NURS-FPX 4050 Final Care Coordination Plan

Sample Answer for NURS-FPX 4050 Final Care Coordination Plan Included After Question

Final Care Coordination Plan “Care coordination is deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This also means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people. This information is used to provide safe, appropriate, and effective care to the patient.” (Agency of Healthcare Research & Quality, 2018). Care coordination aims to fulfill the patient’s needs, assist with transmitting patient information to the right individuals, enhance the patient’s overall health result, and support them in overseeing their healthcare decisions. In the healthcare system, focusing on transferring diabetes treatment from the outpatient to the home setting should be a priority. Care coordinators, working with a multidisciplinary team from various settings along the care continuum, may play an essential role in facilitating smooth, safe, and quality transitions. Care coordination is the practice of assisting health care consumers in safely and efficiently navigating the fragmented and complex healthcare systems (Haas et al., 2019). This provides a chance to ensure that patients are educated, adherent, and engaged in their health along the diabetes treatment continuum. Diabetes “Diabetes is currently the seventh l

Care coordination is a healthcare delivery model developed from the increasin

g awareness of the prevalence of chronic illnesses among patient populations and the associated healthcare costs. Besides, the disintegration and limitations of the healthcare system structured around fee-for-service and acute care have led to care coordination. Strong evidence shows that care coordination promotes improved clinical outcomes and cost outcomes. The purpose of this paper is to evaluate the preliminary care coordination plan for chronic obstructive pulmonary disease (COPD) using best practices.




A Sample Answer For the Assignment: NURS-FPX 4050 Final Care Coordination Plan

Title: NURS-FPX 4050 Final Care Coordination Plan

Patient-Centered Health Interventions and Timelines for COPD

COPD can severely impair patients’ quality of life (QOL) due to an increasing decline in lung function and gradual impairment in physical performance. The healthcare issues identified for this care coordination plan are Limitations of activities of daily living (ADL), Psychological distress, and Smoking. ADLs limitations in COPD are attributed to dyspnea, physical limitations, and inactivity caused by the disease (Ambrosino & Bertella, 2018). As COPD progresses, patients encounter more difficulties performing their normal daily activities due to worsening dyspnea and reduced peripheral muscle strength, decreasing the QoL. Dyspnea is the primary symptom that results in exercise limitation in patients with advanced COPD leading to inactivity and subsequent deconditioning of the peripheral muscles.

The intervention to address ADL limitations is chest physiotherapy, which entails strength and endurance exercises and breathing exercises. Chest physiotherapy techniques include vibration, percussion, active cycle of breathing, postural drainage, continuous or oscillating positive expiratory pressure (PEP), thoracic expansion exercises, intermittent positive pressure ventilation (IPPV), and walking programs (Zhang et al., 2022). The techniques improve lung volumes, increase exercise capacity, reduce the perceived degree of dyspnea, and promote the removal of airway secretions, which limit airflow in COPD. Besides, a walking program is associated with a favorable impact on arterial blood gases. The intervention will be provided immediately after a patient presents with an exacerbation until the respiratory symptoms abate (Zhang et al., 2022). Community resources that can facilitate this intervention include community respiratory physiotherapy services, Community-based exercise training for COPD patients, and a Community Respiratory Team.

COPD patients experience psychological distress and have a higher incidence of depression and anxiety than the general population, impacting their psychological wellbeing. Anxiety and fear linked with dyspnea decrease a patient’s ability to engage in a full life. Besides, the physical, social, and emotional impact of COPD is associated with the development of depression and anxiety (Anlló et al., 2022). The psychological issues can be addressed using psychological interventions like relaxation therapy, cognitive behavioral therapy (CBT), and self-management.

Patients will be trained on Relaxation therapy techniques like breathing exercises, meditation, hypnoses, body positioning, sequential muscle relaxation, and mild exercise. This will seek to improve psychological wellbeing by creating a relaxed state. In addition, CBT can be used to manage depressive and anxiety symptoms in COPD patients. It provides patients with skills for controlling their psychological distress symptoms, consequently enhancing the management of their condition (Anlló et al., 2022). Self-management in COPD entails providing patients with resources and guiding behavior modification in ways that empower the patient. The empowerment increases the patient’s ability to perform treatment regimens to control COPD, improve wellbeing, and minimize exacerbations. The psychological interventions will be initiated once a patient is diagnosed with COPD until they demonstrate adequate stress-relieving measures (Anlló et al., 2022). Community resources will include community assistance programs, community support groups, and community psychotherapy programs.

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Cigarette smoking is the primary causative factor for COPD. In light of this, smoking cessation is the most effective intervention to prevent COPD or slow its progression. Despite the obvious benefits of smoking cessation in COPD, many patients are unable to quit due to nicotine addiction. Tashkin (2021) found that 30–50% of symptomatic COPD patients continue to smoke, and of those who make a serious effort to quit, 65–85% continue to smoke within a year.

Individual behavioral counseling will be part of the care coordination plan and will be initiated once a patient commits to quit smoking until they are successful without relapse. Counseling is vital to the success of nicotine dependence treatment. Intensive behavioral therapy with more frequent and longer sessions is usually necessary (Tashkin, 2021). Counseling will entail problem-solving skills training with discussions on what the patient should do in specific situations. Community resources to facilitate behavioral counseling include smoking support programs, free quit coaching, and referrals to local resources.

Ethical Decisions in Designing Patient-Centered Health Interventions

The care coordination interventions will be based on ethical principles of autonomy, beneficence, nonmaleficence, and justice. The first intervention in chest physiotherapy is driven by the need to improve patient outcomes and wellbeing without compromising their safety. With this regard, the decision on which techniques will be used in chest physiotherapy will be based on an individual patient‘s tolerance and potential adverse effects (Sigurgeirsdottir et al., 2022). A technique will be stopped if a patient reports a significant degree of discomfort and if an adverse effect occurs after it is performed. Besides, a technique will be used if the potential benefits outweigh the health risks (Zhang et al., 2022). This will promote adherence to physiotherapy since patients can withdraw if they experience severe discomfort or adverse effects. Furthermore, patients will be engaged in making decisions when developing the physiotherapy plan, and they will be asked to give consent, which respects their right to autonomy.

Decisions on psychological interventions will also be guided by these ethical principles. The counselor will ensure that each psychological intervention used has the potential to improve the patient’s mental wellbeing and reduce COPD-related anxiety and depression without causing psychological harm. The counselor will also have to seek consent before initiating therapy and assure the patient of confidentiality (Sigurgeirsdottir et al., 2022). The principle of autonomy will be a major determinant in the smoking cessation intervention. COPD patients must make the initiative to quit smoking, and they should not be coerced to do so or join a smoking cessation program. In addition, they will be educated on the benefits and consequences of smoking to make an informed choice on whether to quit.

Some ethical questions surfaced when deciding the interventions, like: Will patients feel that their preferences have been overlooked when asked to quit smoking? What if the psychological interventions worsen patients’ anxiety or depressive states? How will we establish if it is the right time to stop a psychotherapy technique after a patient reports discomfort? Will we be promoting harm if we stop psychotherapy based on objective findings and overlook patient’s complaints?

Relevant Health Policy Implications for the Coordination and Continuum of Care

Federal Medicaid regulation promotes continued quality improvement and evaluation in care coordination. The policy requires managed care organizations (MCOs) to adopt structured quality improvement initiatives to enhance care coordination between primary care providers and other facilities (Blackstock et al., 2021). The Medicaid policy also impacts the coordination and continuum of care. It calls for Medicaid agencies to enlighten patients and their families about the available care coordination services for patients (Blackstock et al., 2021). Thus, healthcare organizations under Medicaid are expected to inform patients and their families of the care coordination services they provide. Medicaid agencies also need the enhanced medical home payment to be committed to funding a care coordinator within a medical home.

The Affordable Care Act (ACA) of 2010 established an optional Medicaid State Plan benefit for states to set up Health Homes to coordinate care for Medicaid patients with chronic illnesses. The Centers for Medicare & Medicaid Services (CMS) require states’ health home providers to work under the holistic care approach. Health Homes providers are expected to integrate and coordinate all acute, primary, behavioral health, and long-term services (Blackstock et al., 2021). Health Home services include Care coordination, Comprehensive care management, Health promotion, Comprehensive transitional care, and Referral to community and social support services.

Priorities That a Care Coordinator Would Establish When Discussing the Plan with a Patient and Family Member

The care coordinator will establish priorities in the care coordination plan when discussing it with the patient and family members. The priorities for the patient include improving gas exchange, breathing patterns, activity tolerance, and achieving airway clearance (Zhang et al., 2022). The care coordinator will inform the patient that if physiotherapy techniques like vibration, percussion, postural drainage, and thoracic expansion exercises are ineffective, more advanced techniques will be used, like positive expiratory pressure and intermittent positive pressure ventilation, will be used.

Another priority to be communicated is achieving smoking cessation. The care coordinator will communicate that Nicotine replacement therapies (NRT) will be used as an adjunct to behavioral psychotherapy if smoking cessation is unsuccessful. The NRT include Nicotine gum, inhaler, lozenge, nasal spray, and patch (Tashkin, 2021).  Improved individual coping strategies is yet another priority for the care coordination plan that the patient and family need to know. Treatment changes like initiating antidepressants or anxiolytics will be necessary if the psychotherapy interventions are not successful in managing the patient’s depressive or anxiety symptoms.

Aligning Teaching Sessions to the Healthy People 2030 Document

Best practices on the management of COPD should be the basis of patient education on COPD self-care management. The Healthy People 2030 goal is to decrease ED visits for COPD (ODPHP, n.d.). Therefore, teaching sessions can be aligned with Healthy People 2030 by educating them on long-term self-management practices at home that will improve COPD symptoms and prevent exacerbations. This includes educating them on breathing exercises, smoking cessation, reducing exposure to air pollutants, physical exercises with activity pacing, weight management, healthy nutrition, and coping measures (Ambrosino & Bertella, 2018). This will slow the progression of the disease, prevent exacerbations, prevent COPD complications, and reduce ED visits.


The healthcare issues identified in COPD are limitation of ADL, psychological distress, and smoking. They will be addressed through chest physiotherapy, psychological counseling, and individual behavioral counseling. The health interventions were determined based on ethical principles of respect for patient autonomy, beneficence, and nonmaleficence. Health policies that impact the coordination and continuum of care include Federal Medicaid regulation and the Affordable Care Act. The care coordinator will establish priorities for the COPD patient, including improving gas exchange, breathing patterns, and activity tolerance, smoking cessation, and improving coping strategies.


Ambrosino, N., & Bertella, E. (2018). Lifestyle interventions in prevention and comprehensive management of COPD. Breathe (Sheffield, England)14(3), 186–194.

Anlló, H., Larue, F., & Herer, B. (2022). Anxiety and Depression in Chronic Obstructive Pulmonary Disease: Perspectives on the Use of Hypnosis. Frontiers in Psychology13, 913406.

Blackstock, S. C., Richards, A. C., & Fleisher, L. A. (2021, October). Shaping Medicare’s Health Care Regulations. In JAMA Health Forum (Vol. 2, No. 10, pp. e213017-e213017). American Medical Association. doi:10.1001/jamahealthforum.2021.3017

ODPHP. (n.d.). Reduce emergency department visits for COPD in adults — RD‑06. Home of the Office of Disease Prevention and Health Promotion –

Sigurgeirsdottir, J., Halldorsdottir, S., Arnardottir, R. H., Gudmundsson, G., & Bjornsson, E. H. (2022). Ethical Dilemmas in Physicians’ Consultations with COPD Patients. International journal of chronic obstructive pulmonary disease17, 977–991.

Tashkin, D. P. (2021). Smoking cessation in COPD: confronting the challenge. Internal and emergency medicine16(3), 545–547.

Zhang, H., Hu, D., Xu, Y., Wu, L., & Lou, L. (2022). Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Annals of medicine54(1), 262–273.