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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


    Government Coordination Plan 

    This assessment aims to evaluate the initial care coordination plan produced in Assessment 1  using evidence-based approaches from the existing literature. This plan deals with the health care challenges of heart disease, a significant public health issue in the United States. The plan was developed with the care coordinator, the patient, and their family. Any changes to the plan will be based on evidence-based methods and adhere to the criteria set in “Healthy People 2030.” This comprehensive approach supports the development of an effective and well-informed care coordination strategy.

    Patient-Centered Health Interventions and Timelines

    Patient-centered health interventions and timelines are crucial to the heart disease final care coordination plan. Healthcare practitioners can help patients manage their disease, enhance their quality of life, and lower their risk of complications by designing a plan that is personalized to the particular needs and goals of the patient. Heart disease is one of the significant health problems caused by some health care issues like lack of health care access, poor lifestyle, and lack of mental and emotional support.

    Lack of Healthcare Access

    Heart disease is a significant public health concern; however, not everyone has equal access to healthcare resources and services. Developing a patient-centered health coordinated plan like a Heart Disease Screening and Education Program is essential to address the lack of healthcare access for heart disease. This plan lasts a year, and in the first two months, it is determined which groups of people are most impacted by a lack of healthcare access to care for heart disease. Collecormation about the prevalence and risk factors for heart disease in the community.

    Months 3 to 4 focus on coordinating with local health care providers, clinics, and community organizations to achieve the goals. Look for financial assistance from local government or health care organizations to start the process. Months 5 and 6 involve developing and sharing educational materials on heart disease prevention and access to care. Conduct community workshops and seminars on the prevention and early diagnosis of heart disease. During 7 to 9 months, organize free or low-cost heart disease screenings in accessible community areas. Create a referral system to connect those at risk with relevant healthcare professionals.

    Finally, in the months ten to twelve, monitor the program’s success, collect participant feedback, and adjust to enhance access to heart disease care if necessary. To address the healthcare access gaps for heart disease, promote the community health centers, connect the community with NGOs such as the American Heart Association, and introduce local transportation services to the community that assist people in receiving necessary care. These resources seek to ensure that everyone has easy access to cardiac care (Ferreira et al., 2019).

    Poor Lifestyle

    Poor lifestyle choices like inadequate diet, smoking and alcohol consumption, and physical inactivity are leading factors that contribute to heart disease. Developing a patient-centered health coordinated plan like the Healthy-Heart Living Program is essential to address the poor lifestyle that causes heart disease. It starts with months 1-3 to identify the at-risk heart disease patients. In months 4-6, monthly educational workshops are arranged that cover nutrition, personal exercise, quitting smoking, and stress management by focusing on cultural sensitivity. During months 7-9, introduce a program “Walk to Wellness” to promote physical activity and start a smoking quitting initiative with regular support meetings. In Months 10-12, promote healthy eating classes that emphasize heart-healthy recipes and portion control.

    Stress reduction workshops are also promoted for mindfulness and relaxation techniques. Introduce the community to local  Young Men’s Christian Association YMCAs and centers that provide affordable fitness programs and nutrition options. Connect the persons with community health clinics that offer preventive care and support, including smoking quitting programs, nutrition counseling, and mental health services. Introduce online heart-healthy apps and websites to the community to facilitate access to exercise routines, healthy recipes, and stress reduction techniques. These resources allow the community to address poor lifestyle factors related to heart disease to promote overall well-being (Krishnamurthi et al., 2023).

    Lack of Mental and Emotional Support

    A lack of mental and emotional support can significantly impact heart disease. Heart disease patients may experience stress, anxiety, and depression. To overcome this, develop a patient-centered health coordinated plan for one year, like the Heart-Strong Community Support Program, to address the mental and emotional support that causes heart disease. In months 1-3, develop support groups for heart disease and monthly workshops about mental health in collaboration with professionals to address stress, anxiety, and depression. In months 4-6, introduce the mentoring programs for emotional support, fostering regular check-ins and weekly sessions to manage stress.

    During the months 7-9, organize support sessions for family and caregiver to address their emotional needs. The community awareness campaign is run to reduce marks around mental health in heart disease. Collaborating with local clinics ensures that mental health services are accessible to everyone. In months 10-12, focus on continuous program evaluation and participant feedback to ensure ongoing improvements. This plan aims to provide crucial emotional support for heart disease patients and their families throughout the year. Introduce the community with resources like heart disease support groups that offer a secure space for patients to share their experiences and get emotional support.

    Promotes mental health clinics in the community that provide specialized therapy and counseling of patients for emotional challenges bound to chronic illnesses such as heart disease. Promoting mental health helplines to the community that offers instant and confidential emotional support to patients during times of distress. These resources collectively address the lack of mental and emotional support, contributing to better heart disease management and overall well-being (Sivak et al., 2021).

    Ethical Decisions in Designing Patient-Centered Health Interventions

    Indeed, patient-centered care is an ethical and effective treatment method with specific consequences for healthcare staff. It might be understood as recognizing the patient as the primary entity equally participating in therapy and decision-making. When dealing with the patient’s personal information, healthcare staff must be conscientious. Patients are treated equally in patient-centered care treatment when treatment decisions are made. There is no privacy between the patient and the healthcare adviser to ensure the best treatment while respecting the patient’s requirements and needs. Healthcare personnel and physicians must be ethical and professional enough to work toward the betterment of their patients rather than exposing personal information about them (Tomaselli et al., 2020).

    The ethical principle of “Justice” is incorporated into the Heart Disease Screening and Education Program by assuring that the collecting data is equitable, the resources are appropriately allocated, and the health care services are accessible to everyone. This principle guides fair collaboration, culturally competent education, and unbiased screening and referral systems by ensuring all community members have access to cardiac care resources and services equally. There are some uncertainties about the availability of resources, program effectiveness, screening uptake, referral system efficiency, and sustainability that must be addressed to implement a successful plan(Ferreira et al., 2019). The “Autonomy” and “Beneficence” ethical concepts are incorporated into the Healthy-Heart Living Program. Respecting individuals’ choices and cultural sensitivity is part of autonomy.

    Capella 4050 Assessment 4

    In contrast, Beneficence supports their well-being through education, assistance, and access to resources for a better lifestyle. Some uncertainties related to cultural sensitivity, efficacy, informed decision-making, and resource allocation must be addressed (Krishnamurthi et al., 2023). The “Beneficence” ethical principle is incorporated into the Heart-Strong Community Support Program. This principle underlines the program’s dedication to improving the well-being of heart disease patients and their families through emotional and mental support, support groups, mentoring programs, and access to mental health resources. There are some uncertainties about the program’s effectiveness, resource allocation, access, measurement, and privacy that must be addressed carefully during implementation.  (Sivak et al., 2021).

    Health Policy Implications for the Coordination and Continuum of Care

    A suggested health policy for coordinated care of patients is The “Million Hearts” initiative, which has a clear mission: preventing a million cardiovascular events, including heart attacks and strokes. It offers valuable guidance and resources to empower individuals to manage their healthcare access to heart clinics, adopt healthier lifestyles by reducing unhealthy diets and physical inactivity, and quit smoking. Care coordinators can utilize these recommendations and resources to craft evidence-based interventions in alignment with national health objectives. 

    These aim to improve heart disease prevention, management, and general well-being by addressing gaps in health care access, poor lifestyle choices, and a lack of mental and emotional support in the community (Wall et al., 2020). This policy promotes an active approach to healthcare by focusing on preventing cardiovascular events and promoting healthier lifestyles. Care coordinators can use the initiative’s guidelines and tools to ensure that patients receive constant evidence-based treatment during their care. This policy supports to improved care coordination and continuum of care for heart disease prevention and management by addressing gaps in healthcare access, treating risk factors related to lifestyle, and promoting community support for individuals.

    Priorities of Care Coordinator for Plan Discuss 

      After discussing the overview of the plan with the patient family and changes made by evidence-based practice, a healthcare practitioner would prioritize the following essential aspects:

    • Ensure that the care plan focuses on the patient and actively involves the patient and a family member in decision-making by considering their preferences, values, and treatment goals. According to evidence-based practice, patient involvement leads to higher outcomes and satisfaction (Fernandes et al., 2020).
    • To increase the possibility of positive outcomes, integrate mental health assistance into care plans, given an important link between mental health and cardiac disease. Adopt evidence-based strategies for stress, anxiety, and depression. Addressing mental health alongside physical health is critical, as emotional well-being plays a vital role in heart disease management (Kovacs et al., 2022).
    • Provide easy access to resources such as community health centers, support groups, transportation services, and technology-based health management tools. Access obstacles can hinder patients from utilizing available services, and reducing these barriers improves their ability to engage in care (Lopez et al., 2022).

    Evaluation Learning Session with Best Practices and to the Healthy People 2030

    To integrate learning sessions with best practices and Healthy People 2030 objectives for heart disease, evidence-based practices must be prioritized. These sessions should be prepared using scientifically approved ways to ensure their effectiveness in educating people about heart disease prevention and management. Furthermore, focusing on the Healthy People 2030 objectives, which aim to minimize heart disease-related mortality and improve lifestyle and mental and emotional support in adults, can guide the content and aims of these learning sessions.

    #To effectively engage participants, sessions must be tailored to the requirements and expertise levels of the target audience. Understanding their basic knowledge of heart disease can help deliver relevant and informative content. Making the sessions exciting and interactive is also essential for keeping participants interested. Various instructional approaches, such as talks, group activities, and hands-on demonstrations, can improve the learning experience. Nurses and health care professionals were able to establish improved strategies and treatment plans for heart disease patients by ranking the data obtained through this program.

    These strategies include determining criteria for treating heart illness as well as reducing the related issues (Teitelbaum et al., 2021). Enhance the lack of healthcare access, refine the poor lifestyle, and arrange the support of mental and emotional programs are used in the treatments. These treatments improve patient care and nursing staff competency and teamwork, resulting in a more effective healthcare environment.


    In conclusion, it showed that Patient-centered health interventions for heart disease are guided by ethical considerations and associated with health policies like the “Million Hearts” policy. These interventions promote patient involvement in treatment, mental health assistance, and equal access to resources. These treatments are aligned with the Healthy People 2030 goals that aim to minimize heart disease-related mortality and increase overall well-being by addressing healthcare access, lifestyle factors, and emotional support.


    Ferreira, J. P., Kraus, S., Mitchell, S., Perel, P., Piñeiro, D., Chioncel, O., Colque, R., de Boer, R. A., Gomez-Mesa, J. E., Grancelli, H., Lam, C. S., Martinez-Rubio, A., McMurray, J. J., Mebazaa, A., Panjrath, G., Piña, I. L., Sani, M., Sim, D., Walsh, M., & Yancy, C. (2019). World heart federation roadmap for heart failure. GLOBAL HEART, 14(3), 197–214.  

    Fernandes, S. M., Marelli, A. J., Hile, D. M., & Daniels, C. J. (2020). Access and delivery of adult congenital heart disease care in the United States. 38(3), 295–304.  

    Krishnamurthi, N., Schopfer, D. W., Shen, H., Rohrbach, G., Elnaggar, A., & Whooley, M. A. (2023). Association of home‐based cardiac rehabilitation with lower mortality in patients with cardiovascular disease: Results from the veterans health administration healthy heart program. Journal of the American Heart Association, 12(5).  

    Kovacs, A. H., Brouillette, J., Ibeziako, P., Jackson, J. L., Kasparian, N. A., Kim, Y. Y., Livecchi, T., Sillman, C., & Kochilas, L. K. (2022). Psychological outcomes and interventions for individuals with congenital heart disease: A scientific statement from the american heart association. Circulation: Cardiovascular Quality and Outcomes, 15(8).

    Capella 4050 Assessment 4

    Lopez, K. N., Baker‐Smith, C., Flores, G., Gurvitz, M., Karamlou, T., Nunez Gallegos, F., Pasquali, S., Patel, A., Peterson, J. K., Salemi, J. L., Yancy, C., & Peyvandi, S. (2022). Addressing social determinants of health and mitigating health disparities across the lifespan in congenital heart disease: A scientific statement from the american heart association. Journal of the American Heart Association, 11(8).  

    Sivak, L., O’Brien, M., Paolucci, O., Wade, V., Lizama, C., Halkon, C., Enkel, S., Noonan, K., & Wyber, R. (2021). Improving the well‐being for young people living with rheumatic heart disease: A peer support pilot program through Danila Dilba Health Service. Health Promotion Journal of Australia, 33(3).  

    Teitelbaum, J., McGowan, A. K., Richmond, T. S., Kleinman, D. V., Pronk, N., Ochiai, E., Blakey, C., & Brewer, K. H. (2021). Law and policy as tools in Healthy People 2030. Journal of Public Health Management and Practice, Publish Ahead of Print.  

    Tomaselli, G., Buttigieg, S. C., Rosano, A., Cassar, M., & Grima, G. (2020). Person-centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: A scoping review. Frontiers in Public Health, 8(44).  

    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.  

    Capella 4050 Assessment 4