Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Care Coordination Plans
Patient Profile:
• 72 year old female with a history of hypertension, COPD, and diabetes.
• No known allergies to medications or foods.
• Living independently with the assistance of an adult daughter who lives nearby and is her primary caretaker.
Hypertension/COPD: A Health Problem

Physical considerations: This patient is a known hypertensive who has been treated with medication and lifestyle modifications such as exercising regularly, reducing the salt in their diets or quitting smoking. In order to control her blood pressure, you should provide her with information and resources about how to continue to make these lifestyle modifications. A COPD diagnosis will also require her to be able to manage any symptoms that flare up due to environmental triggers, or the process of the disease itself.

Psychosocial Considerations: Although it’s difficult for many elderly people living alone without family support or help, this patient lives with her daughter nearby who helps take care of her daily needs and provides emotional support. Her daughter’s presence allows us to formulate a comprehensive plan that includes both physical and psychosocial components which can improve the patient’s overall mental health and quality of life. By providing this patient with community resources like support groups for people with chronic illnesses, she could benefit.

Culture: If you are coordinating care for an older woman who lives independently, there could be some cultural issues to consider. We should, for example, assess if she feels comfortable asking for external assistance. Or if her religious beliefs could affect our treatment recommendations.

The Community Resource:
• AccessCare – free home visits by nurse practitioners in order to evaluate health concerns; monitor vital signs; provide referrals; diagnose & treat medical conditions (https://www.accesscarenyc.org/)
• Senior Services NYC – offers services including meals on wheels & homebound delivery program; senior centers & transportation (www.seniorservicesnyc.com/)
• Visiting Nurse Service – skilled nursing care provided at home along w/case management services (www1.vnsnychoiceseniorplushealthplansyny)
• Elderly Crime Victim Program – Offers advocacy & counseling services specifically designed for victims age 60+ (https://ocdvserviceserfgoalsolutionstrainingstexaswindowsus)