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Final Care Coordination Plan | Write My Paper

Heart failure, also considered congestive heart failure, is a chronic illness that happens when the heart fails to push blood to all part of the body accordingly. The blood backs up, and the fluid can accumulate in the lungs leading to shortness of breath. Care coordination entails the deliberate organization of patient care activities and sharing information with key participants regarding the patient’s care to reach more effective and safe care. This written paper will focus on the care coordination plan for patients with heart failure. Care coordination allows closing of potential gaps in meeting the patient’s social development, interrelated medical, education, behavioral, and informal support systems to meet the preferences and needs of the patient.

Patient-Centered Health Care Interventions

Heart failure is a life-long condition with different treatment options aimed at improving the quality of life, such as medication interventions, Self-care interventions, and therapeutic interventions. The health interventions for heart failure depend on the stages of heart failure on an individual basis.

Self-care Interventions

The lifestyle changes are used to manage the heart failure condition at the initial stage. Lifestyle changes are used to control heart failure for individuals at stages A and B of heart failure. At this stage, there are structural changes but no symptoms. Lifestyle changes include stopping smoking, healthy diet consumption, regular exercising, and reduced alcohol consumption (Toukhsati, Driscoll, and Hare, 2015). Lifestyle changes are an essential factor when managing heart failure. Stage A and B patients are at a high risk of developing heart failure but have not experienced any structural changes, which requires moderate interventions to protect the patient from heart failure.

Medication Interventions

Further deterioration of the patient’s condition requires medication to control the conditions leading to congestive heart failure. At stage C of heart failure, the patient experiences structural changes and symptoms. Depending on the symptoms, a combination of medications is used to relieve the symptoms (Takeda, Martin, Taylor, and Taylor, 2019). A range of medicines is taken to improve prognosis and strengthen the heart. Medication management is used to avoid heart failure exacerbations. Common heart failure medications include beta-blockers that are used to enable the heart to pump blood effectively, slow heart rate, and reduce strain on the heart.

Therapeutic Interventions

In case the patient is experiencing continued deterioration after best optimal medication, device and surgical procedures may be considered. The severity of the heart failure may lead to surgery or therapy whose aim is to improve heart function. At this stage, the patient is encountering refractory heart failure that demands specialized interventions. The surgical procedures may include implanted devices such as pacemakers that support the heart to beat more regularly and pump the blood effectively out of the heart.

Healthcare Issues

The three common health issues linked to heart failure include hypertension, obesity, and smoking. Hypertension is linked to high blood pressure observed in the patient. High blood pressure leads to the blocking and narrowing of blood vessels that heighten the risk of developing heart failure (Messerli, Rimoldi, and Bangalore, 2017). High blood pressure causes the heart to work harder while pumping blood t the rest of the body, which causes the left ventricle to thicken, increasing the risk of heart failure. Exercising regularly and consuming a low sodium diet can help in reducing blood pressure. Obesity is a complex condition that entails having excessive fat, which results from having more calories than what is burned by normal daily activities and exercise. Obesity may lead to heart failure by including myocardial and hemodynamic changes that lead to increased predisposition and cardiac dysfunction. Obese individuals need more blood to supply nutrients and oxygen, which leads to high blood pressure and heart working harder, thus leading to heart failure (Karason and Jamaly, 2020). A healthy diet, checking on weight and cholesterol would be effective interventions to reduce the amount of fat in the body. Smoking leads to damage and strain of the heart muscles that can lead to heart failure. Continued smoking can worsen the heart muscles; thus, the heart cannot pump the required quantity of blood to the body. Smoking cessation is an effective intervention to prevent the damage of heart muscles.

Community Resources

Healthcare centers, Rehabilitation Programs, and Hotline numbers have brought together effective health interventions that reduce the risk of heart failure. The community resources are aimed at connecting, leading, and inspiring heart health and drive change. Patients use the healthcare centers to get advice on their health conditions and medical intervention. The availability of health professionals in healthcare centers makes them more comprehensive community resources used to provide medical intervention and disease management. The community rehabilitation programs have been used to improve the health status through education on lifestyle changes that improve cholesterol, blood pressure, and exercising to reduce the risk of heart failure. The hotline numbers are essential for emergencies and heart failure first aid. The hotline numbers minimize the severity of the condition before the patient arrives in a hospital by obtaining medical help from qualified medical professions.

Ethical Decisions

Ethical decisions in patient-centered health interventions focus on the biomedical ethical principles of autonomy and beneficence. Autonomy in patient-centered health interventions entails assessing and performing interventions for patient care based on knowledge, professional expertise, and competence. Beneficence entails acting in the patient’s best interest and removing conditions that will cause harm (Cohen, 2019). For instance, a collaborative approach will be majorly emphasized in health interventions to allow the involvement of family members and patients in their care. Patients will be allowed to offer their views about the care plan. Through patient involvement, the health care professionals can work to offer individualized and comprehensive care plans that include self-management support interventions. This approach to care allows respect, listening, and attempting to understand the patient and provider. It’s ultimately significant for the patient to be informed about their care, while the healthcare provider must inform the patient about the treatment options (Cohen, 2019). Incorporating the patient in the care process improves the patient’s safety and adherence to medication. However, the ethical question that may arise from the ethical decision is how the collaborative approach will be undertaken.

Relevant Health Policy Implications for the Coordination and Continuum of Care

Coordination and continuum of care are well guided by health policies that restrict any chances of exploitation. The Affordable Care Act well guides the coordination and continuum of care for heart failure patients. The Act offers numerous protections and rights that make health coverage fair and affordable (Gaffney and McCormick, 2017). Apart from making the health provision fair and affordable, it promotes equality and eliminates exploitation. Affordable Care Act is intended to enhance patient protections, increase access to insurance, stress wellness and prevention, and increase quality care and system performance. The Affordable Care Act has impacted heart failure patients through coverage increase, insurance regulation, and delivery system reform. Considerably, patients with heart failure require tests, medications, and implantable devices. Thus, while seeking medication, the insurance coverage may include implantable devices, medications, and cardiac rehabilitation programs.

Priorities of Care Plan

The main objective of the care coordinator is to meet the preferences and needs of the patient in the delivery of high-value and high-quality healthcare. The care coordinator should focus on communication and sharing knowledge. Effective communication between the patient, care coordinator, and family facilitates the delivery of appropriate, safe, and effective care. Effective communication is important in care service and creates an effective working environment since it leads to more openness and transparency linked to the daily requirements. The care coordinator should prioritize communication of the patient preferences and values, health needs, desired outcomes, interventions, and medication management of the patient’s condition. These are important in creating an understanding of the intention of the care plan.

According to McAllister, Keehn, Rodgers, and Lock (2018), care coordination entails the deliberate arrangement of patient care activities between participants engaged in facilitating appropriate care services to the patient. The role of the care coordinator is to facilitate patient navigation from admission up to discharge. Therefore, there is a need to collaborate with the interdisciplinary team about the care plan to prepare for a successful care transition. Heart failure patients experience high counts of hospitalization and emergency department visits that increase the care plan’s cost. The care coordination plan should be adjusted to connect each member to the patient’s team and give patients the resources required to seek help. This will reduce the rate of admissions for patients with care coordination plans compared to routine care patients. The care coordination plan should connect the varying components of care to ensure that everyone in the team has to help the patient. The unity of the patient team is crucial to improving the quality of care.

Teaching Sessions in Relation to Healthy People 2030

Health literacy is the major focus for Health People 2030. The main initiatives of health people 2030 are to achieve health equality, eliminate health disparities and attain health literacy that will improve well-being and health for all (Hasbrouck, 2021). Healthy People 2030 addresses both organizational and health literacy to inform health-related decisions. The teaching sessions will focus on understanding basic health information and the use of health information rather than just understanding it. The teaching sessions will focus on patient teach-back to verify the understanding of patients regarding their health information.


Heart failure is an advanced chronic state where the heart muscles cannot push enough blood to the heart to meet the body’s necessities. Effective care of heart failure requires coordination between the health care providers and the patients. The establishment of the coordinated care plan will address the potential gaps in achieving the patient’s interrelated social, developmental, behavioral, informal, and educational support system. The coordinated plan will keep all the healthcare providers informed about patients’ preferences and needs and connect individuals with human service and health programs.

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Final Care Coordination Plan | Write My Paper . (2022, June 10). Essay Writing . Retrieved March 30, 2023, from https://www.essay-writing.com/samples/final-care-coordination-plan-write-my-paper/
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