Relevant Health Policy Implications for the Coordination and Continuum of Care NURS-FPX 4050 Assessment 4

The Affordable Care Act (ACA) mentions that care coordination is under sections on payment reform, quality improvement, and monitoring savings. It also mentions it under full Medicare Medicaid beneficiaries, special considerations of patients with diabetes and depression, and health home members (Natkin et al., 2023). Section 3502 of the ACA establishes Community Health Teams, which link clinical and community settings to support Patient-Centered Medical Homes. The act outlines the role of the Community Health Teams as coordinating disease prevention and chronic illness management, creating interdisciplinary care plans, and engaging patients and caregivers (Natkin et al., 2023). Furthermore, they support PCPs by coordinating access to preventive services and services that are cost-effective, quality-driven, culturally appropriate, and patient- and family-centered.

Section 2703 of the ACA requires the CMS to establish health home services for Medicaid beneficiaries with chronic illnesses. This is a Medicaid State Plan Option that provides a comprehensive care coordination system for Medicaid beneficiaries (De Marchis et al., 2023). The services include: Comprehensive care management, Care coordination, Health promotion, Comprehensive transitional care, patient and family support, and Referral to community and social support services

Priorities That a Care Coordinator Would Establish When Discussing the Plan with a Patient and Family Member

The care coordinator discussing the above plan with a patient and family members will identify the priorities as attaining optimal BP control, managing weight, and treatment adherence. The care coordinator will inform the patient and family that achieving optimal BP control will be a vital step in reducing the risk of complications. Besides, one has to control the BP to <140/90 to lower the risk of stroke (Gorelick et al, 2020). A controlled BP is an indicator of effective pharmacological and non-pharmacological measures. Weight management is another priority the care coordinator should point out. Overweight and obesity are linked with high BP. Thus, the patient should be informed that changing lifestyle practices will be fundamental to promoting weight loss. Treatment adherence should be emphasized for both pharmacological and non-pharmacological measures. This will be key to lowering BP and maintaining it at optimal levels.

Aligning Teaching Sessions to the Healthy People 2030 Document

Best practices on hypertension management should be the foundation of patient education on measures to control BP and prevent complications like stroke. One of the Healthy People 2030 goals is to improve cardiovascular health and decrease mortalities from heart disease and stroke (ODPHP, n.d.). One of the objectives of preventive care is to increase the proportion of adults with hypertension whose BP is under control. Thus, teaching sessions can be aligned with Healthy People 2030 by educating individuals on measures to control or lower BP. This can help reduce chronic kidney disease, heart failure, heart attack, and stroke. Furthermore, individuals can be educated on the importance of screening for high BP and adopting measures to lower it through lifestyle modification.

Conclusion

The identified healthcare issues related to hypertension are Poor BP control, High risk of stroke, and Poor lifestyle practices. The proposed interventions are educating patients on medication adherence, intensive BP- BP-lowering therapy, and health education on lifestyle modification. The proposed healthcare interventions align with medical ethical principles of autonomy, beneficence, nonmaleficence, and social justice.

References

Carey, R. M., Wright, J. T., Jr., Taler, S. J., & Whelton, P. K. (2021). Guideline-Driven Management of Hypertension: An Evidence-Based Update. Circulation Research, 128(7), 827–846. https://doi.org/10.1161/CIRCRESAHA.121.318083

nity Health Teams, which link clinical and community settings to support Patient-Centered Medical Homes. The act outlines the role of the Community Health Teams as coordinating disease prevention and chronic illness management, creating interdisciplinary care plans, and engaging patients and caregivers (Natkin et al., 2023). Furthermore, they support PCPs by coordinating access to preventive services and services that are cost-effective, quality-driven, culturally appropriate, and patient- and family-centered.

Section 2703 of the ACA requires the CMS to establish health home services for Medicaid beneficiaries with chronic illnesses. This is a Medicaid State Plan Option that provides a comprehensive care coordination system for Medicaid beneficiaries (De Marchis et al., 2023). The services include: Comprehensive ca