The Final Care Coordination Plan

Topic: Cardiology
Words: 1473 Pages: 5

High blood pressure or hypertension is one of the most common cardiovascular diseases, characterized by a higher blood pressure in an individual’s veins and arteries than normal. High blood pressure is attributed to lifestyle habits, some of which are impossible to eradicate. As a result, hypertension is a public health menace that consumes considerable resources in treatment and management. Hypertension can significantly diminish the quality of an individual’s lifestyle because it limits routines and prevents people from actively engaging with their lives. Moreover, it places its victims at risk of more severe conditions resulting from distorted organ functions. Therefore, it is critical to address these patients’ needs using practical solutions backed by evidence-based literature and limit the development of other conditions by offering comprehensive care. On that account, the following passages describe a care coordination plan to address the healthcare issues associated with hypertension and identify resources to facilitate better management of cases. In addition, the explanations will consider the ethical considerations during the interventions and the priorities to ensure high-quality service delivery. Lastly, the essay will explain how the teaching sessions alight with the objectives of Healthy People 2030.

Patient-Centered Health Interventions and Timelines

Hypertension is a condition that affects the normal functioning of blood vessels within the heart and the peripheral circulatory system, thus exposing individuals to several other risks. For example, an individual suffering from high blood pressure is at risk of a heart attack because the condition can limit blood from sufficiently circulating to the heart muscles causing them to weaken and die. Subsequently, hypertension can lead to a stroke if the condition damages blood vessels or arteries delivering blood to the brain. In severe stroke cases, individuals can lose the functionality of some of their brain parts, meaning that their condition must always be monitored (Carey et al., 2018). Lastly, a patient suffering from hypertension is at risk of chronic kidney failure as the condition might constrict blood vessels supplying the kidneys with blood and thus inhibit their functioning. Over time, an individual’s kidneys may weaken and seize to work properly (Ozemek et al., 2018). As a result, it is critical to consider the risk of these conditions when creating a care plan for a patient with hypertension to ensure more favorable results.

The recommended health interventions against a heart attack, a stroke, and chronic kidney failure due to high blood pressure include team-based care to facilitate better blood pressure control, civic engagement, and dietary changes. Hypertension is manageable with the help of multidisciplinary teams to enhance care using evidence-based practices. These teams allow patients to actively engage in personal care by establishing practical follow-up routines and coordinating with family members to offer targeted healthcare (U.S. Department of Health and Human Services, 2020). On the other hand, civic engagement can maximize a patient’s health and limit strokes since they will interact with others experiencing similar issues and participate in social programs to improve health (Carey et al., 2018). Moreover, hypertension patients must observe appropriate nutrition and a balanced diet to limit the adverse implications of hypertension on their kidneys (Ozemek et al., 2018). That being said, the required community resources include healthcare facilities to provide sites to carry out programs, community health workers to create awareness and encourage participation in civic engagement. Moreover, shareholder and community education programs offering nutritional counseling can improve patients’ dietary practices.

Ethical Decisions in Designing Patient-Centered Health Interventions

Evidence-based medical practices provide clear and reliable guidelines to aid clinical decision-making. However, patients are never included in the decision-making process, thus exposing medical cases to non-compliance issues. Physicians are responsible for creating an effective treatment plan to empower patients and put them in a better position to manage their conditions. Nevertheless, the choice about whether to adopt particular practices depends on the patient and the benefits they perceive from these practices (Kjeldsen & Os, 2019). For example, a clinician can advise a patient against smoking since it may expose them to other conditions. However, the patient is not obligated to stop smoking, thus presenting challenges if they fail to comply. Thus, the ethical questions that arise are; can a medical practitioner force a patient to adhere to treatment against their will by enrolling them in institutions like rehabilitation centers? If so, will the treatment initiatives yield the desired results? Moreover, several other factors can interfere with an individual’s medical compliance, including their culture, goals, wishes, and perspectives. Therefore, all these issues must be considered when designing care plans.

Health Policy Implications for the Coordination and Continuum of Care

High blood pressure is a threat to global public health due to its high prevalence and severity, especially as individuals grow older. As a result, the US government works closely with bodies like the World Health Organization to design policies and programs aimed at enhancing the quality of care provided to individuals with hypertension in various regions (Kostova et al., 2020). The HEARTS initiative is one of the most recent policy guidelines against the condition, comprised of recommendations to prevent the development of hypertension using the most effective solutions. The HEARTS initiative advocates for blood pressure control by encouraging an increase in physical activities, reducing salt in the diet, eliminating industrial dietary fat from foods, and controlling the use of tobacco and tobacco products (Kostova et al., 2020). As a result, the policy provides a technical package that standardizes six essential practices. These practices include evidence-based management for hypertension, access to affordable high-quality hypertension medication, management using technological solutions, continuous risk assessment, and team-based care, advanced CVD monitoring systems, and healthy life counseling. These practices can help limit adverse outcomes like strokes, kidney failure, and heart attacks in patients diagnosed with hypertension.

Healthcare Priorities and the Need for Changes to the Initial Plan

Lifestyle habits are the major cause of hypertension in the modern era because most people do not pay attention to what they eat, their levels of physical exercise, and how they live. Instead, individuals are exposed to an increasingly sedentary lifestyle since they can easily access everything they need and communicate with others using technological devices (Carey et al., 2018). Additionally, social and cultural factors play a major role in predisposing individuals to hypertension and other cardiovascular diseases as some cultures support eating food with increased fat content and not paying attention to dieting. Therefore, it is critical to prioritize these issues when working with a patient or their family members so that they can stay informed and make the right choices (Kjeldsen & Os, 2019). On that account, the initial plan will require changes in its structure and prioritized initiatives as these corrections will allow patients and family members to uphold the top recommendations and achieve better results. Moreover, the plan will advocate for patient education and continuous monitoring to maximize health benefits from the initiatives.

Aligning the Teaching Sessions to Healthy People 2030 Goals and Objectives

‘Healthy People 2030’ is a strategy guide that provides reliable insight into the actions that medical practitioners should take to minimize the prevalence of critical health conditions like hypertension. According to the stipulations, public health practitioners and clinicians can achieve higher levels of hypertension control when they integrate clinical initiatives with community outreach programs (Kostova et al., 2020). Hence, the Community Preventive Service Taskforce recommends team-based care solutions to improve blood pressure control in patients with hypertension. Team-based care involves the adoption of structured techniques facilitated by multi-professional teams that address different facets of the disease and its management (U.S. Department of Health and Human Services, 2020). The ultimate aim of team-based care is to ensure effective communication between parties, enhance coordination in care practices, and guide patients and clinicians toward adopting evidence-based solutions. As a result, the care and management initiatives will involve various shareholders in the institution, the areas where the patients reside, and the community.


Hypertension is currently a global public health threat because it affects individuals in all age groups despite being highly preventable. Records suggest that high blood pressure is one of the leading causes of premature death because it does not exhibit any signs and symptoms until its later stages when it starts interfering with critical body functions and organs. However, the condition is manageable through intensive lifestyle changes and adhering to an effective treatment plan. Some of the risks associated with high blood pressure are heart attacks, strokes, and chronic kidney disease or failure. However, these conditions are preventable through occasional monitoring, increased physical activities, and a healthy diet. Thus, it is crucial to prioritize an individual’s lifestyle, cultural practices, and willingness to partake in treatment initiatives when delivering a healthcare plan. Nevertheless, adopting team-based care solutions helps minimize costs and deliver more efficient and effective solutions to managing the condition and limiting associated risk factors. Thus, teams can ensure positive results from treatment and management initiatives.


Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Prevention and control of hypertension: JACC health promotion series. Journal of the American College of Cardiology, 72(11), 1278-1293. Web.

Kjeldsen, S. E., & Os, I. (2019). Are people with masked hypertension adherent to their antihypertensive medication? Hypertension, 74(3), 497-498. Web.

Kostova, D., Spencer, G., Moran, A. E., Cobb, L. K., Husain, M. J., Datta, B. K., Matsushita, K., & Nugent, R. (2020). The cost-effectiveness of hypertension management in low-income and middle-income countries: A review. BMJ Global Health, 5(9), e002213. Web.

Ozemek, C., Laddu, D. R., Arena, R., & Lavie, C. J. (2018). The role of diet for prevention and management of hypertension. Current Opinion in Cardiology, 33(4), 388-393.

U.S. Department of Health and Human Services. (2020). The Surgeon General’s Call to Action to Control Hypertension. Web.

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