Free Essay - Final Care Coordination Plan

Healthcare issues are central in the contemporary environment and are prioritized by most countries through massive investments. Successive governments have designed strategies for enhancing the efficiency of the healthcare system and ensuring that healthcare services are available to all citizens. Lyle-Edrosolo and Waxman (2016) note that advancements in healthcare technologies have led to significant transformations in healthcare, facilitating advanced acute care coordination plans. Besides efficiency, healthcare technologies also permit the delivery of quality care.

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A care coordination plan design enables patient-centric healthcare strategies. Such a plan organizes nurses and other healthcare practitioners to work in collaboration with each other toward the realization of set objectives. Patient-centric objectives allow the realization of comprehensive care coordination. Traditionally the execution of professionalism in healthcare was only possible through direct clinical interactions. According to the Centers for Disease Control and Prevention (CDC), clinical interventions are a function of open collaborations between patients, caregivers, and families (Rutledge et al., 2018). Caregivers, patients, and families must work together to realize comprehensive patient care.

Recap on Patient

This care coordination plan addresses the health issues of 65-year old John Smith, who has a medical history of hypertension and appendectomy surgery. The patient’s current health complications include pain in his right hip, which has worsened over the years. The patient’s primary care provider referred him to an orthopedic consultant, who took him through an x-ray, an MRI, and a physical exam. The consultant diagnosed severe osteoarthritis of the right hip. The patient is to undergo an anterior approach to hip replacement surgery. There is a need for care coordination planning that will permit pre-operative education, surgery, and post-operative care. The patient also needs skilled nurse visits at his home, physical therapy, and occupational therapy to assist his range of motion and manage personal activities such as dressing, respectively.

Patient Health Issues

Hypertension or high blood pressure is a chronic disease associated with blood plasma volume, abnormal hormone activity, and lifestyle (Alarsan & Younes, 2019). Some of the lifestyle causes of hypertension include the intake of large amounts of fats. Alarsan and Younes note that normal human blood pressure ranges between 100 and 130 (mmHg). Any values beyond this range are considered indicators of hypertension. The patient exhibits racing heartbeats, shortened breaths, and dizziness. If the condition management is poor, the patient may suffer heart failure, heart attack, coronary diseases, or kidney failure. The management of a patient’s high blood pressure requires comprehensive care coordination. In the present case, this condition has been a threat to Mr. Smith’s health condition and wellbeing. The World Medical Association recognizes the need to eradicate hypertension through the establishment of enhanced strategies. Also, one objective of healthy people in 2020 is to help eradicate such chronic diseases (Alarsan & Younes, 2019).

The second major healthcare issue that affects Mr. Smith is hip osteoarthritis. Hip osteoarthritis is a degenerative hip disorder that affects middle-aged and older adults. It occurs when the hip joint cartilage snaps as one age and is very painful. Available treatments for hip osteoarthritis include pharmacological treatments such as acetaminophen and application of steroidal anti-inflammatories for mild to moderate pain. Lespasio et al. (2018) also recommend corticosteroid injections at the hip joint, hip arthroscopy, and hip arthroplasty for acute cases.

The third health issue associated with Mr. Smith is a history of appendicitis. Appendicitis is an emergency disease that causes inflammation of the appendix and requires surgery to remove. It is associated with pain in the lower right abdomen, which moves to other parts of the body.

Interventions for the Health Issues

The intervention care plan for hypertension will aim at lowering and controlling Mr. Smith’s blood pressure, ensure that he adheres to the therapeutic regimen, adjusts his lifestyle, and prevents related complications. During the first week, Mr. Smith will be signed up for a hypertension education program (Alarsan & Younes, 2019). The patient will be offered a consultant to evaluate his capacity to self-manage and the capacity of the family members to provide support and guidance as needed. The patient will then be directed to a cardiologist to determine the extent of their heart disease. Next, a personal doctor will help to establish a lifestyle routine and proper medication regime.

For the second issue, osteoarthritis, the patient will visit an orthopedist and a rheumatologist. The primary care will help with the recommendations that lead to changes in lifestyle and home care. The Institute for Healthcare Excellence provides a guideline for the management of osteoarthrosis. During the first meeting, the specialist will diagnose and determine the extent of the problem. An education and self-management strategy will be established. Once the scope of the problem is determined, a team will be established that involves the specialist, the patient, and the family members, which will help establish a holistic approach to regular assessment and management of the disease. A nonpharmacological management regime will be established.

The intervention for issues related to appendicitis will begin with nursing assessment. During this initial stage, the level of pain will be assessed, and relevant laboratory tests conducted. The risk of infection is then determined. A plan for nursing care will focus on pain relief, anxiety, skin integrity maintenance, and proper nutrition. The nursing intervention will include antibiotic and non-antibiotic therapy, while a continuous evaluation process will help with pain relief. Home care procedures will define the physical activity and home care.

Ethical Decisions

There are ethical decisions in designing patient-centered healthcare interventions. Foremost, the ACP Ethics Manual desires that physicians work with patients to ensure access to care. Therefore, the primary care nurse must ensure improved access to care as envisioned. Establishing guideline-consistent care should permit the delivery of care coordination in a manner that puts the interest of the patient at the forefront. The nurse must adhere to doing what helps to improve the health of the patient while accommodating their beliefs. Therefore, it would be important that Mr. Smith receives care in his home where he has the full support of the family as opposed to having him as an inpatient. The actions of the primary nurse and those of the caregivers will be aligned to best-practics. Above all, such practice will be required to promote life and the right to autonomy of the individual. Also, in establishing the care treatment plan, there should be non-maleficence. The care plan should allow advocacy against harm to the client, whether intentional or unintentional.

Relevant Health Policy Implications for Coordination and Continuum of Care

Coordination and continuum care help address several policy issues in the healthcare sector. Foremost coordinated care enables targeting of high-need, clinically high-risk patients. Focusing on such patients permits the improvement of health outcomes and the reduction of healthcare costs. High-need patients have thus handled appropriately through the involvement of communities (Yousefi et al., 2019). Another policy aspect that coordinated care helps advance is improved access to hospital and emergency admission. Timely response to patient needs helps to attend to patients and allows primary care nurses to establish disease causes faster. Coordinated care also permits the establishment of strong transitional care programs. Transitioning from hospital to home-based care allows patients to receive more comprehensive care and heal quickly. This approach allows continuous follow-up and the true definition of primary care. The requirement for patient education and engagement is also addressed. Coordinated care requires the involvement of all stakeholders, hence the need to educate them.

Coordination and continuum of care help to address the need for involvement of multi-disciplinary teams (Yousefi et al., 2019). Patient needs are diverse in the sense that a complication such as a fractured hip leads to pain and psychological breakdown. Coordinated care involves many professionals. Furthermore, the need to use data to ensure quality improvements is also addressed since the coordinated approach allows the use of technologies that link the various stakeholders and notify them when their attention is required.

Conclusion

Healthcare experience is essential for modern value-based healthcare systems. Over time, growth in the healthcare sector has not been commensurate with patient experience. Care coordination helps to bridge the gap. Patient-centered care allows the realization of various health policies and ethical issues, such as respect for patient freedoms. In the case of the current case, a coordinated care plan for treating osteoarthritis, hypertension, and appendicitis is established to ensure the proper treatment of the patient. The care plan is established in anticipation that it is followed so that the patient is involved in their care.

References

Alarsan, F. I., & Younes, M. (2019). Analysis and classification of heart diseases using heartbeat features and machine learning algorithms. Journal of Big Data, 6(1), 1-15. https://journalofbigdata.springeropen.com/articles/10.1186/s40537-019-0244-x

Lespasio, M. J., Sultan, A. A., Piuzzi, N. S., Khlopas, A., Husni, M. E., Muschler, G. F., & Mont, M. A. (2018). Hip osteoarthritis: a primer. The Permanente Journal, 22. doi: 10.7812/TPP/17-084

Lyle-Edrosolo, G., & Waxman, K. T. (2016). Aligning healthcare safety and quality competencies: quality and safety education for nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) magnet® standards crosswalk. Nurse Leader, 14(1), 70-75. https://doi.org/10.1016/j.mnl.2015.08.005

Rutledge, G. E., Lane, K., Merlo, C., & Elmi, J. (2018). Coordinated approaches to strengthen state and local public health actions to prevent obesity, diabetes, and heart disease and stroke. Preventing chronic disease, 15. doi: 10.5888/pcd15.170493

Yousefi Nooraie, R., Khan, S., Gutberg, J., & Baker, G. R. (2019). A network analysis perspective to implementation: the example of health links to promote coordinated care. Evaluation & the health professions, 42(4), 395-421. https://doi.org/10.1177%2F0163278718772887