Preliminary Care Coordination Plan

The Institute of Medicine defines care coordination as a constructive tool capable of improving healthcare systems’ safety, effectiveness, and efficiency. A carefully constructed care plan can improve the outcomes for all the stakeholders involved in the care coordination plan (Khanna et al., 2022). A detailed care coordinated plan outlines the healthcare services and treatments a Patient requires. The preliminary stage entails identifying the patient’s healthcare requirements (Karam et al., 2021). The healthcare facility can determine and evaluate the medical and other associated patient needs using this.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Chronic Obstructive Pulmonary Disease (COPD) has physical, monetary, psychological, and other associated issues. This preliminary care coordination plan aims to develop an effective and efficient strategy to impact the patient, healthcare staff, and individuals associated with the patient. NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan. The plan discusses an evidence-based approach, a list of available community resources, and a preliminary care plan to make the patients manage Copd.

Health Concern: COPD

Chronic inflammatory lung disease, widely known as COPD, is a prevalent and manageable condition characterized by the gradual constriction of airflow and destruction of lung tissue. The disease can result from prolonged exposure to toxic gases or particles which lead to chronic inflammation of the lungs and even structural deformities of the lung. Chronic inflammation causes airway constriction and results in a decreased lung air capacity. COPD particularly manifests with symptoms such as cough, shortness of breath, and sputum production. The most prevalent cause of COPD globally is cigarette smoking. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

COPD is associated with 2.9 million deaths annually and is projected to be included in the top 3 causes of mortality globally (Wang et al., 2022). The initial disease symptoms can worsen over time, and people with severe COPD may require supplemented oxygen or other medical interventions to manage the disease better. NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan.  Hence, the need for an efficient care plan arises to manage the patient’s health better and provide the best possible care.

Best Health Practices

An individual’s personal and psychological health is severely affected by COPD; advanced symptoms of the disease can result in respiratory failure. Different approaches are available to manage the symptoms of COPD best to improve patient health and quality of life (Pyszora & Lewko, 2022). Some of these best practices include:

Smoking Cessation

Smoking is considered one of the main causes of COPD; therefore, quitting smoking can help effectively manage the disease. Different rehabilitation centers and smoking cessation initiatives are available to help people in their journey to quit smoking (Rossaki et al., 2021).

Pulmonary Rehabilitation Program

Ventilator Support

Factors including airway constriction and hyperinflation may result in difficulty breathing and respiratory failure in severe COPD patients. Therefore, providing patients with ventilator support is imperative to facilitate the patient’s airway (Pyszora & Lewko, 2022). 

Airway Clearance Management

Cough and sputum can be an issue in COPD, and the patients may require guidance and support. Different airway clearance techniques are available and recognized for their effectiveness. ACTs application can reduce the COPD patient’s hospital length of stay by decreasing breathlessness and lowering the need for ventilator support (Pyszora & Lewko, 2022). 

Anxiety Management

COPD patients experience anxiety which triggers higher breathing rates leading to enhanced breathlessness. Anxiety harms patient health and may result in social isolation for better disease management. Different techniques include cognitive behavioral therapy, hypnosis, and mindfulness to manage anxiety in patients. These techniques can help improve patients’ health and better manage their symptoms (Pyszora & Lewko, 2022).

Vaccination

Respiratory infections can severely affect COPD patients; therefore, getting vaccinated against influenza and pneumonia can help prevent the worsening of the patient’s health and better manage COPD symptoms (Gogou et al., 2022).

Uncertainty in Analysis

COPD is a chronic disease that can cause trauma and depression. Implementing best practices can help individuals manage their condition and improve their quality of life. Self-management techniques can effectively manage COPD and avoid depression (O’Connell et al., 2021). The points of uncertainty in the analysis include the fact that management of COPD is a multi-faceted approach and no single treatment alone can manage the disease effectively (Agrawal et al., 2019). Moreover, there may exist lack of information sharing between patient and healthcare staff (Shum et al., 2019). It’s also vital to take into consideration thesocioeconomic status or behavioral aspects of patients. It is important to support patients while respecting their culture, norms, and values and considering their mindset and cultural beliefs.

Goals to Address COPD Health Concerns

The primary goal is to develop an efficient preliminary care plan to improve the lung function of COPD patients. It can be accomplished through medication, pulmonary rehabilitation, breathing exercises, and lifestyle modifications like quitting smoking. Healthcare providers must prioritize patient education on COPD and its management options to optimize patient outcomes and enhance the quality of life (Iyer et al., 2021). 

SMART goals should be established to ensure the care plan effectively achieves its objectives.

Goal 1

To improve exercise tolerance in COPD patients by participating in pulmonary rehabilitation for 30 minutes, three to four times a week (S). The progress can be measured through performance enhancement in different pulmonary exercises (M), that can be carried at the local community centers (A). This plan will be implemented under the guidance of pulmonologists who can monitor the progress effectively (R) to ensure the outcomes are positive for an indefinite period of time (T).

Goal 2

COPD patients admitted in the healthcare facility, and prone to smoking, will be encouraged to reduce their cigarette consumption by 50% (S), measurable by tracking the number of cigarettes they smoke daily and comparing it to their baseline data (M). Promoting cigarette usage stoppage by providing behavioral therapy by experts (A) will help in reducing their tobacco usage and lessen the burden of disease on these patients, within a period of 3 months (T).

Goal 3

Educating all COPD patients at our facility through self-management techniques (S) available through home-based telehealth services, carried out once a week (T). The sessions will end by asking patients to fill a questionnaire about COPD self-management to measure the rate of knowledge retention (M). Web-based educational sessions along with group sessions on COPD management and available treatments (A) will be provided, promoting self-management in patients, thereby, encouraging them to learn more about the disease and develop ways to better manage it (R).

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)

The AACVPR provides resources and information to healthcare providers to help them provide the safest and most effective treatment for patients with COPD. One of the resources that they offer is pulmonary rehabilitation programs. These programs are designed to support COPD patients and improve their overall health. They typically include education about the disease and its treatment, supervised exercise, and nutritional guidelines. Pulmonary rehabilitation programs are available at many hospitals and community health centers (Wen et al., 2021).

COPD-Assisted Home Health and Health Facility

Home healthcare services are an important resource for COPD patients who require ongoing care. These services typically include skilled nursing care, education about oxygen therapy, medication, and other COPD-related services. In addition to traditional home healthcare services, some providers offer telehealth services that allow patients to connect with healthcare providers remotely (Gantt & Seifer, 2021) .

COPD Foundation

 The COPD Foundation is a non-profit organization that provides resources and support for COPD patients and their caregivers. One of the services that they offer is support groups for patients. These groups provide a safe and supportive environment for patients to share their experiences, ask questions, and connect with others who understand what they are going through. Support groups are available through local hospitals, community centers, or online resources (Le et al., 2020).

Global Initiative for Obstructive Lung Disorder (GOLD)

GOLD is an international initiative providing guidelines on the diagnosis and management of COPD. It provides strategies for prognosis, treatment and management of disease to improve overall quality of life of patients (Agrawal et al., 2019).

Telehealth Technology

Telehealth technology benefits COPD patients by enabling efficient collaboration between healthcare providers and patients. It includes video conferencing, remote vital sign monitoring, and online education and is especially helpful for patients in remote areas. (Donner et al., 2021).

Conclusion

In conclusion, a care plan that includes best health practices like smoking cessation, pulmonary rehabilitation, ventilator support, airway clearance management, anxiety management, and vaccination is crucial to managing Chronic Obstructive Pulmonary Disease (COPD) effectively. SMART goals can help healthcare providers achieve care plan objectives and optimize patient outcomes. Respect for cultural beliefs and norms and prioritizing patient education on COPD and management options are essential to enhance the quality of life.

References

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