Final Care Coordination

Chronic Obstructive Pulmonary Disease (COPD), a major healthcare issue, necessitates established interventions and care coordination for individuals suffering from the disease. Annually, 2.9 million deaths are associated with the disease, which is soon projected to become a major contributor to mortality globally (Wang et al., 2022).

This final care coordination plan will discuss and develop a Patient-centred health intervention. The interventions will be presented with a proper timeline, a discussion of three major health concerns, and community resources available for each health concern. The health concerns for COPD patients include diabetes, psychological health, as well as physical health. The plan will also entail ethical decisions and policy implications in designing patient-centred health interventions and establishing priorities for healthcare staff to ensure the successful implementation of the care coordination plan.

Patient-Centred Health Interventions and Timelines

Care coordination is a powerful tool to enhance healthcare systems’ safety, effectiveness, and efficiency. By creating a well-designed care plan, all stakeholders can benefit from improved outcomes (Khanna et al., 2022). The third leading cause of death globally is considered to be COPD (Halpin et al., 2019). Many outpatients with COPD (45%) do not receive proper medical assistance and education on self-care in the US, which can reduce the impact of the disease. Additionally, inpatients receive only 30% assistance on effective measures to control activities that may exacerbate COPD (Criner & Han, 2018).

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

The Patient-Centered Medical Home (PCMH) model is recommended as an effective patient-centred strategy to enhance health outcomes for patients with COPD. This model is particularly useful for patients with multiple chronic conditions, such as COPD. The PCMH model emphasizes active care coordination and communication among patients, nurses, and other clinical staff for better health outcomes. Improving coordination and enhancing patient awareness empowers patients with knowledge of activities that lead to improved health outcomes in their battle against COPD (John et al., 2020).

Diabetes: First Health Concern

COPD patients often have multiple comorbidities that lead to poor outcomes. Diabetes is more prevalent in COPD patients than in the general population and is associated with pulmonary complications. Therapeutic strategies for treating diabetes and COPD are similar. Self-management is an effective patient-centred intervention that increases motivation, knowledge, and active involvement in treatment activities to avoid diabetes and improve health outcomes. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Self-management includes patient education on COPD-reducing activities, diet plans, and exercises to improve respiratory and immune system health (Park et al., 2022). This approach improves care coordination and communication among patients and healthcare staff. It can be supported by community resources such as online counselling programs, community-based organizations such as the Centers for Disease Control and Prevention (CDC), healthcare seminars, and the Self-Management Resource Center (SMRC) (Ko et al., 2019).

Timeline for the Patient’s Self-Management 

The Patient’s Self-Management intervention timeline is as follows: 

• On day 1, a qualified dietician will assess the patient’s diet plans for improved health outcomes.
• A trained nurse will provide personalized meal plans and exercise guidance based on the patient’s needs from day 2 to day 5.
• The patient will review the proposed plan between day 6 and day 9 and make any necessary adjustments.
• On day 10, the patient will start following the recommended lifestyle.

Physical Activity: Second Health Concern

Physical activity is a significant concern for COPD patients, which can impact their health outcomes. Patient-specific exercise plans and safe physical activity recommendations can help them improve their health. An individualized exercise plan will be conveyed to improve patient health. Community options, such as local gyms, physical therapy, counseling, and exercise support groups, are available to aid this process. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends daily physical activity to improve the overall health of COPD patients (Xiang et al., 2022).

Timeline for Addressing Physical Health of COPD Patients

The physical activity intervention plan for COPD patients will proceed as follows:

• On Day 1, the patient will meet with a physical therapist to discuss their exercise goals and needs.
• From Day 2 to Day 5, the physical therapist will provide personalized training routines and recommendations to increase physical activity.
• On Days 6 to 8, the patient will review the exercise plan and make any necessary modifications.
• Starting on Day 9, the patient will follow the recommended activity schedule. This plan aims to improve the patient’s physical activity levels and promote better health outcomes. 
• Additionally, community resources such as local gyms, fitness facilities, counseling, community health centers, and exercise support groups are available to increase the patient’s physical activity levels.

Third Health Concern: Psychological Health

Psychological concern is an important health concern for COPD patients as they are prone to depression and social isolation. As the disease progresses, the mental health of COPD patients also becomes difficult to manage. The interventions to improve mental health may include comprehensive, holistic care, reduced emergency room visits, non-invasive ventilation, palliative care, etc. (Rzadkiewicz & Nasiłowski, 2019).

Timeline for Addressing Psychological Health

To address COPD patients mental health concerns, the following intervention schedule will be followed:

• From the very first day of the program, the patient will meet with a clinical psychologist to discuss their specific goals and needs.
• The psychologist will develop a personalized treatment plan to address the patient’s mental health issues, and suggestions will be provided from Day 2 to Day 4.
• The patient will review the proposed treatment plan between the fifth and seventh day, and any necessary modifications will be made.
• The patient will begin implementing the proposed treatment plan on the eighth day.

Ethical Decisions in Designing Patient-Centered Healthcare Interventions

According to the American Nurses Association, ethical decisions for COPD patients require prioritizing patient interests and adherence to ethical principles. Examples of ethical decisions include respecting patient beliefs, providing individualized treatments, and involving patients in decision-making. Such decisions can lead to improved patient satisfaction, care quality, and confidence in treatment. However, ethical dilemmas can arise due to conflicts of interest or values between patients and healthcare personnel. In such cases, health practitioners may choose not to offer interventions against the patient’s best interests. (Lewlett et al., 2020; Pesut et al., 2020). For instance, patients with severe COPD may refuse mechanical ventilation, even though it may save their lives during an exacerbation. In such situations, healthcare providers must respect patients’ autonomy while ensuring they are fully informed of the risks and benefits of their treatment options (Chuang et al., 2020).

An example of ethical decision-making in COPD care is using advance directives. Advance directives are legal documents allowing individuals to state their wishes regarding end-of-life care in advance. In the United States, advance directives are recognized by all states and healthcare providers are legally required to follow them (NHPCO, 2022). Advance directives in COPD help healthcare providers understand patients’ preferences for life-sustaining treatment, such as mechanical ventilation or cardiopulmonary resuscitation (CPR).

Another example of ethical decision-making in treating COPD is using opioids for pain relief. People with COPD may experience significant pain, especially during exacerbations. However, opioids can also cause respiratory depression, worsening COPD symptoms and increasing the risk of death. In this context, healthcare providers must balance the patient’s need for pain relief with the risks associated with opioid use (van Dijk et al., 2021).

Policy Implications for the Coordination and Continuum of Care

COPD is a major healthcare concern in the US, affecting millions annually. In response to this alarming situation, policymakers have implemented a COPD National Action Plan to enhance patient self-management activities and improve health outcomes (NIH, 2020). The policy framework emphasizes patient education, community engagement, and nurse training on effective treatment strategies. The plan also ensures the confidentiality of patient-specific COPD care information under Health Insurance Portability and Accountability Act of 1996 regulations. 

To promote collaboration among healthcare providers and enhance patient-centered care, primary care physicians and other specialists have established PCMH and Accountable Treatment Organizations (Stockdale et al., 2021). Medicare, a government-run healthcare program for those aged 65 and above, covers various COPD-related services, including inpatient care, specialized nursing care, medical treatment at home, and long-term care (Trout et al., 2020).

Care Coordinator Priorities to Discuss the Plan

After discussing the plan with the patient’s family and modifying it based on evidence-based practices, healthcare professionals should prioritize the following critical areas: 

Safety Protocols

People with COPD may be at increased risk of getting respiratory infections (such as pneumonia) and getting worse, requiring hospitalization. Healthcare professionals should educate patients and their families about the importance of proper hand hygiene, avoidance of contact with respiratory irritants, and timely medical intervention to prevent exacerbations (CDC, 2021).

Regular Check-Ups and Therapy

Patients with COPD require continuous monitoring of their respiratory function, symptom management, and medication adjustments. Healthcare professionals should establish a schedule of regular examinations and treatments to ensure that patients’ COPD is adequately managed and that any changes in their condition are promptly addressed (Bollmeier & Hartmann, 2020).

Promoting Healthy Behaviours 

People with COPD benefit from exercise, smoking cessation and a healthy diet. Healthcare professionals should provide resources and support to patients and their families to adopt healthy behaviors that improve their overall health and reduce the risk of COPD exacerbations (Bollmeier & Hartmann, 2020).

A change in the care plan for a person with COPD may be required for various reasons, including changes in the patient’s condition, response to treatment, or new evidence-based practice. Such changes may involve adjusting medications, the frequency or type of treatment, incorporating new interventions, or addressing patients’ psychosocial needs. For example, healthcare professionals may need to increase or adjust medications to better control a patient’s symptoms, consider telemedicine for remote monitoring and intervention, or provide mental health support if a patient develops COPD-related depression or anxiety (Barbosa et al., 2020). Regularly reviewing and revising the care plan to meet the patient’s changing needs is essential to improving their overall health and well-being.

Learning Session Content Evaluation with Best Practices

A complete guide and detailed list of goals to improve overall well-being and health-related quality of life improvement are present in the Healthy People 2030 document (National Academies of Sciences et al., 2019). Following are some of the objectives of Healthy People 2030:

• Improving general healthcare and reducing sickness and harm
• Enhancing preventive services availability and efficiency
• Lowering health disparities and improving the overall health of people

The training workshops will be effective for COPD patients if the following goals are met:

• Cover critical topics such as high-quality medical services, eliminating health disparities, and promoting overall health, in addition to COPD-specific topics like risks, signs, diagnostics, and treatments.
• Teach COPD care, prevention, and lifestyle changes to minimize risk.
• Discuss the importance of regular check-ups, prescriptions, and screenings.
• Emphasize maintaining a healthy lifestyle, including a healthy diet, exercise, stress management, and restful sleeping habits.

Need for Revision

The community care coordination plan can be useful for teaching COPD patients how to access local programs, online resources, and support groups. While these sessions provide crucial information on self-management, effective training is crucial for successful implementation. Providing self-care training to patients has been shown to improve their health outcomes and minimize the impact of COPD. Additionally, training nurses can help align COPD patient education with the goals of the Healthy People 2030 program (Ahmed et al., 2023).

Conclusion

In conclusion, the patient-centered interventions discussed in this care coordination plan can potentially improve health outcomes and quality of life for COPD patients. However, designing and implementing effective interventions require careful consideration of ethical principles, policy implications, and priorities for healthcare staff. By prioritizing patient-centered care and promoting effective care coordination, healthcare systems can provide better care for COPD patients and reduce the disease burden.

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