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 Plan
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.
Health Care Problem: Hypertension/COPD

Physical Considerations: The patient has a history of hypertension that is being managed through medication as well as lifestyle changes such as reducing salt intake, exercising more regularly and quitting smoking if applicable. It is important to provide her with education and resources on how to maintain these lifestyle changes in order to keep her blood pressure under control. Additionally, due to the COPD diagnosis she will need help managing any flare-ups that can occur from environmental triggers or exacerbation of symptoms related to the disease process 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. Furthermore, providing her with access to community resources such as support groups for those living with chronic illness could be beneficial for this patient.

Cultural Considerations: As an elderly woman living independently there may be cultural factors we need to consider when developing our care coordination plan. For example, we should assess whether she is comfortable seeking out external sources for assistance or if there are religious beliefs that could impact our recommendations for treatment options such as medications.

Community Resources:
• 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)