Introduction

NURS FPX 6203 Assessment 4 Final Care Coordination Plan is a systematic, patient-focused process specifically tailored to address complex health requirements through extensive planning, collaboration, and communication. The plan is designed to treat the overall needs of patients with chronic conditions—in this case, a patient with congestive heart failure (CHF)—and coordinate care delivery with evidence-based best practices.

Patient Profile Summary

  • Name: Mr. John Smith
  • Age: 70 years
  • Diagnosis: Chronic heart failure, hypertension, Type 2 diabetes
  • Challenges: Recurrent hospital readmissions, medication non-adherence, poor mobility, low health literacy

Health Concerns and Goals

Primary Health Concerns:

  • CHF symptom control
  • Medication adherence
  • Glycemic control
  • Blood pressure control
  • Dietary adherence

Patient-Centered Goals:

  1. Reduce CHF-related readmissions in 6 months.
  2. Maintain blood glucose in target range (90–130 mg/dL fasting).
  3. Take prescribed medications and diet plan 90% of the time.

Evidence-Based Care Coordination Plan

1. Medication Management

  • Weekly pill box and pharmacist-ordered medication reconciliation
  • Nurse-initiated telephonic monitoring for assistance with adherence
  • Use of mobile health apps as reminders and education
Evidence: Medication compliance improves with pharmacist visits and nurse follow-ups (Odegard & Capoccia, 2020).

2. Diet and Nutrition

  • Consult with a dietitian for a heart-healthy, low-sodium, and diabetic diet
  • Provide educational handouts in lay language
  • Engage family members for shopping and meal preparation support
? CDC Heart-Healthy Diet Resources

3. Physical Activity

  • Consult physical therapy for a tailored exercise regimen
  • Home walking program with monitoring of progress
  • Use of pedometer or mobile health tracker to encourage activity

4. Self-Management and Health Literacy

  • Teach-back method to confirm patient understanding
  • Individualized, culturally tailored education materials
  • Bilingual nurse educator to meet language needs

5. Interprofessional Collaboration

  • Biweekly interdisciplinary team meetings that include:
    • Primary care physician
    • Nurse case manager
    • Social worker
    • Dietitian
    • Pharmacist

Coordination Tools:

  • Shared electronic care plans
  • Secure messaging system between team members

Community Resource Support

Referrals:

  • Home Health Services: Nursing visits for medication management and vital signs initiation
  • Meals on Wheels: Heart-healthy meals delivered to the home
  • Community Diabetes Program: Free glucose monitoring kits and workshops
  • Transportation Assistance: Local nonprofit rides to appointments
? Find Local Resources – Aging & Disability Resource Centers (ADRC)

Evaluation and Follow-Up

Metrics:

  • CHF symptoms tracked by telehealth
  • Medication refill rates
  • Blood glucose records
  • Hospital readmission rates

Follow-Up Plan:

  • 30-day, 60-day, and 90-day nurse home visits
  • Quarterly interdisciplinary reviews
  • Outcome trend and patient feedback-driven adjustments

How To: Develop a Care Coordination Plan

  1. Conduct a thorough patient assessment
  2. Establish goals with the patient
  3. Collaborate with interprofessional team members
  4. Establish connections to local resources and support
  5. Monitor progress and make adjustments to care as needed

FAQs