In the preliminary care coordination plan, stroke was selected as a key and important health care issue to find interventions and develop coordinated care for the patients who suffer from care and after suffering from the care as the mortality rate is 5.5 million when it comes to stroke (Donkor, 2018). Care coordination will be effective in addressing issues associated with stroke and such conditions (“Care Coordination,” 2014). The purpose of the final care coordination plan is to develop a patient-centered health care intervention along with a timeline and analyze evidence through literature for three health care issues. In this paper, stroke, heart disease, and diabetes in adults are considered as three major health issues. 

The paper consists of ethical considerations to design a coordinated plan for three healthcare issues, implications of relevant healthcare policies, priorities for the coordinator to successfully implement the plan, and evaluating best practices and aligning the plan with Healthy People 2030.  

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Patient-centered health intervention design and timelines

Addressing three healthcare issues

Stroke and intervention design

Stroke is one of the leading causes of high mortality rates in the world. Further, its effects are detrimental as it leads to poor quality of life, difficulty in speech, walking, and other daily activities, and chances of recurrence of stroke (Mejia et al., 2017). Healthy People 2030 considers stroke as an outcome of poor cardiovascular health (Health.gov, 2019). Thus, heart disease or cardiac arrest is considered the second key health issue. 

The evidence highlights that strokes are of different types and hence, it is critical to find and apply patient-centered interventions to prevent, treat, and manage strokes (Morris et al., 2017). The intervention will be of multimodal design as different factors were considered and each factor was addressed. 

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The factors such as patient conditions, culture, type of stroke, and causes of the stroke. The first intervention is to promote a healthy lifestyle through a better diet and cardiovascular activities (Wafa et al., 2020). The second part is implementing an endovascular intervention to examine large vessel occlusion. Then the patient who has a severe ischemic stroke will be subjected to a neurological workup (Khaki & Tadi, 2021). Patients who suffer from moderate to severe strokes should undergo urgent carotid interventions within 48 hours of occurrence (Morris et al., 2017).

Nurses should be educated and trained to diagnose each patient and adopt the right interventions such as percutaneous vascular interventions or intravenous thrombolytic treatment for acute ischemic strokes (Lindekleiv et al., 2018). Further, stroke management interventions such as management of antiplatelet and statins should be considered (Khaki & Tadi, 2021).  As psychosocial, social, and cultural aspects affect recovery as stigma can prevent successful recovery, better psychological and emotional support should be given (Merriman et al., 2019).

Timeline and resources

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The plan will take three months to implement and test the outcomes of interventions as the first month will be sufficient for training and educating nurses and providing resources for successful implementation. The three community resources that will be helpful are the local support association for stroke survivors, community health workers, and online support at the Internet stroke center (Stroke Support Association, 2021).   

Cardiovascular disease and interventions

Cardiovascular disease is one of the deadliest diseases, which is caused by a build-up of fatty deposits inside the arteries leading to increased clots of blood. The mortality rate is 655,000 every year in the US and one in every four deaths is due to the condition (CDC, 2021). The condition is selected as it can also lead to stroke. Preventing cardiovascular disease can lead to prevention of strokes (Zhao et al., 2018). The Healthy People 2030 document highlights nutrition and physical activities as key interventions to prevent cardiovascular diseases and manage the condition (Health.gov, 2018). 

To prevent and manage cardiovascular disease, an integration of diet and lifestyle-based, therapeutic, and clinical interventions were included in the final care coordination plan along with interprofessional collaboration to provide patient-centered care (Brandhorst & Longo, 2019). The diet and lifestyle-based intervention include a patient-centered and culture-based nutrition plan, 6 hours of moderate to high-intensity workout, and a balanced diet with better dietary patterns, moderated macronutrients, physician counseling, and BMI (body mass index) tracking (de Jesus et al., 2016). The culture-based treatments are important as obesity and the rate of cardiovascular disease is high in certain communities compared to others (Brandhorst & Longo, 2019). 

Therapeutic interventions include stress management, cell-based therapies, stem cell therapies, and nanomedicines (Ma et al., 2017). Further, meditation, psychological well-being (Rafnsson & Fowkes, 2020), and lifestyle choices based on patient-centered plans developed by clinicians, physicians, and nutritionists will be beneficial (Maulik, 2013). 

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The final care plan takes three months to implement as creating dietary plans and promoting a healthy lifestyle will take time. After that, 3-months to 6-months of evaluation of intervention will be carried out to find the effectiveness of the integrated solutions. The three major community resources will be the American Heart Association, the U.S. Food and Drug Administration: eat for a Healthy Heart, and local nutritional clubs. 

Diabetes and interventions

Diabetes is another major issue in the US and worldwide as every year the rate is increasing as there are 34.2 million diabetic patients with 7.3 million undiagnosed diabetic patients (CDC, 2021). Thus, preventive and management diabetic interventions should be considered. This is an important condition as diabetes will lead to cardiovascular conditions such as heart attack or arrest (Mathews et al., 2017). The Healthy People 2030 document proposes and recommends intensive lifestyle interventions with nutrition and self-management as key interventions (Health.gov, 2020). 

Self-management through education and diabetes self-management education (DSME) is a professional intervention where nurses, patients, physicians, nutritionists, and other professionals collaborate to educate patients to prepare for a patient-centered lifestyle (Lepard et al., 2017). The intervention includes medication taking, self-monitoring (Carpenter et al., 2019), diet, exercise, and the appropriate use of health services (Glazier et al., 2016). 

The process can be implemented in two months where the first months will be used for patient education and promoting healthy lifestyles in the community. The process then moves to creating and implementing culture-based, patient-centered, and socioeconomic-based interventions to reduce obesity and diabetes in the community (Health.gov, 2020). The three major community resources are the Academy of Nutrition and Dietetics, local health and nutrition services, and medical clinics. 

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Ethical decisions in designing patient-centered health interventions

Designing and implementing a final care coordinated plan to treat, prevent, and manage conditions can be beneficial, but it may not be in every patient’s interest as there will be different circumstances and issues, which can result in ethical conflicts and the need for ethical decision-making to fulfill the quality care and health care access obligations. For example, both intravenous thrombolytic treatment and endovascular intervention suit the patient to treat the stroke, but patients prefer urgent carotid interventions within 48 hours of occurrence as some studies and physicians recommend it over others. In such cases, the conflict between a patient’s wish, the availability of evidence, and the patient’s well-being creates conflicts. 

Similarly, high-intensity workout might not suit certain patients who have lung issues and problems of asthma. In this case, questions such as whether to completely change the intervention or modify it and test the intervention despite its possible negative effects, but the high possibility of positive outcomes create conflicts in ethical decision-making (DeCamp et al., 2017). In the case of diabetes, the use of culture-based treatment such as the use of a non-protein-rich diet can lead to complexities. The question of whether to respect a patient’s choice to stick to cultural needs creates ethical decision-making issues (Lulé et al., 2019). 

Also, some cannot afford quality nutrition due to socioeconomic conditions. Thus, it is important to address these questions by adopting an ethical decision-making process based on patient-centered, culture-based, best-quality, and affordable care (Lulé et al., 2019). In such situations, ethical aspects of respect for persons, nonmaleficence or beneficence, and justice should be followed (DeCamp et al., 2017). 

Identifying relevant health policy implications for the coordination and continuum of care

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Healthcare policies and acts directly and indirectly affect coordinated care plans and the continuum of care (Khullar & Chokshi, 2018). The AHRQ identifies key practice and policy recommendations such as population identification, identity protection, delivering services, health care access, and cost of care as key concepts (AHRQ, 2021). The first policy that affects care is the HIPPA Act where each patient’s identity should be protected during coordinated care and privacy should be given (Holt, 2020).

The second kay policy is the Affordable Care Act (ACA) as it includes recommendations for the identified diseases or health issues and the need for Medicaid, treatment plans, and cost-effective care (Khullar & Chokshi, 2018). Further, Centers for Medicare and Medicaid Services management billing policy, and policy related to self-management affects the care and coordination (AHRQ, 2021). Telemedicine and telehealth policies control how a patient can access online community resources and how organizations provide services by adhering to the HIPPA Act and recent telehealth policies (Bescos & Westerteicher, 2018). 

Priorities that a care coordinator would establish when discussing the plan

The care coordinator will include patient well-being and quality of care provided along with patient safety as key or prioritized aspects when discussing the plan with family members and patients to implement the change (Quinn et al., 2017). Also, other aspects such as medical history, culture, and patient’s wishes or consent will be critical in implementing the changes based on EBP (AHRQ, 2019).

However, cost of care, patient and family education, and empowerment should also be the top priority as the coordinator will collaborate with patients, families, and other healthcare professionals to highlight the prevalence of stroke, cardiovascular disease, and diabetes. Further, the need for change should be highlighted as failing to prevent, treat, and manage will result in mortality, morbidity, and other issues (Zhao et al., 2018). 

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Evaluating best practices and healthy people 2030

The literature used in the paper highlights how stroke, cardiovascular disease, and diabetes are related as one leads to another and effective intervention should be used to prevent and manage the health issues. Carotid interventions within 48 hours of the occurrence of stroke are considered EBP solutions (Morris et al., 2017), and patient-centered care recommended by Healthy People 2030 highlights the need for changing or adopting new EBP interventions as the evidence suggests that they aid in better treatment recovery (Health.gov, 2019). A combination of stress management, carotid interventions, percutaneous vascular interventions or intravenous thrombolytic, management of antiplatelet and statins, and care based on the psychosocial, social, and cultural aspects are best practices for stroke (Lindekleiv et al., 2018). 

Similarly, nutrition, therapeutic, and clinical-based intervention with education and community support are the best solutions for cardiovascular diseases (de Jesus et al., 2016). Nutrition, exercise, periodic checkups, and healthy lifestyle-based interventions are best for diabetes (Carpenter et al., 2019). Healthy People 2030 identifies these aspects as key aspects and can lead to a reduction in mortality rate, morbidity rate, hospital stay, hospital readmission rate, and cost of care and an increase in quality care and safety of care through coordination and collaboration, but does not fully identify telehealth services and culture-based care (Health.gov, 2019). Thus, the 2030 vision should include these aspects of care as revisions. 

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Brandhorst, S., & Longo, V. (2019). Dietary restrictions and nutrition in the prevention and treatment of cardiovascular disease. Circulation Research, 124(6), 952-965. https://doi.org/10.1161/circresaha.118.313352

Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of type 2 diabetes: An integrative review. International Journal Of Nursing Sciences, 6(1), 70-91. https://doi.org/10.1016/j.ijnss.2018.12.002

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Glazier, R., Bajcar, J., Kennie, N., & Willson, K. (2016). A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care, 29(7), 1675-1688. https://doi.org/10.2337/dc05-1942

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