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NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Name Capella university NURS FPX4050 Coordinating Patient-Centered Care Prof. Name Date Final Care Coordination Plan Stroke is a major contributor to long-term disability and mortality rates in the US. To enhance patient outcomes and quality of life, care coordination is a critical component in stroke care. An effective care coordination process involves the seamless and integrated transfer of care across various healthcare settings. Nurses are instrumental in this process by offering patient education, facilitating communication among healthcare providers, and connecting patients with available community resources. The aim of this evaluation is to assess the initial care coordination plan created in Assessment 1 using evidence-based approaches from the literature. Strategies for Ensuring Patient-Centeredness in Stroke Care Coordination Stroke can lead to various health issues, including physical disability, cognitive impairment, and depression. The following three health issues require attention in the care coordination plan for stroke: Regarding physical rehabilitation, research suggests that patients should receive at least 45 minutes of each type of rehabilitation therapy (such as physiotherapy, therapy for daily living skills, and therapy for speech and communication) five days a week. The duration of physical rehabilitation interventions may vary depending on the severity of the patient’s physical disability and individual response to treatment (Gittins et al., 2020). NURS FPX 4050 Assessment 4 Final Care Coordination Plan NURS FPX 4050 Assessment 4 Final Care Coordination Plan Cognitive impairment interventions may also vary in duration and frequency depending on the severity of symptoms and individual patient response. Research recommends cognitive rehabilitation therapy for at least 45 minutes per day, five days per week, for up to six months after a stroke (Parisi et al., 2022). Regarding depression management, the duration of treatment varies depending on the severity of symptoms and individual patient response. However, according to a study by “Cognitive-Behavioral Therapy (CBT)”, post-stroke depression should last at least 10–12 weeks, with weekly sessions lasting 60–90 minutes each. Antidepressant medication may also be prescribed and typically should be continued for at least 6–12 months following remission of depression symptoms (Yang et al., 2020). Ethical Considerations for Designing Patient-Centered Interventions in Stroke Care In designing patient-centered health interventions for stroke, ethical considerations are critical to ensuring that healthcare providers provide interventions that are safe, effective, and respectful of the patient’s autonomy. According to a study, ethical considerations are particularly important in stroke care due to the complex nature of the condition and the potential for long-term disability (Kaufman et al., 2019). For physical rehabilitation, it is essential to consider the patient’s physical limitations and tailor the interventions accordingly. Healthcare providers need to ensure that interventions provided to stroke patients do not cause harm. This includes appropriate training and support to avoid injury and reduce the risk of adverse events. Additionally, patient-centered care must be prioritized by considering the patient’s preferences and culture, respecting their autonomy and promoting their participation in decision-making. A recent study suggests that an individualized rehabilitation program based on the patient’s specific needs and capabilities can reduce the risk of adverse events and improve functional outcomes in stroke patients. This highlights the importance of assessing the patient’s condition and tailoring interventions to their specific needs and risks (Ifejika et al., 2021). NURS FPX 4050 Assessment 4 Final Care Coordination Plan Research suggests that cognitive therapy and memory training interventions must be designed with ethical considerations in mind. A research study discovered that cognitive rehabilitation programs that are personalized to meet the specific needs and preferences encouraging patient involvement can result in better outcomes, including improved cognitive function and quality of life. Furthermore, it is crucial for healthcare professionals to ensure that patients have a comprehensive understanding of the potential advantages and disadvantages of these interventions and obtain their consent before initiating any treatment (Yuan et al., 2021). Therefore, healthcare providers must exercise caution in designing and implementing cognitive therapy and memory training interventions to ensure that they promote patient autonomy and well-being while minimizing potential risks. The process of screening and treatment poses several ethical dilemmas that require careful consideration. An important ethical issue that must be addressed is maintaining confidentiality and protecting the privacy of patients. Healthcare providers must ensure that patient information related to depression screening and treatment is kept confidential and only shared with those involved in the patient’s care. Additionally, providers must obtain informed consent from patients before screening for depression and initiating treatment. Research has shown that individuals with depression may experience discrimination and negative attitudes from others, which can lead to social isolation and worsen their mental health outcomes (Sacco et al., 2023). As a result, it is crucial for healthcare providers to uphold the dignity and respect of patients and protect their confidentiality throughout the entire screening and treatment process. Identify Relevant Health Policy Implications for The Coordination and Continuum of Care The “Patient Protection and Affordable Care Act, 2010 (PPACA)” has significant consequences on stroke patients’ care coordination and continuity. The policy aims to enhance healthcare accessibility, elevate the standard of care, and lower expenses for all Americans. To achieve these objectives, the PPACA includes a range of provisions that support preventive services, care coordination, and patient-centered medical homes, all of which are critical components of stroke care (Ifejika et al., 2021). The PPACA has a crucial element called the “Accountable care organizations (ACOs),” which is a group of healthcare providers working collectively to deliver coordinated care to patients, aiming to enhance quality and decrease costs. Stroke patients can benefit from ACOs as it mandates a tight-knit relationship among primary care providers, neurologists, rehabilitation specialists, and other healthcare professionals. ACOs can help ensure that stroke patients receive appropriate and timely care, reduce the risk of complications and readmissions, and improve patient outcomes (Yedavalli et al., 2021). NURS FPX 4050 Assessment 4 Final Care Coordination Plan Another provision of the PPACA that is highly relevant to stroke care is the requirement that insurance plans cover preventive services without cost-sharing. This encompasses various preventive measures, including screenings for blood pressure and cholesterol, which are

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Name Capella university NURS FPX4050 Coordinating Patient-Centered Care Prof. Name Date Care Coordination Presentation to Colleagues Greetings colleagues, I wish you a good afternoon. As nurses, we hold a vital position in both care coordination and the overall continuum of care. Our comprehension of the care coordination process and its influence on patient outcomes in relation to factors such as safety, ethics, policy, physiological, and cultural needs cannot be understated. This presentation will focus on the fundamental principles of care coordination, addressing change management issues, and the effect of healthcare policy on outcomes and patient experiences. By delving into these topics, we aim to enhance our collective capacity to deliver effective care coordination and ultimately improve patient outcomes. I appreciate your participation in this discussion. Effective Strategies for Collaborating with Patients and Their Families In order to achieve the best health outcomes, it is essential to engage in collaborative efforts with patients and their families. Healthcare professionals can adopt two significant strategies to achieve this goal – drug-specific educational interventions and cultural competence strategies. Drug-Specific Educational Interventions The drug-specific educational interventions involve educating patients and their families about the medication, its administration, and possible side effects. It is crucial for patients to possess this knowledge in order to make informed decisions about their treatment, comprehend their ailment, and follow their prescribed medication routine. Studies indicate that not adhering to medication schedules is a frequent issue that may result in adverse health consequences, augmented healthcare expenses, and reduced quality of life for patients (Horne et al., 2022). For example, patients who do not take their medication as prescribed may experience worsened symptoms, complications, and hospitalizations. However, when patients receive drug-specific educational interventions, they are more likely to adhere to their medication regimens and experience improved health outcomes. The research has demonstrated that tailored educational interventions that address the specific needs and concerns of individual patients can be particularly effective in improving medication adherence. The research by Sendekie et al (2022), found that a medication education program tailored to the needs of individual heart failure patients result in a significant increase in medication adherence compared to a control group (Sendekie et al., 2022).  Cultural competence Cultural competence is an important aspect of effective collaboration, and healthcare professionals must respect and incorporate patients’ cultural beliefs and practices into care planning to improve health outcomes. The study found that culturally competent care was associated with reduced disparities in diabetes care for Hispanic patients .The culturally tailored diabetes education program addressed various cultural beliefs and practices that are relevant to Hispanic patients. These beliefs and practices include the role of family in decision-making, the importance of food in social and emotional contexts, and the impact of stress on diabetes management. The program incorporated these cultural factors into the diabetes management plan, such as encouraging family involvement in decision-making, providing recipes that align with cultural food preferences, and addressing the role of stress in diabetes management. This approach helped the patients to better understand and manage their diabetes in a way that was culturally relevant to them. The effectiveness of the program was demonstrated by the significant improvements in the patients’ A1C levels, blood pressure, and lipid profile, indicating better diabetes control. Additionally, the patients reported an increase in diabetes knowledge and self-efficacy, showing that the program helped them feel more confident in managing their diabetes. Overall, this study provides evidence for the importance of incorporating cultural beliefs and practices into diabetes education and management programs. Doing so can improve health outcomes and reduce disparities in care for ethnic and racial minority patients (Babalola et al., 2021).  Change Management and Patient Experience Implementing change management is an indispensable aspect of delivering superior care that prioritizes the needs of the patient. In order to accomplish this, it is crucial to recognize the factors within change management that have a direct influence on the key elements of the patient experience. Effective change management involves more than implementing changes; it also involves managing the process of change. Communication, respect, empathy, and trust are crucial elements of the patient experience that are highly valued by patients and must be taken into consideration during change management. Efficient communication and cooperation are imperative to deliver patient-oriented care that is customized to meet the unique requirements and inclinations of every patient. Clear and concise communication among healthcare providers and with patients and their families is necessary to ensure that patients receive individualized care that meets their unique needs, as emphasized in a study published in the Journal of Healthcare Management (Liu, Huang, & Liu, 2019). In addition, teamwork is essential for delivering patient-centered care that meets the unique needs of each patient. Healthcare providers must collaborate on care plans, share patient information, and address issues together to deliver care that is centered around the patient, as highlighted in a study in the Journal of Nursing Education and Practice (Hao et al., 2020). NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues By incorporating effective communication and teamwork, healthcare providers can provide personalized and patient-centered care, which is associated with better patient outcomes such as improved satisfaction and reduced hospital readmissions. A study published in the Journal of Nursing Management underlines the importance of tailoring care to the individual needs and preferences of each patient, emphasizing the benefits of patient-centered care (Talwar, Kaur, & Kaur, 2021). It is important to distinguish between patient experience and patient satisfaction. Patient experience refers to the overall experience of the patient, including their emotional and psychological response, while patient satisfaction relates to the patient’s perception of their care. Effective change management ensures that the patient’s autonomy is respected, and the care provided is in the patient’s best interest. Involving patients, their families, and other healthcare professionals in the change process is a crucial step in ensuring that patient-centered care is provided.  Ethics-Based Coordinated Care Plans: Rationale, Implications, and Assumptions When it comes to caring for patients, it is essential to have a coordinated approach that takes

NURS FPX 4050 Assessment 2 Ethical and Policy Factors in Care Coordination

Name Capella university NURS FPX4050 Coordinating Patient-Centered Care Prof. Name Date Ethical and Policy Factors in Care Coordination Good afternoon, everyone. This presentation will go through the legal and policy issues that influence the care coordination for homeless people in our society. People experiencing homelessness are part of the most susceptible groups in our community and usually have intricate medical and psychological necessities that demand organized attention. However, providing coordinated care for homeless individuals can be challenging due to a variety of factors, including lack of access to healthcare services, limited resources, and the stigma associated with homelessness. The presentation will explore governmental policies, ethical dilemmas, and the nursing ethical code that affect care coordination for homeless people in our community. Governmental Policies Addressing Community Safety and Health  The coordination of care for homeless individuals is heavily influenced by governmental policies that focus on promoting the health and safety of the community. For instance, the “Affordable Care Act (ACA)” has widened healthcare coverage for many, including homeless individuals. The ACA has had a significant impact on healthcare coverage for homeless individuals. Prior to the ACA, many homeless individuals lacked access to healthcare due to factors such as lack of insurance coverage, inability to pay for care, and lack of transportation to healthcare facilities. The ACA has expanded Medicaid eligibility in many states, allowing more homeless individuals to qualify for free or low-cost healthcare coverage (Ye & Rodriguez, 2021). Additionally the ACA has also provided funding for programs that specifically target homeless individuals. For example, the “Health Care for the Homeless (HCH)”  governmental policies was established under the ACA to provide healthcare services to homeless individuals in various settings, such as shelters and soup kitchens. One of the key features of the HCH is its focus on providing care that is culturally and linguistically appropriate. This means that healthcare providers who work with homeless individuals are trained to understand the unique needs and experiences of this population and are able to provide care that is sensitive to their cultural backgrounds and language needs. Another important aspect of the HCH program is its emphasis on case management and care coordination. NURS FPX 4050 Assessment 2 Ethical and Policy Factors in Care Coordination This involves working closely with other healthcare providers, social service agencies, and community organizations to ensure that homeless individuals receive comprehensive and coordinated care that addresses all of their health and social needs (Lanese et al., 2021).The challenges that homeless individuals face in accessing healthcare services are numerous, but these policies demonstrate the commitment of the government and healthcare providers to address the unique needs of this vulnerable population. By increasing care accessibility, ensuring linguistically and culturally appropriate treatment, and targeting the core causes of homelessness, These policies work towards a society where all societies have equitable access to healthcare services regardless of housing status. Policy Provisions  in Coordinating Care for Homeless Individuals The important policy issue in coordinating care for homeless individuals is the balance between respecting their autonomy and ensuring their safety. The “Health Insurance Portability and Accountability Act (HIPAA)” protects the autonomy and privacy of individuals and their health information. However, for homeless individuals with complex medical and mental health needs, care coordinators must balance their autonomy with their safety and well-being. In situations where homeless individuals refuse to comply with treatment plans or medication regimes, care coordinators face ethical dilemmas in ensuring the individual receives the necessary care while also respecting their autonomy (Lanese et al., 2021). Another policy provision that raises ethical questions is the tension between the needs of the individual and the needs of the community. Homeless individuals may have contagious illnesses that could spread to others in the community, posing public health risks. Care coordinators must balance the individual’s right to privacy and autonomy with the safety and well-being of the community. Additionally, ethical concerns arise regarding access to care for homeless individuals, particularly with the “Affordable Care Act (ACA)” and Expanded medicaid. While the ACA has increased access to healthcare for some homeless individuals, many still face barriers to accessing care due to lack of insurance, transportation, and stigma (Ye & Rodriguez, 2021). These policy provisions raise ethical implications and consequences for care coordination. Care coordinators must navigate complex ethical dilemmas to ensure homeless individuals receive appropriate care while upholding their autonomy and privacy rights. They must also evaluate the influence of policies on care availability and the public health risks associated with homelessness. Code of Ethics for Nurses on Care Coordination and Continuum of Care for Vulnerable Populations The Nursing Code of Ethics provides a strong ethical foundation for care coordination and continuum of care for homeless individuals. It emphasizes the importance of protecting the rights, health, and safety of patients, which is particularly relevant when working with vulnerable populations. Provision 3 of the Code highlights the requirement for nurses to advocate for, support, and safeguard the patient’s autonomy, wellbeing, and safety. Additionally, Provision 8 recognizes the importance of collaboration with other healthcare providers as well as the public in promoting community efforts to meet health needs, which is essential for effective care coordination (Hankset al., 2019). Research has shown that adherence to ethical codes and guidelines is associated with improved health outcomes and quality of care for patients. A study by Davis et al. (2021) found that nurses who reported higher levels of adherence to the Code of Ethics for Nurses also reported higher levels of job satisfaction and perceived patient safety. Another study by Hendricks et al. (2020) found that adherence to ethical guidelines for the care of homeless individuals was associated with improved patient outcomes and increased access to care. Furthermore, the social determinants of health, such as poverty and homelessness, must be considered while evaluating the influence of the nursing code of ethics. Homeless individuals often face significant barriers to accessing healthcare services, including lack of transportation, financial resources, and social support (Hanks et al., 2019). The Nursing Code of Ethics  highlights the importance of

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Name Capella university NURS FPX 4050 Coordinating Patient-Centered Care Prof. Name Date Preliminary Care Coordination Plan The development of a preliminary care coordination plan for a health care problem is an essential responsibility of a staff nurse in a community care center. Preliminary care coordination refers to the initial steps taken in the care coordination process. These steps involve identifying the healthcare problem, assessing the patient’s needs, and developing a comprehensive plan of care. Physical, psychosocial, and cultural considerations are essential components of a comprehensive plan of care (Marimuthu et al., 2022). Patients have unique experiences, beliefs, and values that influence their perceptions of illness and health, and incorporating these aspects into the plan of care is critical to achieving positive outcomes. The emotional and mental health of patients play a significant role in determining the overall health status of an individual. Therefore, it is important to integrate psychosocial support services into the plan of care to address any psychological or emotional barriers that may hinder the patient’s recovery (Kuhney et al., 2023). Furthermore, recognizing the influence of cultural values and beliefs is essential to delivering culturally competent care. Patients’ cultural backgrounds can impact their perceptions of illness and treatment, and this can affect their willingness to adhere to the plan of care (Marimuthu et al., 2022). This assessment aims to present a perceptive analysis of a selected health concern, establish realistic and attainable goals, and identify significant community resources to ensure a safe and effective continuum of care. Furthermore, the plan is the foundation for delivering complete and efficient patient treatment that addresses not only their physical needs but also their psychosocial and cultural elements. Perceptive Analysis of a Health Concern and Evidence-Based Practice Heart disease is a significant health concern that affects a large number of individuals. It includes conditions such as high blood pressure, stroke, and heart failure. Cardiovascular diseases are the primary worldwide cause of death, responsible for 17.9 million fatalities annually, as per the “American Heart Association.” To combat this serious health issue, various research studies have suggested that adopting healthy lifestyle habits and participating in health education programs can considerably lower the possibility of getting heart illness. The research published in the “American College of Cardiology Journal” in 2019 concluded that engaging in regular physical activity, including activities like walking, jogging, swimming, or cycling for a minimum of 30 minutes per day, can enhance heart function, decrease blood pressure, and improve cholesterol levels (Finocchiaro et al., 2023).In addition to lifestyle modifications, medication therapy is also critical for managing heart disease. Several types of medications are available to help manage heart disease risk factors, including those that lower cholesterol levels, control blood pressure, prevent blood clots, and reduce the risk of heart failure. These medications include statins, “Angiotensin-converting Enzyme Inhibitors (ACE)”, and “Angiotensin Receptor Blockers (ARBs)”. NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan For instance, a case study published in the “Journal of Cardiology” Cases in 2019 reported the successful management of heart disease in a patient with a history of myocardial infarction using a combination of high-dose statin therapy and beta-blockers. The individual showed a substantial reduction in their Low-Density Lipoprotein (LDL) cholesterol levels and successfully attained the targeted blood pressure levels. The combination therapy resulted in improved symptoms and overall quality of life for the patient (Chen et al., 2023). Although these best practices have demonstrated efficacy, the analysis is subject to underlying assumptions and areas of uncertainty. For instance, medication therapy may not be well-tolerated by certain patients due to adverse effects, and lifestyle modifications, such as weight loss, may be unattainable for some patients (Marimuthu et al., 2022). Attainable Goals to Address Selected Health Care Problems To address the health concern of heart disease, it is essential to establish specific goals. An impactful objective would be to increase physical activity levels by incorporating at least 30 minutes of activity of moderate intensity into everyday schedules. The number of days per week the individual engages in physical activity, as well as the duration and intensity of the activity, can be tracked to measure progress towards the goal (Chen et al., 2023).An additional goal to avoid heart disease is to consume foods that are good for the heart, such as vegetables, fruits, whole carbohydrates, and protein sources in moderate amounts. Specific targets for the number of servings of each food group to be consumed per day or week can be set to achieve this goal. For instance, at least five servings of fruits and vegetables every day and choosing lean protein sources such as chicken, fish, or legumes instead of red meat. Moreover, incorporating whole grains into the diet by replacing refined grains can further promote heart health. Choosing brown rice instead of white rice is an excellent way to incorporate more whole grains into the diet. These changes should be made gradually, and progress can be tracked by keeping a food diary or using a tracking app to ensure the goals are attainable (Maddox et al., 2021). NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan In addition to lifestyle changes, smoking is a major contributor to cardiovascular disease, thus quitting smoking can significantly reduce the likelihood of getting heart disease. Setting a specific goal to quit smoking within a specified timeframe, such as 6 months, can be effective. Progress can be monitored by keeping track of the number of cigarettes smoked per day and the number of quit attempts.While these goals have been shown to be effective, it’s essential to recognize underlying assumptions and points of uncertainty in the analysis. For example, medication therapy may not be well-tolerated by some patients due to side effects, and some lifestyle modifications such as weight loss may not be achievable for some patients (Maddox et al., 2021).  Thus, it’s important to tailor goals to individual needs and capabilities to achieve the best outcomes. Community Resources for Individuals at Risk of Heart Disease Identifying significant and available community resources is crucial for