Need a perfect paper? Place your first order and save 5% with this code:   SAVE5NOW

Final Care Coordination Plan

Care coordination is critical to the success of any healthcare system. By using care coordination, healthcare professionals may ensure an efficient health transition. The care coordination plan supplements the care coordination process by ensuring that all patients, especially those with lifestyle diseases, receive the best possible health care (Salz & Baxi, 2016). Healthcare stakeholders must collaborate with community resources to achieve the best result, particularly in the care coordination plan. Additionally, the health care coordination plan must be developed with the strictest respect to federal rules and applicable ethical guidelines. This Final Care Plan is built on the groundwork established by Assessment 1, the preliminary care coordination plan. The care coordination plan is primarily for patients who have had a stroke. Additionally, it draws attention to the many underlying diseases discovered during the health examination. As a result, this article will develop a Final Care Coordination Plan for a patient suffering from stroke.

Stroke is one of the leading causes of mortality worldwide; it can also lead to disability and serious adverse health consequences. In the opinion of Campbell et al. (2019), developing countries are the most adversely impacted. Developed countries are also not left behind. For instance, every year in the United States, almost 800,000 people suffer from strokes. 80% of strokes are preventable with screening and treating established risk factors such as hypertension management and diabetes prevention, among other things (George et al., 2017). More than 70% of those who suffer a stroke are diagnosed with diabetes, making it the leading risk factor for stroke (George et al., 2017). Stroke has a huge impact on both the patient’s life and their family since it impacts their work and other facets of life. These areas must be addressed to help minimize stroke cases and ensure that quality care is provided when required.

Patient-Centered Interventions

Patient-centered therapies have crucial implications for critical care because they place the patients at the center of the procedure. This is a significant change from how people used to think about health care, which put the hospital at its heart. Due to the patient’s priority, the therapies are focused on enhancing the patient’s outcomes and wellbeing. Contrary, the hospital-centered approach was built with the hospital’s advantage in mind rather than the patient’s.

Stroke is a life-threatening condition that requires lengthy treatment. Including the patient and their family throughout the care coordination process improves self-management abilities, which is critical for the patient’s treatment outcomes and wellbeing (American Stoke Association, 2021). In this case, the patient has been diagnosed with a stroke, a long-term disorder that hampers coordination as well as other physiological functions. The patient has also developed several health issues, including depression, paranoia, diabetes, anxiety, insomnia, and depression. As a result, he has sought therapy at several clinics to assist him in coping. Additionally, the patient has advisability, which adds to the stress and causes more people to withdraw from him. Care coordination that is patient-centered will be a critical component of his therapy since it will help ensure that he receives the best care available. It might help the patient enhance their life by offering a fresh outlook and a sense of hope. This was reflected in the patient’s excitement upon hearing of the care coordination plan personalized for his condition.

Indeed, it was clear that the patient’s family was eager to support him in leading a more dependent and better life in any way necessary. Three health concerns surfaced throughout the conversation, all relevant to the patient’s health condition. Among them include depression and heart disease: Among them include depression and cardiovascular complications:

  • Cardiovascular complications

Mental illnesses are associated with an increased risk of acquiring health difficulties. Stroke has also been associated with an increased chance of developing other health complications. Cardiovascular disorders are lethal and can result in permanent damage to the patient’s body and death in the worst-case scenario. Thus, it is critical to ensure that the care coordination plan takes this into account. Furthermore, the patient just had a heart attack, underlining the need to consider an underlying condition. To reduce the likelihood of this occurring, it is essential to ensure that the patient maintains critical healthy behaviors such as exercise and a balanced diet (Navi & Iadecola, 2018).

  • Depression

Stroke may result in depression due to the stress associated with the condition. Additionally, the stigma increases the likelihood of the patient going into depression. In most cases, depression arises as a result of the patient’s sustained stress during the episode, which often has a considerable influence on the patient’s health. Patient-centered treatment for depression entails shifting the patient’s focus away from their difficulties (Lappin et al., 2017). Additionally, a routine may assist the patient in developing self-management skills and increasing their optimism, ultimately altering their attitudes and decreasing their risk of depression.

Community Resources

To provide patient-centered care, it is essential to collaborate with several organizations and departments and ensure that the patient is actively involved in their treatment. There are a variety of alternatives for stroke treatment and rehabilitation. Due to a lack of understanding, the patient may be unable to seek treatment or seek it in the appropriate location. The following materials may assist persons who have had a stroke or the family members of someone who has had a stroke.

  • Million Hearts Initiative. This is an initiative co-managed by The CDC and the Centers for Medicare and Medicaid Services, which focuses on essential areas of stroke and heart attack prevention. Community preventative efforts include advising people to adopt better lifestyles, including salt reduction, increased physical activity, and tobacco cessation, as well as the use of technology to identify and manage risk factors for both the patient and families by involving them in making healthcare choices.
  • The National Stroke Association. This not-for-profit volunteer health group is dedicated to preventing strokes by altering public perceptions and treatment. The group connects families and patients by exchanging information, assistance, and support. They offer a 24-hour helpline.
  • The American Stroke Association. This is an origination that offers information concerning stroke, assists in establishing support groups and programs for stroke survivors and their families in the United States, and assists individuals in locating local assistance. By logging onto their website, one can easily access them (NationalStroke Association, 2020).

Ethics in Patient-Centered Health Interventions

Ethics is a key component of the therapy process, even more so when patient-centered care is used. Ethics in health care may be characterized as a key patient-centered component that supports and promotes care coordination. As a healthcare professional, one is obliged by the American Nurses Association (ANA) Code of Ethics, which establishes standards for healthcare delivery. Additionally, there are fundamental ethical standards in healthcare that are critical to observe to ensure the effectiveness of the treatment process. Among them are beneficence, fairness, autonomy, and the absence of malice.

Health Policy Implications for Care Continuum and Coordination

Care coordination is governed by several government policies.

Since its introduction, the Affordable Care Act (ACA) has garnered varied assessments. The legislation required Americans to apply for health insurance, which increased healthcare access. Additionally, it prompted a rise in care coordination efforts due to the increase in patient requests for this service. In addition, Medicare, a health insurance program that has existed since the 1940s, enables most US citizens to apply for insurance coverage that meets their requirements. In 1965, President John F. Kennedy established coverage for senior people in the United States. As the number of patients needing such therapy increases, the policy emphasizes care coordination efforts.

Another government policy governing care delivery is Medicaid. The program was created in 1965 to help low-income individuals obtain health insurance. Currently, the Medicaid program in the United States insures about 70 million individuals (American Stoke Association, 2021). It aids uninsured pregnant women, physically challenged individuals, and temporarily jobless people. The program has changed the landscape of healthcare coverage and is an integral part of care coordination. The Hospital Readmission Reduction Program established under the Affordable Care Act compels the Centers for Medicare and Medicaid Services (CMS) to reduce payments to care institutions with high readmission rates. This is critical to address, particularly given that one of the primary motivations for care coordination is to decrease hospital readmissions. The study cited this as a vital policy for reaching this aim.

Care Coordination Plan Patient Satisfaction and Healthy People 2030

Patient satisfaction was high, with the patient expressing satisfaction with the plan’s effectiveness and offering unwavering support throughout the treatment process. This was crucial in optimizing and resolving the care coordination plan’s demands, hence assuring the plan’s effectiveness. Healthy People2030 is a significant government effort with the purpose of achieving critical targets by 2030. Care coordination is a critical component of healthcare integrated into the Healthy People 2030 (Mager et al., 2020). It identifies stroke as a serious national problem that must be handled per the standards of the policy framework. Additional social elements were identified that would contribute to the success of the care coordination strategy.


This research evaluates a stroke patient’s ultimate care coordination plan. The final care coordination plan is determined to be effective in enhancing the healthcare process considerably. During the face-to-face session, significant aspects of the new plan were determined (ASA, 2021). Additionally, ethical issues played a role in decision-making, and healthcare practitioners needed to ensure they were met. Government policies crucial to the care coordination plan’s effectiveness should also be studied and implemented. Healthy People 2030 is critical as well, and it should serve as a guide for developing the plan and assisting in the attainment of the targeted development objectives.


American Stroke Association. (2021). About stroke.

Campbell, B. C., De Silva, D. A., Macleod, M. R., Coutts, S. B., Schwamm, L. H., Davis, S. M., & Donnan, G. A. (2019). Ischaemic stroke. Nature Reviews Disease Primers5(1), 1-22.

George, M. G., Fischer, L., Koroshetz, W., Bushnell, C., Frankel, M., Foltz, J., & Thorpe, P. G. (2017). CDC grand rounds: public health strategies to prevent and treat strokes. MMWR. Morbidity and mortality weekly report66(18), 479.

Lappin, J. M., Darke, S., & Farrell, M. (2017). Stroke and methamphetamine use in young adults: a review. Journal of Neurology, Neurosurgery & Psychiatry88(12), 1079-1091.

Mager, N. D., & Moore, T. S. (2020). Healthy People 2030: Roadmap for Public Health for the Next Decade. American Journal of Pharmaceutical Education84(11).

Navi, B. B., & Iadecola, C. (2018). Ischemic stroke in cancer patients: a review of an underappreciated pathology. Annals of neurology83(5), 873-883.

Salz, T., & Baxi, S. (2016). Moving survivorship care plans forward: focus on care coordination. Cancer medicine5(7), 1717-1722.


Don't have time to write this essay on your own?
Use our essay writing service and save your time. We guarantee high quality, on-time delivery and 100% confidentiality. All our papers are written from scratch according to your instructions and are plagiarism free.
Place an order

Cite This Work

To export a reference to this article please select a referencing style below:

Copy to clipboard
Copy to clipboard
Copy to clipboard
Copy to clipboard
Copy to clipboard
Copy to clipboard
Copy to clipboard
Copy to clipboard
Need a plagiarism free essay written by an educator?
Order it today

Popular Essay Topics