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NURS FPX 4050 Assessment 4 Final Care Coordination Plan

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    NURS FPX 4050 Assessment 4 Final Care Coordination Plan


    Capella university

    NURS FPX4050 Coordinating Patient-Centered Care

    Prof. Name


    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:

    1. Physical rehabilitation is critical in restoring function and mobility after a stroke. Patients should undergo physical therapy as soon as possible after a stroke to prevent muscle atrophy, improve strength, and promote independence. The strategy for rehabilitating physical function encompasses various interventions, such as therapeutic exercise, rehabilitation of fine motor skills, and speech therapy (Dromerick et al., 2021).  There are several community resources available for physical rehabilitation interventions for stroke survivors. The American Stroke Association offers support groups, educational resources, and rehabilitation programs. The National Institute on Aging provides exercise and physical activity resources specifically for older adults who have had a stroke highlighting individual needs. The National Stroke Association also provides rehabilitation programs and other forms of support for stroke survivors (Harrington et al., 2020).

    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

    1. Stroke can cause cognitive impairment, including memory loss, difficulty with attention, and language problems. Cognitive rehabilitation is essential in improving cognitive function and promoting independence. Cognitive rehabilitation interventions can be tailored to the specific needs of each patient, with cognitive therapy and memory training customized to address the patient’s individual challenges and goals. This personalized approach to cognitive rehabilitation can lead to better outcomes and a greater sense of empowerment and autonomy for stroke survivors (Cicerone et al., 2019). There are several community resources available such as, the “Alzheimer’s Association” provides resources and support for individuals with cognitive impairments, including stroke survivors. The “Brain Injury Association of America” offers a range of resources and assistance to individuals who have experienced brain injuries, including those who have suffered cognitive impairment as a result of a stroke. The “National Aphasia Association” provides resources and support for individuals with aphasia, a language impairment commonly associated with stroke (Monica et al., 2021).

    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).

    1. Stroke survivors are at increased risk of depression due to physical, cognitive, and emotional changes resulting from the stroke. Depression can negatively impact recovery and quality of life (Maalouf et al., 2023).  The intervention for depression includes screening and treatment. The following are three community resources for depression interventions: The “National Alliance on Mental Illness” is one such organization that provides these resources. Additionally, the “Substance Abuse and Mental Health Services Administration” also provides resources and support for individuals with mental illnesses, including depression. Finally, the “American Psychological Association” offers resources and support for those dealing with mental health concerns, including depression (Phillips, K. 2020).

    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 crucial in preventing and managing stroke. By covering preventive services without cost-sharing, the PPACA helps ensure that patients receive the necessary care to prevent strokes from occurring and manage the risks of future strokes (Dugan & Booshehri, 2021).

    Furthermore, the Healthy People 2030 initiative, which sets national objectives for improving health outcomes, including those related to stroke, is closely aligned with the PPACA’s provisions for care coordination and patient-centered care. One of the objectives of this initiative is to increase the proportion of stroke patients who receive timely rehabilitation services. This objective aligns with the PPACA’s emphasis on care coordination and patient-centered care, which are essential for maximizing stroke recovery potential. Healthcare providers and care coordinators should be aware of these provisions and objectives, and work to ensure that their care plans are aligned with these policies (Pahigiannis et al., 2019).

    Priorities for Care Coordinator in Discussing and Modifying Care Plan

    According to the literature, when discussing and modifying a care plan with a patient and their family, a care coordinator should prioritize the following aspects based on evidence-based practice. Such as the care plan should be patient-centered, taking into consideration the patient’s preferences, values, and goals. The care coordinator should involve the patient and their family in decision-making and respect their autonomy (Cicerone et al., 2019). Medication management is crucial in preventing adverse drug events and improving health outcomes. The care coordinator should ensure that the patient understands their medication regimen, including the purpose, dose, frequency, and possible side effects Additionally, they should monitor the patient’s medication adherence and make necessary adjustments to the plan (Kretchy et al., 2021).

    Moreover, chronic diseases, such as diabetes, hypertension, and heart disease, require ongoing management. The care coordinator should provide education and support to the patient to help them manage their condition effectively. This may include dietary changes, physical activity, and regular monitoring of symptoms (Nordfonn et al., 2019). Preventive care is essential in maintaining good health and preventing future complications. The care coordinator should discuss preventive measures, such as immunizations, cancer screenings, and health screenings, with the patient and ensure that they receive appropriate care (Dromerick et al., 2021).

    NURS FPX 4050 Assessment 4 Final Care Coordination Plan

    The care coordinator should ensure that the patient receives coordinated care across different healthcare settings and providers. This includes ensuring that medical records are shared among providers, that referrals are made to appropriate specialists, and that follow-up appointments are scheduled. The care coordinator may have to make modifications to the care plan, based on the patient’s progress and changing needs over time. For example, if the patient is struggling with medication adherence or experiencing side effects, the nurse may need to adjust the medication regimen or provide additional education. Additionally, if the patient’s mobility improves, the nurse may need to adjust recommendations for exercises or equipment to ensure continued progress. Care coordinators must be able to recognize when changes are necessary and communicate these changes effectively with the patient and their family (Yedavalli et al., 2021).

    Stroke Care Education with Healthy People 2030

    Healthcare providers need to keep themselves informed about the most recent research and guidelines to provide optimal care for stroke patients. By using the literature, healthcare providers can compare their current learning session content with best practices and identify any necessary revisions. One such guideline is the Healthy People 2030 document, which provides recommendations for promoting health and preventing disease, including stroke.

    The Healthy People 2030 document emphasizes the importance of physical activity and maintaining a healthy weight in preventing stroke and improving overall health outcomes. As part of a patient-centered evidence-based practice, educational sessions for stroke patients should align with the recommendations from Healthy People 2030. Providers can incorporate information about the importance of physical activity and maintaining a healthy weight into their teaching sessions as part of their stroke prevention strategy (Pahigiannis et al., 2019). 

    In addition, educational sessions should cover approaches for assessing and handling patients’ rehabilitation needs, which could comprise of physical therapy, occupational therapy, and speech therapy (Pahigiannis et al., 2019). By referencing assessment literature and aligning learning sessions with best practices and the Healthy People 2030 initiative, healthcare practitioners can ensure that they provide stroke patients with the most efficient and comprehensive treatment possible. By working collaboratively with patients to achieve their individual goals and needs, healthcare providers can promote long-term health and well-being.


    Effective care coordination is essential to improving health outcomes and reducing healthcare costs. A care coordinator plays a vital role in ensuring that patients receive high-quality, patient-centered care. By prioritizing evidence-based practices, such as patient-centered care, medication management, chronic disease management, preventive care, and coordination of care, the care coordinator can help patients achieve optimal health outcomes. It is important to continually evaluate and revise the care plan based on evidence-based practices to ensure that patients receive the best possible care. Healthcare professionals may improve the quality of treatment for stroke patients and achieve improved health outcomes by incorporating best practices in evaluation and aligning teaching sessions with the Healthy People 2030 initiative.


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    Dugan, J. A., & Booshehri, L. G. (2021). Effects of inadequate coverage on healthcare utilization: A regression discontinuity analysis. Medicine, 100(20).

    Gittins, M., Vail, A., Bowen, A., Lugo-Palacios, D., Paley, L., Bray, B., … & Tyson, S. (2020). Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme. Clinical rehabilitation, 34(7), 981-991. 

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    Ifejika, N., Vahidy, F., Reeves, M., Xian, Y., Liang, L., Matsouaka, R., … & Savitz, S. I. (2021). Association between 2010 Medicare reforms and utilization of post-acute inpatient rehabilitation in ischemic stroke. American journal of physical medicine & rehabilitation, 100(7), 675.

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    NURS FPX 4050 Assessment 4 Final Care Coordination Plan

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