NURS-FPX 4050 Assessment 4: Final Care Coordination Plan

Assessment 4: Final Care Coordination Plan

Hypertension is a major global concern due to its complications like stroke, heart disease, and chronic kidney disease. The purpose of this paper is to present my final care coordination plan for hypertension by identifying three healthcare issues and interventions to address them. The paper will also address ethical decisions in these interventions, the impact of health policy on care coordination, and the priorities of the care coordination plan.

Patient-Centered Health Interventions

The identified healthcare issues related to hypertension that will be addressed in the care coordination plan are Poor BP control, High risk of stroke, and Poor lifestyle practices. This section will address each issue by proposing an intervention for each and community resources for the interventions.

Poor BP Control

Poor BP control is defined as BP of ≥140/90 mm Hg for patients without diabetes and ≥150/90 mm Hg for patients >80 years without diabetes. Various factors have been attributed to poor BP control, including lack of early detection of high BP, inadequate treatment, and poor adherence to treatment (Carey et al., 2021). Besides, poor BP control is identified as a major risk factor for cardiovascular diseases.

Educating patients on medication adherence is the proposed intervention to address poor BP control. Various factors are associated with poor adherence, including little hypertension knowledge and ignorance of the need for long-term treatment, high medication cost, religious practices, cultural beliefs, and complementary medications and practices. The nurse will assess these factors to determine how to design the patient education plan to increase patient’s knowledge and change their attitude toward long-term treatment for hypertension (Carey et al., 2021). The community resources that will foster the intervention include support groups for hypertensive patients, Community-based medication delivery programs, and Hypertension Community Outreach programs.

High risk of stroke

Stroke is one of the complications of poor BP control. Reduction of BP is associated with significant benefits in stroke risk and related mortality risk in older persons. Gorelick et al. (2020) explain that stroke is the second most common cause of death globally and the second leading cause of disability-adjusted life years. Proper BP management is fundamental to the prevention of stroke and acute treatment. The proposed intervention to lower the risk of stroke is intensive BP-lowering therapy via pharmacological and non-pharmacological therapy. Funakoshi et al. (2022) found growing evidence showing that BP-lowering therapies based on renin-angiotensin system (RAS) blockers, calcium blockers, and diuretics effectively prevent recurrent strokes among patients with a history of stroke or transient ischemic attack (TIA).

Patients who fail to achieve optimal BP control will have their medication therapy modified per the current hypertension treatment guidelines and their lifestyle practices reviewed to identify gaps and address them. Community resources facilitating the BP-lowering therapy intervention include Stroke Prevention Programs, Community Health Worker Stroke Prevention programs, and Community stroke and TIA education programs.

Poor lifestyle practices

Hypertension control often becomes challenging due to poor lifestyle practices like smoking, unhealthy dietary habits, physical inactivity, and excessive alcohol drinking. Ojangba et al. (2023) explain that maintaining healthy lifestyle factors can lower systolic BP by 3.5 mm Hg and decrease the risk of CVD by roughly 30%, notwithstanding genetic susceptibility to hypertension. The proposed intervention will be to provide health education on lifestyle modification to improve lifestyle factors. Patients will be empowered to modify behavior like reducing sodium, salt, and fat intake, eating habits to include more fruits and vegetables, cessation of smoking, less alcohol intake, maintaining healthy body weight, exercising regularly, and reducing stress.

Furthermore, lifestyle changes will be recommended in hypertensive patients as an initial therapy before initiating medication and as an adjunct to pharmacologic therapy in those receiving it. Lifestyle changes can support the withdrawal of medication and reduce the number of hypertensive patients with medication-controlled BP if highly motivated patients successfully adopt and maintain lifestyle changes (Ojangba et al., 2023). Community resources for this intervention will include support groups, a CDC-approved curriculum containing lessons and handouts, and community programs that support healthy eating and active living.

Ethical Decisions in Designing Patient-Centered Health Interventions

The decision to educate patients on medication adherence and behavior modification will promote better health outcomes that uphold beneficence. However, there is a need to engage patients in lifestyle changes and allow them to make dietary changes that align with their preferences and cultural diet practices rather than imposing the changes on them (Clark III et al., 2020). This promotes autonomy and increases the likelihood of the patient adhering to the lifestyle changes. In addition, the intervention in intensive BP-lowering therapy promotes beneficence by improving BP control as well as nonmaleficence by protecting patients from complications of uncontrolled BP (Clark III et al., 2020). Patients will be closely monitored for adverse effects to prevent causing more harm. Furthermore, consent will be obtained before initiating new treatments to respect the patient’s right to autonomy. These interventions promote social justice by ensuring that resources for hypertension management are available to the persons who need them most, that is, hypertensive patients.

Nonetheless, ethical questions have surfaced, which has created some level of uncertainty about the decisions I have made above. One of the questions is: Does driving the concept of medication adherence go against the patient’s right to refuse treatment? What if the medications used in intensive BP therapy put the patients at risk of adverse effects from medication errors? How will clinicians establish that a certain drug will promote the best BP control in a specific patient?

Relevant Health Policy Implications for the Coordination and Continuum of Care

The Affordable Care Act (ACA) mentions that care coordination is under sections on payment reform, quality improvement, and monitoring savings. It also mentions it under full Medicare Medicaid beneficiaries, special considerations of patients with diabetes and depression, and health home members (Natkin et al., 2023). Section 3502 of the ACA establishes Community Health Teams, which link clinical and community settings to support Patient-Centered Medical Homes. The act outlines the role of the Community Health Teams as coordinating disease prevention and chronic illness management, creating interdisciplinary care plans, and engaging patients and caregivers (Natkin et al., 2023). Furthermore, they support PCPs by coordinating access to preventive services and services that are cost-effective, quality-driven, culturally appropriate, and patient- and family-centered.

Section 2703 of the ACA requires the CMS to establish health home services for Medicaid beneficiaries with chronic illnesses. This is a Medicaid State Plan Option that provides a comprehensive care coordination system for Medicaid beneficiaries (De Marchis et al., 2023). The services include: Comprehensive care management, Care coordination, Health promotion, Comprehensive transitional care, patient and family support, and Referral to community and social support services

Priorities That a Care Coordinator Would Establish When Discussing the Plan with a Patient and Family Member

The care coordinator discussing the above plan with a patient and family members will identify the priorities as attaining optimal BP control, managing weight, and treatment adherence. The care coordinator will inform the patient and family that achieving optimal BP control will be a vital step in reducing the risk of complications. Besides, one has to control the BP to <140/90 to lower the risk of stroke (Gorelick et al, 2020). A controlled BP is an indicator of effective pharmacological and non-pharmacological measures. Weight management is another priority the care coordinator should point out. Overweight and obesity are linked with high BP. Thus, the patient should be informed that changing lifestyle practices will be fundamental to promoting weight loss. Treatment adherence should be emphasized for both pharmacological and non-pharmacological measures. This will be key to lowering BP and maintaining it at optimal levels.

Aligning Teaching Sessions to the Healthy People 2030 Document

Best practices on hypertension management should be the foundation of patient education on measures to control BP and prevent complications like stroke. One of the Healthy People 2030 goals is to improve cardiovascular health and decrease mortalities from heart disease and stroke (ODPHP, n.d.). One of the objectives of preventive care is to increase the proportion of adults with hypertension whose BP is under control. Thus, teaching sessions can be aligned with Healthy People 2030 by educating individuals on measures to control or lower BP. This can help reduce chronic kidney disease, heart failure, heart attack, and stroke. Furthermore, individuals can be educated on the importance of screening for high BP and adopting measures to lower it through lifestyle modification.

Conclusion

The identified healthcare issues related to hypertension are Poor BP control, High risk of stroke, and Poor lifestyle practices. The proposed interventions are educating patients on medication adherence, intensive BP- BP-lowering therapy, and health education on lifestyle modification. The proposed healthcare interventions align with medical ethical principles of autonomy, beneficence, nonmaleficence, and social justice.

References

Carey, R. M., Wright, J. T., Jr., Taler, S. J., & Whelton, P. K. (2021). Guideline-Driven Management of Hypertension: An Evidence-Based Update. Circulation Research, 128(7), 827–846. https://doi.org/10.1161/CIRCRESAHA.121.318083

Clark III, D., Hall, M. E., & Jones, D. W. (2020). Dilemma of blood pressure management in older and younger adults. Hypertension, 75(1), 35–37. https://doi.org/10.1161/HYPERTENSIONAHA.119.14125

De Marchis, E. H., Doekhie, K., Willard-Grace, R., & Olayiwola, J. N. (2019). The Impact of the Patient-Centered Medical Home on Health Care Disparities: Exploring Stakeholder Perspectives on Current Standards and Future Directions. Population health management, 22(2), 99–107. https://doi.org/10.1089/pop.2018.0055

Funakoshi, S., Kawazoe, M., Tada, K., Abe, M., & Arima, H. (2022). Blood Pressure Lowering for the Secondary Prevention of Stroke. Cardiology Discovery, 2(01), 51-57. doi/full/10.1097/CD9.0000000000000048

Gorelick, P. B., Whelton, P. K., Sorond, F., & Carey, R. M. (2020). Blood Pressure Management in Stroke. Hypertension (Dallas, Tex.: 1979), 76(6), 1688–1695. https://doi.org/10.1161/HYPERTENSIONAHA.120.14653

Natkin, L. W., van den Broek-Altenburg, E., Benson, J. S., & Atherly, A. (2023). Community Health Teams: a qualitative study about the factors influencing the decision-making process. BMC health services research, 23(1), 466. https://doi.org/10.1186/s12913-023-09423-6

ODPHP. (n.d.). Increase control of high blood pressure in adults — HDS‑05. Home of the Office of Disease Prevention and Health Promotion – health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke/increase-control-high-blood-pressure-adults-hds-05

Ojangba, T., Boamah, S., Miao, Y., Guo, X., Fen, Y., Agboyibor, C., … & Dong, W. (2023). Comprehensive effects of lifestyle reform, adherence, and related factors on hypertension control: A review. The Journal of Clinical Hypertension. https://doi.org/10.1111/jch.14653