For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. Introduction NOTE: You are required to complete this assessment after Assessment 1 is successfully completed. Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment co

An effective and efficient care coordination plan has well-established care priorities. The priorities to establish with the patient and their family for the care plan include the specific care goals for the plan based on the patient’s and family’s values, needs, and preferences. The priority goals may include improving blood pressure readings to more tolerable levels, managing their mental health, and preventing complications such as cognitive decline and kidney damage. The other priorities would be to assess the patient’s and their family’s social and economic aspects, such as level of income and education, housing conditions, and access to care services and other social support systems. The outcomes of such assessment have a significant effect on the care coordination plan and can direct changes to the plan, such as on how the care will be delivered, the care professionals to participate in the care plan, and the required levels of economic and social support. A simple change to reduce the economic burden of caring for the patient would be to move the patient from an in-patient setting to home-based care. Notably, according to Peters et al. (2019), improving the patient’s self-efficacy can support self-management with a positive impact on the quality of life in patients with multi-morbid conditions.

Learning Session Content Comparison with Best Practices and Alignment with Healthy People 2030

The learning sessions have been beneficial to the understanding of best practices, such as assessing patient needs, making ethical decisions, involving the patient in the decision-making processes, and shaping interventions based on patient needs to deliver patient-centered care. The learning sessions have also improved one’s skills in searching for, analyzing, interpreting, and applying the best evidence in patient care. Evidence-based nursing education improves the nurses’ knowledge of evidence-based processes and their self-efficacy in practice after training (Oh & Yang, 2019). Evidence-based nursing education methods such as the flipped classroom improve the nurses’ grasp of the concepts of evidence-based practice (EBP) (Chu et al., 2019). The overall impact of the learning sessions has been on how to utilize social determinants of health to best design the care to improve patient outcomes, disease awareness, and testing, as well as reduce the prevalence and effects of chronic diseases such as HBP on the local communication in accordance to the Healthy People 2030 objectives. In the future, the care coordination plan may be revised to either add or remove certain interventions based on the progress achieved in managing HBP and the associated health conditions. Some anticipated revisions may include pushing all care to home settings rather than hospital settings and a caring approach that is more preventive than responsive.

Conclusion

In conclusion, coordinating care for HBP patients requires the consideration of other associated health issues and managing them as well. Regardless of the status of the patient, all decisions made when designing the care coordination plan must follow the ethical principles in nursing and the existing health policy requirements. Furthermore, it is important to always consider the patient’s needs and preferences and the best available evidence to design the best patient-centered care coordination plan to effectively achieve set care goals.

References

Centers for Disease Control and Prevention. (2019). Fluoride Action Network | Chronic Kidney Disease in the United States, 2019. Flouride Action Network. https://fluoridealert.org/studytracker/38332/

Chu, T. L., Wang, J., Monrouxe, L., Sung, Y. C., Kuo, C. li, Ho, L. H., & Lin, Y. E. (2019). The effects of the flipped classroom in teaching evidence-based nursing: A quasi-experimental study. PLOS ONE, 14(1), e0210606. https://doi.org/10.1371/JOURNAL.PONE.0210606

Audthiya, P., Pothiban, L., Panuthai, S., & Chintanawat, R. (2021). Enhancing Autonomy and Self-Management Behaviors Through a Patient-Centered Communication Program for Older Adults with Hypertension: A Randomized Controlled Trial. Pacific Rim International Journal of Nursing Research, 25(4), 525–538. https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/253312

Flythe, J. E., Chang, T. I., Gallagher, M. P., Lindley, E., Madero, M., Sarafidis, P. A., Unruh, M. L., Wang, A. Y. M., Weiner, D. E., Cheung, M., Jadoul, M., Winkelmayer, W. C., Polkinghorne, K. R., Adragão, T., Anumudu, S. J., Chan, C. T., Cheung, A. K., Costanzo, M. R., Dasgupta, I., … Wilkie, M. (2