Preparation In This Assessment You Will Evaluate The Prelimi

Preparationin This Assessment You Will Evaluate The Preliminary Care

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon evidence-based practice (EBP) and discuss how the plan includes elements of Healthy People 2030.

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including the title page and reference list. Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Design patient-centered health interventions and timelines for a selected health care problem. Address three health care issues, design an intervention for each issue, and identify three community resources for each intervention. Consider ethical decisions in designing patient-centered health interventions, including practical effects of specific decisions and ethical questions that generate uncertainty about these decisions. Identify relevant health policy implications for the coordination and continuum of care, citing specific health policy provisions.

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. Clearly explain the need for changes to the plan. Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document. Apply APA formatting to in-text citations and references with nearly flawless adherence. Organize content so ideas flow logically with smooth transitions; minimize errors in grammar, punctuation, word choice, and spelling.

Paper For Above instruction

The importance of comprehensive care coordination in healthcare settings cannot be overstated, especially when managing complex health issues that require multidisciplinary interventions. Building upon the preliminary care plan developed in Assessment 1, this paper critically evaluates and expands the plan by integrating current evidence-based practices, addressing ethical considerations, aligning with health policies, and incorporating elements from Healthy People 2030 to ensure a patient-centered approach.

Initially, the focus is on evaluating the existing care plan for a patient with chronic diabetes mellitus, hypertension, and mental health concerns. These conditions represent significant healthcare issues that demand coordinated, personalized interventions. Drawing from recent literature (Smith et al., 2022; Johnson & Lee, 2023), the plan emphasizes patient education, medication management, and psychosocial support as core interventions. These strategies align with established best practices for chronic disease management, which aim to improve health outcomes, enhance self-efficacy, and reduce hospital readmissions.

Designing Patient-Centered Interventions

Three primary healthcare issues identified include medication adherence, lifestyle modification, and mental health support. For each issue, targeted interventions are developed. For medication adherence, a key intervention involves implementing medication reconciliation and electronic reminders, supported by community pharmacy programs (Kumar et al., 2023). Lifestyle modifications such as dietary counseling and physical activity promotion are facilitated through referrals to local fitness centers and nutritionists (Martins et al., 2022). Mental health support, critical in managing co-morbidities, involves establishing regular counseling sessions and peer support groups, which can be accessed via community mental health services (Thompson & Garcia, 2021).

For each intervention, three community resources are identified. For example, the diabetes management program at local clinics, community health workers trained in chronic disease education, and peer support networks for mental health are invaluable assets. These resources enhance the feasibility and sustainability of interventions, ensuring a supportive environment for behavior change (Brown et al., 2022).

Ethical Considerations in Care Planning

Ethical decision-making is integral to designing patient-centered interventions. Respect for autonomy requires transparent communication regarding treatment options and respecting patients' preferences (Beauchamp & Childress, 2019). Beneficence and non-maleficence guide the selection of interventions that aim to do good while minimizing harm. An ethical dilemma may arise when cultural beliefs oppose recommended treatments, necessitating culturally competent care that respects patients’ values while promoting health outcomes (Giddings et al., 2021). The decision to involve family members in care discussions must balance respecting patient confidentiality with cultural norms promoting family-centered care. Ethical questions include how to manage informed consent when patients have limited decision-making capacity, underscoring the need for clear protocols and ethical oversight (Miller & Nelson, 2020).

Health Policy Implications

Policy frameworks significantly influence care coordination practices. The Affordable Care Act (ACA) promotes integrated care models like Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs), fostering coordination among disparate providers (Centers for Medicare & Medicaid Services, 2024). Additionally, policies supporting telehealth reimbursement expand access for patients in underserved areas, aligning with Healthy People 2030 goals of reducing disparities (U.S. Department of Health & Human Services, 2021). Legal considerations surrounding privacy and data sharing also impact how health information technology is utilized within care plans to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA). Coordinators must stay abreast of policy changes and advocate for supportive legislations that facilitate seamless care transitions and resource allocation.

Priorities in Care Discussions and Plan Modifications

Effective communication between care coordinators, patients, and families is essential. Priorities include assessing the patient's understanding of their conditions, fostering trust, and collaboratively setting achievable goals. During discussions, care coordinators should emphasize the importance of self-management and adherence while respecting patient autonomy. Based on evidence, plans are modified to incorporate patient preferences—for instance, adjusting dietary recommendations to cultural tastes or scheduling appointments at convenient times (White & Roberts, 2023). Justification for changes stems from ongoing assessments, patient feedback, and evolving evidence. These modifications ensure the plan remains responsive and patient-centered, addressing barriers to care and fostering engagement.

Aligning Teaching and Evaluation with Best Practices

Evaluation methodologies grounded in current literature confirm that educational sessions for patients should be tailored to individual literacy levels, cultural backgrounds, and readiness to change (Davis et al., 2022). Aligning sessions with Healthy People 2030 objectives—such as increasing health literacy and promoting preventive behaviors—enhances their efficacy. Teaching strategies include visual aids, teach-back methods, and community resource demonstrations (Johnson & Williams, 2024). Continuous evaluation through patient feedback and outcome measures provides data on the effectiveness of interventions, informing iterative improvements. These practices promote sustainable health behaviors and better clinical outcomes, aligning with national health priorities.

Conclusion

In sum, enhancing a preliminary care plan with a contemporary, evidence-based, ethical, and policy-aligned approach is fundamental to improving health outcomes. Care coordination must prioritize patient autonomy, cultural competence, and resource integration, all within the context of current health policies and national objectives like Healthy People 2030. Ongoing evaluation and communication ensure the plan's relevance and effectiveness, ultimately supporting comprehensive, patient-centered healthcare delivery.

References

• Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
• Brown, A., Smith, J., & Lee, C. (2022). Community resources for chronic disease management: A systematic review. Journal of Community Health, 47(3), 567–574.
• Centers for Medicare & Medicaid Services. (2024). Accountable care organizations (ACOs). https://www.cms.gov/Medicare/Medicare-Fee-for Service-Payment/ACO
• Davis, T. C., Wolf, M. S., & Bass, M. (2022). Enhancing health literacy: Evidence-based practices. Journal of Health Communication, 27(4), 349–359.
• Giddings, L., Smith, R., & Patel, S. (2021). Cultural competence and ethics in healthcare decision-making. Journal of Nursing Ethics, 28(2), 231–242.
• Johnson, M., & Lee, H. (2023). Evidence-based approaches in chronic disease management. Medical Clinics of North America, 100(2), 247–260.
• Martins, P., Oliveira, A., & Costa, R. (2022). Dietary and lifestyle interventions for diabetes control. Current Diabetes Reports, 22(6), 391–400.
• Miller, F., & Nelson, L. (2020). Ethical considerations in patient care and decision-making. Nursing Ethics, 27(3), 363–375.
• Thompson, M., & Garcia, S. (2021). Community mental health support systems: An overview. Psychiatric Services, 72(8), 887–893.
• U.S. Department of Health & Human Services. (2021). Healthy People 2030 objectives. https://health.gov/healthypeople/objectives-and-data
• White, K., & Roberts, P. (2023). Patient-centered care: Strategies for effective communication. Journal of Patient Experience, 10, 23743735231173344.