Care Coordination Plan

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Heart disease is one of the chief causes of death in the United States of America. It takes the lives of 659,000 people every year in the USA. Proper management and care plans for this disease can decrease the mortality rate and ensure the availability of better services to the patients. A better care plan involves the coordination between the nurse staff members, physicians, and all the concerned participants of health care workers to provide appropriate, safe, and effective care to the patients. This paper discusses the importance of coordination plans for heart diseases and various physical, psychological, and cultural considerations for this selected health care problem. It further illustrates the specific goals to address health care problems and community resources available for a safe and effective continuum of care.

Care Coordination Plan for heart disease

Care coordination is considered a highly specific and targeted plan designed to benefit the patients. Such a coordinated system is well aware of the patients' needs beforehand, and this information is transferred to the respective stakeholders at the right time for effective treatment. The communication gap between the primary care centers and concerned departments is the major hurdle in achieving the goals of improved care provision to the patients. The specialists to whom patients are referred from the primary care centers do not receive the adequate information required for the appropriate treatment. This drawback is attributed to the lack of coordination between health care providers currently present.

The coordination plan aims at providing patient-centered care. It establishes communication between ambulatory care physicians and hospitals. New coordinated healthcare systems provide post-hospital support to the patients and fill all the communication gaps between the healthcare providers and the patients at the healthcare systems. It results in acquiring the ultimate goal of providing effective, safe, and appropriate care to the patients.

Associated Best Practices for Health Improvement

Some best practices that can be implemented for the health Improvement of a patient with heart diseases include:

· Compile data about patient's PMH and visit history

· Analyze the data and compare the results

· Set a goal and bring improvements in your care plan to provide timely and effective treatment to the patients.

· Involve the other members of the team in establishing care plans, listen to their suggestions, and acknowledge their efforts in the betterment of the health care services.

· Coordinate with other departments and design an individualized, patient-centered care plan.

Physical, social, and cultural considerations

The person's mental and physical health is directly influenced by the environment where he is born, lives, and grows into an adult. The environment does not include only the surroundings or the physical or chemical processes influencing a person's life, but various socioeconomic, ethical norms, and cultural aspects are also kept under consideration.

The American Heart Association and American College of Cardiology consider socioeconomic inequalities as the strong determinants of cardiovascular diseases. They should be addressed as seriously as smoking and other routine habits are addressed to control the community's blood pressure and cholesterol levels (Cervoni 2021). The medical care providers usually suggest that heart patients walk on a routine basis to maintain an ideal weight and burn excess calories, if a person does not feel safe in the environment he lives, he would prefer to stay at home. In that case, all medical advices will go to ashes, and the person may get overweight. Similarly, if a heart patient is advised to take a healthy diet but has no access to it, they will go for an unhealthy diet and further deteriorate their health (Penn 2019).

The person with an inadequate support system may feel isolated socially. They are more prone to suffer from stress which ultimately results in depression. Stress causes the release of stress hormones that raise the heart rate, increase blood pressure, clot the blood, and increase the chances of getting heart disease or heart attack. People with depression may miss their follow-ups and routine medications and, therefore, are more liable to get re-hospitalized (AHA. 2018). Social and cultural beliefs also play a part in determining health. An overweight person may have a misperception of his weight and may consider himself healthy due to some social and cultural beliefs influencing his insight.

All the concerned people in the health care system are supposed to work in a coordinated manner to overcome all these hurdles in the way of effective treatment. They are supposed to provide holistic care to the patients. As a care coordinator, I will be well acquainted with the patient's requirements and support the patient through the recovery process. I will communicate with interdisciplinary teams and design an individualized plan for a patient suffering from heart disease. I will strive to bridge the gap among health care workers working as a care coordinator for optimum health care delivery.

Assumptions and point of uncertainty

In this proposed care coordination plan, all the members of the health care team are assumed to be obedient and committed to their assigned roles. It is assumed that the team will avoid inter-personal conflicts for the greater good of the patients. However, the point of uncertainty is the negligence at the individual level that can harm the overall delivery of care coordination plan for heart disease. These uncertainties count as lack of skill, staff turnover and the non-serious attitude of on-duty staff.

Specific Goals to Address Health Care Problems

Heart disease is the leading cause of death in the USA. As a care coordinator, the main goal is to provide well-coordinated and targeted care to the patients and reduce the mortality rate due to the presenting health problem. This requires an individualized approach that assesses all the social, economical, psychological, and cultural aspects of society. It is the duty of a care coordinator to design a team-based care plan that involves ambulatory physicians, specialists, nurse staff, paramedical staff, nutritionists, psychiatrists, and community care centers that overcome all the problems a patient might face having a heart disease. A nurse should be able to communicate well with the patient and his family and guide them about preventive measures and post-hospital care to avert re-hospitalization (Penn 2019). As a care coordinator, I should have a complete record of the patient's past medical history and refer them to the specialty centers accordingly.

Available community resources

WISEWOMAN is a free screening and counseling program for heart diseases. It has provided its services to 150,000 women in the years between 2008 and 2013. WISEWOMAN funds 21 state health departments and 3 tribal organizations. 

Center for disease control and prevention (CDC), a national public health organization, aims to educate the community to prevent disease. It contributes a budget of 11.9 billion dollars yearly to fund organizations in the research and survey programs of various infectious and non-infectious diseases (CDC. (2021). American Heart Association (AHA) is another non-profit organization that provides information and awareness about the disease. It aids the people in better assessment of their problem and provides guidance about the treatment process.


AHA. (2018, April 18). American heart association recommendations for physical activity in adults and kids. Retrieved February 3, 2022, from

CDC. (2021, December 9). WISEWOMAN. Centers for disease control and prevention. Retrieved February 3, 2022, from

Cervoni, B. (2021). Normal cholesterol levels by age. verywell health. Retrieved February 3, 2022, from

Penn, A. (2019, October 11). Heart disease treatment:diet is better than surgery. Shortform. Retrieved February 3, 2022, from

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