Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

Preliminary Coordinated Care Plan for Stroke Patient

Introduction: Analysis of Stroke as a Healthcare Concern

Statistically speaking, stroke is the world’s second major cause of death and a top contributor to global disability (Kuriakose & Xiao, 2020). Stroke is caused or associated with heart disease, high blood pressure, atrial fibrillation, high cholesterol, and diabetes. Stroke prevalence is highest in developing countries. However, stroke incidences and mortality vary with age and across regions and ethnic groups (Katan & Luft, 2018). Additionally, strokes vary in type and severity. Incidences can either be ischemic or hemorrhagic strokes. Although ischemic stroke incidences are reported frequently, hemorrhagic stroke is more lethal and causes more deaths, disability, and loss of crucial life years (Katan & Luft, 2018).

According to the Centers for Disease Control and Prevention (CDC) (2022), people who have had previous stroke incidents are at a higher risk of having another episode of stroke. The chances of another stroke incident are as high as 17% within 90 days after a transient ischemic attack (TIA). The CDC also notes that 1 in every 4 stroke patients has a recurring stroke incident within five years. Gilmore-Bykovskyi et al. (2018) concluded that almost 20% of stroke and hip fracture patients discharged to post-acute care facilities lack sufficient clinical follow-ups, leading to an increased risk of hospital readmission and, in the worst outcomes, death.

Patients with complex health needs require extensive coordinated care. Coordinated care interventions enable hospital delivery systems to provide comprehensive, quality, patient-centered care in complex health situations (Perez Jolles et al., 2019). Accordingly, this makes it important to have a team of various health professionals to check a stroke patient and identify and treat all underlying health issues that risk stroke incidents.

Care coordination is the organization of patient care activities to enable health professionals and the patient to share information to improve the effectiveness of care and help achieve positive health outcomes. The coordination plan seeks to best satisfy the needs of the patient through the delivery of quality patient-centered care. Empirical studies have proved care coordination for stroke patients to be an effective strategy to improve care and health outcomes, reduce the overall cost of care, and impact patient satisfaction. For instance, Deutschbein et al. (2020) found that care coordination for a vulnerable patient population led to improved utilization rates of essential health services, impacting risks of readmission, costs of care, and mortality. Successful stroke treatment, recovery, and prevention of future stroke insults are dependent on the efficiency and efficacy of stroke care coordination.

Overview

Stroke patients may recover completely. However, some recover with minor impairments, while a majority recover with moderate to severe impairments and mostly end up in need of special care. Therefore, it is important to implement a coordinated care plan or goals within primary care settings to achieve the best health outcomes for stroke patients.

Outline of the coordinated care plan:

Assessment for Readiness of Coordinated Care

Stroke Coordination Care Plan Goals

Facility Management Support

Physical, Psychosocial, and Cultural Components

Health Records Tool

Coordinated Primary Care Team and Tasks

Opportunities for Quality Improvement

Assessment for Readiness of Coordinated Care

A successful stroke coordination care plan will require the full commitment of all players. The current budget cuts and relocation of case management staff to in-patient care mean that all resources must be systematically analyzed for availability and readiness to support the coordinated care plan. There is also a need to assess the factors that impact the care plan.

Stroke Coordination Care Plan Goals

This coordinated care plan for the stroke patient aims to:

Reduce cases of injury to the brain,

Focus on achieving maximum patient recovery,

Provide appropriate emergency medical care on demand,

Manage any disabilities and impairments associated with stroke

Provide required emotional support to the patient,

Optimize patient health outcomes,

Provide care based on the patient’s state of health and care preferences

Facility Management Support

The success and sustainability of the stroke coordination care plan are dependent on its alignment with the facility’s care plans and priorities. The resources may overlap, w