Preliminary Care Coordination Plan

Develop a 3-4 page preliminary care coordination plan for a selected 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. Introduction- 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. NOTE: You are required to complete this assessment before Assessment 4. Preparation- As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement. 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- Note: You are required to complete this assessment before Assessment 4. Develop the Preliminary Care Coordination Plan Complete the following: • Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to: o Stroke. o Heart disease (high blood pressure, stroke, or heart failure). o Home safety. o Pulmonary disease (COPD or fibrotic lung disease). o Orthopedic concerns (hip replacement or knee replacement). o Cognitive impairment (Alzheimer's disease or dementia).

Sample Solution

Health Concern

The health concern that I will focus on in this care coordination plan is stroke. Stroke is a sudden interruption of blood flow to the brain that can cause permanent damage. Stroke can affect a person's ability to think, move, and speak. It can also lead to death.

Physical Needs

The physical needs of a stroke patient will vary depending on the severity of the stroke. Some common physical needs include:

Rehabilitation therapy to help the patient regain their physical abilities
Medication to control blood pressure, cholesterol, and other risk factors for stroke
Assistive devices, such as a cane or walker, to help the patient with mobility
Home modifications to make the home safe for the patient

Full Answer Section

Psychosocial Needs

The psychosocial needs of a stroke patient can also be significant. Stroke can be a very traumatic experience, and patients may experience a range of emotions, such as fear, anxiety, and depression. They may also have difficulty adjusting to their new physical limitations.

Some common psychosocial needs of stroke patients include:

Emotional support from family and friends
Counseling to help the patient cope with the emotional effects of stroke
Rehabilitation therapy to help the patient regain their independence
Support groups for stroke survivors

Cultural Needs

The cultural needs of a stroke patient should also be considered in the care coordination plan. Patients from different cultures may have different beliefs about health and illness, and they may have different preferences for care. It is important to be sensitive to these cultural differences and to provide care that is culturally appropriate.

Available Community Resources

There are a number of community resources available to help stroke patients and their families. These resources can provide support, education, and practical assistance. Some common community resources include:

Stroke rehabilitation centers
Stroke support groups
Home health agencies
Meals on Wheels
Transportation services
Financial assistance programs

Care Coordination Plan

The care coordination plan for a stroke patient will be individualized to meet the specific needs of the patient. The plan should include the following elements:

Identification of the patient's physical, psychosocial, and cultural needs
Assessment of the patient's strengths and limitations
Development of a goals-oriented plan of care
Identification of the resources that will be needed to implement the plan of care
Coordination of care among the various providers involved in the patient's care
Ongoing evaluation of the plan of care and its effectiveness

The care coordination plan should be reviewed and updated regularly to ensure that it is meeting the patient's changing needs.

Conclusion

Care coordination is an essential part of providing high-quality care to stroke patients. By taking the time to develop a comprehensive care coordination plan, nurses can help stroke patients achieve their best possible outcomes.

In addition to the resources mentioned above, there are a number of other things that can be done to help stroke patients and their families. These include:

Providing education about stroke prevention
Encouraging patients to participate in rehabilitation therapy
Helping patients to develop a support network
Providing financial assistance to cover the costs of care

By working together, we can help stroke patients live long and healthy lives.

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