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Capella 4050 Assessment 4

Capella 4050 Assessment 4 Final Care Coordination Plan

Student Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name


Final Care Coordination Plan

In every healthcare organization, care coordination is pivotal for desired outcomes in patients’ well being. By utilizing care coordination, healthcare personnel can ensure the efficacious health changes in patients. The care coordination plan aids the care coordination procedure by making sure that all the patients, specifically the patients with lifestyle changes, get to acquire the best possible healthcare (Beth et al., 2019).

Nurses must coordinately work with the community resources to obtain the best healthcare results, especially in care coordination. Besides, the healthcare coordination plan must be in accordance with the regulations of Federal rules and practical to ethical guidelines. The following final care coordination plan is developed  on the basis of  assessment 1 which was the preliminary care coordination plan.

In this study, the final care plan discussed is primarily  for patients suffering through COPD (Chronic Obstructive Pulmonary Disease). COPD (Chronic Obstructive Pulmonary Disease) is heterogenous lung disease characterized by shortness of breath, cough and exacerbation due to abnormalities in airways such as bronchitis, emphysema. Use of care coordination plan will help maximize the health benefits to COPD patients (Raaijmakers et al., 2023).

Patient-Centered Health Interventions and Timelines

Patient-Centered care therapies bring astonishing effects to the betterment of a patient’s health as the therapy provided is centered to an individual patient based on the needs of the particular disease of the patient and according to the patient’s priorities. Due to the primary focus of therapy on a patient’s health and well-being, this approach is better than conventional hospital-centered approach which keeps the hospital’s advantage in mind rather than patient’s health (McFarland et al., 2019).

Long term care plan for COPD should try to minimize the risk of exacerbations and delay their onset to decrease the burden on the health care system and enhance health related quality of life. The keys of primary care COPD management comprise smoking cessation, vaccination, physical activity, pulmonary rehabilitation in cases of dyspnea and functional disability, care of exacerbations that arise, and maintenance pharmacotherapy to alleviate exacerbations.

Multiple barriers contribute to the inefficient treatment of patients suffering from COPD. Lack of organizational services during transitions of care is one of these barriers that hinders the proper treatment of COPD patients. Certain health interventions that can be done in this regard are spreading awareness and educating professionals about the disease itself, describing current services and guidelines, and evaluating the resources and practices with respect to the guidelines.

Capella 4050 Assessment 4

Healthcare personnel can also improve the services by facilitating the vaccination process and ensuring access to smoking cessation and pulmonary rehabilitation programs on an ongoing basis. Lack of screening services is another barrier to the proper treatment of COPD patients. This is improved by ensuring the availability and easy accessibility of this spirometer in primary care units and by providing other healthcare professionals with the necessary knowledge about this service.

Another issue that healthcare professionals confront in the poor treatment of COPD is a lack of patient adherence. This can be overcome by providing patient education, developing a questionnaire to identify patients’ educational needs and personalizing the intervention, and involving patients, caregivers, and family members in COPD education interventions (Slevin et al., 2019).

Different community sources practices can connect COPD patients with community stop-smoking groups, gyms, American Lung Association Chapters/BetterBreathers Clubs. A collaborative relationship between the physician, nurse, pharmacist, ER specialists, and physical therapist should be ensured to provide continuous coordinated therapy to the patient. Care transition is done like pulmonologist referral should be made and coordinated when needed. Referral to pulmonary rehabilitation and access to the exercise after formal rehabilitation can be made by practice (Vachon et al., 2022).

Ethical Decisions in Designing Patient Centered Healthcare Interventions

Patient-centered care has achieved  importance lately as it comprises making decisions with regard to patients’ likelihood  along with  incorporating them  in the entire therapeutic plan. Patients’ families equally contribute with nurses and other healthcare personnel to share knowledge about the patients’ conditions, their lifestyles and habits and to help in getting patients’ permission for a certain treatment as prescribed by healthcare professionals.

Autonomy gives the patient the right to choose the care plan according to his will and preferences. Physicians and other healthcare professionals can only guide him about the adverse effects and benefits of a certain therapy plan but are unable to make decisions on patient’s behalf. This is where the healthcare professionals are deemed to put forth extraordinary effort so they can self-motivate patients to choose the best care plan without implementing their care plan. Healthcare professionals try to respect the patients’ choices,whether they are health-improving or not. One of the ethical dilemmas concerned by the physicians is helping patients deal with COPD as an addiction disease, patients’ rejection concerning the harm of smoking, motivation for patient’s self-management and the mystery of disease (Jannick Kuipers et al., 2019).

Capella 4050 Assessment 4

 There is a certain ethical dilemma created while managing COPD and deciding the coordinated care plan. For example, a patient’s nicotine addiction and the physicians’ ethical requirements bring the conflict in this scenario, where the physicians must select the treatment on the basis of scientific knowledge and the patients’ choices. Physicians must listen to the patient’s point of view regarding his own health and well-being so they can target the patient’s likelihood of therapy adherence (Fiorillo et al., 2020). Physicians are supposed to deliver the necessary information about the disease and prospects to patients with truthfulness to make the relationship honest and open-minded between patient and physician.

By acquiring knowledge from the ethical dilemmas that healthcare professionals experience, the care plan should be made keeping these scenarios in mind. Patients show non-adherence in case of continuing smoking and nicotine addiction, they reject the harms of tobacco use and consider themselves to know everything about their disease. Therefore, the care plan should include every possible strategy and tactic for declining ethical issues. For instance, Healthcare professionals  can guide patients about their capabilities of managing their own disease and conditions , share knowledge  about their ailments and incorporate the patient’s family when required, encourage patients to make use of substitutes, for example managing patients’ smoking habit by keeping chewing gums in mouth to avoid smoking. 

Health Policy Implications for coordination and continuum of Care

In order to obtain a flawless continuum of care, there should be health policy implications for every disease. In case of COPD, indistinct policies and laws  should be COPD oriented as COPD is treated with a number of therapeutic procedures. A healthcare plan should consist of the initiatives that bring a smoke-free environment like turning high taxes on cigarettes and to make a comprehensive air environment, by increasing tobacco prices and running campaigns to raise awareness. A platform should be developed that can track the present trends in society to validate whether the care plan is being followed or not.

Development of an official institution or organization to supervise the application of the care plan based upon the regulations should be done. In such an operational body, international organizations such as the US Department of Health Sciences should be constituted by representing legislative power regarding patients. This should facilitate keeping record of care coordination plans. The care coordination plan should be in correspondence  with the quality indicators that are based on the treatment  conducted , that are approved by scientific research data.

Capella 4050 Assessment 4

This care coordination plan should also provide validated quality indicators measured and monitor health care facilities and services delivered in all kinds of healthcare organizations. This care coordination plan is controlled by several government powers. Ever since it was launched, the Affordable Care Act (ACA) has gathered diverse assessments. Americans need to submit applications in order to get health insurance according to these laws, which promote  healthcare access. Additionally, Enhanced care coordination efforts were the consequence of  greater patient requests for this service (Shannon et al., 2022).

Medicaid is the government policy commanding care provision . The purpose of this policy is to facilitate people with poor financial status. and to grant them health insurance. Medicaid covers a high prevalence of COPD among low-income adults. Adults with respiratory diseases such as COPD have higher spending and utilization rates than enrollees without respiratory diseases.

Medicaid adults with respiratory disease were more likely than low-income uninsured adults with these ailments to have access to and utilize services; they also had lower out-of-pocket costs despite higher overall spending for their care. These findings show the crucial role Medicaid plays in supporting the health and well-being of these individuals by providing access to critical health care services with very little financial burden (Admon et al., 2019).

Care Coordinator’s Priorities while Discussing the Plan

Care coordinator should highlight all the essential parameters to alleviate the risk of COPD progression while discussing the care plan with the patient and his family members. Proactive maintenance of COPD demands protected resources like multidisciplinary care teams allowing a division of labor between acute and chronic care and scheduling well-care visits along with pre-visit planning and providing enough time for chronic treatment. All these priorities should be patient centered so the patient and healthcare professional both benefit, as the final decision will be made in the light of the care plan’s discussion.

Each chronic care visit should have a specified plan, e.g., spirometry and disease staging, pharmacotherapy initiation, inhaler training, patient education, the establishment of a smoking cessation program, and physical activity planning (Albitar & lyer, 2020).

It is crucial to discuss the plan with the family members along with the patient and should guide about the treatment procedures and rehabilitation centers for smoking cessation programs, care coordinator should ensure that all the information is conveyed in a manner that the patient and his family members get convinced for the patient’s best health. Involving the family is more important when the patient is elderly and cannot make decisions on his own. Care coordinators should prefer discussing the patient’s consent and patient autonomy for making sure the treatment plan is patient centered (Elaine et al., 2019).

Comparison of Learning Session content and Best Practices in line with Healthy People 2030

Healthy People 2030 provides multiple evidence-based resources on COPD. one of which is highlighting the awareness of COPD in following groups: people with COPD and their families, people with COPD risk factors, health professionals (especially primary care providers) by collaborating with appropriate partners to develop educational resources or by collaborating with health organizations to communicate current standards of diagnosis, including spirometry use and treatment options for COPD. 

Healthy People 2030 also deems it important to work on smoking cessation to improve COPD patients’ health and decrease the progression of disease. Hence, the best practices in providing care for COPD patients involve educating them and providing them with a variety of techniques to deal with the issue. In place of this, the NIH’s National Action Plan for COPD comes in with a holistic view on how to educate and come up with the best practices to cure or alleviate the disease and provide a healthy lifestyle to patients with COPD. 


Consequently , Considering the Patient Centered Approach, a final care coordination plan about the COPD patients can bring drastic improvement in patients’ health. All health-professionals can successfully coordinate to bring out this betterment in COPD patients and improve their quality living. Grasping ample knowledge about the limitations of systems, services and other considerations related to COPD patients’ health, specific interventions using common resources can be made and decrease the progression of COPD. Health policies implications for COPD patients also helps in improving patients’ condition. Ethical considerations while making a plan has to be followed strictly to not disrespect the patients’ values and morals. 


Admon, A. J., Sjoding, M. W., Lyon, S. M., Ayanian, J. Z., Iwashyna, T. J., & Cooke, C. R. (2019). Medicaid expansion and mechanical ventilation in asthma, chronic obstructive pulmonary disease, and heart failure. Annals of the American Thoracic Society, 16(7), 886–893.

 Albitar, H. A., & Iyer, V. N. (2020). Adherence to global initiative for chronic obstructive lung disease guidelines in the real world. Current Opinion in Pulmonary Medicine, 26(2), 149–154.

Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., … & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19, 1-12. 

Jannick Kuipers, S., Murray Cramm, J., & Nieboer, A. P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. International Journal of Integrated Care, 19(4), 315. 

Capella 4050 Assessment 4

McFarland, M. S., Nelson, J., Ourth, H., Groppi, J., & Morreale, A. (2019). Optimizing the primary care clinical pharmacy specialist: Increasing patient access and quality of care within the Veterans Health Administration. JACCP: Journal Of The American College Of Clinical Pharmacy, 3(2), 494–500.

Raaijmakers, L. H., Schermer, T. R., Wijnen, M., van Bommel, H. E., Michielsen, L., Boone, F., Vercoulen, J. H., & Bischoff, E. W. (2023). Development of a person-centred integrated care approach for chronic disease management in Dutch Primary Care: A mixed-method study. International Journal of Environmental Research and Public Health, 20(5), 3824.

Slevin, P., Kessie, T., Cullen, J., Butler, M. W., Donnelly, S. C., & Caulfield, B. (2019). Exploring the barriers and facilitators for the use of Digital Health Technologies for the management of COPD: A qualitative study of clinician perceptions. QJM: An International Journal of Medicine.

Vachon, B., Giasson, G., Gaboury, I., Gaid, D., Noël De Tilly, V., Houle, L., Bourbeau, J., & Pomey, M.-P. (2022). Challenges and strategies for improving COPD primary care services in Quebec: Results of the experience of the Compas+ Quality Improvement Collaborative. International Journal of Chronic Obstructive Pulmonary Disease, Volume 17, 259–272. 

 Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28.

Capella 4050 Assessment 4