Preliminary Care Coordination Plan
School of Nursing and Health Sciences, Capella University
NURS-FPX4050 Coordinating Patient-Centered Care
April 20, 2022
Preliminary Care Coordination Plan
Introduction
Care coordination involves keeping all parties involved in delivering a service, from doctors to consumers and their loved ones, in regular contact with each other and working toward a common goal. Care for the chronically ill must be coordinated meticulously because of the illness’s far-reaching effects on their daily life. Due to the diversity of potential outcomes, healthcare problems can only be effectively treated through a collaborative, interdisciplinary effort. Long-term health problems require a healthcare system that prioritizes coordinated care (Atwood et al., 2022). People with COPD are the focus of an in-depth examination of the goals, best practices, and community resources that underpin the provision of care.
Chronic Obstructive Pulmonary Disease (COPD)
Patients who have the chronic obstructive pulmonary disease (COPD) require a wide range of treatment options, ranging from medications to various kinds of assistance and coordination of services, in order to enhance the quality of care that they get and to lessen the extent of any health consequences (Fekete et al., 2022). Care coordination aids in COPD management by making available additional therapy options. Comorbidities and other systemic impacts of respiratory components of illness are addressed via collaborative treatment to ensure patients’ requirements are met.
Patients suffering from COPD may reap benefits from the abovementioned change in care in the form of enhanced outcomes, care integration, increased care use, and lung rehabilitation. Care for these patients must be delivered in a manner that prioritizes their holistic health due to the complexity of their requirements (Gomez et al., 2023). The treatment of COPD patients is complicated by many unknowns and barriers, despite the lofty aims of COPD case management. Providing emergency treatment that considers the patient’s other medical conditions is essential to healthcare. Care providers face uncertainty in illness diagnosis, treatment, and hospitalization due to the patient’s complicated condition (Atwood et al., 2022). According to recent studies, inadequate patient compliance with illness treatment and management has been linked to various widespread problems.
Best Practices for Health Improvement
Health may be improved and patient outcomes enhanced by using various time-tested strategies. Overall, service quality relies on providers sticking to treatment protocols supported by research (Vachon et al., 2022). People with COPD must prioritize receiving treatment from an interdisciplinary team that includes nurses, physicians, dietitians, and exercise specialists, respiratory experts such as a pulmonary physician and pulmonary therapist, and counsellors. According to Gomez et al. (2023), providing patients with treatment of the best possible quality requires that every medical team member efficiently communicates with one another. The effectiveness of the multidisciplinary care team depends on the team member’s ability to work together effectively and communicate with one another. The patient must be actively involved in team talks if they are to be tasked with overall self-care and management, and the multidisciplinary team must provide extensive education in order to achieve this goal. It is important to include family members in conversations about therapy and other significant choices because of their vital role in their loved one’s care (Neches Garca et al., 2022). Inhalers, both long- and short-acting, and steroids are only two examples of treatments that need to be discussed at length with the patient.
Regular administration of a pulmonary function test (PFT) is recommended to track lung function improvement and decide whether to change therapy (Stanojevic et al., 2022). The effectiveness of therapy may be enhanced by identifying and removing the causes of acute disease aggravation. This is also an essential means of determining if the patient is sticking to their recommended course of therapy. In conclusion, if the intended outcomes of care are to be realized, it is essential to return to the original care objectives.
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Goals to address the problem
- Patient involvement is crucial to achieving the overarching healthcare aim of the interdisciplinary team, which is to improve patient outcomes and satisfaction. In addition to enhancing a patient’s health, good care coordination should enhance their quality of life by making it easier for them to participate in community activities and achieve personal goals. This may be achieved by communication between the patient and their care team regarding concerns, areas of misunderstanding, and methods for better understanding one another’s perspectives.
- Secondly, we want to ensure patients are taking their meds as prescribed and staying in touch with them to ensure their symptoms do not worsen. Exacerbations of COPD are often brought on by infections caused by viruses, inflammation of the pulmonary tract, and prolonged exposure to environmental pollutants. It is crucial to thoroughly understand the hazards the patient confronts in their surroundings to reduce their exposure by including them in the care coordination process.
- Subsequently, one of our objectives is to reduce healthcare expenditure since this will benefit everyone generally. They were considering that COPD is a long-term, debilitating illness and the high cost of the many medications, treatments, and changes to one’s way of life required for effective care. As a result, healthcare providers must be creative in finding cost-cutting measures. One approach may be to have the patient and their family depend less on the outside medical staff. If you estimate the changes needed and establish a time limit for each of the numerous upgrades, you will find that improving outcomes is much less of a hassle.
- Ultimately, the goal is to educate patients so that they are better equipped to manage the challenges posed by their condition. When the goal is to improve the treatment of a disease, it is also important to educate family members, who often play a crucial role in providing support and care.
COPD makes coordinating care and the effectiveness of service delivery more complex, and the presence of comorbidity also makes these things more difficult. Hypertension, depression, and diabetes are all examples of comorbid diseases that a person may have in addition to their primary illness (Fekete et al., 2022). There may or may not be a direct relationship between the disorders, but treating people with comorbidity presents a more incredible difficulty for the medical community than treating patients with COPD alone. This is true even when dealing with the difficulties of treating people with COPD (Vachon et al., 2022). Creating a comprehensive care plan is the only way to ensure that a patient like this receives coordinated care. When patients with co-occurring disorders receive care from a multidisciplinary team, their overall health improves and their chances of therapeutic success rise.
Community Resources to Support the Continuum of Care
Patients with chronic obstructive pulmonary disease (COPD) would benefit most from coordinated and enhanced care if they have access to the care services they need as soon as possible from a community resource (Vachon et al., 2022). Patients with COPD are urged to get involved with the COPD Foundation, a social network of over 51,000 individuals who share their experiences with the condition and provide support and guidance to those dealing with it. It is crucial to have a safe space where people may go to have their questions addressed and connect with others who can relate (Fekete et al., 2022). The American Heart Association (AHA) is a
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resource for people with COPD who suffer from other health conditions, such as hypertension. These individuals may receive assistance from the AHA.
Conclusion
Care coordination promotes communication and efficient service planning. If you want to coordinate treatment efficiently, you need to know all there is to know about the most current state of the profession (often evidence-based approaches) and potential risks. Due to the importance of loved ones in the healthcare delivery process, patient education is a fundamental healthcare goal. The protocol lays forth a plan for treating COPD involving medical professionals and individuals.
References
Atwood, C. E., Bhutani, M., Ospina, M. B., Rowe, B. H., Leigh, R., Deuchar, L., … & Stickland, M. K. (2022). Optimizing COPD Acute Care Patient Outcomes Using a Standardized Transition Bundle and Care Coordinator: A Randomized Clinical Trial. Chest, 162(2), 321-330. https://doi.org/10.1016/j.chest.2022.03.047
Fekete, M., Szarvas, Z., Fazekas-Pongor, V., Feher, A., Dosa, N., Lehoczki, A., … & Varga, J. T. (2022). COVID-19 infection in patients with chronic obstructive pulmonary disease: From pathophysiology to therapy. Mini-review. Physiology International, 109(1), 9-19. https://doi.org/10.1556/2060.2022.00172
Gomez, F. R., Kinsler, J. J., Love‐Bibbero, L., Garell, C., Wang, Y., & Pike, N. A. (2023). Mixed methods evaluation of an oral health education program for pediatric dental, medical and nursing providers. Journal of Dental Education. https://doi.org/10.1002/jdd.13199
Neches García, V., Vallejo-Aparicio, L. A., Ismaila, A. S., Sicras-Mainar, A., Sicras-Navarro, A., González, C., … & García-Peñuela, M. (2022). Clinical and Economic Impact of Long-Term Inhaled Corticosteroid Withdrawal in Patients with Chronic Obstructive Pulmonary Disease Treated with Triple Therapy in Spain. International Journal of Chronic Obstructive Pulmonary Disease, 2161-2174. https://doi.org/10.1080/14737167.2022.2044308
Stanojevic, S., Kaminsky, D. A., Miller, M. R., Thompson, B., Aliverti, A., Barjaktarevic, I., … & Swenson, E. R. (2022). ERS/ATS technical standard on interpretive strategies for routine lung function tests. European Respiratory Journal, 60(1 https://doi.org/10.1183/13993003.01499-2021
Vachon, B., Giasson, G., Gaboury, I., Gaid, D., Noël De Tilly, V., Houle, L., … & Pomey, M. P. (2022). Challenges and strategies for improving COPD primary care services in Quebec: results of the experience of the COMPAS+ quality improvement collaborative. International Journal of Chronic Obstructive Pulmonary Disease, 259-272. https://orcid.org/0000-0003-2899-2120