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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 for Stroke

    A preliminary care coordination plan is a crucial first step in ensuring that patients with stroke receive safe, effective, and efficient care. This plan involves developing strategies and protocols to address the physical, psychosocial, and cultural considerations that are unique to each patient. It further involves identifying available community resources that can support the patient’s recovery and promote continuity of care (Camicia et al., 2021). The plan should be developed in collaboration with the interdisciplinary team and involve ongoing communication and monitoring to ensure its effectiveness and meet the patient’s needs.

    Available community resources that can support stroke care coordination include the American Heart Association, the National Stroke Association, community health centers, senior centers, transportation services, home health services, financial assistance programs, and faith-based organizations. Overall, a well-developed preliminary care coordination plan is a critical component of providing high-quality stroke care.

    Health Concern and Evidence-Based Practice

    As a nurse in a community care center, it’s important to develop a comprehensive care coordination plan that addresses physical, psychosocial, and cultural considerations, as well as available community resources. In this plan, best practices for stroke care will be supported by credible evidence, and underlying assumptions and points of uncertainty will be articulated.

    Physical Consideration

    Physical considerations play a crucial role in care coordination for stroke patients. They involve rapid recognition and assessment of stroke symptoms, timely transport to the appropriate stroke center, and implementation of evidence-based stroke protocols. The American Heart Association and American Stroke Association recommend several best practices.

    These include using the FAST (Face, Arm, Speech, Time) tool to identify and evaluate stroke symptoms promptly, collaborating with Emergency Medical Services (EMS) to ensure rapid transport of patients to the nearest appropriate stroke center, implementing evidence-based stroke protocols such as the administration of thrombolytic therapy and neuroprotective measures, monitoring vital signs, neurological status, and oxygen saturation to detect and manage complications, and collaborating with interdisciplinary teams, including physical, occupational, speech therapies, and nutritionists, to provide comprehensive care for stroke patients. This helps stroke care providers to  ensure optimal outcomes for their patients (Powers et al., 2019).

    Psychosocial Considerations

    Psychosocial considerations are an essential part of care coordination for stroke patients, as they involve addressing emotional needs, providing education and support for adjustment to stroke-related changes, and coordinating with social services for community resource access. The American Heart Association and American Stroke Association recommend best practices for effective psychosocial care. These include routine assessment of emotional needs, such as anxiety, depression, grief, and coping skills, and referring patients and families to resources, such as counseling or support groups. Additionally, they recommend providing education and support to promote adjustment to stroke-related changes, encouraging participation in rehabilitation activities to improve functional outcomes and promote independence, and coordinating with social services to assist with community resources, such as transportation, financial assistance, and home health services (Powers et al., 2019; Dirks et al., 2020).

    Cultural Considerations

    Cultural considerations are important in stroke care, as they involve respecting and acknowledging the cultural beliefs and practices of patients and families. To provide culturally appropriate care, healthcare providers must demonstrate cultural competence and sensitivity in their communication and interactions with patients and their families. This includes understanding the values, beliefs, and practices of different cultures and incorporating them into the care plan. Providers should also be aware of cultural and linguistic barriers that may affect the quality of care provided to patients.

    Collaborating with interpreters or cultural brokers as needed can ensure accurate communication and understanding of health information. Healthcare providers should consider these factors when developing a care plan and promoting stroke prevention. Providing culturally appropriate education and resources can improve patient and family engagement in care, enhance understanding of stroke prevention and treatment, and promote better outcomes. 

    Goals to Address Selected Healthcare Problem

    Stroke is a serious health concern that requires effective management to prevent complications and improve outcomes. To address this health care problem, specific goals need to be established that are realistic, measurable, and attainable. The goals should aim to prevent complications, encourage patient and family involvement in healthcare, promote community awareness and education, and provide culturally appropriate education and resources. The goals can be multi-faceted, including minimizing the incidence of complications and improving outcomes for stroke patients by implementing evidence-based stroke management protocols that adhere to established guidelines.

    It is important to encourage patient and family involvement in healthcare decision-making to help them understand their medical conditions and their management (Korompoki et al., 2020). Increase community awareness about stroke prevention and treatment by raising awareness about the risk factors for stroke, promoting healthy lifestyle choices, and providing information about the signs and symptoms of stroke. Providing culturally appropriate education and resources to ensure that the needs of diverse populations are met is also an important aspect (Caspersen et al., 2019)

    Capella 4050 Assessment 1

    Following are some of the SMART goals for stroke patients:

    • By implementing a standard protocol for cooperation with EMS, 20% more patients will be transported promptly to the proper stroke centre over the course of the following six months.
    • By giving ongoing education and training to healthcare professionals, there will be a 15% increase in the number of patients getting evidence-based stroke protocols. 
    • Implementing a standardised screening tool and recommendation procedure will increase the number of routine assessments of emotional needs and referrals to suitable resources for psychosocial support by 25% over the course of the following four months.
    • It will be possible to increase the amount of culturally relevant education and resources by 30% within a year by working with community organisations and cultural leaders.
    • Adopting monitoring procedures for vital signs, neurological status, and oxygen saturation within the next year to cut the proportion of stroke patients experiencing complications during hospitalisation by 10%.

    Available Community Resources

    Community resources play a vital role in ensuring a safe and effective continuum of care for stroke patients. Support groups, healthcare services, and community organizations are significant resources that can help patients and their families manage their conditions and improve their health outcomes. For instance, the American Stroke Association provides resources and support groups for stroke patients and their families. These groups offer information, education, and emotional support, which can help patients cope with the challenges of stroke and improve their quality of life (American Stroke Association, 2021). Home health services provide skilled nursing care, wound care, and medication management to aid in recovery and prevent complications. Outpatient clinics offer ongoing care and education to prevent recurrent strokes.

    Furthermore, community organizations can play a crucial role in stroke prevention and education. For example, the National Stroke Association provides education and resources on stroke prevention, risk factors, and warning signs. They also offer support groups and a helpline for stroke survivors and their families. Additionally, community-based programs such as blood pressure screenings, smoking cessation programs, and exercise classes can promote healthy behaviors and reduce the risk of stroke in high-risk populations (National Stroke Association, 2021).


    Developing a preliminary care coordination plan for stroke is crucial to ensure that patients receive timely, safe, and effective care. Such a plan should address physical, psychosocial, and cultural considerations, and should involve collaboration with the interdisciplinary team and available community resources. stroke care coordination can lead to better outcomes for patients and families, as well as contribute to reducing the overall burden of stroke on the healthcare system and society as a whole.


    American Heart Association. (2021). About stroke. 

    Caspersen, N. S., et al. (2019). Association between dietary patterns and risk of stroke in a Danish cohort: the Danish Diet, Cancer and Health cohort study. British Journal of Nutrition, 122(5), 555-563. 

    Camicia, M., Lutz, B., Summers, D., Klassman, L., & Vaughn, S. (2021). Nursing’s role in successful stroke care transitions across the continuum: from acute care into the community. Stroke, 52(12), e794-e805. 

    Dirks, M., et al. (2020). Implementation of a multidisciplinary care pathway for stroke patients in an integrated healthcare setting: a cohort study evaluating feasibility and effectiveness. BMC Neurology, 20(1), 1-12. 

    Gilligan, T., Ayala, C., Williams, O., & Lackland, D. (2021). Race, ethnicity, and stroke care: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 52(2), e10-e22. 

    Korompoki, E., et al. (2020). Stroke prevention and management in low-income and middle-income countries: a call to action. The Lancet Neurology, 19 

    Powers, W. J., et al. (2019). 2019 update to the guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50(12), e344-e418. 

    Capella 4050 Assessment 1