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Capella 4050 Assessment 1

Capella 4050 Assessment 1: Preliminary Care Coordination Plan


Capella university

NURS FPX 4050 Coordinating Patient-Centered Care

Prof. Name


Preliminary Care Coordination Plan

The need for care coordination is particularly increased when community healthcare centers go through severe budget cuts and lack case management staff. As a staff nurse, I was provided with this role of care coordination by my nurse manager. Taking this role of case management staff, I deem it important to first plan the care coordination relevant to the health needs of community individuals. The primary health concern as the focus of this care coordination plan is orthopedic concern particularly targeting hip replacement. This assessment will explore hip replacement as a health concern considering the physical, psychosocial, and cultural needs of patients followed by the identification of best practices to improve health in patients who undergo hip replacement. Moreover, I will establish SMART goals and identify community resources to establish an effective continuum of care for affected community people in this assessment.

Analysis of Health Concerns and Best Practices for Health Improvement

Hip replacement which is also known as hip arthroplasty is a surgical procedure that involves the replacement of some parts of the hip joint with artificial implants. Hip replacement is often required in people who have pain in their hips due to osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, osteonecrosis, and childhood hip disease. In cases of severe pain that limits everyday activities like walking or bending, hip replacement is the preferred intervention. The best practices identified for health improvement in hip replacement-affected populations will cover the population’s physical, psychosocial, and cultural needs.

Once the hip replacement is done, the patient will be immobilized for the first few weeks imparting the need for physical support. The nurses as caregivers will be required to provide patients with initial care treatment to manage pain in the first-week post-surgery. Moreover, physical therapists or mobility technicians are required to initiate early mobilization fulfilling their physical needs, and enhance the rehabilitation of hip replacement in affected patients (Mazzei et al., 2020). Various psychosocial factors affect recovery after hip arthroplasty (HA) such as depression, anxiety, resilience, and suffering in silence. These psychosocial needs must be addressed to improve health in patients with HA. Psychoeducation can be an effective intervention to address these psychosocial needs where the psychologist or nurses will educate patients with HA on coping strategies to improve their cognitive behavior therapy (Wei et al., 2020).

Capella 4050 Assessment 1

Every patient belongs to a certain culture and their cultural beliefs and norms can influence the care treatment in the healthcare setup. It is important to take these cultural needs into consideration in patients with HA to improve health such as patient beliefs on pain, recovery, or hip replacement may become a barrier in appropriate care coordination delivery. For this purpose, culturally competent care should be provided to culturally sensitive patients and ensure that the patient’s pain beliefs are effectively answered and patients feel less anxious due to pain beliefs.

Furthermore, some people may use a cultural language requiring interpreters or the use of interpretation services to uplift the communication barrier (Beaulieu et al., 2019; White et al., 2019). Some of the assumptions and points of uncertainty in HA include patients’ lack of trust in the procedure, fear of surgery, variation in recovery time, and risk of surgical complications. The patients may not fully trust the procedure and hesitate to undergo HA due to fear of surgery. 

Specific Goals for Addressing Hip Replacement and Rehabilitation

The specific goals to address hip replacement and its rehabilitation are established on the basis of the SMART goal approach which stands for Specific, Measurable, Attainable, Realistic, and Time-bound. These SMART goals are as follows:

  • Goal #1: The patients who have had hip joint problems since childhood (Specific) should be assessed through x-rays (Attainable and Realistic) once every six months (time-bound) to see any hip joint dislocations (measurable). This will help in the early and timely detection of hip-joint problems and undergo suitable procedures so that hip replacement is prevented (Williams, 2019). 
  • Goal #2: In patients who underwent hip replacement procedures, early mobility initiation is necessary to recover from the surgery. For this purpose, patients must gradually increase walking distance or steps (specific) up to one mile or 5000 steps by following the physical therapist’s guidance (attainable and realistic) for 3 months (time-bound). (None Aprisunadi et al., 2023).
  • Goal #3: Managing weight to reduce stress (Specific) on the hip joints by doing 30 minutes (measurable) of hip-joint-friendly exercise (attainable) as prescribed by physical therapists (realistic) every day (time-bound) (Güler, 2019) 

Community Resources for a Safe and Effective Continuum of Care

To provide a safe and effective continuum of care to patients with HA, one must utilize relevant community resources. These community resources help guide patients in managing their daily life with replaced hip and increase knowledge. Some community resources provide support and rehabilitation services for post-hip replacement rehabilitation. One such community resource is the American Academy of Orthopaedic Surgeons where orthopedic surgeons provide insightful and educational guidance to patients with orthopedic concerns and provide resources for individuals who are undergoing hip or knee replacement surgeries. The resources provided by this organization include online educational materials for patients and information required for improved orthopedic health and clinical guidelines for healthcare professionals (American Academy of Orthopaedic Surgeons, n.d.). 

Other community resources include online support groups such as WeChat community groups on hip replacement are available. These community groups are effective in providing virtual support to patients with HA and are a source of motivation for these patients when fellow patients with HA share their success stories (Zhang et al., 2021). Furthermore, rehabilitation centers for hip replacement patients promote effective recovery and rehabilitation of the hip after hip replacement surgery. One such rehabilitation center is Mayo Clinic Rehabilitation Center (MCRC). These rehabilitation centers are primarily focused on orthopedic care including hip replacement rehabilitation. The MCRC provides patient-centered hip recovery focusing on the restoration of mobility, muscle strength, and normal functioning after surgery (Mayo Clinic, n.d.). These community resources are helpful in providing a safe and effective continuum of care for patients who have undergone hip replacement.


This assessment is based on the preliminary planning of care coordination as a nurse staff for community healthcare. The identified community health concern in this assessment is hip replacement or Hip Arthroplasty. Considering the physical, psychosocial, and cultural needs of the patients with HA, several best practices are identified such as involvement of mobility technicians, psycho-education, culturally competent care, and using interpreters for culturally diverse people using cultural languages. Furthermore, specific goals were established and community sources were identified.


American Academy of Orthopaedic Surgeons. (n.d.). American academy of orthopaedic surgeons – AAOS.

Beaulieu, L., Addington, J., & Almeida, D. (2019). Behavior analysts’ training and practices regarding cultural diversity: The case for culturally competent care. Behavior Analysis in Practice, 12(3). 

Güler, T. (2019). Early improvement in physical activity and function after total hip arthroplasty: Predictors of outcomes. Turkish Journal of Physical Medicine and Rehabilitation, 65(4), 379–388. 

Mayo Clinic. (n.d.). Physical medicine and rehabilitation – overview. 

Capella 4050 Assessment 1

Mazzei, C. J., Yurek, J. W., Patel, J. N., Poletick, E. B., D’Achille, R. S., & Wittig, J. C. (2020). Providing patient mobilization with a mobility technician improves staff efficiency and constrains cost in primary total hip arthroplasty. The Journal of Arthroplasty, 35(8), 1973–1978.

None Aprisunadi, Nursalam Nursalam, Mustikasari Mustikasari, Erlin Ifadah, & Elsi Dwi Hapsari. (2023). Effect of early mobilization on hip and lower extremity postoperative: A literature review. SAGE Open Nursing, 9, 237796082311678-237796082311678.

Wei, S., Li, L., Yang, X., Li, X., & Jiang, Q. (2020). Psychological interventions in the pain management after hip and knee arthroplasty: A mini review. Annals of Joint, 5, 13–13. 

White, J., Plompen, T., Tao, L., Micallef, E., & Haines, T. (2019). What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an australian healthcare setting. BMC Public Health, 19(1). 

Williams, N. (2019). Improving early detection of developmental dysplasia of the hip. Australian Journal of General Practice, 47(9).

Zhang, X., Chen, X., Kourkoumelis, N., Gao, R., Li, G., & Zhu, C. (2021). A social media–promoted educational community of joint replacement patients using the wechat app: Survey study. JMIR MHealth and UHealth, 9(3), e18763.

Capella 4050 Assessment 1

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