NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Name

Capella university

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Final Care Coordination Plan

This care coordination plan extends an earlier plan that was developed for Maria, a 55-year-old Hispanic woman in California diagnosed with Type II Diabetes (T2DM), Hypertension (HTN), and depressive disorder. This final plan will specify scientifically recommended health interventions for Maria to improve her health comprehensively. Moreover, ethical principles have been considered while developing this plan. Besides, it discusses the healthcare policies that assert care coordination for diabetic patients. Finally, the assessment presents the care coordinator’s priorities while discussing the care coordination plan.

Patient-Centered Health Interventions 

The three primary issues that our care coordination plan addresses include poor disease management, psychological distress, and readmission risk. 

• As observed from the case study, Maria’s poor disease management based on insulin resistance and high blood pressure, the six-month Chronic Disease Self-Management Program (CDSMP) is recommended. This highly recognized strategy enables those who have illnesses like diabetes to manage their diseases through changes in their daily practices and sustain medication adherence and tracking regimens (Kerari et al., 2024). Maria can utilize community resources such as the Department of Aging California and the American Diabetes Association – California Chapter. These entities provide group classes supported by audio-visual aids and counseling services that are focused on explaining the fundamental skills of self-care among people with diabetes. Furthermore, the Kaiser Permanente Diabetes Management Program can offer the client more information regarding lifestyle changes and medication adherence in order to improve her quality in managing diabetes. 
• The second major concern is the emotional distress that Maria is experiencing, which can be addressed through culturally competent CBT sessions for six months. Culturally appropriate CBT sessions are helpful for ethnic minorities as these individuals feel accepted and appreciated and gain positive mental health outcomes (Huey et al., 2023). In California, culturally competent mental health resources are available through the LA County Department of Mental Health (DMH), which offers culturally competent resources that reduce health disparities and enhance equity through outreach programs, multilingual services, case consultations, emergency services, etc. (LA County DMH, n.d.). Other available community resources include the California Latino Behavioral Health Association (CLBHA) and NAMI California (National Alliance on Mental Illness), which can be consulted for various kinds of mental health educational and medical services.

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

• Finally, to lower Maria’s risk of hospital readmissions, the plan recommends the use of telehealth check-ins and offering community support workshops. Evidence supports telehealth services as it allows healthcare providers to continuously monitor patients’ blood glucose and other vitals remotely, ensuring timely consultations and advice to reduce the need for hospital readmissions (Anderson et al., 2022). Additionally, culturally sensitive educational workshops focused on self-monitoring techniques and smartphone apps will empower Maria to take control of her health in real-time. The state of California offers a range of telehealth and self-management resources through programs like California Telehealth Network, California Health Information Exchange (HIE), and Health Net’s Disease Management Program. These organizations offer comprehensive digital support, helping Maria stay connected to her care team and maintain consistent disease management to reduce readmission risk. 

Ethical Principles in Decision-making Regarding Health Interventions

The health interventions described earlier are grounded in several ethical principles defined by healthcare ethics. Firstly, the CDSM program for disease management takes into account the principle of autonomy of the patient. The literature demonstrates that patient choice is a key factor in patient-centered care since it ensures improved satisfaction and positive results (Liang et al., 2022). However, the intervention may justify ethical issues touching on health equity due to inadequate resources and access to those resources. Therefore, it is crucial to establish those priority needs or care difficulties associated with identifying autonomous and equitable care solutions. 

Secondly, culturally sensitive CBT sessions make use of the ethical principles of beneficence and non-maleficence, which entails working in patients’ best interest and avoiding harm to the patient or the environment (Cheraghi et al., 2023). At the same time, the intervention must not be biased against or promote cultural stereotypes or harm the patient’s cultural beliefs. However, an ethical uncertainty remains between cultural sensitivity and the effectiveness of healthcare practices, requiring constant communication with Maria to understand her cultural views and mental health.

Finally, the justice and digital fairness of the implementation of telehealth services and educational workshops are the ethical considerations (Petretto et al., 2024). While telehealth offers both convenience and increased surveillance, concerns such as technological accessibility and knowledge may persist. Therefore, this intervention should be ethically prioritized by offering technological training and fair access to the patient.  

Health Policies for Care Coordination 

Several healthcare regulations influence the coordination of diabetes and other chronic diseases. The Affordable Care Act (ACA) was enacted with the purpose of improving care coordination through the integration of technology, health insurance, and chronic illness prevention (Centres for Medicare & Medicaid Services, n.d.). The purpose of this policy is to minimize health inequities and improve health outcomes by increasing Maria’s access to preventive treatment, lowering financial obstacles, and fostering a continuum of care that integrates community resources.

Another law crucial to Maria’s care plan is the Health Insurance Portability and Accountability Act (HIPAA). This policy obligates telehealth practitioners to protect patients and their information privacy and security (Bassan, 2020). For Maria, several telehealth consultations and smartphone apps to monitor diabetes and hypertension need to provide privacy and security of the patient’s medical data while meeting the necessity for adequate treatment and services. 

Priorities of a Care Coordinator and Changes to the Plan 

In order to develop a customized, patient-centered strategy, a care coordinator reviewing Maria’s care coordination plan would place a high priority on effective communication and conduct a thorough needs assessment. Establishing a trustworthy relationship with the patient through lucid and culturally sensitive communication should come first (Kwame & Petrucka, 2021). This entails hearing out her worries, figuring out how well-informed she is about health issues, and making sure she understands her treatment plan. In order to deliver individualized and patient-centered care, the coordinator would also evaluate Maria’s physical, psychological, and social requirements (Kwame & Petrucka, 2021). The care coordinator would alter the plan as needed in light of this assessment. 

In addition, modifications will be implemented using evidence-based procedures. For example, if Maria finds telemedicine difficult, the coordinator could suggest in-person check-ins or remote monitoring technologies, which have been demonstrated to enhance the outcomes of chronic illnesses. According to Huey et al. (2023), there is evidence to suggest that culturally adapted therapies improve mental health outcomes for minority groups. This further supports the need for culturally sensitive cognitive behavioral therapy. Maria’s health will improve, and the likelihood of complications will decrease with these modifications, which will guarantee her full, easily accessible treatment that is in line with best practices.

Evaluating Learning Sessions and Teaching Sessions

To ensure efficacy, learning session material must be evaluated in relation to Healthy People 2030 goals and best practices found in the literature. According to the literature, learning sessions need to be patient-centered, evidence-based, and culturally acceptable. This entails incorporating content that supports lifestyle modifications, self-management, and mental health support for Maria’s diabetes and hypertension, all of which are backed by best practices and cultural competence (Kerari et al., 2024). 

The goal of Healthy People 2030 is to enhance access to health care and lower the prevalence of chronic diseases like diabetes (U.S. Department of Health and Human Services, n.d.). By emphasizing accessible treatment, patient empowerment, and prevention education, learning sessions should help achieve these objectives. Changes are necessary if the learning sessions fail to address specific health inequities. Additionally, if there are no interactive components in the sessions to keep the patients interested, changes can involve the addition of brochures, visual aids, or practical demonstrations. Furthermore, Maria’s technological or cultural background should be taken into account. In that case, changes should be made to guarantee that the sessions are accessible and sensitive to cultural differences, in keeping with the goals of Healthy People 2030.

Conclusion

In conclusion, Maria’s care coordination plan integrates effective approaches to address her diabetes, hypertension, and psychological distress while prioritizing her needs and preferences. Core interventions include self-management programs to support her in controlling her health, culturally sensitive therapy sessions, and assistance through telehealth and educational resources. By utilizing local support services, the plan aims to offer comprehensive care with ongoing aid. It also upholds vital ethical principles such as autonomy, beneficence, non-maleficence, and justice and adheres to healthcare regulations like the ACA and HIPAA. By aligning with best practices and the objectives of Healthy People 2030, the plan emphasizes equitable access to care, prevention, and managing chronic conditions. This approach is designed to enhance Maria’s health, reduce her risk of complications, and minimize future hospitalizations.

References

 Anderson, A., O’Connell, S. S., Thomas, C., & Chimmanamada, R. (2022). Telehealth interventions to improve diabetes management among Black and Hispanic patients: A systematic review and meta-analysis. Journal of Racial and Ethnic Health Disparities, 9(6). https://doi.org/10.1007/s40615-021-01174-6 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Bassan, S. (2020). Data privacy considerations for telehealth consumers amid COVID-19. Journal of Law and the Biosciences, 7(1). https://doi.org/10.1093/jlb/lsaa075 

Centers for Medicare & Medicaid Services. (n.d.). New Affordable Care Act initiative to support care coordination nationwide. Www.cms.gov. https://www.cms.gov/newsroom/press-releases/new-affordable-care-act-initiative-support-care-coordination-nationwide 

Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing, 22(89). https://doi.org/10.1186/s12912-023-01246-4 

Huey, S. J., Park, A. L., Galán, C., & Wang, C. X. (2023). Culturally responsive cognitive behavioral therapy for ethnically diverse populations. Annual Review of Clinical Psychology, 19(1), 51–78. https://doi.org/10.1146/annurev-clinpsy-080921-072750 

Kerari, A., Bahari, G., Alharbi, K., & Alenazi, L. (2024). The effectiveness of the chronic disease self-management program in improving patients’ self-efficacy and health-related behaviors: A quasi-experimental study. Healthcare, 12(7), 778. https://doi.org/10.3390/healthcare12070778

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(158). https://doi.org/10.1186/s12912-021-00684-2 

LA County DMH. (n.d.). Cultural competence resources. Department of Mental Health. https://dmh.lacounty.gov/ccu/ccr/ 

Liang, Z., Xu, M., Liu, G., Zhou, Y., & Howard, P. (2022). Patient-centred care and patient autonomy: Doctors’ views in Chinese hospitals. BMC Medical Ethics, 23(38). https://doi.org/10.1186/s12910-022-00777-w 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Petretto, D. R., Carrogu, G. P., Gaviano, L., Berti, R., Pinna, M., Petretto, A. D., & Pili, R. (2024). Telemedicine, e-Health, and digital health equity: A scoping review. Clinical Practice and Epidemiology in Mental Health, 20(1). https://doi.org/10.2174/0117450179279732231211110248 

U.S. Department of Health and Human Services. (n.d.). Healthy People 2030 | Diabetes. Health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes