NURS FPX 4050 Assessment 4 Final Care Coordination Plan

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Final Care Coordination Plan

A care coordination plan for hypertension patients involves a team-based approach to managing the patient’s care. The team includes the patient, their primary care physician, nurses, and other healthcare professionals involved in the patient’s treatment. The goal of the care coordination plan is to ensure that the patient receives appropriate and timely care and that their blood pressure is effectively managed to prevent complications such as heart attack or stroke. The care coordination plan for hypertension patients includes regular blood pressure monitoring, medication management, and lifestyle modifications such as dietary changes and regular physical activity (Tan et al., 2020). 

The plan (NURS FPX 4050 Assessment 4 Final Care Coordination Plan) should also address any comorbidities that may affect the patient’s hypertension management, such as diabetes or kidney disease. The care coordination plan should include clear roles and responsibilities for each care team member, as well as a schedule for regular check-ins and updates, to ensure effective communication and coordination. The plan should also consider any social and economic factors that may impact the patient’s ability to manage hypertension effectively and include appropriate community resources and support as needed (Burnier & Egan, 2019). 

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Patient-Centered Health Interventions

Hypertension, also known as high blood pressure, is a prevalent chronic medical condition that can cause severe health complications if not managed appropriately. Patient-centered health interventions that use local resources can be an effective approach to managing hypertension and improving patients’ quality of life. One such intervention is the establishment of support groups in the community (Correia et al., 2019). These groups provide individuals with hypertension and their caregivers with a safe and supportive environment where they can interact with others experiencing similar circumstances. Support groups can also provide valuable information on hypertension management and promote healthy lifestyle changes.

The American Heart Association offers support groups and resources (NURS FPX 4050 Assessment 4 Final Care Coordination Plan) for individuals with hypertension and their families. Another essential intervention for hypertension management is physical activity and exercise programs. Exercise has been shown to lower blood pressure, improve cardiovascular health, and promote weight loss (Benjamin et al., 2019). Community-based exercise programs, such as walking groups or fitness classes, can allow individuals with hypertension to exercise in a supportive environment with peers. In the US, programs like SilverSneakers offer exercise classes designed for older adults and individuals with chronic medical conditions like hypertension. Medicare Advantage plans may cover the costs of these exercise programs for eligible patients.

Dietary interventions can also help manage hypertension. Programs such as the Dietary Approaches to Stop Hypertension (DASH) diet encourage the consumption of fruits, vegetables, whole grains, and low-fat dairy products while limiting sodium, saturated fat, and added sugars. Community-based nutrition programs, such as cooking classes or healthy food demonstrations, can give individuals with hypertension and their caregivers the tools and knowledge to make healthy dietary choices (Filippou et al., 2020).

In addition to physical activity and diet interventions, mindfulness-based interventions like meditation, yoga, and relaxation techniques can also be beneficial in managing hypertension. These interventions have been shown to lower blood pressure, reduce stress, and promote overall well-being. Mindfulness-based interventions can be accessed through community organizations, health centers, or online resources such as apps or videos. Accessing community resources and participating in these interventions can help individuals with hypertension develop supportive communities and ongoing support systems.

Timeline for Hypertension

Developing a timeline for hypertension patient-centered healthcare interventions begins with an initial assessment of the patient’s needs and requirements. Based on the assessment, a care plan is developed, which includes a timeline for implementing patient-centered healthcare interventions.

In the first stage of the care plan, which spans from week 1 to week 8, community-based support groups are established to provide a supportive and encouraging environment for hypertension patients and their caregivers. These groups help patients cope with the challenges of managing their condition and provide opportunities for social interaction and emotional support. In the next stage, which spans from week 9 to week 16, programs for physical activity and exercise are introduced. These programs help hypertension patients manage their condition by improving their cardiovascular health and reducing their blood pressure.

Dietary interventions are introduced in the third stage of the care plan, which spans from week 17 to week 26. Nutritionists and dietitians work with hypertension patients to develop a dietary plan that suits their needs and preferences. This plan includes guidelines for healthy eating, such as reducing sodium intake, increasing potassium intake, and eating a balanced diet that includes fruits, vegetables, whole grains, and lean proteins. The patient’s needs and preferences are continually assessed throughout the entirety of the care plan, and adjustments are made to the care plan as required (Marques et al., 2021).

Ethical Decisions

Medical professionals and researchers working on treatments for hypertension face a range of ethical considerations. One fundamental principle in medical ethics is autonomy, which refers to patients’ right to make decisions about their health and care. Patients with hypertension should be allowed to participate in creating their care plans and make choices about their treatment options. This includes decisions about the type of treatment, the timing of treatment, and any associated costs. Another essential ethical consideration is privacy and confidentiality.

Patients with hypertension have a right to access information about their health status and medical treatment while ensuring their sensitive health information is protected. Healthcare professionals must also prioritize the well-being of their patients by addressing their physical, emotional, and spiritual needs and ensuring that they have access to the necessary resources and support (Benetos et al., 2019).

Equity is another crucial factor in hypertension treatment. It is essential to ensure that all patients have equal access to diagnosis, treatment, and support, regardless of their background or circumstances. This includes individuals from underserved and low-income communities, those in rural areas, and those from diverse backgrounds. By considering these ethical factors, healthcare professionals can work to improve hypertension treatment and care, helping patients manage their symptoms, improve their quality of life, and preserve their autonomy and dignity (Doyle et al., 2019).

Health Policy Provisions and Implications

Health policy plays a critical role in the management and treatment of hypertension. It influences the provision of care, access to resources, and overall outcomes for patients. Therefore, understanding the provisions and implications of health policy for hypertension is essential for effective care coordination. Medicare is a federal health insurance program primarily catering to those 65 and over and also covers individuals under 65 with specific disabilities.

Medicare policies significantly impact hypertension treatment since the disease is more common among older adults. Medicare covers several services related to hypertension, including screening, diagnosis, medication, and lifestyle counseling. The policy also covers home blood pressure monitoring devices and telehealth services, enabling remote monitoring of blood pressure levels. This coverage helps patients access treatment and manage their condition more efficiently (Hoehns et al., 2020).

Another federal health insurance program, Medicaid, caters to low-income individuals and families. Medicaid policies help people with hypertension access necessary care and resources, including diagnostic tests, medication, and lifestyle counseling. Medicaid also covers blood pressure monitoring devices, which enables patients to monitor their blood pressure levels at home. This coverage helps patients manage their condition and prevent complications. In addition to government insurance programs, health policies such as the Affordable Care Act (ACA) have implications for hypertension treatment.

The ACA requires insurance companies to cover preventive services, including blood pressure screening, with no out-of-pocket costs to the patient (Huguet et al., 2021). The ACA also mandates that insurers cover medication and counseling for tobacco cessation, which is crucial in managing hypertension since smoking is a risk factor. Furthermore, the ACA prohibits insurance companies from denying coverage based on pre-existing conditions, including hypertension. This provision ensures that people with hypertension can access insurance coverage and necessary treatment.

Finally, apart from insurance policies, there are also government programs and workplace policies that address hypertension treatment. For instance, the Centers for Disease Control and Prevention has a program called the Million Hearts Initiative, which aims to prevent one million heart attacks and strokes by 2022. The program focuses on promoting healthy lifestyle habits, providing clinical care for high blood pressure, and improving the use of hypertension medications. In addition, the National Institutes of Health has launched the NHLBI Strategic Vision, which includes the goal of reducing the prevalence and impact of hypertension by developing and implementing effective prevention and treatment strategies (Wall et al., 2020).

The initiative involves supporting research on hypertension and disseminating information to healthcare providers and the public. All these policies play a crucial role in ensuring that patients with hypertension can access the necessary care and resources to manage their condition effectively. Understanding these policies’ provisions and implications is crucial in providing adequate care coordination for patients with hypertension.

Discussing the Plan with Patients and Relatives

When developing a care plan for patients with hypertension, it is essential to involve both the patient and their relatives. The care coordinator should aim to establish a collaborative relationship with the patient and their family to ensure that the care plan is tailored to their unique needs and preferences. The priority for the care coordinator should be to provide the patient with information about hypertension, including its causes, symptoms, and potential complications.

The patient should also be informed about the importance of lifestyle modifications, including changes in diet, exercise, and stress management. The care coordinator should work with the patient and their family to identify specific goals related to blood pressure control and overall health (Nordfonn et al., 2019).

The care plan should also include a medication regimen tailored to the patient’s needs and preferences. The care coordinator should provide information on the medication, including dosage, possible side effects, and how to take the medication correctly. The patient should be encouraged to follow the prescribed medication regimen and report any adverse effects to the care coordinator or healthcare provider. The care coordinator should also provide the patient and their family with information on self-monitoring blood pressure levels.

The patient should be trained on how to take their blood pressure at home, and the care coordinator should work with the patient and their family to establish a monitoring schedule (Shimbo et al., 2020). The patient should be encouraged to report any changes in their blood pressure levels to the care coordinator or healthcare provider. The hypertension care plan must include regular follow-up appointments with the healthcare provider and community resources for exercise and nutrition counseling. The care coordinator should also prioritize the well-being of the patient’s family members and provide information and training on effective caregiving techniques.

Need for Change

It is essential for the care coordinator to regularly review and modify the care plan for patients with hypertension to ensure that it remains effective and meets the patient’s needs. The patient’s blood pressure levels may change over time, and their health status and lifestyle habits may also change, which can affect their hypertension management plan. The care coordinator should work with the patient to monitor their blood pressure levels regularly and adjust their medication or lifestyle recommendations accordingly.

The care coordinator may also need to modify the care plan if the patient experiences any adverse side effects from their medication or if they are not responding well to their current treatment plan. Additionally, as the patient’s circumstances change, their hypertension management plan may need to be modified. For example, the patient experiences a significant life event, such as moving to a new home or changing employment. In that case, their access to healthcare resources may change, and the care coordinator may need to adjust the care plan accordingly (Muth et al., 2019). 

Alignment with Healthy People 2030

Hypertension is a major public health concern and a leading risk factor for cardiovascular disease, stroke, and renal disease. The Healthy People 2030 initiative aims to reduce the prevalence and impact of hypertension and related conditions by improving prevention, detection, and management (Santana et al., 2021).

Nurses play a crucial role in the care coordination plan for hypertension management. They can help prevent hypertension by educating patients about healthy lifestyles, such as a balanced diet, regular exercise, and stress reduction. Nurses can also screen patients for hypertension, provide counseling on medication adherence, and monitor patients for adverse treatment effects. If the patients have uncontrolled hypertension, nurses can work with physicians and other healthcare professionals to develop individualized treatment plans. This may include prescribing or adjusting medications, recommending lifestyle changes, and referring patients to specialists as needed. Nurses can also monitor patients’ blood pressure and provide ongoing education and support to promote self-management and adherence to treatment plans (Haas et al., 2019).

Furthermore, nurses can support population health initiatives to prevent hypertension and related conditions by engaging in community outreach and education. This includes collaborating with local organizations, schools, and workplaces to promote healthy lifestyles, conducting blood pressure screenings, and providing education on hypertension prevention and management. In alignment with Healthy People 2030, nurses can contribute to the prevention and management of hypertension by providing patient-centered, evidence-based care, promoting healthy lifestyles, and engaging in community outreach and education.

Need for Revisions

Revisions to care coordination plans are essential to ensure they remain up-to-date with the latest best practices and recommendations as healthcare evolves and new information becomes available. For example, if a care coordination plan for hypertension aims to improve physical health outcomes. In that case, it may require revisions to align with the Healthy People 2030 objective of promoting cardiovascular health and reducing the risk of heart disease. Revisions may include updates to treatment protocols, medication regimens, and lifestyle interventions, such as dietary recommendations and exercise programs (Chen & Cheng, 2020). By staying current with the latest best practices and recommendations, care coordinators can ensure that their patients receive the highest quality care possible.

Conclusion – NURS FPX 4050 Assessment 4 Final Care Coordination Plan

In conclusion, managing hypertension requires a coordinated and patient-centered approach that involves regular monitoring, medication management, and lifestyle modifications. Community-based support groups, physical activity and exercise programs, dietary interventions, and mindfulness-based interventions can be effective patient-centered interventions to manage hypertension. Developing a timeline for hypertension patient-centered healthcare interventions begins with an initial assessment of the patient’s needs and requirements, followed by the implementation of the interventions in a coordinated manner. Medical professionals and researchers must consider ethical considerations, including autonomy, privacy, confidentiality, and equity when developing hypertension treatment plans to ensure patients receive high-quality care that addresses their individual needs and respects their rights.

References

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research, 124(7), 1045–1060. https://doi.org/10.1161/circresaha.118.313236 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., (2019). Heart disease and stroke statistics 2019 update: A report from the American heart association. Circulation, 139(10). https://doi.org/10.1161/cir.0000000000000659 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Burnier, M., & Egan, B. M. (2019). Adherence in hypertension. Circulation Research, 124(7), 1124–1140. https://doi.org/10.1161/circresaha.118.313220 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Chen, C.-C., & Cheng, S.-H. (2020). Care continuity and care coordination: A preliminary examination of their effects on hospitalization. Medical Care Research and Review: MCRR, 1077558720903882. https://doi.org/10.1177/1077558720903882 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Correia, J. C., Lachat, S., Lagger, G., Chappuis, F., Golay, A., & Beran, D. (2019). Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries: A scoping review. BMC Public Health, 19(1). https://doi.org/10.1186/s12889-019-7842-6 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Doyle, S. K., Chang, A. M., Levy, P., & Rising, K. L. (2019). Achieving health equity in hypertension management through addressing the social determinants of health. Current Hypertension Reports, 21(8). https://doi.org/10.1007/s11906-019-0962-7 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Filippou, C. D., Tsioufis, C. P., Thomopoulos, C. G., Mihas, C. C., Dimitriadis, K. S., Sotiropoulou, L. I., Chrysochoou, C. A. (2020). Dietary approaches to stop hypertension (dash) diet and blood pressure reduction in adults with and without hypertension: A systematic review and meta-analysis of randomized controlled trials. Advances in Nutrition, 11(5). https://doi.org/10.1093/advances/nmaa041 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Haas, PhD, RN, FAAN, S., Regina Conway-Phillips, P., Beth Ann Swan, P., Laura De La Pena, M. S. N., Rachel Start, M. S. N., & Diane Brown, P. (2019). Developing a case for the care coordination and transition management model: Need, metrics, and measures. College of Nursing Faculty Papers & Presentations. https://jdc.jefferson.edu/nursfp/99/ 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Hoehns, J. D., Witry, M., Al‐Khatib, A., O’Brien, E., Beninga, J., Nichols, R., Greenwood, J., Hodder, J., & Roise, A. (2020). Community pharmacist and family medicine clinic provision of chronic care management services for Medicare beneficiaries with uncontrolled hypertension. JACCP: JOURNAL of the AMERICAN COLLEGE of CLINICAL PHARMACY, 3(4), 729–735. https://doi.org/10.1002/jac5.1224 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Huguet, N., Larson, A., Angier, H., Marino, M., Green, B. B., Moreno, L., & DeVoe, J. E. (2021). Rates of undiagnosed hypertension and diagnosed hypertension without anti-hypertensive medication following the affordable care act. American Journal of Hypertension, 34(9), 989–998. https://doi.org/10.1093/ajh/hpab069 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Marques, M. do C., Pires, R., Perdigão, M., Sousa, L., Fonseca, C., Pinho, L. G., & Lopes, M. (2021). Patient-centered care for patients with cardiometabolic diseases: An integrative review. Journal of Personalized Medicine, 11(12), 1289. https://doi.org/10.3390/jpm11121289 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Muth, C., Blom, J. W., Smith, S. M., Johnell, K., Gonzalez‐Gonzalez, A. I., Nguyen, T. S., Brueckle, M. ‐S., Cesari, M., Tinetti, M. E., & Valderas, J. M. (2019). Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: A systematic guideline review and expert consensus. Journal of Internal Medicine, 285(3). https://doi.org/10.1111/joim.12842 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Nordfonn, O. K., Morken, I. M., Bru, L. E., & Husebø, A. M. L. (2019). Patients’ experience with heart failure treatment and self‐care: A qualitative study exploring the burden of treatment. Journal of Clinical Nursing, 28(9-10), 1782–1793. https://doi.org/10.1111/jocn.14799 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Santana, S., Brach, C., Harris, L., Ochiai, E., Blakey, C., Bevington, F., Kleinman, D., & Pronk, N. (2021). Updating health literacy for healthy people 2030: Defining its importance for a new decade in public health. Journal of Public Health Management and Practice: JPHMP, 27(6). https://doi.org/10.1097/PHH.0000000000001324 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Shimbo, D., Artinian, N. T., Basile, J. N., Krakoff, L. R., Margolis, K. L., Rakotz, M. K., & Wozniak, G. (2020). Self-measured blood pressure monitoring at home: A joint policy statement from the American heart association and American medical association. Circulation, 142(4). https://doi.org/10.1161/cir.0000000000000803 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Tan, J., Xu, H., Fan, Q., Neely, O., Doma, R., Gundi, R., Shrestha, B., Shrestha, A., Shrestha, S., Karmacharya, B., Gu, W., Østbye, T., & Yan, L. L. (2020). Hypertension care coordination and feasibility of involving female community health volunteers in hypertension management in kavre district, Nepal: A qualitative study. Global Heart, 15(1). https://doi.org/10.5334/gh.872 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan: Wall, H. K., Stolp, H., Wright, J. S., Ritchey, M. D., Thomas, R. J., Ades, P. A., & Sperling, L. S. (2020). The million hearts initiative. Journal of Cardiopulmonary Rehabilitation and Prevention, 40(5), 290–293. https://doi.org/10.1097/hcr.0000000000000547 

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