Running Head: CARE COORDINATION 1
Running Head: CARE COORDINATION 1
CARE COORDINATION 8
Preliminary Care Coordination Plan
Capella University
Alexander Ruche
Introduction
The role of care coordination is to ensure that there exists integrated services that meet the needs of individuals. The focus of care coordination lies in the delivery of recovery-focused and collaborative services that connect people to healthcare services. A key necessity for care coordination is the management of chronically sick patients. Chronically ill patients are a part of interconnected problems as they affect the social circles around them (Hannigan et. al., 2018). Just as it is complicated to the patients, so is it on service provision, hence mandating for family and friend to be a part of a multidisciplinary approach in relation to provision of care. Hence as a result, the issue on chronically ill patients is not one that can be handled by a single profession but rather one that requires a multidisciplinary approach and a care coordination plan to best deal with the health concerns (Hannigan et. al., 2018).
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a type of obstructive lung disease often characterized by long-term breathing problems and poor airflow resulting in difficulties when breathing. It tends to be characterized by shortness of breath as well as coughs accompanied with sputum production. Therefore, patients with COPD tend to present various complex health issues that demand for immediate pharmacological interventions (Hanania et. al., 2018). Care coordination assists in solving these complexities and in providing alternatives to quality health care. By offering a collaborative approach it is possible to address not only the patient’s needs in relation to the respiratory aspect of the disease but also in addressing the systemic effects and comorbidities associated with the illness (Hanania et. al., 2018). According to the Journal of Chronic Pulmonary Diseases, the most appropriate practices for care coordination for COPD include pulmonary rehabilitation, care integration, a holistic approach and an inclusion of a care transition model. These practices help to meet the complex needs of managing COPD. However, regardless of the clear goals in managing COPD, there still exist certain challenges (Hanania et. al., 2018). One such challenge is dealing with the hopelessness of the condition. Often physicians face uncertainties in diagnosing the disease, identifying its medications and hospitalizations. Even worse, patients in the past have shown non-compliance as a result of the disease’s complexity (Hanania et. al., 2018). All in all, an effective care coordination plan would help to effectively manage the condition of COPD.
Care Coordination Plan
To help attain success in the care coordination for Mr. Andrew Anderson a team of fifteen professionals will be selected. Although this team seems large, past research shows that a big number of people is important when creating diversity and expertise in COPD management. This team will compromise of nurses, pulmonologists and general experts all with a specific interest in COPD (Korpershoek et. al., 2017). The goal of the plan will be to create awareness around the disease, to offer a guideline based management, rehabilitation and self-management support program. The plan is also aimed at improving patient outcomes as evidenced in the attachment below:
PATIENTS NAME: Mr. Anderson
CONTACT: Private
ADDRESS: Private
| 1. Self-management behavior
a. Adherence to pharmacology- Consume prednisolone 30mg every day. Helps in reducing instances of exacerbation, failure of treatment, admission, and improves hypoxemia. · Adhere to using albuterol (Combivent) 100 mcg/20 mcg after every 6 hours and must not exceed 6 actuations daily. Such helps to boost instances of dyspnea and activity tolerance during the daily exercise regimens (Korpershoek et. al., 2017). · Take ciprofloxacin twice every day because it lowers instances of treatment failure ● Please note that medications will be collected at Walgreens Pharmacy located in Cutler Bay. SCORE OF ADHERANCE
2. Patient Education a. Mr. Anderson will attend a smoking cessation program at Primax Rehabilitation Program. After the end of six months Mr. Anderson will have managed his smoking habits. By being part of the rehabilitation program, you will have modified the occurrence of the disease and lowered instances of contracting myocardial infarction and lung cancer. It is paramount to note that the effects of quitting smoking will not be evidenced until after several months of quitting (Jiménez-Ruiz et. al., 2015). b. Enroll in a muscle relaxation program at the Pembroke Resource Center. Such will promote Mr. Anderson’s respiratory and psychological well-being. The center will offer activities like yoga, muscle relaxation and deep breathing exercises (Volpato, et. al., 2015).These exercises will be aimed at improving his breathing capacity and will be done every Monday and Friday. c. Take part in the training of early detection of exacerbation at the Porta General Hospital as directed by the program coordinator. In the event of an exacerbation contact the care coordinator. While at the training you will be looked after by the lead physician and community nurse (May et. al., 2016).
Write date, day and time of attendance.
●Rate the usefulness of every program in a percentage score: (e.g. 20%, 50%, 100%) – Smoking cessation program: – Relaxation technique – Early detection of exacerbation 3. Influenza Vaccination
After the first week, you will get the influenza vaccine from South Miami Hospital. The vaccine is very useful since influenza is termed as the second most common cause of COPD exacerbations. The vaccination will help reduce instances of attacks (Nici & ZuWallack, 2018). 4. Involvement by the family For effective management of COPD management, family intervention is important. Family will help in offering emotional support during the journey. They will also help in supporting smoking cessation and facilitate drug adherence. Mr. Anderson will involve his spouse in the training programs while attending the monthly COPD clinics with him. Such ensures not just support but will make it easier for the care coordinator to monitor the patient for best outcomes. CONTACTS Signature Care Coordinator: 734-755-602 Walgreens Pharmacy: 965-546-8300 Local clinic: 955-412-0134 Pembroke Resource Center: 308-680-5075 Ambulance: 720-119-3647
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References
Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: findings from a cross-national mental health systems study. International Journal of Integrated Care, 18(3).
Hanania, N. A., Hawken, N., Gilbert, I., Martinez, F. J., Fox, K. M., Ross, M. M., … & Tervonen, T. (2018). What Symptomatic Patients with Asthma and Chronic Obstructive Pulmonary Disease (COPD) Find Important in Their Maintenance Inhaler Therapy: A Focus Group Study. In C37. OPTIMIZING ASTHMA CARE ACROSS DIVERSE PATIENTS (pp. A4863-A4863). American Thoracic Society.
Jiménez-Ruiz, C. A., Andreas, S., Lewis, K. E., Tonnesen, P., Van Schayck, C., Hajek, P., … Gratziou, C. (2015). Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. European Respiratory Journal, 46(1), 61-79. doi:10.1183/09031936.00092614
Korpershoek, Y., Bruins Slot, J., Effing, T., Schuurmans, M., & Trappenburg, J. (2017). Self-management behaviors to reduce exacerbation impact in COPD patients: a Delphi study. International Journal of Chronic Obstructive Pulmonary Disease, Volume 12, 2735-2746. doi:10.2147/copd.s138867
May, C. R., Cummings, A., Myall, M., Harvey, J., Pope, C., Griffiths, P., … Richardson, A. (2016). Experiences of long-term life-limiting conditions among patients and carers: what can we learn from a meta-review of systematic reviews of qualitative studies of chronic heart failure, chronic obstructive pulmonary disease and chronic kidney disease? BMJ Open, 6(10), e011694. doi:10.1136/bmjopen-2016-011694
Nici, L., & ZuWallack, R. (2018). Integrated care in chronic obstructive pulmonary disease and rehabilitation. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(3), 223-230.
Volpato, E., Banfi, P., Rogers, S. M., & Pagnini, F. (2015). Relaxation Techniques for People with Chronic Obstructive Pulmonary Disease: A Systematic Review and a Meta-Analysis. Evidence-Based Complementary and Alternative Medicine, 2015, 1-22. doi:10.1155/2015/628365
