Care coordination focuses on meeting the patient preferences and needs in delivering high-value and high-quality healthcare. Care coordination has been considered as one of the important ways of improving healthcare for the patients, especially in terms of improved safety and efficiency. Care coordination lies in providing collaborative and recovery-focused services to connect individuals to their healthcare services (Mitra and Vadivelu, 2013). A prime necessity for care coordination is to improve Chronic Illness care. Chronic illnesses have remained a persistent and substantial burden on the patients and the healthcare providers. Chronically ill patients have experienced multiple conditions that demand well-coordinated care plans across different providers and settings. Therefore, this paper will focus on the preliminary care coordination plan of heart failure by identifying a safe and effective continuum of care with the available community resources.
Care Coordination Plan
Heart failure is considered a progressive condition in which the muscles of the heart are unable to pump enough blood to meet the body’s needs for oxygen and blood. Heart failure is a condition with high incidences, frequent hospital readmissions, and high mortality (Cowie et al., 2014). The causes of this condition tend to vary, but some of the major risk factors include diabetes, old age, overweight, and high blood pressure. The condition is most common in men and older people, causing symptoms that may be life-threatening even while resting. Common symptoms linked to heart failure include tiredness, shortness of breath, swelling of legs, chest pains, and cough.
The goals of the coordinated care plan in the management of heart failure are to help reduce the healthcare costs and ensure that there is an effective care plan, good communication, and a focus on the general healthcare needs of the patient (Veras, Gomes, and Macedo, 2019). The healthcare providers will implement coordinated care through a continuum of care. The high healthcare costs have led to demand for efficiency and effectiveness in the healthcare system. Patients that have heart failure have been forced to navigate into inefficient and complex systems. Lack of proper communication and coordination between the physicians and healthcare settings can lead to challenges in the recovery process of the heart failure patient, often leading to adverse outcomes and re-hospitalization.
Physical, Psychosocial, and Cultural Considerations
The care coordination plan needs to focus on the psychosocial, physical, and cultural considerations in managing heart failure. Physical, psychosocial, and cultural considerations include the protective and risk factors for heart failure. These include stress, negative emotions, and social relationships (Shi, Tao, Wei, and Zhao, 2016). Several studies have supported the importance of physical, cultural, and psychosocial considerations in developing heart failure. These issues have been overlooked, although they harm patients with heart failure. For instance, lack of social support and depression have been shown to negatively influence patients with heart failure. Ideally, patients with heart failure and experience depression and lack of social support have shown to have high hospital readmission rates and increased morbidity. Many intertwined factors have contributed to higher rates of heart failure among some groups. The socio-economic condition may affect what the patient eats, where they live, places to exercise, and healthcare quality. For instance, Latinos and Hispanics have higher rates of cardiovascular risk as compared to whites. Therefore, health disparities have remained to influence the treatment, prevention, and outcomes of heart failures.
Community Resources for a Safe and Effective Continuum of Care
The healthcare centers are effective in providing care and follow-up of a patient from preventive care through maintenance and medical incidents. The health centers offer a wide spectrum of services and are at the front line in providing continuum care needed for heart failure patients. Some of the healthcare centers include skilled nursing facilities, long-term care hospitals, and home health services.
Health Promotion Programs
The health promotion programs aim to empower and engage individuals to choose healthy lifestyles and behaviors to make changes and lower the risk of developing chronic illnesses such as heart failure. Health promotion programs inform individuals of what they need to stay healthy and address some of the things that may influence the well-being and health of those with heart failure. Health promotion programs focus on facilitating environmental and behavioral changes that lower the occurrence and impact of the disease.
Learning institutions and health agencies offer education services such as awareness that have promoted healthcare significantly. The education institutions and forums have access to and learn more about health check-ups, stay healthy and manage diseases. Education services are considered significant resources for an effective and safe continuum of care. The health education programs will support individuals in maintaining their well-being and health.
Transportation Services and Programs
Transportation is considered a significant social determinant of health. Therefore, the availability of reliable transport influences the ability of an individual to access well-coordinated and appropriate healthcare. Transportation as part of a community infrastructure enables individuals to easily access nursing homes, hospitals, and clinics. For instance, terrible transportation can reduce the chances of survival in an emergency case of heart failure.
In summation, care coordination involves the healthcare organization, the family, and the patient coordinating resources to improve the health outcomes. Care coordination offers an opportunity for solutions to healthcare challenges through linking health and non-health networks to promote health. An effective care coordination plan should focus on factors affecting the patient’s well-being and have clearly defined goals that will meet the changing patient and community needs in the provision of care.
Cowie, M. R., Anker, S. D., Cleland, J. G., Felker, G. M., Filippatos, G., Jaarsma, T., … & López‐Sendón, J. (2014). Improving care for patients with acute heart failure: before, during, and after hospitalization. ESC heart failure, 1(2), 110-145.
Mitra, S., & Vadivelu, N. (2013). Multidisciplinary approach and coordination of care. In Essentials of palliative care (pp. 7-21). Springer, New York, NY.
Shi, A., Tao, Z., Wei, P., & Zhao, J. (2016). Epidemiological aspects of heart diseases. Experimental and therapeutic medicine, 12(3), 1645-1650.
Veras, R. P., Gomes, J. A. C., & Macedo, S. T. (2019). Coordination of care increases the quality of care and reduces costs. Revista Brasileira de Geriatria e Gerontologia, 22.