Preliminary Care Coordination Plan

Instruction 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- 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 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: • Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to: o Stroke. o Heart disease (high blood pressure, stroke, or heart failure). o Home safety. o Pulmonary disease (COPD or fibrotic lung disease). o Orthopedic concerns (hip replacement or knee replacement). o Cognitive impairment (Alzheimer's disease or dementia).

Diabetes is a chronic health condition that affects how the body turns food into energy. There are two main types of diabetes: type 1 and type 2. Type 1 diabetes is an autoimmune disease, meaning that the body's immune system attacks the cells in the pancreas that produce insulin. Insulin is a hormone that helps the body use glucose for energy. Type 2 diabetes is caused by a combination of genetics and lifestyle factors, such as being overweight or obese, having a family history of diabetes, or being physically inactive.

Diabetes can cause a number of health problems, including heart disease, stroke, blindness, kidney disease, and nerve damage. It is important for people with diabetes to manage their blood sugar levels to prevent these complications.

Physical Considerations

The physical considerations for diabetes care coordination include:

Monitoring blood sugar levels
Taking medication, if necessary
Eating a healthy diet
Exercising regularly
Managing stress
Getting regular eye exams, foot exams, and dental exams

Psychosocial Considerations

The psychosocial considerations for diabetes care coordination include:

Coping with the emotional and psychological impact of diabetes
Managing stress
Maintaining a healthy lifestyle
Adhering to the treatment plan
Dealing with the financial burden of diabetes

Cultural Considerations

The cultural considerations for diabetes care coordination include:

Understanding the patient's cultural beliefs and practices about health and illness
Respecting the patient's privacy and confidentiality
Providing culturally appropriate care

Available Community Resources

There are a number of community resources available to help people with diabetes manage their condition. These resources include:

Diabetes support groups
Diabetes education classes
Diabetes cookbooks
Diabetes exercise programs
Diabetes financial assistance programs

Care Coordination Plan

The care coordination plan for diabetes should be individualized to the patient's specific needs. However, some general components of a care coordination plan might include:

Regular communication between the patient, the healthcare team, and other important individuals, such as family members or caregivers
Development of a treatment plan that is tailored to the patient's individual needs
Monitoring of the patient's blood sugar levels and other health indicators
Provision of education and support to help the patient manage their condition
Coordination of care with other healthcare providers, such as specialists or mental health providers

The care coordination plan should be reviewed and updated regularly to ensure that it is meeting the patient's needs.

Conclusion

Care coordination is an essential part of managing diabetes. By working together, the patient, the healthcare team, and other important individuals can help the patient achieve better health outcomes.

In addition to the resources mentioned above, there are a number of other resources available to help people with diabetes. These resources can be found by searching online or by contacting the American Diabetes Association.

I hope this preliminary care coordination plan is helpful. Please let me know if you have any questions.

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