Final Care Coordination Plan: Chronic Obstructive Pulmonary Disease

NURS FPX 4050 Assessment 4 Final Care Coordination Plan CG

Based on the preliminary care coordination plan, the specific healthcare condition that was selected was chronic obstructive pulmonary disease (COPD). COPD can be defined as a progressive yet treatable and preventable disease that is characterized by incomplete reversible airway obstruction due to inflamed lungs, cough, phlegm, and dyspnea. According to Swan et al. (2019), COPD has been one of the leading diseases in the United States since 2020, and currently, the number of patients affected by the disease globally is approximately 328 million. COPD affects the patient’s mental, social, cognitive, and economic capabilities, resulting in poor living standards, financial deficits, and inadequate social provisions. However, nurses play a key role in care coordination practices that are essential for patients experiencing COPD to ensure seamless care transitions. For this care coordination plan, the paper will provide a description of the priorities that a care coordinator would establish when discussing a COPD treatment plan with a patient, their family members, and identify changes to the plan based on evidence-based practices and a discussion on how the plan includes elements of Healthy people 2030. 

Patient-Centered Health Interventions and Timelines for COPD

Several factors need to be considered with the requirements of designing patient-centered health interventions and timeliness for chronic obstructive pulmonary disease. For instance, care providers need to be aware of the available community resources, cultural norms involving the patient, safety considerations, policy issues, ethical considerations, and the patient’s physiological needs. However, while seeking to maintain care coordination for patients with COPD, there are health care issues that may affect its effectiveness. First, with inadequate self-management skills and standards, patients are unlikely to fully support themselves, increasing the risk of worsening the condition (Lenferink et al., 2018). In this case, COPD patients are unable to recognize that their condition is deteriorating. Consequently, the rate of readmissions to hospitals increases, leading to increased medical costs. The second issue is inadequate social support for COPD patients. Often, COPD patients experience anxiety that requires positive social support to enable them better their health status, reduce hospitalization, lessen disease exacerbation, and improve their disease management behaviors (Haddad & Geiger, 2018). In other words, lack of social support is associated with social isolation and lack of social connections, which will lead to increased mental complications. The third healthcare issue associated with COPD patients is the management of comorbidities related to COPD (Lenferink et al., 2019). Common comorbidities include cardiovascular diseases, depression and anxieties, sleep disorders, diabetes and metabolic syndrome, lung cancer and osteoporosis. Undoubtedly, comorbidities associated with COPD increases overall treatment complexity and poorer quality of care management among patients. 

However, professional healthcare providers have a responsibility to resolve adverse healthcare issues affecting the well-being of patients in the care continuum by initiating patient-centered interventions and timeliness to achieve and maintain optimal health and better quality of life for them. Based on the above healthcare issues, the intervention for inadequate self-management skills could enhance their knowledge through education and increase their ability to comply with medication regimens. Through education, patients with COPD are likely to acquire and practice the skills needed to guide them through changes in their health behavior and provide emotional support to enable them to adjust to optimal control of the disease. Self-efficacy in the management skills will require interventions centered on ensuring patients interpret the symptoms, solve the problems within their reach, make appropriate decisions and utilize the available resources effectively. With the issue of inadequate social support, the appropriate patient-centered intervention will require healthcare providers to link the patient with volunteer social communities and families who serve to provide social connections and relationships that will influence their behaviors to improve health-related quality of life. According to Lenferink et al. (2018), social support refers to the provision of psychological and material resources, including the emotional, instrumental, informational and appraisal facets, aimed at improving the individual’s ability to cope with the disease. Adequate social support for patients with COPD is associated with reduced hospitalization and fewer exacerbations hence reduced medication costs (Lenferink et al., 2018). The most prevalent intervention in dealing with the issue of comorbidities associated with COPD is through a comprehensive approach that will enable the management and mediation of risk factors simultaneously. However, the process will require modification of risk factors such as smoking. Overall, through extensive care coordination practices, healthcare providers will engage to ensure that the patients achieve a better quality of life. 

Ethical decision considerations and ethical questions

Designing patient-centered health interventions for COPD require consideration of ethical decisions. Also, care coordination practices intend to eradicate replication of care services, reducing disparities and saving on hospitalization costs. Overall, the goal of care coordination is to facilitate the appropriate and efficient delivery of healthcare services across the health systems. Therefore, ethical decisions need to consider provisions of coordinated care for COPD patients to ensure quality and patient-centered care. One of the ethical guiding principles is patient autonomy. Ethical decision-making among COPD patients requires upholding informed consent (McDermott-Levy et al., 2018). Through informed consent, patients participate in decision-making specific medication procedures. However, the healthcare professionals should assess the decision-making ability of the patient. For instance, in the last stages of COPD, the patient’s cognition severely altered. In this case, decisions are transferred to others, who can provide decisions in the patient’s best interest. The idea leads to the other ethical principle of beneficence. The beneficence guiding principle of ethical decision-making applies to the ‘best interest’ of the COPD patient through which comparative assessments are made, and the maximizing benefit is in relation to the highest probable net benefit to the patient (Haddad & Geiger, 2018). The patient’s best interest needs to be based on both the medical and care knowledge along with respect for their values and preferences. Based on such guiding principles, care coordinators need to consider patient safety by ensuring that medical risks, errors, and harm are minimized when considering patient-centered care. 

However, the initiated ethical decision-making procedures may be vulnerable to dilemmas and uncertainties when dealing with COPD patients. For instance, ethical questions may arise in the best interest of the patient, such as, should the healthcare professional consider an informed but poor choice of a COPD patient on the grounds of respecting their autonomy? Is there an ethical obligation to persuade or change the perspective of the patient otherwise? If so, from what concern does the obligation arise? Is the patient able to make competent decisions? The analyzed concept relates to patient-centered intervention dilemmas whose specified solutions are achieved through an evidence-based approach. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan CG

Relevant health policy implications

With the adversity of COPD complications, health policy implications for the coordination and continuum of care are significant in determining the patients’ well-being. Health policies play a vital role in facilitating guidelines that benefit patients, healthcare organizations and healthcare systems whose implications for medical practices aid decision-making. According to Purnell & Fenkl (2019), health policies uphold universal resources that nurture the overall well-being of COPD patients by promoting consistency in practices, reducing mistakes, and keeping patients and staff safe. Agencies such as the Centers for Medicare and Medicaid Services (CMS) Centers of Disease Control (CDC) have a significant impact in facilitating policies whose decisions have direct effect n patients and those who care about them. Health policies often provide opportunities for health accessibilities and quality considerations influenced by health choices. The specific health policy that may be associated with COPD patients is the Affordable Care Act (ACA). The health policy facilitates preventive care services without charge, including smoking cessation programs. The healthcare providers for COPD patients have been granted the incentive of reducing repeat hospital visits among patients. In this case, readmissions related to COPD have been reduced, and hospitalization costs reduced. 

Description of priorities a care coordinator would establish when discussing the plan with a patient and family member.

When discussing planning with the COPD patient and their family members, several priorities need to be established by the care coordinator, who is responsible for initiating changes grounded on evidence-based practices. Having discussions facilitates advanced care planning, improves satisfaction with end-of-life care and potentially reduces the use of inappropriate life-sustaining therapies among COPD patients. In one way, the health care professional needs to acknowledge the need for cultural competency so that communication and interaction with the patient and families can be made effective. Cultural competence enables the care coordinator to understand the patient’s customs and beliefs through which they are required to transform their services to meet the patient’s needs be addressed, hence establishing a patient-centered care delivery (MCkeel, 2021). Also, the care coordinator should prioritize establishing accountability and agreeing on responsibility through communications and assessment of patient needs and goals so that the transitions of care are made effective. With differences between the patient’s goals and the intended care plan, there may be a need to modify the plans. For instance, if the plan does not accommodate the patient’s cultural considerations in the medication process or the plans can be costly, the care coordinator will need to adjust and modify the plans to ensure patient-centered care is provided. Also, the care coordinator will need to modify the plans in consideration of the patient’s safety and the assurance of receiving COPD quality care services. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan CG

Literature on Evaluation as Guide in Comparing Learning Session Content with Best Practice

The use of literature on evaluation as a guide in comparing learning session content with best practice is evidenced through patient experience feedback and satisfaction level (Padilha et al., 2018). Based on the literature of evaluation, patient involvement in care coordination is fundamental in establishing trust between the patient and the healthcare provider. With such a relationship, patients with COPD are likely to take responsibility for self-care and management to prevent the worsening of the disease and the attack of comorbidities. Consequently, the frequency of hospitalizations reduced, and costs are lowered. Also, increasing patients’ emotional and social support is essential, especially when informing them about their progress in medication and outcomes. 

Teaching alignment to the Healthy people 2030 document

The healthy people 2030 set data-driven national objectives to improve health and well-being over the next decade. The overarching goals of Healthy People 2030 include attaining healthy, thriving lives and well-being free of preventable diseases, injuries, disabilities, and premature deaths (Graffith, 2021). Also, it focuses on eliminating health disparities, achieving health equity, and attaining health literacy to improve the health and well-being of all. The teaching sessions align with the Healthy people 2030 document on the framing that communicates the principles underlying ethical decision-making in healthcare systems and encouragement of patient-centered care. On the other hand, the Healthy people 2030 document aligns with the teachings in the sense that, since COPD can be prevented, the framework works towards eliminating the diseases and improving the well-being of individuals. 

References

Griffith, D. M. (2021). Well-being in Healthy People 2030: a missed opportunity. Health Education & Behavior, 48(2), 115-117.

Haddad, L. M., & Geiger, R. A. (2018). Nursing ethical considerations.

Lenferink, A., van der Palen, J., & Effing, T. (2018). The role of social support in improving chronic obstructive pulmonary disease self-management. Expert review of respiratory medicine, 12(8), 623-626.

Lenferink, A., van der Palen, J., van der Valk, P. D., Cafarella, P., van Veen, A., Quinn, S., … & Effing, T. W. (2019). Exacerbation action plans for patients with COPD and comorbidities: a randomized controlled trial. European respiratory journal, 54(5).

NURS FPX 4050 Assessment 4 Final Care Coordination Plan CG

McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, 66(5), 473-481.

McKeel, J. J. (2021). Undergraduate Nursing Education: Culturally Competent Care Coordination for a Vulnerable Population (Doctoral dissertation).

Padilha, J. M., Sousa, P. A. F., & Pereira, F. M. S. (2018). Nursing clinical practice changes to improve self‐management in chronic obstructive pulmonary disease. International Nursing Review, 65(1), 122-130.

Purnell, L. D., & Fenkl, E. A. (2019). Transcultural diversity and health care. In Handbook for culturally competent care (pp. 1-6). Springer, Cham.

Swan, B. A., Haas, S., & Jessie, A. T. (2019). Care coordination: Roles of registered nurses across the care continuum. Nursing Economics, 37(6), 317-323.

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