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MGT1101 Assessment 2 Part 1

A care coordination plan is a proposition that is designed and kept going by the patient or the family, the appropriate healthcare providers and the community services where necessary. It is formulated to help patients with their daily health care needs. The plan includes the long term and short term needs of the patient, recovery plan and it points out the person who is responsible for each part of the written plan (Weaver et al., 2018). A plan is a tool that facilitates communication between the parties that are involved in the care of the patient. One important aspect of the care coordination plan is that the patient is involved in the planning process where he/she sets his/her own goals. They are therefore more encouraged to take the responsibility for their well-being. This essay demonstrates a heart disease care coordination plan by identifying efficacious methods and ensuring the continuation of care through available resources in the community (Weaver et al., 2018).

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Heart disease is a disorder that influences the heart or damages the heart or the blood vessels. It’s the number one cause of death in the U.S. An estimated 17.5 million people in 2012 died from CVD worldwide than from any other cause. Some of the risk factors include behavioural factors: using tobacco, eating unhealthy foods, excessive alcohol consumption and physical activity that inadequate. Physiological factors include hypertension and high levels of cholesterol and glucose in the blood. The effect of Heart disease can not only be seen physically but it also affects the individual emotionally and socially contributing to various morbidity and mortality of the said disease (Boykin et al., 2018). Patients with heart disease require not only physical needs but also both psychosocial and cultural needs. A physical need required is physical exercise. Such individuals should exercise regularly to hasten their recovery and improve heart function. Some of the benefits include: Strengthening the cardiovascular system, improving the circulation of blood in the body, lowering one’s blood pressure and also reducing the levels of cholesterol in the body. The patient has to always check with the doctor before starting any exercise program (Boykin et al., 2018). A psychosocial need encompasses patients’ mental, social, spiritual & developmental needs that arise from the emotional responses related to the diagnosis and role limitations. The absence of social support and depression has a bad outcome on patients with heart disease. Such patients have higher readmission rates, death rates and are not compliant with their medications resulting in a higher cost of medical care. Kostis et al noted that exercise and cognitive therapy, management of stress and interventions in the diet improved depression scores in patients who had heart failure.

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There are various evidence-based health improvement practices for heart disease patients. This includes incorporating team-based care to improve the control of high blood pressure. It consists of a team of healthcare providers that work together to improve patient care. The team comprises the patient, the primary care provider of the patient and other health professionals like the dietitian, nurses, and pharmacists. It allows for communication between the members of the team, the team members can use clinical guidelines, the patients’ progress of consistently monitored and patients engage themselves in their care. Health care institutions that used Team-based care raised the number of patients with controlled High Blood Pressure by a median of 12 percentage points when it was compared to the usual care. Reducing the out of pocket cost for medications. Reducing the cost increases patient adherence to medications which also helps raise the number of patients that’s meet the required blood pressure goal. The Community Preventive Services Task Force discovered that reducing the cost for individuals taking HBP and cholesterol medications increased drug adherence by 3 percentage points and also raised the number of patients achieving 80% adherence by 5.1 percentage points. BP and cholesterol outcomes were significantly improved (Bozkurt, 2018).

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The use of Clinical Decision-Support Systems is also beneficial. These are computer-based information systems that were created to help healthcare providers with information that’s patient-specific during healthcare visits. These systems allow the healthcare providers to screen patients for cardiovascular disease risk factors, to assess the risk of a patient acquiring the cardiovascular disease and to notify patients when any risk factors for cardiovascular disease are elevated. Self-measured blood pressure monitoring (SMBP), the trained patient uses their blood pressure monitoring device regularly and records the results. This is usually done in the comfort of their home. The readings are later on shared with their healthcare provider during clinic visits or through a phone call.

Various Community resources are essential for a safe and effective continuum of care. Nurses can broaden the continuum of care by visiting the patients at home to carry out assessments and to provide essential services required.  The principles of home visits include: Identifying and reducing the barriers to the patient receiving care, building trust and a connection with the patient, helping to engage the caregivers in the home and to help the healthcare professional understand the “story” of what might be hindering the patient from being healthy. This ensures a closer follow up of patients and more aggressive therapy if needed. There are also heart disease management programs (Bozkurt, 2018). They constitute a multidisciplinary team of healthcare professionals but the nurses can lead quality initiatives that are created to meet the needs of the involved group. In St. Luke’s Boise (Idaho) Medical Center, about 95% of the cardiac patients were enrolled in a cardiac rehabilitation program and this contributed to lower readmission rates. Finally, there is training and empowerment of community health workers. The staff should be intensively educated on the management of diseases, education interventions and counselling on nutrition (Bozkurt, 2018). The community health workers will be able to provide screening, promote follow up to care, coordinate educational classes and other necessary social services.

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Various goals should be established to address the management of heart disease patients. One such goal is the prevention of risk factors like physical inactivity. This would specifically involve planning to walk for twenty minutes every day for four times a week. Measurability will entail marking on a calendar the days walked or using a Monthly physical activity tracker. This is attainable if they begin with walks for three times per week and add an extra day for the subsequent weeks (Zerbo, 2019). This will be realistic because it will start with walks then progress to jogging after the body is accustomed to it. The assessment for individuals engaging in physical activity and their frequency will be done monthly. Another goal is managing cholesterol levels by increasing the intake of fruits and vegetables. This will be measured by determining the number of times fruit or vegetable will be eaten per meal and measuring the cholesterol levels after every month. This is attainable because the goal is to include meals without meat once a week. Realistic because people can easily incorporate fruits and vegetables in their diet when they have a proper eating schedule. The time for assessing cholesterol levels will be monthly.

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In summary, care coordination is an important transformative trend in health care systems. Primary care providers like nurses can work with their co-workers, the patient and caregivers of patients so that they offer high-quality care with a reduction in costs. Effective care coordination requires a good preliminary plan and allocation of adequate resources. This is depicted in this write up by showing the care coordination plan of heart disease patients. It is also important to have specific, measurable, attainable, realistic and time-bound plans for the success of the whole program.


Boykin, A., Wright, D., Stevens, L., & Gardner, L. (2018). Interprofessional care collaboration for patients with heart failure. American Journal Of Health-System Pharmacy75(1), e45-e49.

Bozkurt, B. (2018). What Is New in Heart Failure Management in 2017? Update on ACC/AHA Heart Failure Guidelines. Current Cardiology Reports20(6).

Talluto, C. (2018). Establishing a successful transition care plan for the adolescent with congenital heart disease. Current Opinion In Cardiology33(1), 73-77.

Weaver, S., Che, X., Petersen, L., & Hysong, S. (2018). Unpacking Care Coordination Through a Multiteam System Lens. Medical Care, 1.

Zerbo, D. (2019). The benefits of physical activity and exercise on physical, cognitive and daily life activities in ageing adults. Annales Kinesiologiae10(1), 59-71.


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