Final Care Coordination Plan Essay

Final Care Coordination Plan Essay

Health care problems compromise the health status of individuals and the entire community. Thus, healthcare organizations should implement evidence-based intervention to address a particular health issue, improving individuals’ health status, health-related quality of life, and overall well-being. This paper presents patient-centered health interventions and timelines for addressing selected health care issues; ethical decisions to be considered in designing patient-centered health interventions; health policy implications relevant to coordination and continuum of care; a care coordinator’s priorities when discussing the care plan with a patient and family member; and a comparison of learning session content with best practices, indicating how the teaching sessions align to the Healthy People 2030 document.

Patient-Centered Health Interventions and Timelines for chosen Health Care Issues

The selected healthcare issues include a high rate of hypertension, increased mental health conditions, and a high prevalence of cognitive impairment.

High Rate of Hypertension or High Blood Pressure

Studies show that high blood pressure is one of the most prevalent chronic illnesses diagnosed among American adults. According to CDC (2022), approximately 47% of American adults are diagnosed with hypertension. Carey et al. (2018) reported that high blood pressure (BP) is the most significant factor contributing to cardiovascular disease (CVD). Additionally, hypertension is the leading cause of disability-adjusted life years globally (Carey et al., 2018).

Hypertension is caused by a combination of various factors, including environmental, genetic, and social determinants. However, environmental and social factors, including being overweight or obese, excessive intake of dietary sodium, consuming an unhealthy diet, inadequate dietary potassium, consumption of alcohol, and limited physical activity significantly increase the risk of hypertension. Therefore, environmental and social factors should be considered in designing an evidence-based intervention for reducing the high rate of hypertension among the community members.

The most effective intervention addressing this health care issue involves implementing targeted or population-based strategies. According to Carey et al. (2018) targeted or population-based strategies are effective in preventing and controlling hypertension. Targeted strategies for controlling hypertension include increasing awareness by educating the population on how to regulate blood pressure through lifestyle modifications and taking antihypertensive medication. According to Akbarpour et al. (2018) a comprehensive lifestyle modification, including quitting smoking; healthy nutrition such as taking a balanced diet, reducing dietary sodium, increasing dietary potassium; increasing physical activity, and maintaining a healthy weight results in blood pressure control. Additionally, people using antihypertensive medications achieve more blood pressure control than their counterparts who are not under any medication (Akbarpour et al., 2018). Therefore, educating community members about lifestyle modifications and antihypertensive medication will enhance control of blood pressure, preventing cerebrovascular and cardiovascular diseases associated with high blood pressure, including hemorrhagic, ischemic stroke, heart failure, ischemic heart disease, and peripheral arterial disease.


Three community resources supporting population-based strategies for people with hypertension include community support, a continuum of self-management training and support services, and the Community Preventive Services Task Force (CPSTF). These resources support patient education, creating awareness regarding effective strategies for improving blood pressure among community members diagnosed with hypertension.

Increased Mental Health Conditions

The dramatic increase in the number of Americans diagnosed with various mental health illnesses is a significant public concern in the United States. According to ODPHP (2020), the mental illnesses disease burden is the highest among other diseases in the United States. Approximately 18.1%, representing 43.6 million of the total U.S. adult population aged 18 years and above are diagnosed with at least one mental condition annually (ODPHP, 2020). Additionally, a severely debilitating mental condition is reported in about 4.2%, representing 9.8 million American adults in any given year (ODPHP, 2020). These mental health conditions are associated with altered thinking, mood, and behavior, and impaired functioning capacity. Other problems attributed to mental illnesses include pain, disability, or death. ODPHP (2020) reported that mental diseases are among the leading causes of disability in the United States. Thus, evidence-based intervention should be adopted to lower the high rate of mental health disorders among the community members.


The most effective intervention for reducing the high rate of mental health conditions involves implementing health promotion, disease prevention, and early screening for mental illnesses strategies. According to Colizzi et al. (2020), screening and early detection interventions provide more effective healthcare management approaches. The interventions allow healthcare professionals to prevent disease onset or act before a health problem worsens, preventing related adverse health outcomes. Therefore, implementing these evidence-based strategies will prevent the onset of mental illnesses, reducing the rate of mental conditions substantially. Additionally, these approaches will prevent mental illnesses from worsening, improving an individual’s quality of life, health, and overall well-being.

Three community resources supporting prevention and early screening for mental illnesses include the Mental Health America (MHA), school-based mental health awareness programs, and community support groups. The MHA supports universal screening for individuals at risk of mental health problems, reducing the likelihood of these disorders. School-based mental health awareness programs are aimed at educating school-going children about mental illnesses and screening those at risk of mental diseases, reducing the likelihood of mental illnesses in this population. Lastly, community support groups conduct early screening for mental illnesses among the general population, reducing the risk of mental health disorders in this population.

High Prevalence of Cognitive Impairment

The incidence of cognitive impairment is relatively high, particularly among elderly individuals diagnosed with Alzheimer’s disease (AD). Age is a significant factor contributing to Alzheimer’s disease, which is the most contributing factor to dementia among the geriatric population in the United States. Elderly individuals diagnosed with Alzheimer’s disease experience cognitive impairment. According to Lane et al. (2017), progressive cognitive impairment in individuals diagnosed with AD or dementia compromises activities of daily living, making one highly dependent. Additionally, cognitive impairment significantly contributes to high disability and mortality rates both in the United States and worldwide (Lane et al., 2017). Therefore, an evidence-based intervention should be adopted to address cognitive impairment among elderly adults with AD or dementia.


Cognitive impairment in dementia or AD patients can be addressed by developing a management plan. First, the plan involves reviewing the patient’s current over-the-counter and prescribed medications to identify any cognitive deficits. Secondly, the management plan entails informing the patient and caregivers about potential drug-related adverse side effects associated with drugs used in treating dementia or AD patients with cognitive impairment. The next step involves warning the caregivers about giving drugs of off-label use to patients with dementia or AD. The last step involves scheduling a follow-up clinic every 6 weeks to assess the effectiveness of prescribed medication in improving the client’s cognitive impairment. The client is advised to continue with the current medication and dosage if it is effective in improving cognitive impairment and is well tolerated by the client. On the other hand, alternative medication is prescribed if the client does not report improvement in cognitive impairment or the drug is associated with adverse side effects.

Three community resources supporting the management of cognitive impairment in dementia or AD patients include Alzheimer’s Association, Alzheimer’s Foundation of America, and the National Institute on Aging Information Center. These institutions provide people diagnosed with AD or dementia and their caregivers with the support needed to manage and cope with cognitive impairment in this patient population.

Ethical Decisions to be considered in Designing Patient-Centered Health Interventions

Ethics guide healthcare professionals in making significant decisions in clinical practices. Thus, ethical guidelines should be adhered to while designing patient-centered health interventions for addressing selected health issues. First, healthcare professionals should consider patient autonomy in implementing health promotion, disease prevention, and early screening for mental illnesses strategies to reduce the high rate of mental illnesses. Patient autonomy gives individuals the right to make all significant decisions involving diagnosis and treatment (Liang et al., 2022). In this case, individuals should be educated about the significance of early screening for mental illnesses and be allowed to decide if they will participate in the exercise. Failure to consider patient autonomy may result in actions being taken against healthcare professionals for violating this ethical guideline. On the other hand, screening for mental health illnesses without obtaining patient autonomy will reduce the prevalence of mental health disorders in the general population. An ethical question to be considered in this case is; “Is it ethically right to screen for mental illnesses without one’s consent?”

Secondly, clinicians should consider the ethical guideline of confidentiality and non-disclosure in developing a management plan for managing cognitive impairment in dementia or AD patients. This ethical principle prohibits the disclosure of a patient’s health-related information to third parties without one’s consent. Thus, clinicians should obtain informed consent from the patient or family before sharing out health information. Failure to obtain informed consent might result in an action being taken against the healthcare provider. On the contrary, failure to obtain informed consent while sharing health-related information will result in high-quality patient-centered care and positive health outcomes. An ethical question to be considered states; “Is it ethically right to share health-related information of a patient with cognitive impairment without his or her consent?”

Health Policy Implications That Apply In Coordination and Continuum of Care

The healthcare policy that impacts coordination and continuum of care is the Health Insurance Portability and Accountability Act (HIPAA). This health policy prohibits sharing of patients’ health-related data, which is stored electronically with third parties without the owner’s consent (Keshta & Odeh, 2021). Therefore, the HIPAA compromises coordination and continuum of care since it involves sharing patients’ health-related information among parties involved in healthcare delivery, including healthcare professionals, patients, and family members.


A Care Coordinator’s Priorities when Discussing the Care Plan with a Patient and Family Member

A care coordinator can prioritize the delivery of quality health care and positive patient outcomes when discussing the plan with a patient and family member. These superior results can only be achieved by using evidence-based intervention in managing a patient’s condition. According to Colizzi et al. (2020), pharmacological interventions are effective in treating various health conditions, including mental illnesses. Thus, care coordinators should emphasize the significance of adhering to the prescribed medication and dosage to achieve positive health outcomes. Additionally, the management plans should be changed to include pharmacological interventions for individuals with various health problems, indicating recommended medication and dosage.

A Comparison of Learning Session Content with Best Practices, Indicating how the Teaching Sessions align with the Healthy People 2030 Document

Learning sessions aim at creating awareness regarding identified health issues among the community members. These health problems can be resolved by educating the general public on how to prevent, control, or manage them, improving health-related quality of life, health, and overall well-being of the community members. Similarly, the Healthy People 2030 document aims at achieving national objectives of improving health and well-being for future generations. However, the learning session differs from the Healthy People 2030 document in terms of the targeted population. These learning sessions only target the community members while the Healthy People 2030 document targets all Americans countrywide.



Patient-centered health interventions play a significant role in addressing health care issues, including the high rate of hypertension, increased mental health conditions, and high prevalence of cognitive impairment. These issues are resolved through learning sessions that aim at educating the general public on how to prevent, control or manage them. The learning session is similar to the Healthy People 2030 document since both aim to improve health-related quality of life, health, and overall well-being of individuals. However, the learning session targets community members; hence it differs from the Healthy People 2030 document, which is a nationwide initiative.


Akbarpour, S., Khalili, D., Zeraati, H., Mansournia, M. A., Ramezankhani, A., & Fotouhi, A. (2018). Healthy lifestyle behaviors and control of hypertension among adult hypertensive patients. Scientific Reports8(1), 1-9.

Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Prevention and control of hypertension: JACC health promotion series. Journal of the American College of Cardiology72(11), 1278-1293. Doi: 10.1016/j.jacc.2018.07.008.

CDC. (2022). Facts about Hypertension. National Center for Chronic Disease Prevention and Health Promotion.

Colizzi, M., Lasalvia, A., & Ruggeri, M. (2020). Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? International Journal of Mental Health Systems14(1), 1-14.

Keshta, I., & Odeh, A. (2021). Security and privacy of electronic health records: Concerns and challenges. Egyptian Informatics Journal, 22(2), 177-183.

Lane, C, A., Hardy, J., & Schott, J, M. (2017). Alzheimer’s disease. European Journal of Neurology.

Liang, Z., Xu, M., Liu, G., Zhou, Y., & Howard, P. (2022). Patient-centred care and patient autonomy: doctors’ views in Chinese hospitals. BMC Medical Ethics23(1), 1-12.

Office of Disease Prevention and Health Promotion (ODPHP). (2020). Mental Health and Mental Disorders. HealthyPeople. Gov.

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

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