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NURS FPX 4050 Assessment 4 Final Care Coordination Plan

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    NURS FPX 4050 Assessment 4 Final Care Coordination Plan


    Capella university

    NURS FPX 4050 Coordinating Patient-Centered Care

    Prof. Name


    Final Care Coordination Plan Evaluation

    In this conclusive care coordination plan, we will assess the initial care coordination plan presented in Assessment 1, applying best practices identified in scholarly sources and focusing specifically on Chronic Obstructive Pulmonary Disease (COPD) healthcare issues. This comprehensive plan emphasizes the development of patient-centered health interventions, accounting for ethical considerations, the impact of health policy, care coordinator priorities, and alignment with the Healthy People 2030 strategy.

    Timelines and Patient-Centered Interventions for COPD Healthcare

    Patient-centered health interventions for COPD necessitate an integrated approach addressing various aspects such as symptom control, lifestyle adjustments, education, and support. Timelines for interventions may vary based on disease severity and individual patient needs. The following interventions are proposed for COPD management, each assigned a specific timeline to ensure timely and effective care.

    1. Awareness and Education (Timeline: Initial 3 months):
      • Primary patient-centered intervention focusing on raising awareness about COPD, its symptoms, causes, and progression.
      • Regular patient education on relevant medical issues, including smoking cessation, physical activity, and medication adherence.
      • Emphasizes self-management plans in line with National Institute for Health and Care Excellence (NICE) recommendations (Boyer, 2023).
      Community resources: Community centers, nonprofit organizations (e.g., American Lung Association), and local healthcare professionals.
    2. Medication Adherence (Timeline: 3-6 months, followed by annual sessions):
      • Key intervention ensuring patients adhere to prescribed medications through educational sessions and reminders.
      • Utilizes mobile applications, local support groups, and telemedicine services for effective medication adherence.
      Community resources: Mobile application specialists, local support groups, and telemedicine services.
    3. Pulmonary Rehabilitation (Timeline: 6-12 months after diagnosis):
      • Organized exercise regimens to enhance lung capacity, stamina, and overall quality of life.
      • Available in home-based, community-based, and hospital settings, addressing individual challenges to encourage adherence.
      Community resources: Fitness centers, rehabilitation support groups, and hospital-based rehabilitation programs (Barata et al., 2022).

    Ethical Considerations in Patient-Centered Health Interventions

    Developing interventions for COPD requires careful consideration of ethical principles. Awareness and education interventions must prioritize fairness, equity, and destigmatization, incorporating experiences of individuals with COPD to foster empathy (Woo et al., 2021).

    Medication adherence interventions should align with ethical principles such as long-term patient wellness and minimizing potential negative outcomes. Pulmonary rehabilitation interventions must uphold ethical values like patient autonomy and informed consent, respecting individual health conditions (George & Bender, 2019; Martinez-Martin et al., 2021).

    Health Policy Implications for Care Coordination

    Effective patient-centered health interventions necessitate alignment with relevant health policy provisions. The Affordable Care Act (ACA) and the Family Smoking Prevention and Tobacco Control Act play pivotal roles in supporting COPD patients through expanded Medicaid programs, emphasizing preventative care, and implementing smoke-free policies (Bhadra et al., 2021; Stallings-Smith et al., 2019).

    Priorities and Evidence-Based Changes in Care Coordination

    Care coordinators must prioritize literacy about COPD, ensuring open communication and engagement to overcome cultural and linguistic barriers. Evidence-based changes involve optimal care plans, telehealth monitoring, and adapting care plans based on patient conditions (Handtke et al., 2019; Guerra-Paiva et al., 2021).

    Aligning Learning Sessions with Best Practices and Healthy People 2030

    Learning sessions should align with Healthy People 2030 objectives, emphasizing evidence-based interventions like awareness and education, medication adherence, and pulmonary rehabilitation. Continuous evaluation and adjustments ensure that learning sessions effectively address COPD management goals (Aliakbari, 2022).


    This COPD care coordination plan underscores the importance of patient-centered interventions, ethical considerations, and alignment with health policy and best practices. Care coordinators, by establishing priorities and implementing evidence-based changes, can enhance the quality of care for COPD patients. The alignment of educational sessions with best practices and Healthy People 2030 goals ensures ongoing relevance and effectiveness of interventions.


    Aliakbari, F., Tavassoli, E., Alipour, F. M., & Sedehi, M. (2022). Promoting health literacy and perceived self-efficacy in people with chronic obstructive pulmonary disease. Iranian Journal of Nursing and Midwifery Research, 27(4), 331.

    Barata, P. I., Crisan, A. F., Maritescu, A., Negrean, R. A., Rosca, O., Bratosin, F., Citu, C., & Oancea, C. (2022b). Evaluating Virtual and Inpatient Pulmonary Rehabilitation Programs for Patients with COPD. Journal of Personalized Medicine, 12(11), 1764.

    Bhadra, R., Bhattacharya, S., D’Souza, G. A., Schols, A. M. W. J., & Sambashivaiah, S. (2021). Pulmonary rehabilitation in the management of chronic obstructive pulmonary disease among asian indians- current status and moving forward. COPD: Journal of Chronic Obstructive Pulmonary Disease, 1–6.

    NURS FPX 4050 Assessment 4 Final Care Coordination Plan

    Boyer, P. (2023). What are the benefits of using self-management plans for COPD patients in the community: a critical review of the literature. British Journal of Community Nursing, 28(1), 22–32.

    George, M., & Bender, B. (2019). New insights to improve treatment adherence in asthma and COPD. Patient Preference and Adherence, 13, 1325–1334.

    Guerra-Paiva, S., Dias, F., Costaa, D., Santos, V., & Santos, C. (2021). DPO2 Project: Telehealth to enhance the social role of physical activity in people living with COPD. Procedia Computer Science, 181, 869–875.

    Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE, 14(7), 1–24. (n.d.). Reduce deaths from COPD in adults — RD‑05 – Healthy People 2030 |

    Martinez-Martin, N., Luo, Z., Kaushal, A., Adeli, E., Haque, A., Kelly, S. S., & Milstein, A. (2021). Ethical issues in using ambient intelligence in health-care settings. The lancet digital health, 3(2), e115-e123.

    NURS FPX 4050 Assessment 4 Final Care Coordination Plan

    Stallings-Smith, S., Hamadi, H. Y., Peterson, B. N., Apatu, E. J. I., & Spaulding, A. C. (2019). Smoke-Free Policies and 30-day readmission rates for Chronic Obstructive Pulmonary Disease. American Journal of Preventive Medicine, 57(5), 621–628.

    Woo, S., Zhou, W., & Larson, J. L. (2021). Stigma experiences in people with Chronic Obstructive Pulmonary Disease: An integrative review. International Journal of Chronic Obstructive Pulmonary Disease, 16, 1647–1659.