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 for Stroke Patients
Care coordination is vital in the continuum of care, especially for patients with complex care needs (Karam et al., 2021). The main objective of coordinating care is to achieve better health outcomes at the lowest costs of care possible. Care coordination achieves this by eliminating care provision silos and scattered procedures that affect timely care delivery. Stroke is a disease that results from reduced blood supply to parts of the brain. It can occur as an ischemic stroke or as a hemorrhagic stroke. People with high blood pressure, smoking habits, high cholesterol, diabetes, and atrial fibrillation have the highest risk of stroke attacks (Boehme & Esenwa, 2018). Stroke attacks, especially hemorrhagic strokes, can result in death, disability, and other complications that impact the patient’s quality of life. Stroke is the second leading cause of death globally and the third cause of global disability (Hay et al., 2017). Care coordination is, therefore, essential in the management of stroke patients.
Health Care Issues Related to Stroke
Stroke survivors experience severe healthcare issues that require coordinated care, including paralysis, clinical depression, and aphasia. Paralysis after a stroke is related to loss of muscle function and muscle movement. Post-stroke paralysis may cause overall muscle and body immobility (McGlinchey et al., 2018). Patients may experience paralysis on a particular side of the body and loss of muscle control on multiple parts of the body. Extended immobility affects all aspects of daily living and may lead to other complications, such as the inability to speak, eat, sleep, and bladder dysfunction, among other related functional complications (Lui & Nguyen, 2018).
Clinical depression is another serious healthcare issue related to stroke. Post-stroke depression is associated with a majority of poor quality-of-life outcomes (Medeiros et al., 2020). Patients experiencing depression are likely to feel sad, easily irritated, develop difficulties concentrating, and experience health-impacting changes in sleep and food appetite (Lui & Nguyen, 2018). Patients may also express feelings of emptiness, self-worthlessness, and helplessness, leading to further complications and issues such as suicidal thoughts and suicide attempts.
Aphasia is the reduced ability of stroke survivors to communicate effectively (Rohde et al., 2018). The patient experiences issues with speech, such as the expression of words or understanding expressions. It results from the damage of certain parts of the brain post-stroke attack, with others due to brain damage after a stroke. Aphasia can complicate the treatment process of stroke patients with a negative impact on their daily living. Aphasia can lead to secondary and tertiary healthcare issues of concern, such as isolation.
Interventions for Stroke-Related Health Care Issues
The interventions for post-stroke healthcare issues require multidisciplinary professional inputs and efforts to manage. Interventions for post-stroke paralysis must focus on supporting the patient in their daily living. According to McGlinchey et al. (2018), interventions need to focus on rehabilitating and optimizing physical function to manage immobility-related complications better. The interventions for paralysis are physical therapy, including assisted and self-performed movements. The interventions also consider the diet of the patient during the recovery process.
Patients recovering from stroke and experiencing clinical depression require psychological treatments such as psychotherapy and counselling (Medeiros et al., 2020). Post-stroke depression hurts the recovery of the stroke patient. Psychosocial therapy interventions for clinical depression and related complications require diagnosis and treatment from certified mental health providers. In addition, the management of aphasia in the continuum of stroke care requires accurate diagnosis, including both informal and formal speech assessments (Rohde et al., 2018); speech therapy is the best recommended intervention for aphasia.
Available Community Resources for Health Care Issues
The optimization of the coordinated care for stroke patients requires the integration of community resources into the care coordination plan to support the recovering patient and related caregivers. The integration of community resources includes the use of community-based interventions to facilitate patient recovery, including the community in the recovery process and raising awareness of stroke and stroke survivors (Magwood et al., 2020).
Community resources are available throughout the United States to support stroke recovery. The US has well-equipped adult daycare centres, meal programs, home heal