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NURS FPX 4050 Assessment 4 – Final Care Coordination Plan

NURS FPX 4050 Assessment 4 – Final Care Coordination Plan


Capella university

NURS4050 Coordinating Patient-Centered Care

Prof. Name


Final Care Coordination Plan

The preliminary care coordination plan from Assessment 1 will be evaluated utilizing best practices found in scholarly sources for this final care coordination plan. This plan will focus on the Chronic Obstructive Pulmonary Disease (COPD) healthcare issue. This plan will strongly emphasize creating patient-centered health interventions while also considering ethical issues, acknowledging the impact of health policy, identifying priorities for care coordinators, and coordinating the Healthy People 2030 strategy.

Timelines and Interventions for Patient-centered Healthcare

Chronic obstructive pulmonary disease (COPD) patient-centered health interventions must be developed using an integrated approach that addresses the condition’s numerous aspects, including symptom control, lifestyle changes, education, and support. Depending on the disease’s severity and the demands of each patient, timelines can change. Following interventions can be integrated into COPD management for patient-centered care. A timeline is also created for every intervention to guarantee that the patient gets the necessary care on time.

  1. Awareness and Education: Primary patient-centered intervention for COPD can be awareness of the disease and symptoms, causes, and progression. Patients with COPD should receive regular education on medical issues relevant to managing COPD, such as quitting smoking, engaging in physical activity, and taking medications. A study reveals that patient education can lessen the need for up to 85% of hospital visits. Moreover, patient education increases patient satisfaction with their overall disease treatment. The study further mentions that the National Institute for Health and Care Excellence (NICE) encourages individuals with chronic obstructive pulmonary disease (COPD) to utilize self-management plans to help them take control of their health and recognize any warning signs or symptoms of an exacerbation (Boyer, 2023). The optimal timeline for patient education about COPD is initial three months. Community resources that will be utilized for this intervention are community centers, nonprofit organizations, such as American Lung Association, and healthcare professionals from the community. 
  2. Medication Adherence: Another key intervention for controlling respiratory disorders is ensuring patients adhere to medication. Sessions on the significance of medication compliance and the obstacles that can arise can be set up by healthcare practitioners. Smartphones can also be used to remind users to take their medications. The most effective timeline to achieve this goal is 3-6 months and then annual sessions on adherence importance. Community resources that can be effectively utilized for medication adherence are mobile application specialists, local support groups, and telemedicine services.
  3. Pulmonary Rehabilitation: It provides well-organized exercise regimens to enhance lung capacity, stamina, and general quality of life. Pulmonary rehabilitation (PR) intervention can occur in home-based, community-based, and hospital PR settings. Patients’ capacity to attend PR is impacted by their health, social support, transportation, financial situation, and program characteristics. To encourage adherence to PR, interventions targeting these interpersonal, intrapersonal, and institutional challenges are required. The pulmonary rehabilitation and exercise programs will be implemented within 6-12 months after diagnosis (Barata et al., 2022). Community resources that can efficiently be utilized for pulmonary rehabilitation are fitness centers, rehabilitation support groups, and hospital-based rehabilitation programs.

Ethical Considerations in Formulating Patient-Oriented Health Interventions

Several ethical factors must be considered while promoting awareness of COPD and developing interventions for its treatment. Awareness-raising and teaching as an intervention must be based on moral principles such as fairness and equity in information delivery, stigma reduction, and addressing cultural factors. Increasing knowledge and awareness allows people from all socioeconomic backgrounds to acquire information on the disease and the available treatments. Awareness can also be achieved ethically by sharing the experiences of people with COPD, and it can assist develop empathy and compassion, ultimately leading to destigmatization (Woo et al., 2021).

Medication adherence as an intervention for COPD can incorporate ethical considerations such as long-term patient wellness, non-maleficence, and beneficence. To improve patient’s quality of life, medication adherence treatments should be patient-centered, minimizing disease exacerbations and improving disease control. While implementing adherence as an intervention, potential negative outcomes of the intervention should be carefully considered to avoid any unanticipated repercussions (George & Bender, 2019). Another intervention that must incorporate ethical values is pulmonary rehabilitation. Moral principles such as patient autonomy and informed consent are fundamental in the planning and execution of this intervention. Due to different medical conditions, COPD patients may have restrictions on how much physical activity they may engage in. Before enrolling patients in an exercise program, healthcare professionals must also get informed permission to ensure they know the advantages and potential risks (Martinez-Martin et al., 2021). 

Implications of Health Policy for Care Coordination and Continuity of Care

Designing effective and efficient patient-centered health interventions requires the identification of appropriate health policy provisions. Firstly, Affordable Care Act (ACA) allowed the expansion of Medicaid programs, which is a governmental health insurance scheme for people over 65, often covering prescription drugs, hospital stays, pulmonary rehabilitation, and outpatient visits. A study mentioned that eight out of nine persons living in rural areas and one-fifth of all adults with COPD need access to pulmonary rehabilitation due to a lack of economic resources (Bhadra et al., 2021). For this purpose, ACA, as a federal-state program, helps low-income people with medical expenses. By encouraging the use of health information technology, emphasizing preventative care and wellness, enhancing access to healthcare services, and encouraging patient participation, the ACA improves care coordination, and people with chronic diseases like COPD can also have access to healthcare services.

Secondly, Family Smoking Prevention and Tobacco Control Act, implemented in 2009, have a very significant role at the state and national level in helping people with COPD. Smoke-free laws, tobacco taxation, and anti-tobacco campaigns are examples of policies. The reduction of 30-day readmissions following hospitalization for COPD can be achieved by implementing smoke-free policies. The study showed that the stronger the level of the free-of-tobacco policy, the greater the reductions in hospitalizations (Stallings-Smith et al., 2019). Healthcare organizations can greatly enhance COPD patients’ outcomes and quality of life by implementing an extensive tobacco-free policy and upholding effective care coordination.

Priorities and Evidence-Based Changes in Care Coordination

People with COPD require a care coordinator’s aid when accessing the healthcare system. Before the care coordinator discusses treatment options with patients and their families, priorities are established. It must be based on evidence-based methods to guarantee the patient receives the best care possible. To meet the diverse needs of patients and their families, care must be provided in a way that is culturally competent. The first and foremost priority is literacy about the disease, which can be met with open communication and engagement with the patients and their families. Considering cultural and linguistic barriers, suitable steps must be taken to overcome these barriers so that effective communication is achieved. Changes in the care plans should be based on various sociocultural factors, which should be supported by evidence. One of the changes include training healthcare providers to provide culturally competent care (Handtke et al., 2019).

Another priority is the provision of an optimal care plan involving physical and emotional support. Changes based on evidence-based practice involve tracking patients’ symptoms, medication compliance, and lung function using telehealth monitoring and telemedicine systems. Telehealth has been suggested for treating COPD patients as a novel approach that reduces the expenses associated with medical help while enhancing patient care and health outcomes (Guerra-Paiva et al., 2021). Changes are also required due to new information or the patient’s deteriorating condition. For instance, the care coordinator should speak with the patient about the possibility of a new medication that might help the patient’s condition. A care coordinator would place a high priority on involving the patient and their carers in the decision-making process to ensure that the care plan is patient-centered and meets their individual requirements. 

Align Learning Sessions with Best Practices and Healthy People 2030

The Healthy People project outlines a thorough set of long-term, national health goals known as Healthy People 2030. The particular objectives for COPD include improved quality of life for COPD patients, reduced hospitalization, improved early detection, and decreased COPD-related death rate (Health.gov, n.d.). Evidence-based best interventions to achieve the above goals are awareness and education, medication adherence, and pulmonary rehabilitation. According to Aliakbari (2022), patients with COPD who receive an educational intervention show higher perceived self-efficacy and health literacy. The learning sessions must align with Healthy People 2030 objective and follow best practices. According to the assessment literature, practical learning sessions should align with program goals and objectives, address the target audience’s particular needs, and use research-proven techniques. Future changes are to be implemented if the learning sessions do not appropriately address the importance of physical activity and compliance. It is essential to refer to the literature on the best practices for COPD patients and caregivers, including drug therapy, lifestyle changes, and customized care plans, while assessing the learning session’s content. Incorporating objectives like raising the percentage of patients receiving medicine and PR, lowering caregiver stress, and boosting community-based support services align the instructional sessions with Healthy Patients 2030 objectives. 


This study about COPD care coordination emphasizes the value of developing patient-centered health therapies that address specific healthcare issues while considering moral considerations and relevant ethical standards. Care coordinators can improve the quality of care for patients and their loved ones by establishing priorities and making evidence-based improvements to the care coordination plan. A further assurance that interventions continue to be relevant and effective in addressing healthcare issues is the alignment of educational sessions with best practices and the Healthy People 2030 goals.


Aliakbari, F., Tavassoli, E., Alipour, F. M., & Sedehi, M. (2022). Promoting health literacy and perceived self-efficacy in people with chronic obstructive pulmonary disease. Iranian Journal of Nursing and Midwifery Research, 27(4), 331.  


Barata, P. I., Crisan, A. F., Maritescu, A., Negrean, R. A., Rosca, O., Bratosin, F., Citu, C., & Oancea, C. (2022b). Evaluating Virtual and Inpatient Pulmonary Rehabilitation Programs for Patients with COPD. Journal of Personalized Medicine, 12(11), 1764. https://doi.org/10.3390/jpm12111764 

Bhadra, R., Bhattacharya, S., D’Souza, G. A., Schols, A. M. W. J., & Sambashivaiah, S. (2021). Pulmonary rehabilitation in the management of chronic obstructive pulmonary disease among asian indians- current status and moving forward. COPD: Journal of Chronic Obstructive Pulmonary Disease, 1–6. https://doi.org/10.1080/15412555.2021.1962267 

Boyer, P. (2023). What are the benefits of using self-management plans for COPD patients in the community: a critical review of the literature. British Journal of Community Nursing, 28(1), 22–32. https://doi.org/10.12968/bjcn.2023.28.1.22 

George, M., & Bender, B. (2019). New insights to improve treatment adherence in asthma and COPD. Patient Preference and Adherence, 13, 1325–1334. https://doi.org/10.2147/ppa.s209532 

Guerra-Paiva, S., Dias, F., Costaa, D., Santos, V., & Santos, C. (2021). DPO2 Project: Telehealth to enhance the social role of physical activity in people living with COPD. Procedia Computer Science, 181, 869–875. https://doi.org/10.1016/j.procs.2021.01.241 

Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE, 14(7), 1–24. https://doi.org/10.1371/journal.pone.0219971 

NURS FPX 4050 Assessment 4 – Final Care Coordination Plan

Health.gov. (n.d.). Reduce deaths from COPD in adults — RD‑05 – Healthy People 2030 | Health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/respiratory-disease/reduce-deaths-copd-adults-rd-05 

Martinez-Martin, N., Luo, Z., Kaushal, A., Adeli, E., Haque, A., Kelly, S. S.,  & Milstein, A. (2021). Ethical issues in using ambient intelligence in health-care settings. The lancet digital health, 3(2), e115-e123. https://doi.org/10.1016/S2589-7500(20)30234-9.

Stallings-Smith, S., Hamadi, H. Y., Peterson, B. N., Apatu, E. J. I., & Spaulding, A. C. (2019). Smoke-Free Policies and 30-day readmission rates for Chronic Obstructive Pulmonary Disease. American Journal of Preventive Medicine, 57(5), 621–628. https://doi.org/10.1016/j.amepre.2019.06.008 

NURS FPX 4050 Assessment 4 – Final Care Coordination Plan

Woo, S., Zhou, W., & Larson, J. L. (2021). Stigma experiences in people with Chronic Obstructive Pulmonary Disease: An integrative review. International Journal of Chronic Obstructive Pulmonary Disease, 16, 1647–1659. https://doi.org/10.2147/copd.s306874