FPX4050-Coord Patient-Centered Care -Assessment 1:  Preliminary Care Coordination Plan

FPX4050-Coord Patient-Centered Care -Assessment 1:  Preliminary Care Coordination Plan

FPX4050-Coord Patient-Centered Care -Assessment 1:  Preliminary Care Coordination Plan

Assessment 1:  Preliminary Care Coordination Plan

Emenkeng Njukang

Capella University

FPX4050: : Coord Patient-Centered Care

Prof. Jennifer Liehr

April 17, 2022

Preliminary Care Coordination Plan

The systematic integration of care activities between two or more persons participating in a person’s care to support the appropriate delivery of health services has been termed as “care coordination” (McDonald et al., 2007). Nurse care coordination is defined by Lamb and Sofaer (2008) as measures taken by nurses in collaboration with patients, families, and/or members of the health care team to manage and connect the sequence/timing and/or efficacy of patient care from admission to discharge. Care coordination is a method of connecting persons with specific health care requirements and their families to services and resources in a coordinated effort to maximize the client’s potential and offer the best possible health care.

Care coordination should be accessible, comprehensive, continuous, compassionate, culturally competent, and family-centered, according to the ideology. In care coordination, the primary caregiver and family are an important part of the interdisciplinary team. Patient/family education and self-help support groups are used to facilitate behaviour change. Combining patient education with a more prominent role for non-medical practitioners (such as nurses and social workers) appears to promote behaviour modification and have a greater impact on new models. To ensure the best possible outcomes and avoid confusion, a dedicated care coordinator is required. Essay NURS FPX 6008 Assessment 2 Attempt 2 Developing a Business Case EZ

The requirements of patients with chronic illnesses are not properly fulfilled by the US health care system, according to several nurse leaders. Nurses are proposing innovative ways to meet the requirements of those suffering from chronic illnesses. Mary Naylor and colleagues at the University of Pennsylvania School of Nursing created the transitional care model (TCM). For chronically unwell, high-risk older persons hospitalized with numerous chronic illnesses, TCM provides complete in-hospital planning and home follow-up. The Transitional Care Nurse, a master’s-prepared nurse with specialized training in the model, is at the centre of the paradigm (Weierbach & Stanton, 2018).

Analysis of Health Care Concern

Chronic conditions are those that endure longer than a year, limit activities, and demand continuing medical attention. The Centers for Medicare and Medicaid Services classified a number of chronic diseases that are posing a threat to the US health-care system as the population ages. HIV/AIDS, uncontrolled hypertension, chronic obstructive lung disease, end-stage renal illness, insulin-dependent diabetes, and type 2 or adult-onset diabetes are among these diseases. Medicare and state Medicaid initiatives have identified these conditions, as well as their co-occurring problems of pneumonia, peripheral vascular disease, stroke, myocardial infarction, and poor treatment compliance, as major areas of concern (Centers for Medicare & Medicaid Services, 2004a; Centers for Medicare & Medicaid Services, 2004b).

Care Coordinators (CC) face a difficult task in putting the parts of diabetes disease care, patient self-management education, and patient engagement together in order to improve patient outcomes while lowering costs. Having a CC on staff at a primary care clinic is critical for effectively managing chronic diseases like diabetes. The CC has the power to promote patient engagement, stimulate ongoing education and goal-setting, and deliver well-managed, coordinated care across the health-care continuum. The protocol for this project, as well as the implementation and assessment plans, are described in this section of the study.

According to the Institute for Alternative Futures (IAF) Diabetes Model, the overall number of persons with type 2 and type 1 diabetes will rise by 54% between 2015 and 2030. (Institute for Alternative Futures, 2017). Diabetes is a primary cause of heart illness, kidney failure, lower limb amputations, and adult-onset blindness when left uncontrolled. Hyperglycemia is the 7th greatest cause of death in the United States today, with diabetics having double the risk of age-adjusted mortality as those without the illness (American Diabetes Association, 2017; Centers for Disease Control & Prevention, 2017a, 2017b; Institute for Alternative Futures, 2017). According to the IAF, diabetes costs in the United States are predicted to rise from $408 billion to $622 billion between 2015 and 2030.

The development of novel diabetic based on sustainable and education strategies should be emphasized in health-care delivery. Integrating a collaborative team that ensures regular access to care, promotes healthy lifestyles, and diminishes patient risk factors and comorbidities is critical when developing new solutions (Rowley et al., 2017). Care coordination that includes telehealth for specialty consultations as well as diabetes self-management education (DSME) has shown to improve glycemic control, reduce complications, and save costs (Conway, O’Donnell, & Yates, 2019).

Specific Goals for managing chronic illness (diabetes)

Diabetes mellitus (DM) is a chronic condition marked by insufficient insulin synthesis in the pancreas or inefficient insulin utilization by the body. As a result, the proportion of sugar in the blood rises (hyperglycemia). Disturbances in carbohydrate, protein, and lipid metabolism are key indicators of the disease.Effective therapy to stabilize blood glucose levels and reduce problems employing insulin replacement, a balanced diet, and exercise are among the nursing care planning goals for diabetic patients. Through good patient education, the nurse should focus on the impact of adhering to the specified care plan. Customize your instruction to the patient’s specific needs, abilities, and developmental stage. The importance of blood glucose regulation for long-term health should be highlighted.

As part of my professional activity treating patients with chronic health issues, I had some involvement with a different age diabetes patient population. This demographic has transformed my complete business because I discovered certain finest strategies for increasing diabetic treatment impacts in such persons. According to studies, nursing staff must use alternative approaches to truly accept guidelines because they face a number of challenges while treating people with chronic diabetes, including ambiguity about medication usages, a lack of understanding of dietary changes and therapeutic approaches, and a longer patient care period.

Nurses coordinate care in a variety of ways, including Sharing patient-care expertise with other members of a care team. Working to ensure smooth care transitions. Developing a personalized, proactive care plan for a patient’s healthcare requirements in coordination with many clinicians within a healthcare team. Assisting patients in achieving their healthcare objectives, such as through connecting them with community services.

A dietitian, pharmacist, eye doctor, dentist, podiatrist, nurse educator, and social worker may be part of the healthcare team. It’s understandable how care fragmentation could occur. Nurses who work with diabetes patients might help them achieve better results by coordinating their treatment. It’s critical to identify care gaps, such as annual diabetes eye exams.The RN to BSN curriculum at USI lays the groundwork for care coordination and collaborative care models. Nursing informatics coursework can also help nurses enhance care coordination .  

BSN-prepared RNs can lead the way in coordinating care and improving outcomes as healthcare requirements become more complicated.In rural southeast Georgia, the Georgia Department of Community Health funded an innovative pilot diabetes care approach. The goal of this study was to undertake a thorough evaluation of the pilot phase, including clinical outcomes, patient and provider satisfaction with telemedicine technology use (Powers et al., 2020).

Community Resources for Safe and Effective Continuum Care

People, places, events, and things are all examples of community resources. Businesses, organizations, public service agencies, or community members could be among them. Resources for the community might be funded in a variety of ways. Following are the important community resources that are used in making care coordination plan by nurses.

Community based organizations (CBOs)

CBOs can offer the National Diabetes Prevention Program (National DPP) lifestyle change intervention, which has been shown to prevent or delay type 2 diabetes, or assist persons in their community in enrolling. CBOs are critical in assisting patients with diabetes in lowering their blood sugar and managing their disease. Diabetic self-management education and support (DSMES) services enable patients to achieve their daily and long-term diabetes goals. CBOs provide the DSMES by becoming accredited by the Association of Diabetes Care and Educators by assisting people in their communities in finding these services (Tehan, Smith, Draucker, & Martsolf, 2018).

The Centers for Disease Control and Prevention (CDC)

It offers webinars and online learning modules to assist you in supporting persons who are at risk of developing type 2 diabetes or who currently have diabetes. Find CDC webinars and podcasts on diabetes subjects that give continuing education credits. The multilingual fotonovela (illustrated novel) tells dramatic stories of Latinas communicating to other Latinas about preventing or postponing type 2 diabetes and staying healthy for their children and themselves (Control & Prevention, 2020).

Community Health Worker Forum

 It Involves Community Health Workers in the Development of a Sustainable Statewide Infrastructure.Meeting with Community Health Workers (CHWs), CHW allies, and state health department leaders to discuss challenges around the development of the a statewide infrastructure to support CHW long-term viability and funding. Moreover, many support groups help people share their condition and make them better able to cop with the condition (Yeager, 2018).


Control, C. f. D., & Prevention. (2020). Testing guidelines for nursing homes. 

Conway, A., O’Donnell, C., & Yates, P. (2019). The effectiveness of the nurse care coordinator role on patient-reported and health service outcomes: A systematic review. Evaluation & the health professions, 42(3), 263-296. 

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., . . . Maryniuk, M. D. (2020). Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care, 43(7), 1636-1649. 

Tehan, R., Smith, C., Draucker, C., & Martsolf, D. S. (2018). Use of a Systematic Consultation Process to Facilitate Nursing Research Projects: An Exemplar. Clinical nurse specialist CNS, 32(5), 249. 

Weierbach, F. M., & Stanton, M. P. (2018). Rural community case management experience for bachelor of science in nursing students: A focus group evaluation. Journal of Nursing Education, 57(9), 557-560. 

Yeager, P. (2018). A Colorado-based CBO launches a pilot to keep people with disabilities out of nursing homes. Generations, 42(1), 74-78. 

FPX4050-Coord Patient-Centered Care -Assessment 1:  Preliminary Care Coordination Plan

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