To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Final Care Coordination Plan

Care coordination increases accountability among the stakeholders involved in patient care. Each member of the interdisciplinary team completes their unique role in patient care. As such, the quality of healthcare services is improved. Furthermore, care coordination promotes patient-centeredness because the stakeholders collaborate to address the unique needs of each patient. This paper evaluates a preliminary care coordination plan for patients with diabetes mellitus.

Patient-Centered Health Interventions and Timeline

Patients with diabetes mellitus are faced with various healthcare uses. They can be categorized into three: psychosocial, cultural, and physical healthcare issues. Examples of psychosocial problems this population faces include fear, distress, depression, anxiety, and changes in feeding habits. Fear and anxiety among these patients have been attributed to diabetic complications such as hypoglycemia (Kalra et al., 2018). People with diabetes are usually worried about both acute and chronic complications. Data indicate that people with diabetes are twice as risk for depression compared to the general population (Kalra et al., 2018). Depression is caused by the necessity for lifestyle modification that accompanies diabetes mellitus. Furthermore, these patients are likely to consider themselves a burden to their families (Kalra et al., 2018). Psychosocial problems worsen the prognosis of the disease by lowering patient adherence to treatment plans.

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Various psychotherapy interventions can be used to address psychosocial problems. They include cognitive behavior therapy, motivation, interpersonal therapy, family behavior therapy, and social rhythm therapy (Kalra et al., 2018). The timeline is three sessions per week for eight months. Examples of community resources that support psychosocial interventions include Four Rivers Behavioral Health, River Valley Behavioral Health, and NorthKey Community Care (Kentucky.gov, n.d.).

Lack of cultural congruence is the main cultural issue associated with diabetes mellitus. People from different ethnic backgrounds are affected by diabetes mellitus. Findings indicate that the highest incidences of the disease have been recorded among African Americans, Latinos, and American Indians, respectively (CDC, n.d.). As such, the healthcare workforce should embrace cultural sensitivity when managing these patients. They should respect patients’ beliefs and perspectives. Findings reveal that cultural sensitivity increases access to healthcare services because patients feel that they are understood and respected (Henderson et al., 2018). Cultural sensitivity can be achieved by initiating various strategies. Healthcare providers should collaborate with community contacts to understand patients’ cultures. Furthermore, they should conduct thorough research to learn about patients’ beliefs and perspectives (Henderson et al., 2018). Recruitment of language translators will eliminate language barriers between healthcare providers and patients. Regarding the timeline, cultural congruence should be upheld perpetually during healthcare service provision. Community resources include the Kentucky Diabetes Prevention and Control Program, Kentucky Diabetes Network, and Kentucky Health Collaborative (Kentucky.gov, n.d.).

Physical problems associated with diabetes mellitus emanate from the poor management of the disease. Both macrovascular and microvascular complications cause physical problems. Non-adherence to medication and lifestyle modification increases the risk of physical problems associated with diabetes mellitus (Martinez et al., 2019). Diabetic retinopathy is a microvascular complication associated with diabetes mellitus. Late diagnosis of this complication has a poor prognosis and can lead to blindness (Martinez et al., 2019). Diabetic neuropathy causes diabetic foot. Diabetic foot can be classified as neuropathic, ischemic, and neuro-ischemic (Martinez et al., 2019). Diabetic foot is the leading cause of amputation among people with diabetes (Martinez et al., 2019). These complications can be addressed via three major strategies. Patients should be educated on the importance of lifestyle modifications. This entails both dietary modification and physical activity (Martinez et al., 2019). The timeline is four sessions of both aerobic and anaerobic physical exercises per week. In addition, the second strategy is educating the patient on the importance of medication adherence, and the third is conducting routine screening exercises. Community resources include the Kentucky Diabetes Prevention and Control Program, the Kentucky Prescription Assistance Program, and the Kentucky Diabetes Network (Kentucky.gov, n