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Capella 4050 Assessment 1

Capella 4050 Assessment 1 Preliminary Care Coordination Plan

Student Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name


Preliminary Care Coordination Plan

The care coordination model was developed in response to the increasing awareness of the high incidence and expenses related to chronic illnesses within patient communities. It also evolved due to the limitations and disconnection in a healthcare system mainly structured around fee-for-service and acute care (Williams et al., 2019). An interdisciplinary team must collaborate to develop a care plan for heart disease. It should include ongoing communication and monitoring to determine its efficacy in addressing the patient’s needs. The primary purpose of this assessment is to analyze heart disease as a health concern, set SMART goals, and discover community resources for care coordination.

Health Concerns and Evidence-Based Practice for Improving Health

According to the World Health Organization (WHO), heart disease is the leading cause of death globally, accounting for an estimated 15 million deaths annually. Heart disease is known as the “silent killer” because it can kill a person without causing noticeable symptoms. Early diagnosis is critical in enabling high-risk patients to make lifestyle adjustments lowering problems (Shah et al., 2020). As a community care nurse, I emphasize developing a comprehensive care plan that relies on evidence-based best practices for heart diseases, considering physical, psychosocial, and cultural aspects, and utilizing available community resources. The assumptions made for the care plan for heart diseases are the relevancy and credibility of research, patient preferences and values, and balance in benefits and harms.

Physical Considerations

One should focus on physical considerations to make a well-coordinated care plan for patients with heart disease. A patient-centered care plan involves physical considerations while providing the best evidence-based practices for the recognition, medication, and treatment of heart diseases. Best practices in the care plan for cardiac diseases such as heart failure begin with quick patient transportation to a healthcare facility. These practices incorporate a range of interventions including, but not limited to, cardiac output intervention, diagnostic laboratory testing, administering appropriate medications, managing respiratory function, and addressing acute pain.

Ensuring patient engagement in heart disease care with evidence-based information is crucial for effective secondary prevention. Patient-centered and evidence-based approaches while considering individual needs and preferences are vital. Incorporating digital tools like text messaging programs and smartphone apps supports education about diseases and engagement in healthcare (Zwack et al., 2023). The point of uncertainty is the need for flexible strategies, which are the key to success, as there is no universal approach suitable for all patients with heart disease.

Psychosocial Considerations

Psychosocial considerations are a vital component of the coordinated care plan for patients with chronic heart diseases. The approach of incorporating these factors will improve the rehabilitation process of patients in post-cardiac surgery phases. This approach will address stress, anxiety, and depression through counseling and emotional support via social service organizations, community resources, and cardiac rehabilitation programs. The psychosocial adjustment of patients after cardiac surgery needs improvement.

Social support and psychological resilience positively impact adjustment, while limited cardiac function and household responsibilities for individuals with chronic diseases affect middle-aged patients (Xiao et al., 2022). The point of uncertainty is the challenge in adjustment post-surgery that can impact a patient’s quality of life and disease management outcomes, posing emotional and financial burdens on individuals and society.

Cultural Considerations

Cultural influences are critical in the treatment of cardiac disease. They impact attitudes, beliefs, and behaviors concerning heart health. It is essential for effective interventions to recognize and respect cultural elements such as dietary behaviors, language, and traditions (Henry et al., 2021). Healthcare practitioners’ techniques should be modified to accord with individual beliefs and habits, encouraging improved patient participation and enhancing heart health outcomes.

Goals to Address Heart Disease Healthcare Problem

Clear and well-defined goals are paramount for improving heart disease management within healthcare systems. These goals should be focused on prevention management and be attainable. Specific goals enable healthcare practitioners and organizations to collaboratively reduce the effects of heart disease and enhance patient outcomes. Below are the SMART goals to address heart disease:

  • Goal: Increase awareness and health literacy about cardiac problems.
    • Strategy: Implement a targeted educational program for high-risk individuals focusing on heart disease awareness and promoting healthy lifestyles. This approach aims for a 20% increase in awareness within two years. A study by Gunes et al. (2019) underlines the significance of disseminating information regarding heart disease risk factors to a wider community. The primary target will be high-risk groups, such as the obese, smokers, or those with a family history of heart disease.
  • Goal: Launch cardiac rehabilitation programs within one year.
    • Strategy: Initiate post-cardiac psychosocial support programs to reduce stress, anxiety, and depression in patients. The intent is to enhance their quality of life and overall satisfaction, thereby reducing the recovery time of cardiac patients by 30% and facilitating their return to everyday activities. Addressing these challenges is crucial, as these factors can profoundly affect patients struggling to manage their responsibilities during their illness, as highlighted by Xiao et al. (2022).

Community Resources for Care Coordination

In the U.S., effective care coordination for heart disease patients relies on several targeted community resources. Million Hearts, a U.S.-specific organization, focuses on achieving cardiac rehabilitation targets, underlining evidence-based priorities for cardiovascular health improvement. In collaboration with partner organizations, they aim to prevent one million cardiovascular incidents like heart failures and actively promote cardiac rehabilitation awareness via their online platforms, including social media and web pages (Wall et al., 2020).

Another U.S.-centered resource is The American Heart Association (AHA), known for its comprehensive heart health and educational materials. Beyond this, the AHA organizes community events, workshops, and fundraisers while also functioning as a bridge, connecting patients directly to heart health specialists and facilitating support groups (Heidenreich et al., 2022). Moreover, many institutions and organizations, including the AHA, offer dedicated helplines for heart patients, ensuring immediate guidance and support.


Setting clear and measurable SMART goals is essential for effective chronic heart disease care coordination. These goals should emphasize awareness, rehabilitation, and physical and psychosocial components of heart disease. Community services such as cardiac rehabilitation programs and the American Heart Association are crucial in attaining the goals. These goals ensure a comprehensive and patient-centered strategy for addressing the difficulties of heart disease in individuals and society.


Güneş, F. E., Bekiroglu, N., Imeryuz, N., & Agirbasli, M. (2019). Awareness of cardiovascular risk factors among university students in Turkey. Primary Health Care Research & Development, 20.  

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., & Milano, C. A. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Journal of the American College of Cardiology, 79(17).  

Henry Osokpo, O., James, R., & Riegel, B. (2021). Maintaining cultural identity: A systematic mixed studies review of cultural influences on the self‐care of African immigrants living with non‐communicable disease. Journal of Advanced Nursing, 77(9), 3600–3617.   

Capella 4050 Assessment 1

Shah, D., Patel, S., & Bharti, S. K. (2020). Heart disease prediction using machine learning techniques. SN Computer Science, 1(6).  

Wall, H. K., Stolp, H., Wright, J. S., Ritchey, M. D., Thomas, R. J., Ades, P. A., & Sperling, L. S. (2020). The Million Hearts Initiative. Journal of Cardiopulmonary Rehabilitation and Prevention, 40(5), 290–293.  

Williams, M. D., Asiedu, G. B., Finnie, D., Neely, C., Egginton, J., Finney Rutten, L. J., & Jacobson, R. M. (2019). Sustainable care coordination: A qualitative study of primary care provider, administrator, and insurer perspectives. BMC Health Services Research, 19(1).  

Xiao, X., Su, J., & Su, I. J. (2022). Psychosocial adjustment in young and middle-aged adults after coronary stent implantation: A mixed-method study. Heart & Lung, 52, 86–94.  

Zwack, C. C., Smith, C., Poulsen, V., Raffoul, N., & Redfern, J. (2023). Information needs and communication strategies for people with coronary heart disease: A Scoping Review. International Journal of Environmental Research and Public Health, 20(3), 1723.  

Capella 4050 Assessment 1