Preliminary Care Coordination Plan

Health Concerns and Best Practices for Health Improvement

The individual who has agreed to participate in the care coordination plan session is a 65-year-old woman from Houston, Texas. Based on the self-management practices that the participant currently implements, there are three important health concerns that require attention – high blood pressure, type II diabetes, and obesity. The first concern, hypertension, affects multiple Americans, especially when it comes to older adults of any health status (Benetos, Petrovic, & Strandberg, 2019). In those older than 65, chronic hypertension is a risk factor for cardiovascular disease, cognitive decline, and the partial or total loss of autonomy (Benetos et al., 2019). Poorly treated hypertension is associated with life-threatening complications, including poor blood flow and arterial damage (Benetos et al., 2019). Regarding health improvement practices, hypertension often deteriorates with age, and it is critical for older adults with this condition to adhere to the prescribed medications, use blood pressure monitors for self-assessment, and maintain a healthier lifestyle (Benetos et al., 2019). The lifestyle recommendations are selected individually based on focused assessments and may include decreasing or eliminating caffeine and alcohol consumption, quitting smoking, or age-appropriate exercise.

Type II diabetes is another chronic health concern affecting the participant. The lack of proper diabetes self-management practices may result in a variety of complications, including neuropathy and damages to blood vessels, vision, and hearing (Powers et al., 2017). This diagnosis changes any individual’s life to a large extent, requiring him or her to make effective self-management and self-monitoring decisions on a daily basis. The most popular practices to improve such patients’ overall health are presented by patient counselling to improve diabetes literacy, patient education on blood glucose measurement, and the provision of diabetes diet guidelines (Powers et al., 2017). As modern research suggests, the implementation of diabetes self-management education results in decreases in haemoglobin A1c levels and the reduced frequency of diabetes complications (Powers et al., 2017). Moreover, timely and systematic education in diabetes patients encourages the development of healthier eating habits and lowers the risks of mental health issues, such as depressive disorders and diabetes-related distress (Powers et al., 2017).

Excessive weight is another issue that affects the participant’s quality of life. Being overweight and obese is increasingly common, and it impacts health in many ways, ranging from decreased mobility and lower independence in daily life to knee pain and the increased risk of cardiovascular disease. Regarding health improvement practices, in overweight and obese patients with type II diabetes, weight loss achieved with the help of diets, exercise, or pharmaceutical therapy leads to better glycemic control (Holland-Carter et al., 2017). Aside from physical health, it is particularly important that the combination of weight loss programs and regular counselling with diabetes educators results in better mental health outcomes in obese type II diabetes patients compared to standard diabetic diet education (Holland-Carter et al., 2017).

The Patient’s Needs and Factors Affecting Care

During the preliminary conversation, the participant has provided the key facts regarding her current health needs and the goals that she is willing to achieve to improve her daily life. To begin with, the participant highlights that her health issues are not acute at the moment, and she demonstrates the awareness of the key self-care activities required in her situation. With that in mind, the patient’s current goals are to maintain her general health and receive high-quality patient education to further improve her eating choices and self-monitoring practices. Also, it would be beneficial to make sure that her weight loss program is effective and safe for diabetics. The preliminary goals mainly refer to education and improvements in the patient’s knowledge regarding how to control her health issues more effectively. Also, they include increasing her awareness of tools and resources that can be utilized to maximize the beneficial effects of her current self-monitoring and self-care practices. However, regarding the points of uncertainty, the client’s current health issues involve the risks of exacerbation. With that in mind, it is possible that she will decide to place more emphasis on specific problems and set priorities in a different way during further collaboration.

Next, to improve the participant’s quality of life as much as possible, it is of utmost importance to give consideration to factors that make her needs more unique. The basic physiological factors that service providers must consider are the history of chronic health conditions and the client’s being a senior citizen. As for the ethical considerations, any healthcare providers and care educators should take the participant’s autonomy and good support from her family into account when formulating recommendations. Finally, as a Hispanic woman, the participant demonstrates specific food preferences and nutritional habits which can be difficult to depart from and are peculiar to her native culture. To respect the participant’s identity and preferences, the nutritional education should be culturally competent. Particularly, it should help the participant to make healthier food choices in the context of the traditional Mexican diet instead of imposing options that are healthy but totally foreign to the woman and her family.

Community Resources: Education Services

1. The diabetes education program: self-management, dietary choices, medication use, physical activity (Medical Clinic of Houston, 1701 Sunset Blvd, Houston, TX 77005, (713) 520-4774).
2. Classes in healthy nutrition for the various age groups, including older adults (Houston Food Bank, 535 Portwall St., Houston, TX 77029, (713) 223-3700).
3. Available online: hypertension educational resources and Check.Change.Control program for self-monitoring (American Heart Association, 7272 Greenville Ave. Dallas, TX 75231 1-800-242-8721).

References

1. Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research, 124(7), 1045-1060.
2. Holland-Carter, L., Tuerk, P. W., Wadden, T. A., Fujioka, K. N., Becker, L. E., Miller-Kovach, K.,… Kushner, R. F. (2017). Impact on psychosocial outcomes of a nationally available weight management program tailored for individuals with type 2 diabetes: Results of a randomized controlled trial. Journal of Diabetes and its Complications, 31(5), 891-897.
3. Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H.,… Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 43(1), 40-53.