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NURS FPX 4050 Assessment 4 Coordination Patient Centered Care

Final Care Coordination Plan

NURS FPX 4050 Assessment 4 Coordination Patient Centered Care

The coordination of care continuum is the process of maintaining a smooth and effective delivery of care as part of the nursing system. Nursing personnel must be familiar with social operations, potential repercussions, policy issues, socio-cultural norms, therapeutic results, and physiological requirements. Nursing personnel is vital in providing the necessary knowledge and understanding to ensure successful care transitions. Professionals utilize EBP techniques to enhance healthcare efficiency and patient health to provide a safe environment conducive to sustaining and increasing the patient’s health quality, families, or organizations in a population. Patients benefit from a safe atmosphere conducive to rehab and a healthier lifestyle when they are provided with a plan and the tools to achieve and sustain a healthier livelihood.

Patient-centered Health Interventions & Timelines

The concept of patient-centred treatment has grown in prominence and is now recognized as a vital goal of specialized healthcare organizations including Vila Health Hospital to reach individual rehabilitation goals for cardiac diseases. Patient-centred treatment is defined as therapy that is sensitive to the patients and receptive to individual patient preferences, needs, and belief systems, as well as ensuring that patient morality guides every therapeutic decision. Healthcare coordination that is adequately communicated to the relevant individuals has the potential to increase efficiency for everyone: patients, providers, and financiers (Smith et al., 2017). Despite the obvious need for coordinated care, there are limitations within the US medical system that must be overcome to provide this level of care. For the following considerations, it is necessary to redesign a medical system to correctly manage patients’ care:

  • Health care organizations nowadays are generally unorganized, with processes differing across primary care and tertiary medical contexts.
  • Patients are usually perplexed as to why they were referred from regular practitioners to a specialist, how to schedule visits, and what tasks to do after visiting an expert.
  • Specialists do not usually give explicit justifications for previous experiments’ referencing or informational mechanisms. Healthcare professionals are seldom informed of what happens during a prescribing session.
  • Referring personnel deal with several protocols and incomplete information, leading to suboptimal treatment (Poitras et al., 2018)

1st Physical therapists assist patients in understanding such aspects by encouraging patients to participate in a variety of musculoskeletal exercises. Additionally, speech therapists aid stroke survivors who have been negatively influenced in aspects of eating, comprehension, and accent. This doctor may collaborate with nutrition experts to help the team understands the sorts of foods that patients should consume. These 3 professionals occasionally assure that patients effectively deal with their environment. Individuals participating in medical coordination typically have diverse agendas. Before the patient is discharged from the hospital, the aforementioned experts must collaborate to design the patient’s medication regimen (Better et al., 2017). 

NURS FPX 4050 Assessment 4 Coordination Patient Centered Care

To construct the treatment regimen, these doctors must specify the material and resources that the individual will require. Collaborative effort goals include ensuring that the patient has gained sufficient sturdy diagnostic products, trying to arrange for cardiovascular training materials, attempting to categorize for continuing outpatient therapy, preparing for residential care, attempting to recover to the medical facility, as well as providing the patient with prescription meds to use at the client’s house (Gallagher et al., 2019).

Mental health crisis management is among the most significant form of intervention. In a situation of crisis, the individual suffering from mental illness may be in imminent risk or constitute a danger to oneself and society. Suicidal impulses are a typical indication that need immediate mental health crisis help. Mental health crisis care is critical in addressing stress, anxiousness, and other psychological illnesses before they become severe, hazardous, or even fatal. The community resources for this intervention include mental health crisis hotline, The National Suicide Prevention Line and Crisis Text Line (Poitras et al., 2018).

Another intervention is the use of Psychotherapy and counselling. Psychotherapy and counselling are an excellent intervention strategy for a multitude of causes. To begin, psychotherapist, such as a qualified counsellor, can guide patients and their beloved ones through painful talks in a secure setting. Furthermore, therapeutic counseling in a long-term treatment program can integrate treatments such as Personalized psychotherapy, Group counseling, and Families psychotherapy to address behavioral, psychological, and maladaptive habits. Community resources for this intervention includes Assessment & Care Team (ACT) Recommendations, local counseling services and nonprofessional support groups (Poitras et al., 2018). 

Another intervention is the cognitive restructuring. Cognitive restructuring, also known as cognitive reframing, is a psychotherapy intervention that assists clients in discovering, challenging, and changing or replacing negative, unreasonable ideas (or cognitive illusions). It is based on the premise that how we think influences how we feel. It is simple to comprehend the reasoning underlying this concept, as well as the consequences of incorrect thinking. Community resources for this intervention includes CPSTF (Community Preventive Services Task Force), surveys and social phobias guiding worksheets (Poitras et al., 2018).  

Ethical Decisions in Designing patient-centred Healthcare Interventions

Health care organizations & entities throughout the world are seeking to enhance their performance by using the person-centred care (PCC) approach. PCC is a practical and thoughtful therapeutic & caregiving strategy that takes into account individuals’ requirements, preferences, and beliefs. It increases patient participation by incorporating individuals in particular therapeutic decision-making protocols. In this way, it is an evolution of the initial creation of patient-centred treatment, which is characterized in papers as “acknowledging the patient as a separate human entity.” PCC is the most well-known concept in literature; nonetheless, this method views the patient as a much more distanced person receiving care, with the exclusive emphasis upon medical assessment and rehabilitation (Goldfarb et al., 2017). 

NURS FPX 4050 Assessment 4 Coordination Patient Centered Care

PCC would go over and beyond since it is ethically acceptable and therefore can perceive the human (not simply the illness) as an active participant in therapy, considering everything they need, their families, their past, their weak aspects, and their imperfections. This method depends on Aristotle’s idea of human flourishing, which also states that performance is not even a routine because it is morally acceptable and could see the person (rather than just the service user) as such an active participant in diagnosis, trying to take into consideration their needs, family, context, positive aspects, and imperfections. Because a PPC approach is by far the most respectful means of meeting patients’ needs and wants, acceptable ethical decisions typically result in their equality by participating in the therapeutic approach (Moore et al., 2017).

There appear to be a handful of outlets for exchanging notions that might be highly valuable when it comes to developing powerful ethical judgements.

  • Wash away any preconceptions.
  • Give heed, even if we have to contradict it Recognize your underlying biases
  • Be prepared to alter the viewpoint.
  • Be upfront.
  • Make some suggestions.

This exemplifies why Vila Health Hospital should adopt pace and adopt a PCC approach. Additionally, an important moral criterion that should’ve been fulfilled at Vila Health Hospital seems to be the development of persons’ ties with their surroundings as well as the comprehension of patients’ narratives via discourse and engagement. As a consequence, ethical factors such as acknowledging individuals and contributing towards development may help to better clinical outcomes for inpatient critical care.

Policy implications for the coordination and continuum of care

PCC is a core for health professionals striving to improve the efficacy of treatments provided to ischemic heart disease patients. Implementing patient-centred solutions at Vila Health Hospital has the potential to enhance cardiovascular patient care (Kleven et al., 2020). Individuals hospitalized at the CCU face a variety of issues, despite tough conditions, odd environments, the seclusion of beloved relatives and friends, and aggressive therapy. Irritant stimulation, limited time, personnel shortages, and difficult clinical results situations all influence the professional nursing technique and can lower the quality of treatment provided by nursing staff on such sections.

The major goal, according to Fremont et al. (2018) was to focus on the core features of cardiac crisis treatment, such as pharmaceutical therapy and specific approach. Research also revealed that non-tech components of therapy that have a significant impact on the person receiving care, such as patient education, mental health support, and rehabilitation services, are rarely studied, and there is no study on all these PCC methods. The Research Council outlines the basic elements of PCC therapy.

  • When people ailing from cardiac problems seek medical attention, they frequently yield away their freedom, jeopardizing their dignity.
  • Person-centred therapy helps you to defend individual beliefs by following the preferences and providing patients with compassion and affection.
  • To offer ongoing person-centred caring, you have to cooperate with several additional clinical staff and organizations.
  • The registered nurse must tailor care so that each individual is distinct. Depending on the distinctive situations and mindsets, a viable approach could impede patients’ ability to recover or manage any illness effectively and might hurt their wellness.

NURS FPX 4050 Assessment 4 Coordination Patient Centered Care

PCC approach necessitates involving patients in the selection and aiding patients in initiating self-help efforts. This helps individuals improve their skills and understanding of how to manage for themselves in the absence of colleagues (Swan et al., 2019). Vila Health Hospital, on the contrary side, might be able to use essential innovative techniques to improve patient-centred capacity and successfully handle cardiovascular clients. Vila Health Hospital’s positive impact might well be boosted by the complete treatment strategy. For example, the hospital’s administration found that not implementing a patient-centred strategy for medical clinicians had resulted in half a million dollars in needless hospitalizations during the previous 25 months. Healthcare institutions have indeed been able to benefit and function better in contrast to transferring information and improving care excellence as a result.

In regards of accessibility to mental health coverage, ACA was a defining moment. People with psychological health conditions are covered under the Affordable Care Act. Many private and smaller enterprise medical coverage policies, as well as all policies sold through the Insurance Marketplaces, are required by law to include psychological health and drug abuse disorder treatment. The Affordable Care Act mandates that all insurance plans include free preventative treatments such as depressive screenings for individuals as well as community mental health evaluations for children (U.S. Department of Health & Human Services,2021.

 The Centers for Medicare and Medicaid Services (CMS) urges states using the Medicaid discretion to develop new reimbursement mechanisms for telehealth services for mental health patients. Moreover, Medicaid pays for mental health care, such as addictive behavior and rehabilitation therapy. To assist more Individuals, Medicaid is extending its participation in the funding of drug use problem and mental health condition treatments. These laws were enacted by Congress in order to enhance psychological health treatment and drug use disorder therapies for Medicaid recipients, making it simpler for them to locate a psychological health professional without needing to pay from their own pocket (U.S. Department of Health & Human Services,2021.

HIPAA acknowledges that certain people suffering from mental illnesses or drug abuse would be incompetent to determine their own health selections. In general, the Privacy Rule pertains similarly to all personal health information, irrespective of its kind. Psychotherapy records are an exemption to this standard operation, as they are granted exceptional protection. Psychotherapy documents are regarded separately than other mental health data since they contain notably confidential material and because they have become the therapist’s personal observations that are usually not considered necessary or valuable for therapies, disbursement, or health care services reasons by anyone except mental health professional who generated the documents. As a result, with a few exemptions, the Privacy Rule mandates a regulated organization to get a patient’s agreement before disclosing psychotherapy records for whatever purpose (US Department of Health and Human Services, 2020)..

The Centers for Disease Control and Prevention (CDC) has revised its list of medical disorders that lead to worse prognosis with Covid-19 disease. It is a necessary list for prioritized diagnosis, therapy, and immunization. It now encompasses specific mental health disorders for the very first instance. During the epidemic, the CDC has introduced the Household Pulse Survey that measure anxiety and stress. This is an excellent instance of an organization responding rapidly to an urgently needed demand, and it shows how well the organization may monitor behavioral health problems related to the epidemic (CDC, 2021).

Care coordinator Priorities to Discuss the Plan

Anyone will benefit if care workers collaborate to improve outcomes. Medication administration errors, unnecessary or repetitive diagnostic operations, unnecessary hospital readmissions, preventable discharges and hospital visits are all decreased via concerted effort, leading to improved patient outcomes, improved experiences, and lower costs. Even though integrated services must connect multiple elements of the health care system, enhanced resource consolidation could result in a $2.4 trillion yearly reduction (Smith et al., 2017). The National Excellence Approach promotes all stakeholders to improve communication and coordination of care across the healthcare profession by focusing on following long-term targets:

  • Improve the quality of treatment transitioning via professional coordination.
  • Improving the health of people with chronic illnesses and impairment by following a new plan of care that takes into account and addresses pain and symptom therapy, psychological needs, and physiological performance.
  • By linking individual responsibility and connecting communities and health organizations, we may improve clinical standards and reduce healthcare disparities.

Furthermore, competent medical staff engages with clients’ caregivers genuinely and kindly. Whenever a member of the staff nurses doesn’t understand a directive, they must not give an incorrect response but instead explain their lack of expertise. As a result, patients will have considerably greater trust in staff nurses whenever it comes to medical care (Baker et al., 2021).

Learning Session Content Comparison with Best Practices

Healthy People 2030 goals are established in 2020, providing public medical authorities with a helpful tool for advancing their careers. The document supports Vila Health Hospital’s professional and clinical personnel in enhancing their care treatment results to successfully manage the cardiovascular effected person. Healthy People 2030 includes innovative efforts and responses to illness and other difficulties. It implies that integrating this in the matter of a practice program will become a terrific start in improving cardiac problems administration because it will surely establish a foundation for professional nurses to use as benchmarks (Baker et al., 2021). As per Walton’s study, Healthy People 2030 places a greater emphasis on the quality of lifestyle and ambient medical benefits (Walton et al., 2020).

 It implies that the nursing experts at Vila Health Hospital might use analogous characteristics to uncover more effective approaches for reducing cardiac discomfort, cerebrovascular dysfunction, and compromised blood vessel function, but also inequities in pertinent settings. This enables caregivers to keep a record of their hospital’s progress by recognizing the needs of heart patients.


Baker, J. M., Grant, R. W., & Gopalan, A. (2018). A systematic review of care management interventions targeting multimorbidity and high care utilization. BMC Health Services Research18(1), 65. https://doi.org/10.1186/s12913-018-2881-8

CDC. (2021, December 8). CDC Mental Health. Centers for Disease Control and Prevention. https://www.cdc.gov/mentalhealth/index.htm

Fremont, A. M., Cleary, P. D.., & Ayanian, J. Z. (2018). Patient-centered processes of care and long-term outcomes of myocardial infarction. Journal of General Internal Medicine16(12), 800–808. https://doi.org/10.1111/j.1525-1497.2001.10102.x

Gallagher, C., Rowett, D., Nyfort-Hansen, K., Simmons, S., Brooks, A. G., Moss, J. R., Middeldorp, M. E., Hendriks, J. M., Jones, T., Mahajan, R., Lau, D. H., & Sanders, P. (2019). Patient-centered educational resources for atrial fibrillation. JACC. Clinical Electrophysiology5(10), 1101–1114. https://doi.org/10.1016/j.jacep.2019.08.007

Poitras, M. E., Maltais, M. E., Bestard-Denommé, L., Stewart, M., & Fortin, M. (2018). What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC Health Services Research18(1), 446. https://doi.org/10.1186/s12913-018-3213-8

Smith, S. M., Cousins, G., Clyne, B., Allwright, S., & O’Dowd, T. (2017). Shared care across the interface between primary and specialty care in management of long-term conditions. The Cochrane Database of Systematic Reviews2(2), CD004910. https://doi.org/10.1002/14651858.CD004910.pub3

Smith, S. M., Soubhi, H., Fortin, M., Hudon, C., & O’Dowd, T. (2012). Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. The Cochrane database of Systematic Reviews, (4), CD006560. https://doi.org/10.1002/14651858.CD006560.pub2

Smith, S. M., Wallace, E., O’Dowd, T., & Fortin, M. (2021). Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. The Cochrane Database OF Systematic Reviews1(1), CD006560. https://doi.org/10.1002/14651858.CD006560.pub4

Swan, B. A., Haas, S., & Jessie, A. T. (2019). Care coordination: Roles of registered nurses across the care continuum. Nursing Economics37(6), 317-323. https://doi.org/10.1016/j.ajog.2019.11.1271

Tomaselli, G., Buttigieg, S. C., Rosano, A., Cassar, M., & Grima, G. (2020). Person-centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: a scoping review. Frontiers in Public Health8, 44. https://doi.org/10.3389/fpubh.2020.00044

U.S. Department of Health & Human Services. (2021, October 29). HHS.Gov. Retrieved February 18, 2022, from https://www.hhs.gov/answers/health-insurance-reform/does-the-aca-cover-individuals-with-mental-health-problems/index.html#:%7E:text=Health%20and%20Safety-,Does%20the%20Affordable%20Care%20Act%20cover%20individuals%20with%20mental%20health,Yes.&text=The%20law%20requires%20that%20most,and%20substance%20use%20disorder%20services.

US Department of Health and Human Services. (2020). HIPAA privacy rule and sharing information related to mental health. Office for Civil Rights. https://www. hhs. gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health. pdf

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