Running head: FINAL CARE COORDINATION PLAN
1
Final Care Coordination Plan
Jennifer Bruce
Capella University
Coordinated Patient Centered Care
June 2020
, FINAL CARE COORDINATION PLAN 2
Final Care Coordination Plan
Stroke is the number five cause of death and leading cause of disability in the United
States. Mrs.G.T. is a 72-year old female with a past medical history of hypertension and type 2
diabetes mellitus. She recently suffered a stroke and is getting ready to be discharged home from
acute rehabilitation. Prior to her stroke she lived alone, and her son believes that it will be best
for her to move in with him and his wife. We will be meeting today to discuss the
implementation of a care coordination plan.
Coordination of care assist with continuity of care once a patient is discharged home. The
purpose of care coordination is to organize Mrs.G.T.’s services to deliver safe effective care,
ensure all her and her family’s needs are met, reduce the chance of rehospitalization, eliminate
fragmented care, and improve her outcomes. I will address her current stroke along with her
history of hypertension and type 2 diabetes mellitus. I will also discuss; ethical decisions as they
relate to designing patient-centered health interventions, how to identify relevant health policy
implications for the coordination and continuum of care, how care coordination is evaluated,
patient satisfaction versus experience, and Healthy People 2020.
Patient-Centered Health Interventions and Timelines for Care
The American Stroke Association states that one in four stroke survivors will suffer from
another. The purpose of care coordination is to have the proper interventions and resources to
prevent or reduce the likelihood of that happening. Mrs. G.T. has already chosen her home health
therapy providers and follow up care with the Neurologist has been established. Within the first
week of plan implementation Mrs. G.T. will register for a stroke education and support group.
Stroke education is an important resource because it identifies healthy eating habits, exercise
programs, and provides information on signs and symptoms of another stroke. Johnson et al.
1
Final Care Coordination Plan
Jennifer Bruce
Capella University
Coordinated Patient Centered Care
June 2020
, FINAL CARE COORDINATION PLAN 2
Final Care Coordination Plan
Stroke is the number five cause of death and leading cause of disability in the United
States. Mrs.G.T. is a 72-year old female with a past medical history of hypertension and type 2
diabetes mellitus. She recently suffered a stroke and is getting ready to be discharged home from
acute rehabilitation. Prior to her stroke she lived alone, and her son believes that it will be best
for her to move in with him and his wife. We will be meeting today to discuss the
implementation of a care coordination plan.
Coordination of care assist with continuity of care once a patient is discharged home. The
purpose of care coordination is to organize Mrs.G.T.’s services to deliver safe effective care,
ensure all her and her family’s needs are met, reduce the chance of rehospitalization, eliminate
fragmented care, and improve her outcomes. I will address her current stroke along with her
history of hypertension and type 2 diabetes mellitus. I will also discuss; ethical decisions as they
relate to designing patient-centered health interventions, how to identify relevant health policy
implications for the coordination and continuum of care, how care coordination is evaluated,
patient satisfaction versus experience, and Healthy People 2020.
Patient-Centered Health Interventions and Timelines for Care
The American Stroke Association states that one in four stroke survivors will suffer from
another. The purpose of care coordination is to have the proper interventions and resources to
prevent or reduce the likelihood of that happening. Mrs. G.T. has already chosen her home health
therapy providers and follow up care with the Neurologist has been established. Within the first
week of plan implementation Mrs. G.T. will register for a stroke education and support group.
Stroke education is an important resource because it identifies healthy eating habits, exercise
programs, and provides information on signs and symptoms of another stroke. Johnson et al.
