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Final Care Coordination Plan Amanda Renfro Capella University NHS-FPX4050: Coordinating Patient-Centered Care Prof. Gina Causey September 18, 2023

Final Care Coordination Plan

Hypertension is a blood pressure reading above 130/80 mmHg, and a hypertensive crisis is 180/20 or higher. The persistent application of excessive force to the arterial walls is a characteristic of hypertension. As Brown (2022) notes, men are more prone to suffer from high blood pressure than women. Hypertension-related comorbidities include heart disease, diabetes, hyperlipidemia, and stroke. It is estimated that hypertension causes approximately 10 million deaths annually.

Consistent care management is essential for all patients, especially those with long-term or complicated conditions. This is accomplished by easing patients into their new lifestyles, providing them with better access to information and care for health difficulties, and maintaining a consistent course of therapy. Strategies for coordinating care, informing patients, and providing individualized treatments supported by evidence will be explored. When developing a strategy for coordinating patient care, it is crucial to consider how federal health legislation and the code of ethics for caregivers could affect the process.

Patient-Centered Health Interventions

Patients diagnosed with hypertension are often advised to make significant changes to their way of life to reduce the risk of subsequent health complications. Health care that puts patients at the center of decision-making is vital to providing care that patients use. When dealing with hypertension, knowledge is power, as is the ability to keep tabs on one's blood pressure. Patients who need to comprehend a blood pressure reading or why theirs is abnormal will not be incentivized to follow the treatment plan. Knowing more about one's body increases the likelihood that prescriptions will be taken as recommended, contributing to better health literacy. Education alone is insufficient to alter people's beliefs about the severity of hypertension, and medication adherence has little impact on health outcomes. Therefore, hypertension patients require more comprehensive treatment plans (Tan et al., 2019). This research also established that patients need more than one clinic appointment with an educator before fully grasping their diagnosis and treatment options.

Alternatively, home visits appear to be better accepted and comprehended when the patient is more at ease and engaged, allowing the nurse to assess the patient's educational needs (Tan et al., 2019). When someone is diagnosed with high blood pressure, they are given information about how to make positive changes to their lifestyle. The aim is to exercise at least 30 minutes daily, five days a week. When getting started, one should prioritize forward motion above all else. It is better to have some motion than none at all. By initially engaging in three 10-minute walking sessions daily, individuals can gradually progress towards 30 minutes. Modifying one's behaviors can yield a substantial impact, even in minor ways. Instead of choosing to park in close proximity to the office, it is advisable to go for a location further away inside the parking lot or to utilize the stairs instead of the elevator.

Changing one's diet is one of the most challenging things for adults. The Dietary Approaches to Stop Hypertension (DASH) diet is widely advocated for those with hypertension. According to Juraschek et al. (2017), the DASH (Dietary Approaches to Stop Hypertension) diet has demonstrated efficacy in lowering blood pressure when implemented alongside a low-sodium diet. This can be attributed to its emphasis on consuming fruits, vegetables, and low-fat dairy products while minimizing saturated fat and cholesterol intake.

Patients and doctors can benefit from a more accurate average reading of blood pressure when patients take their readings often. Some individuals suffer what is known as "white-coat syndrome" when they first step foot inside the medical facility. "White-coat syndrome" is known as getting a high blood pressure reading at the doctor's office but getting an average reading at home due to being nervous about being at the doctor. Avoiding the "white-coat syndrome" by keeping tabs on one's blood pressure at home is possible. Consider a patient who wants to track their hypertension readings. If so, they need to know that smoking, caffeine, or exercise should all be avoided for at least 30 minutes before taking their blood pressure. Patients should be advised to bring their blood pressure machines to the doctor's office so that the cuff can be adequately measured and the device can be handled appropriately (Scordo, 2018). Patients can change their diet and lifestyle when they know their blood pressure measurements. Veterans Health Administration enrollees in a particular area can get home blood pressure monitoring equipment that transmits daily readings to the treating physician via satellite. With daily updates, doctors may make necessary prescription changes without patients having to make extra journeys to the office. Better treatment for the patient is achieved while time and money are saved by all parties involved.

Ethical Decision-Making in Designing Health Interventions

Before addressing the matter of ethical decision-making in the design of health interventions, it is imperative to possess an extensive understanding of the ethical principles that govern the implementation of all patient care. Four cornerstone ethical principles guide healthcare. The term "beneficence" refers to the obligation of a physician to "act for the benefit of, safeguard the rights of, and prevent damage to" a patient (Varkey, B., 2021). The obligation of nonmaleficence is the refusal to harm or deprive another person intentionally. The foundation of autonomy is the freedom to act unilaterally. Finally, Justice is responsible for providing care for all patients regardless of ethnicity or socioeconomic class and allocating care and resources fairly per each person's unique need (Varkey, B., 2021). It is imperative that, when planning care for patients, adherence to this code of ethics and making decisions consistent with these values be maintained.

Health Policies Pertinent to Care Coordination

The nurse responsible for care coordination must possess a comprehensive understanding of the regulations that dictate the payment rates for healthcare providers, as these policies significantly impact the effectiveness of care delivery. The Hospital Readmissions Reduction Program (HHRP) may benefit those diagnosed with hypertension, cardiovascular disease, or strokes. HRRP became operational under the ACA on October 1, 2012. For better patient outcomes and lower costs, this plan authorizes the Department of Health and Human Services to penalize hospitals for unnecessary readmissions. Due to apprehensions over financial ramifications, hospitals may treat recurrent patients' symptoms in the emergency room instead of readmitting them. Patients frequently seek medical attention in emergency rooms due to the gravity of cardiovascular disease and stroke and the fear of mortality or experiencing unfavorable consequences. The care coordination nurse conducts post-discharge follow-ups with patients to minimize avoidable hospital readmissions, improve treatment compliance, and bolster patient safety. It is recommended that patients maintain regular appointments with their primary care physicians or specialists to verify the fulfillment of their healthcare needs and minimize the probability of emergency room visits (CMS, 2022).

Establishing Priorities When Implementing Changes

Treatment coordination involves examining a patient's treatment plan with the patient and their family to determine its efficacy and make any required adjustments based on that assessment. When formulating a treatment plan for individuals diagnosed with hypertension, it is imperative to consider various factors, including their dietary patterns, amount of physical activity, and stress levels. It is imperative to ascertain the patient's preferred learning modality before educating them on hypertension. During the discussion, it is imperative for the nurse to guarantee that the patient comprehends the treatment regimen and will have the chance to pose any pertinent questions. This practice enables patients and their family members to process the information provided and address any relevant concerns. The nurse's top priority should be Making sure the patient understands their responsibilities and working with the family to establish a support system. Any changes that improve the patient's condition while still allowing them to reach goals can be made to the care plan. Clinical results for the management of chronic illness are enhanced when patients take their medications as prescribed (CDC, 2017).

Aligning Teachings with Healthy People 2030

Considering our present understanding, Healthy People outlines the top physical and mental wellness priorities that can be enhanced over the next decade. The objective of Healthy People 2020 is to improve public consciousness regarding the consequences of unmanaged chronic ailments such as hypertension on an individual's overall well-being by 2020.

The objectives of Healthy People 2030 include the reduction of hypertension prevalence among individuals (HDS 04) and improving hypertension management in the adult population (HDS 05). Hypertension patients are susceptible to cardiovascular disease, stroke, heart failure, and renal impairment. Hypertension can be lowered by encouraging healthy lifestyle choices such as eating right, losing weight, and exercising regularly (Healthy People, 2030). The primary objective of HDS 05 is to examine the management and maintenance of blood pressure to prevent chronic illnesses such as heart failure, heart attack, chronic kidney disease, and stroke. The findings of this study align with the overarching goal of the Healthy People 2030 campaign. Pharmaceutical intervention may be a viable option for those who have not achieved the desired outcomes with alternative approaches such as dietary modifications, physical activity, and lifestyle adjustments.

Conclusion

Symptoms of hypertension don't typically present themselves until the disease has reached a severe stage. It has been called the "silent killer" due to its association with the two most significant causes of death: cardiovascular disease and stroke. To prevent complications, patients with hypertension require continuous education and coordinated care. Quality of care and patient compliance can be improved by focusing on the needs of individual patients. Regular utilization of dietary and lifestyle adjustments is a successful approach to treating and reducing blood pressure in patients. If lifestyle modifications such as dietary adjustments and physical activity are ineffective in regulating blood pressure, a medical professional may prescribe medication as a potential course of action. Access to community resources, such as informational brochures or flyers about local wellness centers or exercise groups, is essential for patients to enhance their comprehension and self-management of their illnesses. Patients with hypertension who cooperate with their doctors and adhere to their treatment plans have the best chance of a positive outcome.

References

Centers for Disease Control and Prevention. (2022, September 8). Cdc high blood pressure home. Centers for disease control and prevention.

Hospital readmissions reduction program (HRRP). CMS. (2022, August 5). Retrieved November 25, 2022, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Juraschek, S. P., Miller, E. R., Weaver, C. M., & Appel, L. J. (2017). Effects of sodium reduction and the dash diet in relation to baseline blood pressure. Journal of the American College of Cardiology, 70(23), 2841–2848.

Mayo Clinic Staff. (2022, September 15). High blood pressure (hypertension). Mayo Clinic. Retrieved November 5, 2022, from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417

Scordo, K. (2018). Hypertension management options. The Nurse Practitioner, 43(6), 33–37. https://doi.org/10.1097/01.npr.0000532761.83756.e4

Tan, J., Cheng, K., & Siah, R. (2019). A systematic review and meta‐analysis on the effectiveness of education on medication adherence for patients with hypertension, hyperlipidaemia and diabetes. Journal of Advanced Nursing, 75(11), 2478–2494.

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17–28