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NURS-FPX-4050 Assessment 4-1 – Final Care Coordination
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Final Care Coordination Plan
University
Capella University
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Coordinating Patient Centered Care (FPX4050)
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CF
Carissa Floyd
Academic year2022/2023Final Care Coordination Plan
Capella University NURS-FPX-4050 Coordinating Patient-Centered Care
Final Care Coordination Plan Mrs. Simpson is a sixty-seven-year-old African American female who was diagnosed with transverse myelitis 3 years ago. Although she had been mobile prior, the disease process caused weakness and numbness in her lower extremities. As a result of the loss of strength and sensation, she developed an infected unstageable left hip pressure injury that led to sepsis. This wound required debridement ultimately leaving her with a stage 4 pressure injury with exposed bone. To aid wound healing, Mrs. Simpson also received a diverting colostomy to prevent stool soilage and contamination. After a long hospital stay for antibiotics and wound care, she is discharged home in the care of her husband and son. She and her family initially refused home health services for wound care as well as rehab. A few weeks after her hospital discharge, she and her husband presented to the community care center for a follow-up visit. They expressed concerns over caring for her wound. Although Mrs. Simpson is beginning to make a slow recovery from her transverse myelitis, she remains quite weak and unable to fully care for herself. Her husband feels he is not doing the best job with wound care and fears he will not know if the wound worsens. Mrs. Simpson also expresses body image issues regarding her colostomy, as well as difficulty with pouching and obtaining supplies for her colostomy. Since Mrs. Simpson has Medicare coverage, it should not be difficult to assist her in obtaining the care she needs. Goals and Plan Mrs. Simpson needs proper wound care to assist in healing her wound and preventing infection. The primary goals of wound care are to prevent infection, prevent further skin breakdown, relieve pain, and promote wound closure (Kirkland-Kyhn et al., 2018). Initially, the patient and her husband refused home health services but after further discussion, the family
al., 2017). As such, Mrs. Simpson will also need a more long-term solution to managing her wound than home health alone. One objective of Healthy People 2030 is reducing the rate of pressure ulcer related hospitalizations among older adults ( Health People 2030 , n.). Mrs. Simpson would also benefit from a consultation and ongoing care from an outpatient wound clinic. The local outpatient wound clinic utilizes wound care certified nurses to assess and administer patient care. Research has shown that patients receiving nurse-led care for chronic wounds experience better outcomes (Dhar et al., 2020). This clinic also utilizes two wound care and sharps debridement certified nurse practitioners full-time and two general surgeons part-time. Mrs. Simpson can have her wound assessed on a regular basis to adjust her treatment to facilitate healing. Mrs. Simpson should present to the outpatient wound clinic every other week (EPUAP et al., 2019, p. 252). Her goals are for her wound to be free of signs and symptoms of infection such as larger size or depth, foul odor, necrotic tissue, increased pain, increased exudate, or change in nature of exudate (EPUAP et al., 2019, p. 252). Clinical staff can continue educating the family on proper wound care in the home. Conservative debridement can also be done in the clinic when needed, eliminating the need for hospital-based surgery in some cases. The clinicians can monitor for signs and symptoms of infection and prescribe appropriate antibiotics. Studies demonstrate that outpatient management of medically stable wound patients through multispecialty wound care clinics frequently resulted in wound resolution and reduced hospitalization (Lundeen et al., 2017). Medical transport for appointments is scheduled via the wound clinic and is covered by Medicare. Another important factor in wound healing is proper nutrition. NPUAP recommends thirty to thirty-five calories per pound of body weight per day for patients with pressure injuries.
In addition, NPUAP recommends one gram of protein per kilogram of body weight per day for these patients (EPUAP et al., 2019). Another objective of Healthy People 2030 is improving health by promoting healthy eating and making nutritious foods available. The Community Preventative Services Taskforce (CPSTF) recommends home delivery of meals to adults sixty and older to reduce malnutrition after their studies found that home delivered meals increased energy intake and improved quality of life and well-being as well as reduced malnutrition by 15% ( The Community Guide , n.). Mrs. Simpson will receive meals daily five days per week delivered to her home by the local Meals on Wheels program. These meals follow nutritional guidelines and may follow cultural or health related needs ( The Community Guide , n.). Mrs. Simpson will eat at least 75% of each meal to help ensure proper nutrition. Her goal will be to increase her pre-albumin levels from 8 to 18 in 4 weeks. Mrs. Simpson has also suffered a loss of strength and decreased ability to mobilize herself. She did receive some physical and occupational therapy while inpatient and some of her strength was restored but admits she has been mostly chair bound since her discharge. She is now able to transfer in and out of her wheelchair. Although she is slowly regaining her strength, she remains at high risk for falls. Another objective of Healthy People 2030 is reducing fall related deaths for older adults ( Healthy People 2030 , n.). Mrs. Simpson would greatly benefit from outpatient rehab services. Physical therapy (PT) is a rehabilitation modality aimed at preserving, enhancing, and restoring movement and physical function damaged by disease, injury, or disability. PT uses exercise, assistive devices, and patient training to help patients become stronger and adapt (Fonzo et al., 2020). PT is an important tool in managing neuromuscular diseases with strong evidence of effectiveness (Quinn et al., 2017). The hospital from which she was discharged has an outpatient physical therapy clinic that provides wheelchair-accessible
Mrs. Simpson has also expressed several issues related to her colostomy. She states she is embarrassed by wearing a pouch to contain stool. She says that she doesn’t know anyone who has had a similar issue and that no one understands what she is experiencing. There is a United Ostomy Associations of America, Inc affiliated support group in Columbia, SC that meets monthly ( United Ostomy Associations of America , n.). This support group is led by an ostomy- certified RN. Meetings include informative presentations, the introduction of new products, assistance with ostomy issues, and fellowship for individuals with ostomies. This group would give Mrs. Simpson a chance to connect with others in a similar situation. This will give her a sense of support and belonging that she is lacking at this time. Mrs. Simpson will attend the ostomy support group meeting the first Sunday of every month. Mrs. Simpson and her husband will receive ostomy education and reinforcement via home health services in addition to wound care. The home health nurse will demonstrate pouch changes at the first three visits, then the Simpson will teach back pouching procedures to the nurse and return demonstration at each subsequent visit until they are able to complete the task with no verbal cues from the nurse. Mrs. Simpson’s pouching supplies are covered in limited quantities by Medicare. Due to her pouching difficulties, she has been using more than her allotted supplies. Pouches are expensive and since her family is on a fixed income, she requires some assistance with obtaining supplies. The outpatient wound clinic offers a supply closet comprised of donated ostomy supplies from former ostomy patients. Since this will likely be a temporary issue until the Simpsons become more proficient at pouching, the wound clinic has agreed to provide Mrs. Simpson with additional pouching supplies for now. Mrs. Simpson can obtain these supplies when she visits the wound clinic for the care of her wound.
Nursing Code of Ethics and Care Coordination The American Nurses Association (ANA) code of ethics consists of nine provisions to guide nurses in ethical decision-making and practice. Codes one through three speak to the nurse’s commitment to the patient and practicing with respect for the patient’s dignity and respecting the patient’s rights and safety. Mrs. Simpson needs a plan that is coordinated and tailored specifically with her needs and wishes in mind. This was accomplished in this care plan by respecting Mrs. Simpson’s wishes regarding home health services. Her safety was considered by obtaining a ramp for her home and using evidence-based interventions to improve her strength to reduce her risk of falling. Provision four acknowledges the nurse’s obligation to act in a way that promotes optimal care of the patient. This care plan includes evidence-based interventions to give Mrs. Simpson the best chance at wound healing and infection prevention. Nurses must coordinate care to ensure patients have the best chance at good outcomes. Provisions five and seven promote the nurse’s duty to maintain competency and continue professional growth, as well as use research to advance the profession. Care coordination requires staying up to date on emerging evidence, healthcare, and community resources to assist patients with their needs. Community resources such as the ramp building ministry, the ostomy supply closet, and the ostomy support group were utilized. Provisions eight and nine speak on the nurse’s duty to collaborate with other health professionals to promote health, reduce disparities, and integrate social justice into health policy. This was accomplished by coordinating with home health services and the outpatient wound clinic. Ethical Considerations in Care Coordination Nurses must adhere to the ethical principle of justice. Patients have a right to fair and impartial care no matter their insurance status or financial resources, gender identification, age,
Medicare has also increased coverage for some services to 80% but the ACA specification that private insurance must provide consistent treatment for both physical and does not apply to Medicare. The care of geriatric patients is more time-consuming due to their complex care needs, polypharmacy, and comorbidities. The benefit to providers who care for this population is decreasing. As a result, some providers have stopped accepting Medicare, diminishing access to quality care for these patients (Collins & Saylor, 2018). Culture Competence Twenty years ago, the Institute of Health released a report showing that racial and ethnic minorities in the United States receive lower quality of care and have increased mortality and morbidity compared to whites. Today some improvement has occurred but large gaps in quality of care between Blacks and Whites persist (Parker et al., 2020). In addition, African American distrust of orthodox healthcare is the product of generations of real- life experiences and racism in medicine and public health (Ferdinand, 2021). As a result, nurses must be mindful when communicating and caring for minority patients. Nurses must educate themselves regarding cultural competence and use effective communication to establish trust and rapport with their patients. Culturally competent care should effectively meet social and cultural needs of patients to improve outcomes and eliminate health disparities. Conclusion The ultimate goals for Mrs. Simpson are to help her regain some of her independence and manage the care of her wound and ostomy. She will work towards these goals by working on strengthening her body through physical therapy and exercise, adequate nutrition, education, and community support programs.
References Andersson, H., Lindholm, M., Pettersson, M., & Jonasson, L.-L. (2017). Nurses’ competencies in home healthcare: An interview study. BMC Nursing , 16 (1). doi/10.1186/s12912-017-0264- Collins, B. L., & Saylor, J. (2018). The affordable care act. Nursing Management , 49 (8), 42–48. doi/10.1097/01.numa.0000538917.37912.d Dhar, A., Needham, J., Gibb, M., & Coyne, E. (2020). The outcomes and experience of people receiving community based nurse led wound care: A systematic review. ‐ ‐ Journal of Clinical Nursing , 29 (15-16), 2820–2833. doi/10.1111/jocn. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/ injuries: Clinical practice guidelines (3rd ed.). EPUAP, NPIAP, PPPIA. Falls prevention in community-dwelling older adults: interventions. (n.). uspreventiveservicestaskforce. Retrieved July 11, 2022, from uspreventiveservicestaskforce/uspstf/recommendation/falls-prevention- in-older-adults-interventions Ferdinand, K. C. (2021). Overcoming barriers to covid-19 vaccination in african americans: The need for cultural humility. American Journal of Public Health , 111 (4), 586–588. doi/10.2105/ajph.2020. Fonzo, M., Sirico, F., & Corrado, B. (2020). Evidence-based physical therapy for individuals with rett syndrome: A systematic review. Brain Sciences , 10 (7), 410. doi/10.3390/brainsci
Lord, J., Borkowski, N., & Weech-Maldonado, R. (2021). Patient engagement in home health: The role of health literacy and “ask me three®”. Home Health Care Management & Practice , 33 (3), 202–209. doi/10.1177/ Lundeen, G., Diefenbach, C., Smith-Gagen, J., Whitlow, S., White, L., Sidorski, A., & Johnson, M. (2017). Outpatient surgical management of patients with complex wounds through a multispecialty wound care clinic. Foot & Ankle Orthopaedics , 2 (3), 2473011417S0002. doi/10.1177/2473011417s Nutrition: home-delivered and congregate meal services for older adults. (n.). health. Retrieved July 11, 2022, from health/healthypeople/tools-action/browse- evidence-based-resources/nutrition-home-delivered-and-congregate-meal-services-older- adults Parker, M., Fang, X., & Bradlyn, A. (2020). Costs and effectiveness of a culturally tailored communication training program to increase cultural competence among multi- disciplinary care management teams. BMC Health Services Research , 20 (1). doi/10.1186/s12913-020-05662-z Quinn, L., Busse, M., Carrier, J., Fritz, N., Harden, J., Hartel, L., Kegelmeyer, D., Kloos, A., & Rao, A. (2017). Physical therapy and exercise interventions in huntington’s disease: A mixed methods systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports , 15 (7), 1783–1799. doi/10.11124/jbisrir-2016- Quinn, L., Kegelmeyer, D., Kloos, A., Rao, A. K., Busse, M., & Fritz, N. E. (2020). Clinical recommendations to guide physical therapy practice for huntington disease. Neurology , 94 (5), 217–228. doi/10.1212/wnl.
Ramps builders, organizations, and projects in South Caroline. (n.). ramps. Retrieved July 13, 2022, from ramps/projects-southcarolina.htm Siclovan, D. M., Bang, J. T., Yakusheva, O., Hamilton, M., Bobay, K. L., Costa, L. L., Hughes, R. G., Miles, J., Bahr, S. J., & Weiss, M. E. (2021). Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the us. International Journal of Nursing Studies , 119 , 103946. doi/10.1016/j.ijnurstu.2021. The community guide. (n.). thecommunityguide. Retrieved July 11, 2022, from thecommunityguide/content/cpstf-recommends-home-delivered-and- congregate-meal-services-older-adults United Ostomy Associations of America. (n.). ostomy. ostomy/support-group-finder/
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FINAL CARE COORDINATION PLAN 1
Final Care Coordination Plan
Carissa Floyd
Capella University
NURS-FPX-4050 Coordinating Patient-Centered Care
Cynthia Payne
July 15, 2022
FINAL CARE COORDINATION PLAN 2
Final Care Coordination Plan
Mrs. Simpson is a sixty-seven-year-old African American female who was diagnosed
with transverse myelitis 3 years ago. Although she had been mobile prior, the disease process
caused weakness and numbness in her lower extremities. As a result of the loss of strength and
sensation, she developed an infected unstageable left hip pressure injury that led to sepsis. This
wound required debridement ultimately leaving her with a stage 4 pressure injury with exposed
bone. To aid wound healing, Mrs. Simpson also received a diverting colostomy to prevent stool
soilage and contamination. After a long hospital stay for antibiotics and wound care, she is
discharged home in the care of her husband and son. She and her family initially refused home
health services for wound care as well as rehab. A few weeks after her hospital discharge, she
and her husband presented to the community care center for a follow-up visit. They expressed
concerns over caring for her wound. Although Mrs. Simpson is beginning to make a slow
recovery from her transverse myelitis, she remains quite weak and unable to fully care for
herself. Her husband feels he is not doing the best job with wound care and fears he will not
know if the wound worsens. Mrs. Simpson also expresses body image issues regarding her
colostomy, as well as difficulty with pouching and obtaining supplies for her colostomy. Since
Mrs. Simpson has Medicare coverage, it should not be difficult to assist her in obtaining the care
she needs.
Goals and Plan
Mrs. Simpson needs proper wound care to assist in healing her wound and preventing
infection. The primary goals of wound care are to prevent infection, prevent further skin
breakdown, relieve pain, and promote wound closure (Kirkland-Kyhn et al., 2018). Initially, the
patient and her husband refused home health services but after further discussion, the family
FINAL CARE COORDINATION PLAN 3
agrees with allowing home health services into the home. Home health serves as a bridge
between hospital care and home-based care (Siclovan et al., 2021). An objective of Healthy
People 2030 is increasing the proportion of adults whose healthcare provider checked their
understanding. One method recommended by Healthy People 2030 is the teach back method in
which patients will be taught information or a skill and will then teach that back to a healthcare
provider to assess for understanding (Healthy People 2030, n.d.). A home health nurse will need
to visit Mrs. Simpson in her home a few times per week to monitor her wound for signs and
symptoms of infection and teach her and her family how to care for the wound and signs and
symptoms to report. The home health nurse can also assist with teaching about proper use of pain
medications and non-pharmaceutical modalities to aid in reducing the patient’s wound-related
pain. Studies have shown that assessment and management of pain are not well managed in
patients with pressure injuries (Jackson et al., 2017). Nurses are vital in teaching caregivers
about wound care, including basic assessment and treatment (Kirkland-Kyhn et al., 2018). The
roles of home health nurses include assessment, providing treatments, and handling
pharmaceuticals. These tasks are carried out in the patient’s home environment and home health
nurses must be aware and adaptable to the preferences, culture, and habits of the patient and their
family (Andersson et al., 2017). Patients with engaged caregivers who are themselves engaged
are found to have better outcomes, lower morbidity, better chronic condition management, and
fewer hospital readmissions (Lord et al., 2021). Mrs. Simpson’s husband is to practice hands-on
wound care with a home health nurse for the first three visits. The goal is for him to be able to
complete her dressing change with minimal verbal cues from the nurse. Mr. Simpson will be able
to list signs of infection and symptoms to report (European Pressure Ulcer Advisory Panel
[EPUAP] et al., 2019, p.353). Pressure injury is most commonly a chronic condition (Jackson et
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FINAL CARE COORDINATION PLAN 4
al., 2017). As such, Mrs. Simpson will also need a more long-term solution to managing her
wound than home health alone.
One objective of Healthy People 2030 is reducing the rate of pressure ulcer related
hospitalizations among older adults (Health People 2030, n.d.). Mrs. Simpson would also benefit
from a consultation and ongoing care from an outpatient wound clinic. The local outpatient
wound clinic utilizes wound care certified nurses to assess and administer patient care. Research
has shown that patients receiving nurse-led care for chronic wounds experience better outcomes
(Dhar et al., 2020). This clinic also utilizes two wound care and sharps debridement certified
nurse practitioners full-time and two general surgeons part-time. Mrs. Simpson can have her
wound assessed on a regular basis to adjust her treatment to facilitate healing. Mrs. Simpson
should present to the outpatient wound clinic every other week (EPUAP et al., 2019, p. 252). Her
goals are for her wound to be free of signs and symptoms of infection such as larger size or
depth, foul odor, necrotic tissue, increased pain, increased exudate, or change in nature of
exudate (EPUAP et al., 2019, p. 252). Clinical staff can continue educating the family on proper
wound care in the home. Conservative debridement can also be done in the clinic when needed,
eliminating the need for hospital-based surgery in some cases. The clinicians can monitor for
signs and symptoms of infection and prescribe appropriate antibiotics. Studies demonstrate that
outpatient management of medically stable wound patients through multispecialty wound care
clinics frequently resulted in wound resolution and reduced hospitalization (Lundeen et al.,
2017). Medical transport for appointments is scheduled via the wound clinic and is covered by
Medicare.
Another important factor in wound healing is proper nutrition. NPUAP recommends
thirty to thirty-five calories per pound of body weight per day for patients with pressure injuries.
FINAL CARE COORDINATION PLAN 5
In addition, NPUAP recommends one gram of protein per kilogram of body weight per day for
these patients (EPUAP et al., 2019). Another objective of Healthy People 2030 is improving
health by promoting healthy eating and making nutritious foods available. The Community
Preventative Services Taskforce (CPSTF) recommends home delivery of meals to adults sixty
and older to reduce malnutrition after their studies found that home delivered meals increased
energy intake and improved quality of life and well-being as well as reduced malnutrition by
15% (The Community Guide, n.d.). Mrs. Simpson will receive meals daily five days per week
delivered to her home by the local Meals on Wheels program. These meals follow nutritional
guidelines and may follow cultural or health related needs (The Community Guide, n.d.). Mrs.
Simpson will eat at least 75% of each meal to help ensure proper nutrition. Her goal will be to
increase her pre-albumin levels from 8 to 18 in 4 weeks.
Mrs. Simpson has also suffered a loss of strength and decreased ability to mobilize
herself. She did receive some physical and occupational therapy while inpatient and some of her
strength was restored but admits she has been mostly chair bound since her discharge. She is now
able to transfer in and out of her wheelchair. Although she is slowly regaining her strength, she
remains at high risk for falls. Another objective of Healthy People 2030 is reducing fall related
deaths for older adults (Healthy People 2030, n.d.). Mrs. Simpson would greatly benefit from
outpatient rehab services. Physical therapy (PT) is a rehabilitation modality aimed at preserving,
enhancing, and restoring movement and physical function damaged by disease, injury, or
disability. PT uses exercise, assistive devices, and patient training to help patients become
stronger and adapt (Fonzo et al., 2020). PT is an important tool in managing neuromuscular
diseases with strong evidence of effectiveness (Quinn et al., 2017). The hospital from which she
was discharged has an outpatient physical therapy clinic that provides wheelchair-accessible
FINAL CARE COORDINATION PLAN 6
transportation to and from therapy sessions free of charge to patients. Restoring Mrs. Simpson’s
mobility will increase her confidence and independence. Her first short-term goal is to attend her
PT sessions as prescribed, typically three times per week initially (Quinn et al., 2017).
Additional, more focused goals will be set for her during her time in therapy. Her first functional
goal will be to increase her bilateral lower extremity strength from 3/5 to 4/5 by ambulating 15
feet by the end of the first month.
The US Preventative Services Taskforce recommends exercise programs for those at risk
for falls after studies have found that falls and the number of those that experience falls can be
reduced using group and individual exercise programs that include strength and resistance
exercises (Falls Prevention in Community-Dwelling Older Adults: Interventions, n.d.). Mrs.
Simpson qualifies for a free gym membership at her local gym due to her health concerns. This
gym offers a senior strength training group class twice a week. Mrs. Simpson will attend this
class twice weekly for 3 months.
Another Healthy People 2030 objective is to increase the number of homes with
entrances without steps. Healthy People 2030 identifies stairs as a leading cause of accidental fall
in the United States (Healthy People 2030, n.d.). Entrances without stairs are also easier to use
for individuals who use assistive devices such as wheelchairs, walkers, and canes. The
Lighthouse Ministry in Florence, SC is a Christian volunteer organization that created the
R.A.M.P. program to help those who need a wheelchair ramp but cannot afford it (Ramps
Builders, Organizations, and Projects in South Caroline, n.d.). The ministry has agreed to build a
ramp for Mrs. Simpson for the entrance to her home. Mrs. Simpson will use the ramp to make
safer entry to her home and remain free of falls.
FINAL CARE COORDINATION PLAN 7
Mrs. Simpson has also expressed several issues related to her colostomy. She states she is
embarrassed by wearing a pouch to contain stool. She says that she doesn’t know anyone who
has had a similar issue and that no one understands what she is experiencing. There is a United
Ostomy Associations of America, Inc affiliated support group in Columbia, SC that meets
monthly (United Ostomy Associations of America, n.d.). This support group is led by an ostomy-
certified RN. Meetings include informative presentations, the introduction of new products,
assistance with ostomy issues, and fellowship for individuals with ostomies. This group would
give Mrs. Simpson a chance to connect with others in a similar situation. This will give her a
sense of support and belonging that she is lacking at this time. Mrs. Simpson will attend the
ostomy support group meeting the first Sunday of every month.
Mrs. Simpson and her husband will receive ostomy education and reinforcement via
home health services in addition to wound care. The home health nurse will demonstrate pouch
changes at the first three visits, then the Simpson will teach back pouching procedures to the
nurse and return demonstration at each subsequent visit until they are able to complete the task
with no verbal cues from the nurse.
Mrs. Simpson’s pouching supplies are covered in limited quantities by Medicare. Due to
her pouching difficulties, she has been using more than her allotted supplies. Pouches are
expensive and since her family is on a fixed income, she requires some assistance with obtaining
supplies. The outpatient wound clinic offers a supply closet comprised of donated ostomy
supplies from former ostomy patients. Since this will likely be a temporary issue until the
Simpsons become more proficient at pouching, the wound clinic has agreed to provide Mrs.
Simpson with additional pouching supplies for now. Mrs. Simpson can obtain these supplies
when she visits the wound clinic for the care of her wound.
FINAL CARE COORDINATION PLAN 8
Nursing Code of Ethics and Care Coordination
The American Nurses Association (ANA) code of ethics consists of nine provisions to
guide nurses in ethical decision-making and practice. Codes one through three speak to the
nurse’s commitment to the patient and practicing with respect for the patient’s dignity and
respecting the patient’s rights and safety. Mrs. Simpson needs a plan that is coordinated and
tailored specifically with her needs and wishes in mind. This was accomplished in this care plan
by respecting Mrs. Simpson’s wishes regarding home health services. Her safety was considered
by obtaining a ramp for her home and using evidence-based interventions to improve her
strength to reduce her risk of falling. Provision four acknowledges the nurse’s obligation to act in
a way that promotes optimal care of the patient. This care plan includes evidence-based
interventions to give Mrs. Simpson the best chance at wound healing and infection prevention.
Nurses must coordinate care to ensure patients have the best chance at good outcomes.
Provisions five and seven promote the nurse’s duty to maintain competency and continue
professional growth, as well as use research to advance the profession. Care coordination
requires staying up to date on emerging evidence, healthcare, and community resources to assist
patients with their needs. Community resources such as the ramp building ministry, the ostomy
supply closet, and the ostomy support group were utilized. Provisions eight and nine speak on
the nurse’s duty to collaborate with other health professionals to promote health, reduce
disparities, and integrate social justice into health policy. This was accomplished by coordinating
with home health services and the outpatient wound clinic.
Ethical Considerations in Care Coordination
Nurses must adhere to the ethical principle of justice. Patients have a right to fair and
impartial care no matter their insurance status or financial resources, gender identification, age,
FINAL CARE COORDINATION PLAN 9
or ethnicity. Nursing decisions must be based upon fairness. Nurses coordinating care for elderly
patients with Medicare face the challenges of ensuring patients receive the care they need. Care
coordinators must sometimes rely upon community resources such as the ostomy supply closet
and gym membership to meet the patient’s needs.
Beneficence is doing what is best for the patient. Beneficence was exercised in this care
plan by providing Mrs. Simpson with the resources and interventions needed to help her regain
her strength not only for her independence but also for her safety. She will receive the care and
education she needs to heal her wound and minimize her risk of rehospitalization.
Mrs. Simpson initially refused home health services. Although the care coordinator did
not agree with this decision, Mrs. Simpson has an ethical right to autonomy. After
reconsideration, she and her family agreed to rehab services and home health. Care coordinators
must be mindful to respect patient’s decisions even when they do not align with their own
beliefs.
Policies Affecting Care Coordination
The care coordinator will need to be mindful of Mrs. Simpson’s legal right to privacy
under HIPAA while connecting to community resources to assist Mrs. Simpson. Mrs. Simpson
will need to be involved and aware of who may be receiving information about her. Information
must be shared on a need-to-know basis only requiring Mrs. Simpson’s consent.
The Affordable Care Act (ACA) was signed into law by President Obama on March 3,
- The goals were to ensure all Americans had greater access to care, increase the quality of
care, and reduce healthcare spending (Collins & Saylor, 2018). The geriatric population has both
benefitted and met challenges with this legislation. Medicare now provides full coverage for
preventative services and expanded prescription benefits including discounted name-brand drugs.
FINAL CARE COORDINATION PLAN 10
Medicare has also increased coverage for some services to 80% but the ACA specification that
private insurance must provide consistent treatment for both physical and does not apply to
Medicare. The care of geriatric patients is more time-consuming due to their complex care needs,
polypharmacy, and comorbidities. The benefit to providers who care for this population is
decreasing. As a result, some providers have stopped accepting Medicare, diminishing access to
quality care for these patients (Collins & Saylor, 2018).
Culture Competence
Twenty years ago, the Institute of Health released a report showing that racial and ethnic
minorities in the United States receive lower quality of care and have increased mortality and
morbidity compared to whites. Today some improvement has occurred but large gaps in quality
of care between Blacks and Whites persist (Parker et al., 2020). In addition, African American
distrust of orthodox healthcare is the product of generations of real- life experiences and racism
in medicine and public health (Ferdinand, 2021). As a result, nurses must be mindful when
communicating and caring for minority patients. Nurses must educate themselves regarding
cultural competence and use effective communication to establish trust and rapport with their
patients. Culturally competent care should effectively meet social and cultural needs of patients
to improve outcomes and eliminate health disparities.
Conclusion
The ultimate goals for Mrs. Simpson are to help her regain some of her independence and
manage the care of her wound and ostomy. She will work towards these goals by working on
strengthening her body through physical therapy and exercise, adequate nutrition, education, and
community support programs.
FINAL CARE COORDINATION PLAN 11
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NURS-FPX-4050 Assessment 4-1 – Final Care Coordination
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