NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

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Preliminary Care Coordination Plan for Heart Diseases

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Numerous people around the world have complex needs for social care and fitness. One essential component of integrated care for those patients is care coordination, which is also a major duty of primary healthcare. The role of registered nurses in care coordination is significant. Integration has become the norm for many governments and healthcare systems over the previous few decades. Many nations have acknowledged the need to move away from fragmented and abandoned care and toward a more integrated healthcare system because to limited financial resources, ageing populations, and coexisting chronic illnesses. Despite the fact that the goal of care coordination is broadly accepted, there may not yet be universal agreement on an unmarried conceptual formulation. As long as they are equipped with and trained on the relevant abilities, professionals from a variety of backgrounds, including nursing, social work, physiotherapy, and occupational therapy, can perform the role of care coordinator in first-rate healthcare (Karam et al., 2021). Effective communication between patients, their families, and providers, including between providers and the health systems that assign them, is a crucial component of most effective care coordination. This communication translates scientific knowledge into services throughout complex healthcare structures.

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Analysis of Heart Diseases

Heart failure (HF) is a chronic, varied clinical illness that is characterized by the difficulty in diagnosing and treating it, the prevalence of clinical congestion signs and symptoms, and both. It affects 6.5 million individuals in the USA, and its prevalence is rising as a result of increased incidence rates and improvements in medical, interventional, and technology therapies that lengthen the lives of those with the condition. Despite these developments, HF is still characterized by sporadic and repeated exacerbations that are linked to high rates of morbidity, death, and expenditures.  A care coordinator should be used to manage patients with HF in this patient-centered comprehensive inpatient and outpatient care strategy (Halacha et al., 2020).

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Millions of people throughout the world suffer from chronic heart failure (CHF), and this number is growing as the population ages and treatment options advance. People with CHF have physical and psychological problems that lead to complex needs up to the time of death because the syndrome is progressing (Singh et al., 2019). A key component of the reducing the risk of cardiovascular illnesses is adopting a healthy lifestyle. Patients might be strengthened and motivated to change and adopt a healthy lifestyle by nurses. Therefore, nurses should learn to employ cutting-edge educational techniques like motivating speeches. In preventative health care, nurses are entrusted with promoting clients to receive preventative treatments like screenings, counselling, and prophylactic drugs while improving patients’ health through evidence-based recommendations. Nurses can motivate a greater number of individuals to live a healthy lifestyle by providing public health education. The epidemic of heart failure is evolving. Heart failure is still a serious clinical and public health issue even though age-adjusted incidence has stabilised and appears to be dwindling. This is because the total number of patients with heart failure is rising, which is a result of the chronic nature of the condition as well as population growth and ageing. Best practices for cardiovascular disease prevention include following strategies:

  • Utilizing a paradigm of team-based treatment.
  • Increasing the pharmacy’s role in patient care.
  • Including community health professionals into clinical care teams.
  • Promoting patient participation through self-management.
  • Making use of clinical decision assistance tools.
  • Lowering out-of-pocket expenses for prescription drugs

Particularly for the elderly, the load of comorbidities and risk factors is substantial and rising. While obesity is on the rising and is anticipated to become a more significant factor in the aetiology of heart failure, MI is now playing a less significant role. Any potential benefits of a new therapeutic approach will probably be overshadowed by the benefits of lowering risk factors and enhancing primary treatment and prevention adherence.  As people will live with heart failure for longer than ever before, care programs should concentrate on controlling multi-morbidity and chronicity (Groenewegen et al., 2020).

Goals for Health Care 

Certain adjustments can be difficult to implement. In order to manage multidimensional treatment processes, such as those for patients with HD, integrated care has been recognized as an effective strategy. It is recommended to employ an interdisciplinary management approach for treating atrial fibrillation (AF). Basic components of the strategy include a patient-centred approach (with patients actually engaging in their care process), comprehensive therapeutic interventions (including AF management, stroke preventative measures, risk factor and lifestyle changes), provided by an interdisciplinary team, and technology support. In order to facilitate collaborative decision-making and maybe enhance adherence to the prescribed treatment plan, it is also advised to educate patients about the applicable and prospective treatments as well as the associated burden for the patient. Goals will be as follows

  • Counselling regarding physical activities will be done once in a week for 2 months
  • Exercise for 20 min for next 40 days 
  • Nutritional and diet advice will be taken and followed for a personalized diet plan. 
  • Management of weight will be done and a healthy BMI will be maintained
  • Blood pressure management

Returning to regular physical activity is advised if the patient can exercise without experiencing any problems; if not, they should start at 50% of their maximum exercise capacity and build up over time. Depending on the patient’s interests and ability, physical activity should include a variety of activities like walking, stair climbing, cycling, and supervised, medically prescribed aerobic exercise. Exercise on a regular basis is strongly advised. To obtain and maintain a healthy BMI, it is advised that calorie intake and energy expenditure (physical activity) be balanced. It is advised to consume a diet low in saturated fat, low in cholesterol, with a concentration on wholegrain foods, vegetables, fruit, and fish.

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NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Psychosocial risk factor analysis should be taken into account. It is advised to use a multimodal behavioural intervention. (Elgendy et al., 2019).

First and foremost, it is crucial for all engaged health professionals to actively communicate with one another. We advise coordinating diagnostic evaluations, therapeutic interventions, the duration of monitoring intervals, and other information and exchanging it in writing. Routine check by a cardiologist is advised for all patients, including those who have heart dysfunction but have little or no symptoms; the intervals among check-ups should be indicated by the cardiologist and suitable to the severity of the condition. We have created a list of typical or prognostic factors significant patterns of symptoms and signs because patients with heart failure frequently have comorbidities. If these patterns are present, it is advised that the family physician or cardiologist consult with experts in other fields (such as nephrology, diabetology, pneumology, or psychiatry) or refer the patient for treatment. (Edelmann et al., 2018).

In managing chronic illnesses, notably heart failure, self-management is essential (HF). Culture and ethnicity have a significant impact on knowledge, attitudes, and beliefs about health and illness, which can affect a person’s ability to practice self-care behaviors. Facilitating culturally appropriate self-care behaviors is essential for effective HF management because it helps patients adhere to both pharmaceutical and non-pharmacological treatments. People with severe diseases are surviving longer due to population ageing and medical advancements, and chronic care now accounts for the majority of the health-care system. A well-designed care continuum that places a strong emphasis on patient safety is necessary for the effective care of patients with chronic diseases. Health care fragmentation and poor coordination are major contributors to ineffective treatment and rising health-care costs (Brown, 2018).

Community Resources for Effective and Continued Care

When working with patients, healthcare professionals should discuss social factors in the same way that they may discuss a smoking habit or methods to lower blood pressure. A person’s cardiovascular health characteristics and habits are influenced by social determinants of health. For instance, a person’s capacity to exercise and eat healthily might be influenced by their area and how safe they feel there. The majority of health inequities are caused by social determinants, which are described as the circumstances surrounding a person’s birth, development, employment, ageing, and the larger collection of factors and systems influencing the conditions of daily living. Social determinants have its roots primarily in resource distribution and have an impact on variables at the local, national, and international levels. Future generations who are born into situations that contribute to poor health outcomes may also be impacted by a lack of economic or social mobility. Additionally, studies show that spending money on initiatives that target social determinants of health, like housing, financial assistance, and care coordination, pays well. The term “social determinants of health” refers to non-medical factors that affect health, such as income and social status, education, physical environment, including clean water and air, safe housing, communities, and roads, healthy workplaces, employment and working conditions, social support networks, and access to health services. These elements are linked to poor health outcomes and may have immediate or long-term effects on those results. (Daniel et al., 2018).

Innovative programmes that give mental health interventions remotely and encourage psychological well-being may enhance cardiovascular health in an increasing number of ways. Beyond collaborative treatment, there are an increasing number of initiatives to support wellbeing, healthy habits, and general health that may be used by all heart disease patients, not only those with a mental health diagnosis. In patients with heart disease, mindfulness-based interventions,  have all shown some promise. Since they can reach out to all segments of the community and, if successful, result in widespread behavioural change and risk reduction, community-based methods to CVD prevention are appealing. As these programmes advance, their content will probably be further refined and novel delivery systems will be used to expand their reach, cut costs, and align with patients’ use of mobile devices for health-related purposes (Huffman et al., 2018).

A few organisations, such as the  Centre for Disease Control and Prevention (CDC), Heart Disease and Stroke Prevention Programs, which include heart disease and stroke prevention, the American Heart Association that campaigns for significant funding.  The American Heart Association (AHA), a nationwide, non-profit organisation that promotes voluntary health care and is supported by private donations, is committed to lowering the death and disability rates from cardiovascular illnesses, such as heart disease and stroke. 


Care coordination, which is also a key responsibility of primary healthcare, is one crucial element of integrated care for such patients. Registered nurses play a big part in care coordination. Over the past few decades, integration has become the standard for several governments and healthcare systems. Heart failure (HF) is a chronic, multifaceted clinical condition that is distinguished by its difficulty in being identified and treated, by the predominance of clinical congested signs and symptoms, and by both. The effective management of patients with chronic diseases requires a well-designed care continuum that places a high emphasis on patient safety. A growing number of innovative programs that provide intervention programs remotely and promote psychological well-being may improve cardiovascular health. 


Brown, M. M. (2018). Transitions of care. In Chronic illness care (pp. 369-373). Springer, Cham. 

Daniel, H., Bornstein, S. S., Kane, G. C., & Health and Public Policy Committee of the American College of Physicians*. (2018). Addressing social determinants to improve patient care and promote health equity: An American College of Physicians position paper. Annals of Internal Medicine168(8), 577-578.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Edelmann, F., Knosalla, C., Mörike, K., Muth, C., Prien, P., Störk, S., & Group, H. F. D. (2018). Chronic heart failure. Deutsches Ärzteblatt International115(8), 124.

Elgendy, I. Y., Mahtta, D., & Pepine, C. J. (2019). Medical therapy for heart failure caused by ischemic heart disease. Circulation Research124(11), 1520-1535. 

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal of Heart Failure22(8), 1342-1356.

Halatchev, I. G., McDonald, J. R., & Wu, W. C. (2020). A patient-centred, comprehensive model for the care for heart failure: the 360 heart failure centre. Open Heart7(2), e001221. 

Huffman, J. C., Adams, C. N., & Celano, C. M. (2018). Collaborative Care and Related Interventions in Patients With Heart Disease: An Update and New Directions. Psychosomatics59(1), 1–18.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Karam, M., Chouinard, M. C., Poitras, M. E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: a scoping review. International Journal of Integrated Care21(1), 16. 

Singh, G. K., Davidson, P. M., Macdonald, P. S., & Newton, P. J. (2019). The perspectives of health care professionals on providing end of life care and palliative care for patients with chronic heart failure: an integrative review. Heart, Lung and Circulation28(4), 539-552.