NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan
Student Name
Capella University
NURS-FPX 4050 Coord Patient-Centered Care
Prof. Name
Date
Preliminary Care Coordination Plan
A preliminary care coordination plan is a manageable plan aiming at solving a particular medical issue through physical, psychosocial, and cultural aspects. Therefore, this assessment looks at chronic disease management (CDM) in Houston, Texas. As a staff nurse in a community care center, I have supervised care plans that can close gaps in the case management system. Within this plan, the health concerns will be described, objectives will be defined, and community resources for this purpose will be provided. This movement aims to improve patient care using knowledge and individualized action plans.
Analysis of CDM and Best Practices for Health Improvement
CDM deals with several diseases, including diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases, affecting 129 million individuals in the US (Benavidez et al., 2024). These conditions result from diet, exercise, smoking, hereditary, and other rendering factors and influences. Chronic diseases affect physical health by altering functional state, decreasing life quality and span, and receiving care services. Some of the psychosocial impacts include stress, depression, and anxiety, as these illnesses are chronic and also have financial implications.
Furthermore, cultural beliefs will determine how diseases progress and how people respond to their management. These conditions are rather problematic, and healthcare systems require integrated and patient-oriented strategies in management.A proper approach to chronic illness includes practicing research-based measures to reduce the effects, improve well-being, and avoid future risks. These include the patients’ aspects of making healthy decisions, including eating balanced meals and exercising. Coordinated care models that involve different care professionals within a care organization ensure the management of various aspects of the patient is more effective for self-management and better than the traditional one-doctor approach (Huang et al., 2022).
NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan
Mobile health is preferred for constant and distant checks of the adoption of technological advancements like telehealth. Evidence tells that mobile health allows self-management, patients can participate in their treatment processes while close follow-up and intervention also lead to high treatment compliance (Fan & Zhao, 2021). Another research supports this practice stating adding lifestyle changes to steady healthcare utilization significantly decreases pathologic deterioration and enhances outcomes (Jeong, 2024).
The importance of CDM approaches may depend on several critical assumptions. For instance, it is postulated that patients can seek health care, have health literacy, be competent in care management plans, and be economically endowed to fund treatment commodities and processes. Some risks are the inconsistency of participants’ responses to treatment plans and ways of community-dwelling to facilitate adherence. Cultural beliefs and stigma may cause individuals not to seek care or disclose their conditions to anyone (Sikuła & Kurpas, 2023). Managing these uncertainties calls for more agile interventions, from which consideration should be given to client and community characteristics that enhance inclusion within care delivery.
SMART Goals to Address CDM
The SMART framework is a tool for establishing clear and effective objectives by ensuring goals are Specific, Measurable, Achievable, Relevant, and Time-bound. This method provides structure to planning efforts and facilitates progress tracking, enabling more targeted outcomes in CDM. Below are three SMART goals tailored to address CDM effectively.
Goal 1: Enhance Patient Education
The first goal is to improve patient education with disease-specific information on the need to change their lifestyles by adopting diet, exercise, and medication regimens in individuals with chronic diseases in the adult population (S). This will be done by conducting educational sessions for at least 50 patients within three months, with records of attendance and patients’ feedback available (M). To make it achievable, relationships with the dietitian, physiotherapist, and pharmacist will be strengthened so they can write content and materials for the sessions jointly (A). Educating patients will help prevent disease complications and help them self-manage through better understanding and control (R) (Wu et al., 2023). Due to time constraints, the sessions will be done every 14 days for three months, starting from January 2025 (T).
Goal 2: Improve Patient Adherence to Care Plans
The second goal is enhancing patient compliance with the outlined care plan through a standardized follow-up system (S). Even though the anticipated percentage of compliance equals 80%, the main indicators that will be used to monitor the level of adherence include follow-up visits, medication refill ratios, and self-compliance questionnaires (M). This will be achieved through daily/Weekly SMS/WhatsApp reminders and client follow-up to ensure they are utilizing them as intended (A). If care plans are followed strictly, patient hospitalization incidences will be few, and patients’ lifelong health will be considerably enhanced (R) (Losi et al., 2021). The system shall have been imputed within two months, and compliance rates shall be assessed within six months (T).
Goal 3: Train Health Professionals for Enhanced Care Coordination
The third goal is capacity building on care coordination interventions and models for managing chronicity using Coordinated Care Management, communication, patient involvement, and technology (S). It will be implemented through at least three workshops and 30 healthcare workers and pre- and post-training tests to increase knowledge by at least 60% (M). It will be achievable since incorporating professional trainers and using sourced training materials guarantee that the training is thorough and relevant (A). Training is essential to improve knowledge of care coordination among workers, improve patient outcomes, and drive more efficient chronic illness management (R) (Bierman et al., 2021). Training sessions will be accomplished in three months starting in February 2025 (M).
Community Resources and Care Coordination
The section entails determining resources within a specific region that can be utilized to help people with their health issues. It ensures people get the desired services, treatment for their ailments, and support for better health.Houston Health Department Chronic Disease Prevention Programs: The department offers a range of initiatives focusing on diabetes management, heart disease prevention, and healthy living workshops. It provides essential education, screenings, and community engagement activities to support individuals with chronic diseases in leading more nutritious lives.
For more information, visit houstontx.gov/health or call 832-393-5169.Memorial Hermann Community Benefit Programs provides vital services, including diabetes management, heart health clinics, and wellness workshops, for underserved populations as mentioned in a study (Oestman et al., 2024). These programs aim to improve chronic disease outcomes by delivering care and education tailored to community needs. Contact them at 713-222-2273 or visit their website at memorialhermann.org.
NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan
American Diabetes Association (ADA): The guidelines provided by ADA empowers individuals living with diabetes through educational resources, support groups, and advocacy initiatives (ElSayed et al., 2022). Its programs focus on increasing awareness and providing tools for effective self-management. For additional details, reach out at 713-977-7706 or visit diabetes.org.BakerRipley Senior Services: It promotes chronic disease self-management and overall wellness for seniors in Houston through workshops and care coordination. Their programs enhance quality of life and help older adults maintain independence and better manage their health. Learn more by calling 713-667-9400 or visiting bakerripley.org.
UTHealth Houston—Center for Health Promotion and Prevention ResearcH: This center conducts community outreach and research on chronic disease prevention and management. It develops evidence-based strategies to support improved health outcomes and address public health challenges for instance, by partnering with DAWN centers (McKenny, 2024). For inquiries, visit uth.edu or call 713-500-9032.
Conclusion
Therefore, to prevent chronic disease from worsening, one has to encourage patient education, compliance with care plans, and caregiver training. This publication exemplifies how employing community resources and integrating care approaches might help physicians find better patient treatment outcomes and minimize disease progression. Conclusions are drawn about the importance of further cooperation in implementing sustainable practices that will lead to healthy change in Houston, Texas.
References
Benavidez, G. A., Zahnd, W. E., Hung, P., & Eberth, J. M. (2024). Chronic disease prevalence in the US: Sociodemographic and geographic variations by zip code tabulation area. Preventing Chronic Disease, 21(21). https://doi.org/10.5888/pcd21.230267
Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda. Health Services Research, 56(1). https://doi.org/10.1111/1475-6773.13863
ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B. S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A. (2022). Improving care and promoting health in populations: Standards of care in diabetes—2023. Diabetes Care, 46(1), 10–18. https://doi.org/10.2337/dc23-s001
NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan
Fan, K., & Zhao, Y. (2021). Mobile health technology: A novel tool in chronic disease management. Intelligent Medicine, 2(1). https://doi.org/10.1016/j.imed.2021.06.003
Houston Health Department. (2024). Chronic Disease, Health Education and Wellness. Www.houstonhealth.org. https://www.houstonhealth.org/services/disease-prevention/chronic-disease-health-education-wellness
Huang, J., Xu, Y., Cao, G., He, Q., & Yu, P. (2022). Impact of multidisciplinary chronic disease collaboration management on self-management of hypertension patients: A cohort study. Medicine, 101(28), e29797. https://doi.org/10.1097/MD.0000000000029797
Jeong, S.-M. (2024). Primary care physicians’ important role: Lifestyle modification for chronic disease management. Korean Journal of Family Medicine, 45(5), 237–238. https://doi.org/10.4082/kjfm.45.5e
NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan
Losi, S., Berra, C. C. F., Fornengo, R., Pitocco, D., Biricolti, G., & Orsini Federici, M. (2021). The role of patient preferences in adherence to treatment in chronic disease: A narrative review. Drug Target Insights, 15, 13–20. https://doi.org/10.33393/dti.2021.2342
McKenny, E. (2024, August). CHPPR-partner the DAWN center provides diabetes and chronic disease prevention and management services throughout Houston. Uth.edu; UTHealth Houston School of Public Health. https://sph.uth.edu/news/story/chppr-partner-the-dawn-center-provides-diabetes-and-chronic-disease-prevention-and-management-services-throughout-houston
Oestman, K., Rechis, R., Williams, P. A., Brown, J. A., Treiman, K., Zulkiewicz, B., Walsh, M. T., Basen-Engquist, K., Rodriguez, T., Chennisi, C., Macneish, A., Neff, A., Pomeroy, M., Bhojani, F. A., & Hawk, E. (2024). Reducing risk for chronic disease: Evaluation of a collective community approach to sustainable evidence-based health programming. BMC Public Health, 24(1). https://doi.org/10.1186/s12889-024-17670-3
Sikuła, M. D., & Kurpas, D. (2023). Barriers and facilitators in implementing prevention strategies for chronic disease patients—best practice guidelines and policies’ systematic review. Journal of Personalized Medicine, 13(2), 288. https://doi.org/10.3390/jpm13020288
Wu, H., Lin, W., & Li, Y. (2023). Health education in managing chronic diseases among the elderly in the community with the assistance of a Mask R-CNN model. American Journal of Translational Research, 15(7), 4629. https://pmc.ncbi.nlm.nih.gov/articles/PMC10408518/