Plan for diabetes care coordination research work analysis

Make a final plan for diabetes care coordination.
Coordination of care may be characterized in several ways: “The coordination of conscious patient-care actions and information exchange across all patient-care stakeholders to provide safer and more effective care.” Another definition of care coordination is “information exchange among all parties involved in patient care in order to provide safer and more effective treatment.” This includes ensuring that patient needs and preferences are anticipated and communicated to the individual promptly. This information provides patients with safe, appropriate, and effective care (“Coordination of Care | Agency for Research and Quality in Care,” 2018). Regardless of how care coordination is defined, meeting patient requirements, aiding in the transmission of important patient information in relevant nations, enhancing overall patient health, and enabling patients to make choices about their medical treatment are similar aims.
Diabetes is currently the sixth greatest cause of mortality in the United States, affecting more than 34 million people. It is the world’s third leading cause of death (CDC, 2020). The number of adults diagnosed with diabetes is decreasing, but the number of young people (aged 10 to 19 years) having type 1 and type 1 diabetes is growing. Diabetes is more prevalent among Alaskan Natives, who now make up the majority of individuals afflicted.

Nursing home conditions and patient-centered health interventions

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Diabetes may cause several additional health problems, including high blood pressure and cholesterol, leading to heart disease, stroke, blindness, renal failure, limb amputation, and early death. Diabetes raises the risk of liver, breast, pancreas, uterus, and bladder malignancies. Diabetes raises a person’s chances of developing heart disease and stroke (CDC, 2019).

One of the essential aims in the treatment of diabetes is to obtain adequate blood sugar control. The A1C should be less than 5.6 percent, and fasting blood glucose levels should be between 70 and 100. To maintain your blood sugar within your goal range, eat nutritious food, such as the American Diabetes Association’s diet, and remain active for at least 10 minutes most days, aiming for no more than 30 minutes (Colberg et al., 2016). Blood sugar levels should be tested four times a day at home, first on an empty stomach in the morning, then before eating in the morning and evening, and finally before going to bed. However, the treating physician has the authority to alter this practice. Every three months, or as the provider advises, A1C levels should be tested.

Controlling blood pressure may help prevent heart disease, stroke, and renal failure. The optimal systolic and diastolic blood pressure values are between 140 and 90. Eat a heart-healthy, low-salt diet and exercise for 10-30 minutes most days of the week to achieve this. When you see the doctor, take your blood pressure and, if feasible, maintain a blood pressure monitor at home in case you detect anything unusual.

Medication adherence may sometimes be a concern when treating diabetic patients as part of medical treatment. Diabetes drugs are costly, and in certain circumstances, neither health insurance nor Medicare will pay them. It is crucial to have an open and honest discussion with patients, providers, and care coordinators so that patients know that their therapy may not be reimbursed by insurance and that physicians are aware that this is a treatment with potential negative effects. The patient must inform the doctor if they are taking their medicine as directed, differently, or not.

If providers do not know how to utilize medicine or if it should be used at all, they will not be able to give adequate therapy. These conversations should occur at the start of each visit, and anytime concerns develop.

Resources and Efforts in the Community

People with diabetes may utilize the clinic’s Chronic Care Management Team (called CCM) as an example of a community resource to enhance their overall health. Patients meet with registered nurses and health coaches in person or over the phone to set personal objectives, methods for reaching those goals, and plans for overcoming barriers. The CCM team also works closely with the patient’s primary care physician to ensure that the patient adheres to the treatment plan and the examination and blood test schedule. They may also help with financial concerns, such as the prescribing Program if the drug’s price is a problem. Another option to help you manage your blood sugar and blood pressure objectives are the clinic, where you may visit with your diabetes instructor and nutritionist. They can help you prepare nutritious meals and provide you with advice on how to change your diet so that you do not have to give up all of your favorite foods. Health facilities are another alternative for parishioners who want to maintain a particular physical condition.

A sports trainer works at the health clinic. These instructors may help individuals create objectives and teach them how to use the equipment properly not to get hurt. Another valuable resource is the Better Choices Better Health website. is a diabetes self-management program. The BCBH Diabetes Self-Management Assistance Program is a that teaches individuals how to manage their diabetes independently with the help of healthcare experts. Just a few of the subjects addressed include how to handle stress and strong emotions, exercise properly, prepare a healthy meal, and communicate effectively with your doctor. Except for the BCBH program, each of these public programs is personalized to the patient and their unique requirements to best satisfy their demands. Their cultural ideas and traditions may be integrated into methods to get the greatest results since their generations have been handed down.

Ethical judgments must be taken while establishing patient-centered health solutions.

The main concepts of the nurse’s code of ethics are autonomy, compassion, innocence, and justice. These are the four basic concepts. Everything a healthcare practitioner performs daily should be based on these principles (Gaines, 2020). Allowing patients to exercise their autonomy, or right to self-determination and decision-making is one of the fundamental purposes of care coordination. The care coordinator’s goal is to ensure that patients have access to all information, education, risks, benefits, and treatment alternatives related to their diagnosis and therapy so that they may make well-informed decisions. The care coordinator must support the patient’s choice while also offering any required information.

Compassion-oriented action is defined as “charity” that “works for the benefit and the good of the sufferer” (Gaines, 2020). The care coordinator must serve as a patient advocate and ensure that the patient’s treatment plan is in their best interests. In both judgment and treatment, justice needs a measure of fairness. Regardless of race, gender, religious views, or financial status, the care coordinator must guarantee that each patient gets the same amount of justice and compassion. Actions that do not damage others are known as non-harming. This protection safeguards the safety of the patient during therapy. The role of the care coordinator is to be informed of all treatment choices available and to aid in picking the one with the fewest side effects to achieve the desired objectives.

Health policy implications in terms of care coordination and continuity

According to the Medicare & Medicaid Services (CMS) website, chronic care management (CCM) must contain at least 20 minutes of clinical staff time every calendar month, according to the Medicare & Medicaid Services (CMS) website. This clinical staff time might be provided by a physician or another registered healthcare practitioner. You must satisfy all of the following prerequisites to be eligible for the CCM program: Multiple (two or more) chronic conditions that are expected to last at least 12 months or until the patient’s death, a chronic condition that puts the patient at high risk of death, acute exacerbation/decompensation, or impairment of function, all of which necessitate the development, implementation, revision, and monitoring of a comprehensive treatment plan. Multiple chronic medical illnesses (at least two) are predicted to endure at least a year or until the patient dies. Arthritis, atrial fibrillation, COPD, cardiovascular disease, depression, diabetes, and hypertension are just a handful of the chronic conditions that qualify. The CCM program is the backbone of the care coordination program, and it enables hospitals to charge patients for the service.

The Patient Protection and Affordable Care Act’s Hospital Readiness Reduction Program encourages hospitals to enhance communication, and care coordination to better include patients and caregivers in planning and discharge care, thereby lowering readmissions. Patients and nurses will be more engaged in discharge planning due to this. By tying hospital reimbursement to patient care efforts, this project helps the national aim of improving Americans’ health (Medicare Centers and Medicaid Services, 2016). The capacity to address patients’ medical requirements without having them return to the hospital is at the core of this ambition.

the control of change

Care coordination is not immune to changes in the healthcare business. Finally, even the most successful treatment plan must be changed to account for changes in the patient’s condition as it improves or deteriorates. Changes are necessary to permit or continue repairs. It is beneficial to employ a change management approach to cooperate with patients and their families when modifying a treatment plan. This model illustrates how to begin and maintain a change throughout the process. The following phases in Lewin’s three-step method for planned change: Informing individuals about the problem, letting them quit old behaviors, and modifying their present behavior is all part of defrosting.

This may be accomplished via disseminating information, questioning the current quo, or presenting a subject or inquiry. Identifying the positive consequences of change and eliminating barriers that impede behavior change are critical phases in altering behavior or discovering new possibilities. Brainstorming, role modeling, mentoring, and training are used. The act of merging and retaining new alterations so that they become habitual and do not repeat themselves is known as refreezing. This is done by retraining practices and recognizing achievements (Source: “Case Study: Integrating Lewin Theory with a Lean Systematic Approach to Change,” 2016).

Healthy People 2020 is a campaign aimed at improving people’s health by 2020.

Healthy People 2020 aspires to enhance everyone’s health by achieving health equality, reducing inequity, and reducing inequity. Another objective is to establish a social and physical environment that supports everyone’s health, increases the quality of life, and encourages healthy behavior. Healthy People 2020 is a nationwide project focused on improving the health of all Americans by 2020 (About Healthy People | Healthy People 2020, 2020). Some of their diabetes goals include reducing the number of newly diagnosed diabetes cases, increasing the proportion of people diagnosed with diabetes who have their blood pressure under control, improving lipid control in people diagnosed with diabetes, and empowering more people diagnosed with diabetes. At least once a year, people with diabetes should see a dentist (Healthy People 2020, 2020). This goal is consistent with studies that have identified some of the most effective therapies for diabetes and diabetes-related illnesses.

A study published in the British Dental Journal in 2019 looked at some of the most beneficial dental hygiene habits for diabetes. It focuses on three clinical behaviors that need to be further improved. These behaviors include informing diabetic patients about the link between diabetes and periodontitis rather than treating periodontitis apart from diabetes and contacting doctors regarding patient care for patients with periodontitis and uncontrolled diabetes. Bissette, Presseau, Rapley, and Preshaw, 2019). Bissette, Presseau, Rapley, and Preshaw, 2019). Bissette, Presseau, Rapley, and Preshaw, 2019. Bissette, Presseau, Rapley, and Preshaw, 2019. Patients are more likely to avoid solving their health diagnosis if more providers, not only healthcare experts, are aware of recommended practices and result objectives.


Nursing coordination is gaining popularity, and it will continue to play a crucial role in delivering high-quality medical care to patients. Coordination of care helps not just the patient, but it may also help the patient’s family navigate the healthcare system, decreasing stress brought on by the disease. The care coordinator is in charge of organizing patient care and decisions and providing support and information to patients throughout the process.

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