Preliminary Care Coordination Plan

A significant increase in the rate of chronic illnesses among community members is becoming a major public health concern. About 45% of the total population (133 million) of the total US population has been diagnosed with a minimum of one chronic illness, and this number is rising significantly (Raghupathi & Raghupathi, 2018). The most prevalent chronic illnesses in the United States include diabetes mellitus, cancer, hypertension, heart disease, stroke, respiratory diseases, obesity, arthritis, and oral diseases. These illnesses lead to hospitalization, long-term disability, reduced quality of life, and high mortality rates. According to Raghupathi and Raghupathi (2018), chronic diseases are one of the most common and costly health problems in the United States. Therefore, the medical community prioritizes the prevention and treatment of chronic illnesses. This paper presents a care coordination plan for addressing health needs associated with a chronic illness, namely high blood pressure, including an analysis of the health concern and best practices for health improvement, underlying assumptions and uncertainty, and specific goals that should be established while addressing this health care issue, and available community resources.

Analysis of the Selected Health Concern: High Blood Pressure

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High blood pressure or hypertension is one of the most prevalent chronic illnesses affecting US citizens. In the United States, hypertension is diagnosed in approximately 47% of the total population, or 116 million Americans (CDC, 2022). Hypertension is a condition that is characterized by blood pressure at or exceeding 130/80 mmHg (CDC, 2022). On the other hand, stage 2 hypertension is characterized by blood pressure of more than 140/90 mmHg (CDC, 2022). Having hypertension increases the risk of developing stroke or heart disease. This chronic illness is also associated with a high mortality rate. In 2020, hypertension was associated with over 670,000 deaths in the US (CDC, 2022). Thus, a care coordination plan for health improvement should be adopted to address physical, psychosocial, and cultural needs.

The plan should include evidence-based practice (EBP) for preventing and managing high blood pressure. A population health management approach for improved disease management and coordination of care should be implemented in preventing and controlling high blood pressure among the community member. According to Price et al. (2020), the population health management approach is a customizable and collaborative evidence-based approach, which allows health departments to initiate change locally by connecting practice to policy. This EBP allows medical professionals to address the healthcare needs of underserved communities, improving their health status and quality of life. Therefore, healthcare providers can adopt population health management approach physical, psychosocial, and cultural needs of people diagnosed with hypertension.

First, in addressing physical needs, the approach will enable healthcare providers to identify the lack of the required diet as the most significant need among people diagnosed with or at risk of hypertension. These individuals will then be provided with the recommended foodstuffs such as food with low salt, controlling their blood pressure. Secondly, by using the population health management approach clinicians will address psychosocial needs among people with hypertension. For instance, the approach will point out to low-income status among the minority groups as a significant factor hindering the management of blood pressure in this population. Consequently, the minorities and people with low-income status will be provided with providing subsidized hypertensive, resulting in blood pressure control in this population. Lastly, the approach will be applied in addressing cultural needs such as lack of awareness regarding hypertension risk factors, prevention, and control in some communities. The community members will then be educated about hypertension reducing the risk of developing hypertension among people at high risk and controlling blood pressure among people diagnosed with hypertension. The plan is associated with underlying assumptions, involving the willingness of the community members to accept healthcare services provided to address their healthcare needs. Addressing the community’s health needs is associated with some uncertainties, which might compromise the achievement of the targeted outcomes. For instance, proposed food components might contradict with cultural beliefs of the community members. In another example, cultural beliefs might be against the use of drugs. Consequently, community members will not comply with proposed interventions if they recommend the use of a particular food or drug in managing blood pressure. Failure to comply with guidelines will result in adverse outcomes such as high rates of hypertension-related deaths.

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Goals for Addressing Hypertension

The success of the care coordination plan in addressing this health issue will significantly depend on the set goals. Goals for addressing hypertension among the community members can be categorized into short- and long–term goals;

Short-Term Goals

To identify the physical, psychosocial, and cultural needs of people diagnosed with hypertension.
To establish adverse health impacts of hypertension on individuals and the entire community.
To educate community members about the rising prevalence of hypertension.
To create awareness concerning risk factors contributing to hypertension.
To educate community members about hypertension preventive measures such as reducing salt intake.
To educate community members about effective blood pressure control interventions.
To inform community members about hypertension-related health complications including stroke and heart diseases.

Long-Term Goals

To reduce the rate of hypertension in the community by 50% by August 2023.
To lower hypertension-related deaths in the community by 30% by December 2023.

Available Community Resources for Hypertension

Resources and tools for supporting individuals with hypertension are available in the community. Interactive platforms allow people with hypertension to interact with healthcare professionals. These patients are educated on how to monitor blood sugar levels during the interactive program. Secondly, BP trackers are available, enabling community members with hypertension to monitor their blood pressure. Lastly, support groups enable people with hypertension to network amongst themselves, providing each other with the required psychological support and enhancing their understanding of hypertension and associated health complications. Thus, community resources provide people with hypertension with a safe and effective continuum of care.

Overall, hypertension is a significant health concern facing community members. A care coordination plan for health improvement should be adopted to address physical, psychosocial, and cultural needs. The plan should include a population health management approach as an evidence-based practice (EBP) for preventing and managing high blood pressure. Incorporating this approach into the care plan will enable healthcare providers to address the physical, psychosocial, and cultural needs of all people with depression, including minorities. Resources and tools for supporting individuals with hypertension are available in the community.

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References

CDC. (2022). Facts about Hypertension. National Center for Chronic Disease Prevention and Health Promotion. https://www.cdc.gov/bloodpressure/facts.htm

Price, J. D., Jayaprakash, M., McKay, C. M., Amerson, N. L., Jimenez, P. L., Barbour, K. E., & Cunningham, T. J. (2020). Peer Reviewed: Evidence-Based Interventions for High Blood Pressure and Glycemic Control Among Illinois Health Systems. Preventing Chronic Disease, 17. DOI: http://dx.doi.org/10.5888/pcd17.190058external icon

Raghupathi, W., & Raghupathi, V. (2018). An empirical study of chronic diseases in the United States: a visual analytics approach to public health. International journal of environmental research and public health, 15(3), 431. Doi: 10.3390/ijerph15030431.

 Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.