Diabetes is a chronic illness that affects many people across the world. It requires ongoing support and management in order to prevent complications and improve the overall well-being of individuals living with the condition. Inadequate care coordination frequently results in healthcare that is fragmented, lacking consistency, and poorly organized. To address these challenges, it is crucial to develop an effective diabetic care coordination plan that promotes optimal health outcomes, empowers individuals, and enhances their overall quality of life. In developing an individualized care plan, this assessment considers the case of Mr. Cullen, a 69-year-old male with Type 2 diabetes who has been discharged for home care. He lives with his wife and son in Morristown, New Jersey, and we will be meeting to discuss the implantation of his care coordination plan.
Diabetes
Diabetes is a prevalent and severe health condition in the United States, ranking as the eighth leading cause of death (CDC, 2023). Approximately 34.2 million Americans, which account for 1 in 10 individuals, are affected by diabetes, and an additional 88 million have prediabetes, placing them at a higher risk of developing the disease (CDC, 2022). The impact of diabetes is far-reaching, affecting individuals of all ages and ethnic backgrounds. Therefore, a care coordination plan provides coordinated and comprehensive care for individuals living with diabetes and aims to address multifaceted issues related to diabetes management, improve the quality of care, and enhance health outcomes for such individuals.
Patient-Centered Health Interventions and Timelines for Diabetic Care
With patients like Mr. Cullen with Type 2 diabetes, there are other health concerns like high blood pressure and high cholesterol, which can result in kidney failure, blindness, stroke, and heart disease. Having diabetes can put Mr. Cullen at risk of developing some particular cancers like blood cancer, pancreatic and liver cancers. Therefore, the aim of care coordination is to implement proper interventions and resources to reduce or prevent any health concerns or complications associated with Mr. Cullen’s health. Mr. Cullen and his family have already selected their home health providers for follow-up care with a suitable endocrinologist. Hence, within the first week of the care coordination plan, Mr. Cullen will register for diabetes education and support groups. According to Lambrinou et al. (2019), diabetes education enables individuals to learn about diabetes management, including self-care, physical activities, medication, and nutrition. Besides, diabetes management can feel overwhelming sometimes, and emotional support from support groups is vital for overall well-being. This helps individuals find encouragement, gain insights, share experiences, and understand the challenges of living with diabetes, hence reducing feelings of isolation and providing a sense of belonging. Some resources available for Mr. Cullen in Morristown for education and support include:
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Adult Diabetes Center (Support group)
Address: 435 South St#340, Morristown, NJ 07960.
Phone +1 973-971-5524
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Marie Nevin (Endocrinologist in Morristown)
Address: 95 Madison Ave # B00, Morristown, NJ 07960, United States
Phone: +1 973-775-5115
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Morristown Medical Center (Diabetes Education)
Address: 100 Madison Ave, Morristown, NJ 07960, United States
Phone: +1 973-971-5000
Mr. Cullen should begin regular physical activities like exercise immediately after discharge. According to Amanat et al. (2020), regular exercise promotes weight loss, improves insulin sensitivity, reduces the risk of cardiovascular complications, and helps control blood sugar levels. Mr. Cullen should physical activities he enjoys, like dancing, cycling, swimming, or walking, and aim for at least three hours of moderate-intensity aerobic exercise each week. Besides, incorporating strength training exercises in one’s daily routine improves metabolic health and helps build muscle mass. During and after physical exercise, individuals with diabetes should check their blood sugar levels to prevent hypoglycemia or hyperglycemia. Various community resources available in Morristown for physical activities and exercise include:
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Ideal Strength & Fitness (nutritional consulting, personal training)
Address: 60 E Hanover Ave Ste B-5, Morris Plains, NJ 07950, United States
Phone: +1 973-945-4092
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CrossFit Morristown (Nutritional counselling, consulting, and personal training).
Address: 38 Dumont Pl, Morristown, NJ 07960, United States
Phone: +1 973-975-5782
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Camisa Fitness Dynamics (strength training, cycling, kickboxing, aerobics, recovery sessions)
Address: 1 Evergreen Pl, Morristown, NJ 07960, United States
Phone: +1 973-998-7738
Furthermore, a culturally appropriate diet entails recognizing and respecting cultural diversity in dietary preferences, as well as adapting management strategies accordingly (Dragomanovich & Shubrook, 2021). Mr. Cullen and his family will immediately consult with registered dieticians in Morristown or nearby towns who understand their cultural background in order to develop a diabetes-friendly meal plan that promotes balanced nutrition, incorporates familiar foods, and portion control. In terms of diet, Mr. Cullen should consume fiber-rich foods such as legumes, whole grains, vegetables, and fruits to regulate blood sugar levels. Meal plans should have moderation of proteins, fats, and carbohydrates, and also a lower glycemic index since they have less impact on blood sugar levels. Community resources available for Mr. Cullen and his family include for his nutrition concern include:
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Integrative Center for Nutrition, LLC (Personalized nutrition program for Mr. Cullen)
Address: 64 MacCulloch Ave, Morristown, NJ 07960, United States
Phone: +1 973-723-3468
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Center for Nutrition Services
Located in: Morristown Medical Center
Address: 100 Madison Ave, Morristown, NJ 07960, United States
Phone: +1 973-971-5454
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Nutrition Counseling at New Jersey Center for Nutrition and Dietetics
Address: 7 Washington St, Morristown, NJ 07960, United States
Phone: +1 973-944-0171
Ethical Decisions in Designing Patient-Centered Health Interventions.
In care coordination, ethical decision-making is an essential factor. The ANA Code of Ethics guides the professional practice of care management. According to Khanna et al. (2022), ethical care in nursing implies doing what is right for patients in order to attain the best possible outcome. Nurses are guided by the ethical principles of autonomy, beneficence, non-maleficence, and justice. When developing the care coordination plan for Mr. Cullen, such ethical principles were applied. Autonomy allowed Mr. Cullen to choose whether or not to participate in the developed interventions and let him decide which services or healthcare providers, like endocrinologists, he was comfortable with. Besides, respecting his autonomy entailed explaining the care coordination plan, benefits, and any risks involved to enhance his understanding. Beneficence entails doing what is best for Mr. Cullen, and the interventions that have been developed in his care coordination plan are in the best interest of his health. Therefore, various interventions like physical exercise and an appropriate diet aim to maximize benefits and promote Mr. Cullen’s well-being.
Non-maleficence involves not doing harm to the patient, and the developed care coordination plan for Mr. Cullen is designed to be safe and for his overall well-being. Possible risks and potential benefits have been carefully considered, and the selected interventions have the greatest likelihood of enhancing Mr. Cullen’s outcomes while minimizing harm. Further, the justice principle states that health interventions should be accessible to all individuals, irrespective of ethnicity, race, or socioeconomic status (Khanna et al., 2022). Mr. Cullen’s care coordination plan was developed without considering his race or socioeconomic status in order to reduce health disparities and enhance health outcomes in society. Ensuring ethical principles in decision-making contributes to increased patient satisfaction, reduced adverse events, and improved patient outcomes.
Health Policy Implications
The Affordable Care Act (ACA) supports accountable care organizations and the implementation of patient-centered medical homes, which promote care coordination and continuity for chronic illnesses like diabetes. ACA provisions encourage the adoption of a chronic care model, which focuses on planned, proactive, and coordinated care (Myerson et al., 2019). An initiative under ACA is the Hospital Readmissions and Reduction Program (HRRP), which aims to minimize avoidable hospital readmissions and enhance care quality for patients. HRRP indirectly influences diabetic care by providing incentives to health facilities to enhance post-discharge planning and improve care coordination through patient education and medication reconciliation to aid in preventing complications and reducing readmission rates among patients with diabetes. Health provisions also influence payment and reimbursement mechanisms in order to provide incentives for care coordination efforts for diabetes. For example, value-based payment models reward health organizations that achieve positive patient outcomes through coordinated care. Various initiatives implemented by the Centers for Medicare and Medicaid Services (CMS) support care coordination and reward healthcare facilities for meeting cost and quality targets.
Health provisions also foster patient empowerment and engagement in care coordination. For example, policies may require shared decision-making tools for patients, self-management support, and the provision of educational resources. The Patient-Centered Outcomes Research Institute (PCORI) funds research on comparative effectiveness and patient-centered outcomes to promote patient engagement and inform healthcare decisions in care coordination. Moreover, the National Committee for Quality Assurance (NCQA) develops standards for patient-centered medical homes and sets policies that require the use of evidence-based guidelines and care protocols for chronic conditions such as diabetes.
Need for Changes to the Plan
When discussing the care plan with Mr. Cullen and his family, various areas of priority collaboration to develop individualized treatment goals. This involves engaging in a discussion with Mr. Cullen and his family to develop goals like managing blood pressure and cholesterol levels, attaining target blood glucose levels, and maintaining a healthy weight based on evidence-based guidelines. The care coordinator also reviews Mr. Cullen’s current medication regimen and ensures it aligns with evidence-based practice guidelines. In order to optimize medication therapy, changes may be proposed where necessary, like adding or removing medications, adjusting dosages, or using newer medications with proven safety and efficacy profiles (Khanna et al., 2022). Emphasizing the importance of self-management education and care coordinators should provide evidence-based resources to patients and their families. Areas of education may include glucose monitoring, physical activity, healthy eating, and medication adherence. To reduce the risk of complications and improve diabetes management outcomes, changes should be made as required to educational resources to advance patients’ understanding of the chronic condition.
Further, the care coordinator will explore dietary modifications based on evidence-based practice in order to foster glycemic control and overall health. Changes in diet may involve increasing fiber intake, minimizing consumption of high-carbohydrate and high-sugar foods, and encouraging a well-balanced diet with suitable portion sizes. The rationale behind such dietary changes is improved blood glucose as well as long-term health benefits. physical activity recommendations should also be discussed, and tailored to the patient’s preferences and capabilities. For example, flexibility exercises, strength training, and regular aerobic exercise. Such physical activity changes reduce the risk of cardiovascular complications and weight management, and aid improve insulin sensitivity (Lambrinou et al., 2019). Moreover, the care coordinator should stress the importance of monitoring and follow-up. This may include monitoring blood pressure and glucose levels. Based on evidence-based practice, there is a need to explain why ongoing monitoring is necessary for identifying potential issues, assessing treatment effectiveness, and making adjustments to the care plan as required. Regular follow-up appointments with health providers help address care concerns, review progress, and also ensure adherence to an evidence-based diabetic care plan.
Evaluation
According to Albertson et al. (2022), health organizations may fail to coordinate care when discharging patients, leading to increased hospital readmissions and risks of complications. With proper care coordination, such issues are minimized. Using electronic health record (EHR) systems outcomes of care coordination can be monitored and tracked for diabetic patients. The Agency for Healthcare Research and Quality (AHRQ) developed the Atlas framework which measures caregiver and patient experiences with care coordination. Also, according to CMS, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey reports patients’ perspectives of hospital care. The survey collects information and data regarding patient satisfaction and experiences. Hence, this reporting enables healthcare organizations to make comparisons of their care coordination plans and find ways of improving their quality of care.
Healthy People 2030
Healthy People 2030 aims to attain healthy, thriving lives, and well-being free of preventable diseases, injury, disability, and premature death. It also aims to eliminate health disparities, attain healthy literacy, and attain health equity to improve the health and well-being of all. In this diabetic care coordination plan for Mr. Cullen, various goals included attaining healthy diets, physical activities, and promoting education and self-management. Healthy People 2030 goals align with such best practices for managing diabetes. Adopting evidence-based practices for diabetes management can facilitate the achievement of Healthy People 2030 goals, including attaining healthy and thriving lives.
Conclusion
Receiving a diagnosis of diabetes can be life-changing, but with a well-implemented diabetic care coordination plan, individuals like Mr. Cullen can easily navigate this journey. Care coordination programs play a vital role in empowering individuals with diabetes, equipping them with the necessary tools and support to manage their condition effectively by striving towards promoting self-care management, enabling early detection treatment of problems, and enhancing the overall quality of life. Hence, through collaborative efforts, diabetic care coordination plans can make a significant positive impact on the lives of individuals with diabetes.
References
Albertson, E. M., Chuang, E., O’Masta, B., Miake-Lye, I., Haley, L. A., & Pourat, N. (2022). Systematic review of care coordination interventions linking health and social services for high-utilizing patient populations. Population Health Management, 25(1), 73–85. https://doi.org/10.1089/pop.2021.0057
Amanat, S., Ghahri, S., Dianatinasab, A., Fararouei, M., & Dianatinasab, M. (2020). Exercise and Type 2 diabetes. Advances in Experimental Medicine and Biology, 1228, 91–105. https://doi.org/10.1007/978-981-15-1792-1_6
CDC. (2022, June 29). National Diabetes statistics report. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/
CDC. (2023, January 18). Leading causes of death. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
Dragomanovich, H. M., & Shubrook, J. H. (2021). Improving cultural humility and competency in diabetes care for primary care providers. Clinical Diabetes: A Publication of the American Diabetes Association, 39(2), 220–224. https://doi.org/10.2337/cd20-0063
Khanna, A., Fix, G. M., Anderson, E., Bolton, R. E., Bokhour, B. G., Foster, M., Smith, J. G., & Vimalananda, V. G. (2022). Towards a framework for patient-centred care coordination: A scoping review protocol. BMJ Open, 12(12), e066808. https://doi.org/10.1136/bmjopen-2022-066808
Lambrinou, E., Hansen, T. B., & Beulens, J. W. (2019). Lifestyle factors, self-management and patient empowerment in diabetes care. European Journal of Preventive Cardiology, 26(2_suppl), 55–63. https://doi.org/10.1177/2047487319885455
Myerson, R., Romley, J., Chiou, T., Peters, A. L., & Goldman, D. (2019). The Affordable Care Act and health insurance coverage among people with diagnosed and undiagnosed diabetes: Data from the national health and nutrition examination survey. Diabetes Care, 42(11), e179–e180. https://doi.org/10.2337/dc19-0081
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