Care coordination. Retrieved 20 July 2021, from

AHRQ. (2021). Care management: implications for medical practice, health policy, and health services research. Retrieved 20 July 2021, from

Baatiema, L., de‐Graft Aikins, A., Sarfo, F. S., Abimbola, S., Ganle, J. K., & Somerset, S. (2020). Improving the quality of care for people who had a stroke in a low‐/middle‐income country: A qualitative analysis of health‐care professionals’ perspectives. Health Expectations, 23(2), 450–460.

Bescos, C., & Westerteicher, C. (2018). Act programme: Breaking the barriers for care coordination and telehealth. International Journal Of Integrated Care, 13(5).

Brandhorst, S., & Longo, V. (2019). Dietary restrictions and nutrition in the prevention and treatment of cardiovascular disease. Circulation Research, 124(6), 952-965.

Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of type 2 diabetes: An integrative review. International Journal Of Nursing Sciences, 6(1), 70-91.

CDC. (2021). Heart disease facts. Centers for Disease Control and Prevention. Retrieved 20 July 2021, from,United%20States%20from%20cardiovascular%20disease.&text=About%20655%2C000%20Americans%20die%20from,1%20in%20every%204%20deaths.

CDC. (2021). National diabetes statistics report, 2020 | CDC. Retrieved 20 July 2021, from

de Jesus, J., Kahan, S., & Eckel, R. (2016). Nutrition interventions for cardiovascular disease. Medical Clinics Of North America, 100(6), 1251-1264.

DeCamp, M., Pomerantz, D., Cotts, K., Dzeng, E., Farber, N., & Lehmann, L. et al. (2017). Ethical issues in the design and implementation of population health programs. Journal Of General Internal Medicine, 33(3), 370-375.

Donkor, E. S. (2018). Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life. Stroke Research and Treatment, 2018, 1–10.

Glazier, R., Bajcar, J., Kennie, N., & Willson, K. (2016). A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care, 29(7), 1675-1688. (2018). Improve cardiovascular health in adults. Retrieved 20 July 2021, from (2019). Heart disease and stroke – healthy people 2030 | Retrieved 25 July 2021, from (2020). Diabetes management: intensive lifestyle interventions for patients with type 2 diabetes – Healthy People 2030 | Retrieved 20 July 2021, from

Holt, R. (2020). Healthcare compliance and barriers to the implementation of healthcare IT initiatives across the continuum of care. Journal Of Health Care Financ. Retrieved 25 July 2021, from.

Khaki, A. S., & Tadi, P. (2021). Cerebrovascular disease [Statpearls]. Retrieved from

Khullar, D., & Chokshi, D. (2018). Can better care coordination lower health care costs?. JAMA Network Open, 1(7), e184295.

Lepard, M., Joseph, A., Agne, A., & Cherrington, A. (2017). Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review. Current Diabetes Reports, 15(6).

Lindekleiv, H., Berge, E., Bruins Slot, K., & Wardlaw, J. (2018). Percutaneous vascular interventions versus intravenous thrombolytic treatment for acute ischaemic stroke. Cochrane Database Of Systematic Reviews.

Lulé, D., Kübler, A., & Ludolph, A. (2019). Ethical principles in patient-centered medical care to support quality of life in amyotrophic lateral sclerosis. Frontiers In Neurology, 10.

Ma, C., Avenell, A., Bolland, M., Hudson, J., Stewart, F., & Robertson, C. et al. (2017). Effects of weight loss interventions for adults who are obese on mortality, cardiovascular disease, and cancer: systematic review and meta-analysis. BMJ, j4849.

Mathews, E., Thomas, E., Absetz, P., D’Esposito, F., Aziz, Z., & Balachandran, S. et al. (2017). Cultural adaptation of a peer-led lifestyle intervention program for diabetes prevention in India: the Kerala diabetes prevention program (K-DPP). BMC Public Health, 17(1).

Maulik, N. (2013). Cardiovascular diseases: nutritional and therapeutic interventions (1st ed.). CRC Press/Taylor & Francis.

Mejia, A., Leijten, P., Lachman, J., & Parra-Cardona, J. (2017). Different strokes for different folks? contrasting approaches to cultural adaptation of parenting interventions. Prevention Science, 18(6), 630-639.

Merriman, N., Sexton, E., McCabe, G., Walsh, M., Rohde, D., & Gorman, A. et al. (2019). Addressing cognitive impairment following stroke: systematic review and meta-analysis of non-randomised controlled studies of psychological interventions. BMJ Open, 9(2), e024429.

Morris, D., Ayabe, K., Inoue, T., Sakai, N., Bulbulia, R., Halliday, A., & Goto, S. (2017). Evidence-based carotid interventions for stroke prevention: state-of-the-art review. Journal Of Atherosclerosis And Thrombosis, 24(4), 373-387.

Quinn, M., Robinson, C., Forman, J., Krein, S., & Rosland, A. (2017). Survey instruments to assess patient experiences with access and coordination across health care settings. Medical Care, 55(Suppl 1), S84-S91.

Rafnsson, S., & Fowkes, G. (2020). Positive and negative well-being of older adults with symptomatic peripheral artery disease: A population-based investigation. JRSM Cardiovascular Disease, 9, 204800402096171.

Stroke Support Association. (2021). Community resources for survivors of stroke – stroke support association. Stroke Support Association. Retrieved 20 July 2021, from

Wafa, H., Wolfe, C., Bhalla, A., & Wang, Y. (2020). Long-term trends in death and dependence after ischaemic strokes: A retrospective cohort study using the South London Stroke Register (SLSR). PLOS Medicine, 17(3), e1003048.

Zhao, D., Liu, J., Wang, M., Zhang, X., & Zhou, M. (2018). Epidemiology of cardiovascular disease in China: current features and implications. Nature Reviews Cardiology, 16(4), 203-212.

NURS FPX 4050 Final Care Coordination Plan Assignment Example Two

Effective healthcare systems rely heavily on care coordination, ensuring a smooth transition between different aspects of patient care. The Care Coordination Plan, particularly for individuals with lifestyle diseases, enhances the care coordination process, emphasizing collaboration with community resources to achieve optimal results (Salz & Baxi, 2016). This plan must adhere strictly to federal regulations and ethical guidelines. Building upon the groundwork laid in Assessment 1, this Final Care Coordination Plan addresses stroke patients’ unique needs, considering underlying health issues identified during assessments.

Stroke, a major global cause of mortality and disability, affects both developed and developing countries. In the United States alone, nearly 800,000 people suffer from strokes annually, with 80% preventable through screening and managing risk factors (George et al., 2017). As stroke often coexists with other health issues, the Final Care Coordination Plan addresses the broader health spectrum discovered during assessments.

Patient-Centered Interventions play a pivotal role in stroke care. Shifting from a hospital-centered approach to a patient-centered one places the individual and their family at the core, improving self-management and treatment outcomes (American Stoke Association, 2021). In this case, the patient diagnosed with stroke faces additional challenges, including depression, paranoia, diabetes, anxiety, insomnia, and advisability. Patient-centered care coordination becomes essential for tailored, effective treatment.

Considering the patient’s specific conditions, the plan delves into two primary concerns: cardiovascular complications and depression. Given that more than 70% of stroke patients are diagnosed with diabetes, a leading risk factor, the plan emphasizes healthy behaviors to prevent cardiovascular issues (George et al., 2017; Navi & Iadecola, 2018). Addressing depression, often exacerbated by the stigma associated with stroke, involves patient-focused strategies to shift focus, establish routines, and develop self-management skills (Lappin et al., 2017).

Community Resources are integral to patient-centered care coordination. Collaborating with organizations like the Million Hearts Initiative, National Stroke Association, and American Stroke Association ensures comprehensive support for stroke survivors and their families, aligning with the care coordination plan (National Stroke Association, 2020). These resources provide preventive advice, support networks, and helplines for a holistic approach to stroke care.

Ethics is a cornerstone in patient-centered health interventions, guided by principles like beneficence, fairness, autonomy, and non-maleficence. Adhering to ethical standards, as outlined by the American Nurses Association (ANA) Code of Ethics, is crucial for healthcare professionals involved in the care coordination process.

Health Policy Implications for Care Continuum and Coordination are evident in government policies like the Affordable Care Act (ACA) and Medicaid. These policies, by increasing healthcare access and coverage, have heightened the importance of care coordination efforts. The Hospital Readmission Reduction Program, a part of the ACA, emphasizes reducing readmission rates, aligning with care coordination goals.

Care Coordination Plan Patient Satisfaction and Healthy People 2030 are key indicators of success. Patient satisfaction ensures the plan’s effectiveness, while Healthy People 2030 guides stroke care coordination by setting objectives for national stroke prevention and treatment.

In conclusion, this Final Care Coordination Plan addresses the multifaceted needs of stroke patients. Ethical considerations, collaboration with community resources, and alignment with health policies contribute to the plan’s effectiveness. Patient-centered interventions and a focus on cardiovascular health, mental well-being, and community resources ensure a comprehensive approach, ultimately improving stroke care outcomes.


American Stroke Association. (2021). About stroke.

George, M. G., Fischer, L., Koroshetz, W., Bushnell, C., Frankel, M., Foltz, J., & Thorpe, P. G. (2017). CDC grand rounds: public health strategies to prevent and treat strokes. MMWR. Morbidity and mortality weekly report, 66(18), 479.

Lappin, J. M., Darke, S., & Farrell, M. (2017). Stroke and methamphetamine use in young adults: a review. Journal of Neurology, Neurosurgery & Psychiatry, 88(12), 1079-1091.

Navi, B. B., & Iadecola, C. (2018). Ischemic stroke in cancer patients: a review of an underappreciated pathology. Annals of neurology, 83(5), 873-883.

National Stroke Association. (2020). Retrieved from

Salz, T., & Baxi, S. (2016). Moving survivorship care plans forward: focus on care coordination. Cancer medicine, 5(7), 1717-1722.

NURS FPX 4050 Final Care Coordination Plan Assignment Example Three

The participant involved in the care coordination plan session is a 65-year-old woman residing in Houston, Texas. Her existing self-management practices bring attention to three significant health concerns: high blood pressure, type II diabetes, and obesity. Chronic hypertension, prevalent among older adults, poses risks such as cardiovascular disease, cognitive decline, and diminished autonomy. Effectively managing hypertension requires adherence to prescribed medications, self-assessment with blood pressure monitors, and lifestyle adjustments tailored to individual assessments, such as moderating caffeine and alcohol intake, quitting smoking, or incorporating age-appropriate exercise.

Type II diabetes, another health concern for the participant, demands careful self-management to avoid complications like neuropathy and vascular damage. Patient education on blood glucose measurement, diabetes literacy improvement through counseling, and adherence to diabetes diet guidelines emerge as effective practices. Research indicates that structured diabetes self-management education contributes to reduced hemoglobin A1c levels and fewer complications, fostering healthier eating habits and lowering mental health risks.

The participant’s weight issue compounds her quality of life, affecting mobility, independence, and cardiovascular health. Weight loss programs, encompassing diets, exercise, or pharmaceutical therapy, show promise in enhancing glycemic control in overweight and obese individuals with type II diabetes. The integration of weight loss programs with counseling by diabetes educators demonstrates improved mental health outcomes compared to standard diabetic diet education.

Patient Needs and Care-Affecting Factors

The participant, recognizing her current health needs, seeks to maintain overall health, enhance eating choices, and optimize self-monitoring practices. The goals emphasize education and awareness, ensuring the effectiveness and safety of her weight loss program for diabetics. Uncertainties may prompt the reevaluation of priorities during ongoing collaboration.

To tailor care to the participant’s unique needs, factors such as chronic health conditions, senior citizenship, autonomy, family support, and cultural preferences must be considered. As a Hispanic woman, her food preferences rooted in her native culture necessitate culturally competent nutritional education that aligns with the traditional Mexican diet.

Community Resources: Educational Services

Diabetes education program covering self-management, dietary choices, medication use, and physical activity (Medical Clinic of Houston, 1701 Sunset Blvd, Houston, TX 77005, (713) 520-4774).

Classes on healthy nutrition for various age groups, including older adults (Houston Food Bank, 535 Portwall St., Houston, TX 77029, (713) 223-3700).

Online resources for hypertension education and the Check.Change.Control program for self-monitoring (American Heart Association, 7272 Greenville Ave. Dallas, TX 75231, 1-800-242-8721).


Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research, 124(7), 1045-1060.

Holland-Carter, L., Tuerk, P. W., Wadden, T. A., Fujioka, K. N., Becker, L. E., Miller-Kovach, K.,… Kushner, R. F. (2017). Impact on psychosocial outcomes of a nationally available weight management program tailored for individuals with type 2 diabetes: Results of a randomized controlled trial. Journal of Diabetes and its Complications, 31(5), 891-897.

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H.,… Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 43(1), 40-53

NURS FPX 4050 Final Care Coordination Plan Assignment Example Four

The Care Coordination plan is a critical step for the prompt recovery of patients and ensuring the delivery of appropriate treatment at the right time. It encompasses all planned activities to provide high-quality care and treatment to patients, fostering a secure and effective environment where patients can trust their healthcare providers and receive efficient services. Nurses and healthcare staff must be vigilant and proactive to handle diverse circumstances. The primary goal is to create a patient-centered treatment plan that prioritizes the patient’s needs, ensuring effective communication at the right time with the right individuals for optimal patient care. Nursing staff should possess knowledge of medical and ethical practices to formulate and negotiate effective plans for patients (Izumi, et al., 2018). Proper guidance and instructions from healthcare advisors instill positivity and motivation in patients.

Patient-centered Health Interventions & Timelines for Selected Healthcare Problem:

Patient-centered care coordination focuses on addressing individual patient needs, aiming to provide the best possible treatment with improved clinical outcomes. This approach has gained popularity in healthcare as it facilitates personalized care and enhances patient satisfaction. Villa Health Hospital is dedicated to effectively managing Gestational Diabetes patients through patient-centered care coordination. The patient-centered treatment plan emphasizes patient well-being and involves coordination among patients, healthcare workers, and families to utilize available resources for patient support, education, and quality care (Otero, et al., 2015).

A care coordination plan is a devised methodology for delivering enhanced, efficient, safe, and quality healthcare services, supporting patients in managing their health and well-being, particularly important for diabetic patients who need to focus on health, diet, and physical activity. The patient-centered health care plan aims to promote diabetes self-management through systematic improvements in primary care quality and delivery. This involves scheduled appointments, mini-group health consultations, and a Self-Management program. The “self-management goal cycle” guides individuals in developing clear, achievable goals, recorded in the medical chart and available to the entire patient care team. This ensures continuous review of patient goals during interactions, resulting in a consistent healthcare continuum (Langford et al., 2007).

In the subsequent step, a detailed evaluation is conducted concerning the patient’s diet and daily routine, analyzing previous routines and their effectiveness. Based on this information, the healthcare team helps the patient develop meaningful objectives. Quarterly or monthly follow-up visits and telephone appointments with the healthcare team assess patient improvement based on the plan. This procedure gradually becomes a standard part of primary care visits, easily integrated with clinical treatment.

Another intervention involves patient education, implementing various strategies to control diabetes. Knowledge about illnesses and their therapeutic techniques is crucial for effective disease management. Disseminating information about diseases to nursing and healthcare professionals can be an effective intervention for reducing blood pressure.

Developing a health promotion plan for Type 2 Diabetes Mellitus (T2DM) in a nursing care home involves setting care objectives, monitoring pharmaceutical and sugar levels, and detailing insulin administration. While treatment plans are tailored to individuals, certain common strategies can be applied. Physicians and therapists should plan appropriate medication and physical activities to mitigate the risk of T2DM. Psychologists can assist in stress reduction through sessions and therapies, and dietitians can design suitable diet plans for both mothers and children to lower the risk of uncontrolled sugar levels and obesity.

1st intervention: Self-management education and support from healthcare professionals. Continuous support from healthcare personnel is crucial for guiding patients in dealing with T2DM. Efficient use of available resources, including community seminars, counseling sessions, and workshops, can provide necessary education and promote self-care. Physicians should devise home care plans and prescribe medications for a prompt recovery. Healthcare workers must ensure the utilization of preventive care services, organizing random checkups, and management programs (Zhao, 2022).

2nd intervention: Blood sugar monitoring regime. Care plans should include a segment on blood sugar testing, specifying the type of glucose monitor used and the target blood sugar level before meals. This section also addresses how blood sugar tests will be performed and which body part is suitable for testing, such as fingers, thighs, calves, or arms (Li & Hao, 2019).

3rd intervention: Insulin therapy management. The insulin therapy section outlines the insulin administration tools, including needles, insulin pen fills, or insulin syphons. It also covers the insulin-to-carbohydrate ratio, enabling users to measure the appropriate insulin dose, along with a timetable for self-administration of insulin (Lauver et al., 2019).

4th intervention: Family support during the treatment schedule. Recognizing the significant impact of family on disease care, providing diabetes education to the individual with T2DM may be limited in its influence. Family-based approaches to chronic illness care consider the family’s environment, addressing intellectual, social, and psychological needs. Involving families in learning programs can encourage diabetic patients, establish functional family practices, and promote diabetic self-management (Tomaselli et al., 2020).

Ethical Decisions in Designing Patient-Centered Healthcare Interventions

Patient-centered care is a commendable approach that prioritizes individualized treatment, considering the patient’s personality, lifestyle, and relationships along with their physical illness. However, ethical considerations arise in the implementation of this approach, including concerns about breaching privacy, potential biases in patients’ narratives, the development of personal relationships, and shared decision-making that could lead to negative outcomes.

Implementing a patient-centered care plan is considered ethical and efficient, placing the patient at the center of decision-making. Healthcare workers must handle patients’ personal information with utmost care and professionalism. The emphasis is on treating patients equally and involving them in decisions about their treatment while respecting their privacy and needs.

Ethical decision-making in patient-centered care involves questioning the legality of decisions, working with dedication and professionalism, and understanding the patient to provide appropriate guidance. Some critical ethical questions to address include whether the decision is in the best interest of the patient, whether it is legal, whether it fulfills ethical requirements, and whether the patient’s privacy is secured.

Patient-centered intervention, while crucial, necessitates addressing ethical issues. Ethical dilemmas may arise when the patient’s and practitioner’s views differ regarding treatment goals. Respecting autonomy and dignity may sometimes conflict with acting in the patient’s best interest.

Villa Health Hospital strives to provide patient-centered care for gestational diabetes patients while considering ethical perspectives. Autonomy, cultural values, personal choices, and the freedom to reject therapy are essential aspects of patient-centered healthcare.

The ethical concept of human prosperity, as proposed by Aristotle, emphasizes viewing patients as human beings rather than merely as patients. Nurses play a vital role in considering the cultural values and traditions of patients, embracing emotional intelligence, and adhering to ethical judgments to enhance the quality of care coordination.

Reducing ethical issues in healthcare organizations involves improving patient coordination and participation in treatments. Nurses can enhance their emotional intelligence, recognize prejudices, and adopt ethical practices to foster better relations with the environment and contribute to organizational progress. Overall, patient-centered models are viewed as more appreciable, ethical, and courteous in healthcare settings.

Policy implications for the coordination and continuum of care

The implementation of a patient-centered care (PCC) approach requires careful consideration of policies to ensure effective delivery and continuity of care. Policymakers play a crucial role in shaping the healthcare system to support and encourage patient-centered care. Here are some policy implications for the coordination and continuum of care in the context of gestational diabetes patients at Villa Health hospital:

Performance Requirements for Patient-Centered Care:

  • Policymakers should establish precise performance requirements that healthcare service providers must meet to deliver patient-centered care effectively.
  • Focus on concerted and integrated efforts to develop patient-centered care, acknowledging that it involves more than just infrastructural and technical advancements.

Strategic Plan for Patient-Centered Care:

  • Develop a strategic plan to encourage the acquisition and maintenance of skills related to patient-centered care by healthcare workers.
  • Urge healthcare organizations to adopt a patient-centered approach, emphasizing self-management assistance and shared decision-making.

Quality Care and Compassion:

  • Policies should emphasize the provision of quality care by nursing staff with utmost compassion and compatibility.

Privacy Protection:

  • Ensure policies that protect the privacy and personal information of patients while providing the right treatment after understanding their concerns.

Healing Relationship and Technical Care:

  • Policies should encourage healthcare staff to establish healing relationships with patients, ensuring enhanced technical care and interpersonal relationships.

Meaningful Use of Health Information Technology (HIT):

  • Encourage the meaningful use of Health Information Technology provided by the federal government to benefit patients.

Inter-Professional Coordination:

  • Policies should emphasize proper coordination among the inter-professional team to provide patient-centered care.

Individualized Care Strategies:

  • Encourage nursing staff to plan individualized and personalized care strategies for each patient, treating them as unique entities.

Public Awareness Programs:

  • Policies should mandate the organization of health seminars and workshops to enhance public awareness, promoting proactive healthcare.

These policies not only contribute to the betterment of patients but also enhance the overall performance and reputation of healthcare organizations. Furthermore, they can serve as a foundation for proposing new technologies and improved treatment strategies in the future.

Additionally, government initiatives, such as those implemented by the Centers for Medicaid & Medicare Programs, play a role in shaping healthcare policies. For instance, scoring systems that impose monetary penalties for high readmission rates incentivize hospitals to provide better and more effective clinical care during stays. Legislative approaches, like approving the use of e-cigarettes to control tobacco, and financial support provided by the Affordable Care Act for chronic case programs and medicinal options, contribute to a comprehensive healthcare framework.

The regulation of environmental standards and support for innovative research also reflects a commitment to overall health, demonstrating a recognition that healthcare extends beyond direct medical care to include environmental factors. The supervision of tobacco industry restrictions and clean air campaigns by regulatory bodies like the United States Food and Drug Administration further emphasizes the importance of a holistic approach to healthcare.

Priorities for Discussion in Healthcare Planning

It is imperative for healthcare professionals to operate in a collaborative and coordinated manner to ensure positive outcomes. The foremost priority of nursing and healthcare staff is delivering effective and high-quality care to patients. The healthcare field necessitates continual dedication and professionalism to navigate unforeseen challenges. A well-coordinated care plan is essential to prevent adverse events, mistreatment, incorrect prescriptions, unnecessary readmissions, excessive screening, and prolonged hospital stays. Such a plan not only reduces hospital expenditures but also safeguards the hospital’s reputation. Healthcare advisors should exercise caution when communicating with patients and their families, following evidence-based priorities as per national standards:

  • Prioritize the patient’s needs and preferences in treatment and communication.
  • Enhance treatment strategies to meet ethical and medical standards.
  • Maintain composure, take responsibility, and handle patients professionally.
  • Avoid arguments and acknowledge inexperience or lack of practice instead of conveying incorrect information.
  • Establish a connection with patients, seeking to understand their challenges.
  • Clearly communicate treatment plans or changes based on available evidence-based practices.

Care coordinators play a crucial role in discussing treatment plans with patients and fostering trust by providing patient-centered care.

Comparison of Teaching Session Content with Best Practices

The Healthy People 2030 initiative, a governmental public health framework from 2020, proves instrumental in guiding healthcare professionals in effectively addressing challenges posed by Gestational diabetes. This initiative encompasses a comprehensive framework outlining the issues related to gestational diabetes and effective strategies to overcome them. Aimed at ensuring the well-being of the population and promoting a healthier lifestyle, the initiative serves as a valuable guide for nursing staff to acquire new strategies and enhance their knowledge for effective patient treatment. The initiative aligns with goals of promoting public health and preventing diseases.

The data gathered from Healthy People 2030 has significantly aided nursing and healthcare staff at Villa Health Hospital in formulating improved strategies for dealing with gestational diabetes patients. This initiative enables the identification of criteria for treating mothers with gestational diabetes, addressing symptoms like high blood pressure, breathing difficulties, cardiovascular diseases, depression, and anxiety. Solutions include increased physical activities, regular monitoring of sugar levels, timely medication, and a proper diet plan. Consequently, the nursing staff’s abilities and skills are enhanced, contributing to the creation of a more collaborative and effective healthcare environment.


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