The first step in any effective project is planning.

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.

Preparation:

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:

Develop the Preliminary Care Coordination Plan

Complete the following:

· Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan (ATTACHED BELOW) 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

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

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.

Sample Solution

Preliminary Care Coordination Plan: Hypertension in a Community Setting

Introduction

Hypertension, or high blood pressure, is a significant public health concern affecting millions worldwide. It is a major risk factor for cardiovascular disease, stroke, kidney disease, and other serious health problems. Effective management of hypertension in the community setting is crucial for preventing complications and improving quality of life. This preliminary care coordination plan focuses on addressing the physical, psychosocial, and cultural needs of individuals with hypertension within a community care center setting. It also identifies available community resources to ensure a safe and effective continuum of care.

Analysis of Hypertension and Best Practices

Hypertension is defined as a sustained elevation in blood pressure, specifically systolic blood pressure greater than or equal to 140 mmHg or diastolic blood pressure greater than or equal to 90 mmHg (American Heart Association, 2017). It is often asymptomatic, making regular screening essential. Best practices for hypertension management include lifestyle modifications, such as dietary changes (DASH diet), regular physical activity (at least 150 minutes of moderate-intensity exercise per week), weight management, smoking cessation, and limiting alcohol consumption (National Institute of Health, n.d.). Pharmacological interventions, including various classes of antihypertensive medications, are often necessary to achieve and maintain blood pressure control. Regular monitoring of blood pressure, medication adherence, and potential side effects are crucial components of ongoing management.

Underlying Assumptions and Uncertainties

This plan assumes that individuals with hypertension have access to primary care providers and are motivated to engage in self-management behaviors. It also assumes the availability of community resources to support lifestyle changes. Uncertainties include the level of individual motivation, access to healthy food options, and the presence of co-morbidities that may complicate hypertension management. Furthermore, cultural beliefs and practices surrounding health and illness may influence an individual’s willingness to adopt recommended lifestyle changes or adhere to medication regimens.

Specific Goals

The following specific goals should be established to address hypertension in the community:

  1. Improve Blood Pressure Control: Achieve and maintain blood pressure below 140/90 mmHg for the majority of individuals with hypertension.
  2. Promote Lifestyle Modifications: Increase the number of individuals with hypertension who adopt healthy dietary habits, engage in regular physical activity, and achieve or maintain a healthy weight.
  3. Enhance Medication Adherence: Improve medication adherence rates among individuals prescribed antihypertensive medications.
  4. Increase Awareness and Education: Raise community awareness about hypertension, its risk factors, and the importance of regular screening and management.

Physical, Psychosocial, and Cultural Considerations

  • Physical Needs: Regular blood pressure monitoring, medication management, education on healthy diet and exercise, and management of co-morbidities are essential physical needs. Access to affordable and healthy food options, safe spaces for physical activity, and transportation to medical appointments are also important considerations.
  • Psychosocial Needs: Hypertension management can be impacted by stress, anxiety, and depression. Addressing these psychosocial factors through counseling, stress management techniques, and support groups can improve adherence to treatment plans. Social support from family and friends can also play a vital role in promoting healthy lifestyle changes.
  • Cultural Needs: Cultural beliefs and practices related to health, diet, and illness can influence an individual’s approach to hypertension management. Culturally sensitive education materials and communication strategies are essential. Incorporating culturally appropriate dietary recommendations and physical activity suggestions can enhance engagement and adherence.

Community Resources

The following community resources can support a safe and effective continuum of care for individuals with hypertension:

  • Local Health Departments: Offer blood pressure screenings, educational programs, and resources on healthy lifestyle choices.
  • YMCA/YWCA or Community Centers: Provide access to affordable exercise programs and facilities.
  • Food Banks and Pantries: Offer access to healthy food options for individuals with limited resources.
  • Registered Dietitians: Provide individualized nutrition counseling and meal planning.
  • Mental Health Services: Offer counseling and support groups for individuals experiencing stress, anxiety, or depression.
  • American Heart Association: Provides educational materials and resources on hypertension and heart health.
  • Support Groups: Peer support groups can provide valuable emotional support and encouragement for individuals managing hypertension.
  • Transportation Assistance: Programs that provide transportation assistance to medical appointments can improve access to care.

Conclusion

Effective care coordination is crucial for managing hypertension in the community setting. Addressing the physical, psychosocial, and cultural needs of individuals with hypertension, along with connecting them to appropriate community resources, can improve blood pressure control, promote healthy lifestyle changes, and prevent complications. A collaborative approach involving healthcare providers, community organizations, and individuals with hypertension is essential for achieving optimal outcomes and improving the overall health of the community.

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