NURS FPX 4050 Assessment 4 Final Care Coordination Plan

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Final Care Coordination Plan

NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

The Care Coordination plan is an extremely crucial step for the speedy recovery of the patient and for ensuring the provision of the right treatment at the right time. It involves all the activities planned to provide quality care and treatment to the patient. A care coordination plan helps in developing a secure and effective atmosphere for the patient where they can trust their healthcare provider and are provided with quality and efficient services. It is the utmost duty of the nurses and healthcare staff to be vigilant and active in order to deal with all sorts of circumstances. The main objective is to prepare a patient-centered treatment plan that prioritizes the patient’s needs and predilections guaranteeing effective communication with the right person at the right time to ensure the best treatment for the patients. It is mandatory for the nursing staff to have knowledge about medicinal and ethical practices in order to plan and negotiate a better plan for the patients (Izumi, et al., 2018). A patient when provided with the proper guidelines and instruction by the healthcare advisor, develops certain positivity and will to achieve better. 

Patient-centered Health Interventions & Timelines for Selected Healthcare Problem

Patient-centered care coordination revolves around the idea of addressing the needs of patients and concentrates on providing them with the best possible treatment that yields enhanced and better clinical outcomes. This intervention includes specifically patient centred, the treatment varies from patient to patient. Patient-centered intervention has become increasingly popular in the healthcare world because it helps the healthcare facility achieve the objective of providing personalized care and patient satisfaction. The Villa Health Hospital is also uplifting its objective of dealing with Gestational Diabetes patients in an effective and efficient manner via the road of patient-centered care coordination. The patient-centered treatment plan is concerned with the wellness of the patients. It is the coordination between patients, healthcare workers, and patients’ families to integrate and mobilize all the available resources to support and treat the patient, educate them, and provide them with quality care (Otero, et al., 2015).

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A care coordination plan is a methodology devised for delivering improved, efficient, safe, and quality healthcare services and also help patient manage their health and wellbeing, as diabetic patient requires to take care of their health, diet and physical activity. The patient-centered health care plan purpose to promote diabetes self-management by implementing systematic improvements to improve primary care quality and delivery. Scheduled appointments, mini-group health consultations, and a Self-Management program. The first step is the “self-management goal cycle”. Its main objective is to guide individuals in developing clear, achievable goals that they are confident they can achieve. The patient is analyzed to see where they think the intensity of their disease lie, secondly it is analyzed that to which extent patient believe that they will be able to achieve their goals to control diabetes. All goals are written in the medical chart and available to the whole patient care team, which is a great advantage of this Cycle. This guarantees that patients goals are reviewed at every moment of interaction with the patient, resulting in a uniform healthcare continuum (Langford et al., 2007).

In next step, a detailed evaluation is made regarding the patient diet and daily routine. In this an evaluation can, be made to see what routines patient has followed previously and whether those evaluations have worked for them. Based on this information, the patient’s healthcare team can help him or her develop a thorough and coherent objective that is meaningful to them. The team may make a duplicate of the aim and provide it to the patient. The improvement of patients based on this plan can checked by quarterly or monthly floow0up visits or through telephone appointment with the healthcare team (Martinez et al., 2017; Ritchie et al., 2021). This will make both sides more familiar with the approach and will ultimately be capable of achieving high goals without using formal goal-setting tools. The procedure gradually will become a standard part of primary care visits and is easily combined with clinical treatment. 

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Another intervention will be the use of patient education. Several diabetes-controlling strategies have been implemented. Understanding an illness and its possible therapeutic techniques is critical for conquering its detrimental consequences. When people have prior information about a sickness and its remedy, it is far easier for them to manage that sickness than when patients are completely uninformed of the ailment. As a result, developing and disseminating knowledge about various diseases to the broader nursing and healthcare professionals might be an effective intervention for lowering blood pressure.

A t2dm health promotion plan in a nursing care home will normally include care objectives, pharmaceutical and sugar levels monitoring data, as well as insulin administration details. Nevertheless, because treatment plans are customized for each individual, particular facts may differ. The doctors and therapists must plan for the right medication and various physical activities to uproot the risk of developing Type 2 diabetes. Secondly, the psychologist must help them to get rid of unnecessary stress via sessions and therapies. Thirdly, a dietitian must organize and design a proper diet plan for the mother as well as the child to reduce the risk of developing uncontrolled sugar levels and obesity.

1st intervention will be the self-management education and support from healthcare professionals. Constant and dedicated support from all the healthcare personnel can guide the patients and help them to deal with the disease. In order to plan for the best treatment care plan, the practitioners must use all the available resources in an efficient way considering the requirements of patients (Zhao, 2022). The patients must be provided with the necessary education by utilizing the community resources such as seminars, counseling sessions, and workshops to spread awareness and promote self-care. The physicians must provide them with the necessary healthcare plan for home care and the necessary medications and suppositories for a speedy recovery.  The healthcare workers must ensure the utilization of preventive care services and must organize random checkups and management programs.

NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

2nd intervention would be the blood sugar monitoring regime. Care plans must contain a segment on blood sugar testing. This part will include information such as the kind of glucose monitor used and the goal blood sugar level preceding mealtime. This will also discuss how blood sugar tests would be performed and which body part is most suited for the testing, including the fingers, thighs, calves, or arm (Li & Hao, 2019).

3rd intervention regarding care plan would be the Insulin therapy managment. The insulin therapeutic section of the proposal will include the following information: the insulin administration machine used, including a needle, an insulin pen fill, or an insulin syphon; Insulin-to-carbohydrate proportion, that also allowed the user to quantify the appropriate dose of insulin; and a timetable for self-administration of insulin (Lauver et al., 2019).

4th intervention can be the use of family support during treatment schedule. Because family could have a big effect on disease care, giving diabetes training to only the person with t2dm may restrict its influence on individuals. Family-based methods to chronic illness care stress the environment in which the disease is endemic, such as the family’s physical surroundings and also patients’ and relatives and friends’ intellectual, social, and psychological requirements. Family involvement in learning programmes may assist to encourage diabetic patients, build functional family practices, and encourage diabetic self-management (Tomaselli, et al., 2020).

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Ethical Decisions in Designing Patient-Centered Healthcare Interventions

The trend of patient-centered care is becoming increasingly common and adaptable around the globe as its positive consequences cannot be denied. The patient-centered treatment revolves around the concept of treating patients individually while considering the patient’s personality issues, lifestyle, and relationships along with physical illness. This concept has allowed physicians to improve the care and treatment provided to the patients and think more logically. However, some group thinks that there are certain conflicts associated with patient-centered care such as breaching patients’ privacy, seeking patients’ narrative that can be biased, developing personal relationship, and a shared decision that can result in negative outcome putting the responsibility on healthcare worker and many more (Tomaselli, et al., 2020). 

By far patient-centered care plan is the most ethical and efficient way of treatment with certain implications for healthcare workers. It can be seen as a way of entitling the patient as the main entity and equally involved in the treatment and decisions. The healthcare workers must be very mindful and careful while dealing with the patient’s personal information. In patient-centered care treatment, the patients are treated equally while taking the decisions for their treatment. There is no privacy between the patient and healthcare advisor to ensure the best treatment while respecting the requirement and needs of patients. The healthcare workers and physicians must be ethical and professional enough to work with the objective of betterment of their patients rather than leaking their personal information or dealing with them adversely (Tomaselli, et al., 2020).

Patient-centered care is a unique ethical practice that emphasizes the well-being of the patient and believes in gaining the trust of the patient by guiding them and considering their advice while deciding for them. The main idea is to utilize all the resources in the best possible manner to yield maximum positive outcomes. The practical results of a shared decision are more in favor of patients and fulfill the needs of patients in an ethical manner. The patient-centered care depends upon various elements including the type and intensity of the disease, social, and economic condition of the patient, and technological resources available. Therefore, in order to make an ethical judgment that is in the service of the patient following aspects must be considered:

  • Question the legality of the decision before implementation.
  • Work with full dedication and professionalism.
  • Be ready to understand the patient and give the right suggestion.

Following are some ethical questions that must be catered to while making the decision:

  • Is the decision in the best interest of the patient?
  • Is this the legal approach?
  • Is this fulfilling the ethical requirements?
  • Is the patient’s privacy secured?

Though, Patient-centered intervention approach is of great importance, but these ethical issues are important to address. a patient and a practitioner may differ regarding the substance or objectives that must be met. Respecting the autonomy and dignity of the patient may contradict with acting in the best interests of the patient’s general wellbeing.

NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

Also, doctors’ provision of patient-centered data may help patients and healthcare team align their aims. Conversations on a patient’s condition or objectives, on the other hand, may exacerbate the gap between patient and their healthcare team. When agreeing on the subject of a therapy and the technique for providing it, researchers must examine these potential ethical problems (Lauver et al., 2019).

In this way, Villa Health hospital is striving to provide the best patient-centered care to the patients while considering the ethical views that produce positive outcomes for the patients suffering from Gestational diabetes and securing their future. 

Patient-centered treatment is guided by the ethical concept of autonomy that takes into account patients’ culture and traditions, personal choices, beliefs, family circumstances, and occupations. Patient decision-making ability, substitute decision-making even without a patient’s advance care planning, as well as the freedom to reject therapy are key patient concerns that are essential both to the risk manager’s as well as the medical ethicist’s job and have considerable significance to patient-centered healthcare. These key challenges and provides two neoprene sleeve experiments conducted patient-centered treatment that show how well a patient care discussion can help deter the development that really can result to a litigation suit.

Moreover, according to Li & Hao (2019), the Aristotle also provided the idea of human prosperity that is morally correct and can help others to observe a patient as a human being instead of a patient. As an equal partner in treatment, nurses should consider and believe in the cultural value of their patients, their traditions of forefathers and parents, and their weaknesses. This means that the principle of prosperity explains that quality is not an expression; it is a routine for nurses in the nursing settings to improve their emotional intelligence skills to improve quality of care coordination. This means that patient-centered models are far more appreciable and more ethical and courteous (Zhao, 2022). 

Furthermore, ethical issues can also be reduced in organizations by helping pateints to improve their coordination and participation in treatments. This involves nurses to improve their sentimental intelligence and embrace their ethical judgments to reduce misconceptions and recognize prejudices and be willing to improve their mindset.  Therefore, in our healthcare organization, additional moral requirement is to be adopted for creating better relations with the environment to help the organization progress

Policy implications for the coordination and continuum of care

Patient-centered care (PCC) approach is the way of dealing with patients in a unique and responsible way that prioritizes their needs and provides them with an effective health plan (Brandi & Fuentes, 2020). The Villa Health hospital is continuously striving to implement PCC to improve the healthcare facilities for the patients suffering from Gestational diabetes. Policies play a major role in making any treatment easy to implement or resist the continuum of such approaches in the healthcare system

Policymakers should look for ways to improve care delivery while also getting more profit possible, the approach of patient-centered care deserves special attention. Policymakers must openly agree to a concerted and integrated effort to develop patient-centered care, establishing precise performance requirements which will allow healthcare service officials to monitor performance toward their improved objectives. To this aim, policymakers must recognize that patient-centered intervention is not merely a result of infrastructural and technical advancements. To effectively maximize the advantages of this approach, the health-care organization must concentrate on making significant improvements in the efficiency of patient-clinician interrelationships, as outlined in this study (Poitras et al., 2019). To encourage patient-centered care, there ought to be a planned and targeted strategic plan. This policy should aid health care workers in acquiring and maintaining the skills of this approach. It should also urge firms to adopt a patient-centered approach. Such groups, in response, should assist individuals in managing themselves and shared decision-making (Epstein et al. 2010). Considered collectively, such actions will make it easy for the health service to deliver on the majority’s expectations for value and reliability.

NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

Following are some of the health policies in the hospital that have been devised for the proper treatment and continuum care for gestational diabetes patients.

  • Nurses must provide quality care to the patients with utmost compassion and compatibility.
  • Protect the privacy and personal information of patients with the provision of the right treatment after understanding their concerns.
  • Healthcare staff must have a healing relationship with the patients while ensuring enhanced technical care and interpersonal relationship.
  • The hospital facility must ensure meaningful use of Health information technology provided by the federal government in the best interest of patients. 
  • There must exist proper coordination among the inter-professional team to provide patient-centered care.
  • The nursing staff must plan an individualized and personalized care strategy for each patient to treat them as a special unique entity.
  • The organization of health seminars and workshops must be ensured to enhance public awareness.

These strategies will not only help the hospital management to gain profit but will also enhance their performance and ability to gain patients’ trust. The provision of patient-centered care enhances the effectiveness of treatment available for the patients suffering from gestational diabetes and increases the medical knowledge as well which can help in proposing new technologies and better treatment strategies in the future. 

The Centers for Medicaid & Medicare Programs have implemented a facility scoring system to impose monetary penalties for a rise in readmission rates (Rinne et al., 2018). This can serve to improve’ quality of life for people better and more effective clinical care during hospital stays. In November 2021, the government approved the use of e cigs as a legislative approach to control tobacco and dangerous substances as a smoke-free legislation. The Affordable Care Act gives financial help to diabetic patients who were previously refused due to high hospital readmissions and a predilection for urgent drug therapy. This legislation also provides financial support for “chronic case” programs and medicinal options. The harmonization of cardiac screening is important on the 2022-2023 social policy platform (Adab, 2021). 

It also gives cash for innovative research for the air quality standards program in order to get better air quality. The Regulation establishes the National Quality Environmental Standards, which is considered safe for breathing. To minimize air toxicity, the United States smoke-free and clean air campaign encourages the adoption of less environmentally harmful appliances, mobile phones, and energy sources. The United States Food and Drug Administration supervises tobacco industrial and assembly restrictions, in addition to heavy government taxation.

Priorities of a Care Coordinator to Discuss the Healthcare Plan

The healthcare staff must work in proper coordination and a collaborative environment to ensure productive outcomes. The topmost priority of the nursing and healthcare staff is to provide efficient and quality care to the patients. The healthcare profession demands continuous dedication and professionalism to deal with unforeseen circumstances. In order to avoid adverse cases, mistreatment, wrong prescription, unnecessary readmissions, screening tests, and lengthy hospital stays can only be achieved via a properly coordinated care plan. This will also reduce the hospital expenditures and mitigate the chances of putting blame on the hospital’s name. It is extremely important for healthcare advisors to be careful while communicating with the patients and their families (Moore, et al., 2017). According to the national standard nurses must abide by the following evidence-based priorities while dealing:

  • Prioritize the patient’s needs and preferences while treating and communicating with the patient.
  • Improve the treatment strategies for providing the best care that fulfills all the ethical and medical requirements.
  • Stay calm while dealing and take responsibility for your actions.
  • Never argue and deal with patients professionally.
  • Do not communicate wrong information rather admit your inexperience or lack of practice.
  • Connect with the patients and try to understand their sufferings.
  • Clearly explain your treatment plans or any change in the decision depending upon the available evidence-based practices.

It is extremely important for the care coordinator to discuss the treatment plan with the patient and gain their trust. Moreover, they must provide patient-centered care that reflects the confidence and trust of the patient in their care provider.

Teaching Session Content Comparison with Best Practices

Healthy People 2030 is a governmental public health initiative issued in 2020. This framework is highly helpful in assisting the healthcare staff and professionals to deal with the patients suffering from Gestational diabetes in an effective and efficient manner. It includes a complete framework regarding the challenges faced due to gestational diabetes and how to overcome them. The main aim of this initiative was to ensure the well-being of healthy people and an improved lifestyle. This includes the practices that serve as a landmark for the nursing staff to learn new strategies and enhance their knowledge to treat patients effectively (Teitelbaum, et al., 2021). Furthermore, it works for the aspiring and assessable objectives of promoting public health and preventing diseases. 

NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

The data gathered via this initiative clearly helped the nursing and healthcare staff at Villa health hospital to develop new strategies and better plans to deal with the Gestational diabetes patients. They can identify the criteria to treat mothers suffering from gestational diabetes and reduce the symptoms of high blood pressure, breathing difficulties, cardiovascular diseases, depression, and anxiety (Teitelbaum, et al., 2021). The relevant solution includes enhanced physical activities, regular monitoring of sugar levels, timely medication, and a proper diet plan. Therefore, this will enhance the abilities and skills of nursing staff to create a better collaborative and effective environment. 


Brandi, K., & Fuentes, L. (2020). The history of tiered-effectiveness contraceptive counseling and the importance of patient-centered family planning care. American Journal of Obstetrics and Gynecology222(4S), S873–S877.

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Langford, A. T., Sawyer, D. R., Gioimo, S., Brownson, C. A., & O’Toole, M. L. (2007). Patient-Centered. The Diabetes Educator33(S6), 139S-144S.

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NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

Martinez, N. G., Niznik, C. M., & Yee, L. M. (2017). Optimizing postpartum care for the patient with gestational diabetes mellitus. American journal of obstetrics and gynecology217(3), 314-321.

Moore, L., Britten, N., Lydahl, D., Naldemirci, Ö. Elam, M., & Wolf, A. (2017). Barriers and facilitators to the implementation of person-centred care in different healthcare contexts. Scandinavian Journal of Caring Sciences31(4), 662–673.

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Plows, J., Stanley, J., Baker, P., Reynolds, C., & Vickers, M. (2018). The Pathophysiology of Gestational Diabetes Mellitus. International Journal of Molecular Sciences19(11), 3342. 

NURS FPX 4050 Assessment 4 Attempt 3 Final Care Coordination Plan

Poitras, M. E., Maltais, M. E., Bestard-Denommé, L., Stewart, M., & Fortin, M. (2018). What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC health services research18(1), 1-9.

Ritchie, N. D., Sauder, K. A., Kaufmann, P. G., & Perreault, L. (2021). Patient-centered goal-setting in the National Diabetes Prevention Program: a pilot study. Diabetes Care44(11), 2464-2469.

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Tomaselli, G., Buttigieg, S. C., Rosano, A., Cassar, M., & Grima, G. (2020). Person-centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: a scoping review. Frontiers in Public Health8, 44.