Sample Final Care Coordination Plan: Final Care Coordination Plan

Sample Final Care Coordination Plan: Final Care Coordination Plan

Jane Doe is a 77 year old, African American, female, who is a recent widower and has no children, was admitted to the hospital due to complaints of shortness of breath, chest pain, and fatigue. She was diagnosed with Congestive Heart Failure (CHF) during this admission and we are creating a care coordination plan for Jane Doe to control signs and symptoms of CHF and prevent further admissions to the hospital.

Three Health Care Issues

• CHF

The interprofessional team, this includes physicians, nurses, specialists, case management, the patient, and family if available, to create a care plan to improve signs and symptoms of CHF that is individualized. Jane Doe will be educated on CHF, follow-ups, medication adherence, low-sodium diet and fluid restrictions, and maintain weight by self- management as these elements are known to improve patient outcomes. 

Self-management is an intervention that puts the patient in control. The patient is required to have CHF knowledge, meaning they understand the disease and signs of symptoms, how to eat a low sodium diet, fluid restrictions, and be able to recognize fluid overload and when to seek additional health care (Zakrisson et al., 2019). To make behavioral changes, support groups are a key element in success. Support groups allow patients to see that they are not alone and can be persuaded by trustworthy people to see and accept positive changes. 

There are many community resources available. There are many online support groups and information such as, https://www.heartfailurematters.org, but for the older population it may be difficult to use technology. The American Heart Association also offers support groups online and in person for patients and caregivers. They also have print out educational pamphlets available such as care sheets for Selfcheck management and about the disease itself.

2. Physical Activity And Nutrition

Poor physical activity and nutrition is linked to increased risk of CHF. Several reviews have found that sedentary behavior consistently increases the risk of both non-fatal and fatal cardiovascular diseases and CHF in the general adult population. As patients are educated on an exercise program following a cardiovascular event, preventative care works too. CHF patients should partake in an exercise program to improve quality of life (Tan, M. K. H., Wong, J. K. L., Bakrania, K., Abdullahi, Y., Harling, L., Casula, R., . . . Jarral, O. A, 2019). 

Nutrition is also linked to heart conditions. African American culture tends to eat a “southern diet.” These are foods that include fruits and vegetables but are prepared in an unhealthy fashion. This diet is high in added fats, sugars, and sodium, with prominent use of high-fat meats for main dishes and the use of deep frying and other cooking techniques that add excess calories and sodium (Mercedes R. Carnethon, Jia Pu, George Howard, Michelle A. Albert, Cheryl A.M. Anderson, Alain G. Bertoni, Mahasin S. Mujahid, Latha Palaniappan, Herman A. TaylorJr, Monte Willis, and Clyde W. Yancy, 2020). 

Jane Doe must be educated on how to prepare the foods she likes in a healthier fashion. Jane Doe can meet with a Dietician to obtain the resources to learn how to cook foods she likes. She is an elderly woman and may need help obtaining groceries and preparing meals. Transportation, affordability of food, and physical activity has to be examined.

There are community resources to help with physical activity and nutrition. Occupational or physical therapists can be prescribed to help improve physical activity. Home care can help with activities of daily living such as grocery shopping, cooking, and cleaning. And there are organizations such as meals on wheels that will bring healthy meals to the patient’s home.

3. Access To Health Care

According to the American Heart Association, an estimated 7.3 million Americans with cardiovascular disease (CVD) are currently uninsured. As a result, they are far less likely to receive appropriate and timely medical care and often suffer worse medical outcomes, including higher mortality rates (AHA, 2018). Efforts are being made to extend health care coverage to all Americans; so that patients have a continuum of care and better outcomes. The Affordable Care Act has expanded on rural and urban populations. 

The patient also needs to be able to go to appointments. If transportation is an issue, there are community resources such as senior citizens transportation. There are bus services available to transport s
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