Running Head: CARE COORDINATION 1 CARE COORDINATION 8 Preliminary Care Coordination Plan Capella University Alexander Ruche Introduction The role of care coordination is to ensure that there exists integrated services that meet the needs of individuals. The focus of care coordination lies in the delivery of recovery-focused and collaborative services that connect people to healthcare services. A key necessity for care coordination is the management of chronically sick patients. Chronically ill patients are a part of interconnected problems as they affect the social circles around them (Hannigan et. al., 2018). Just as it is complicated to the patients, so is it on service provision, hence mandating for family and friend to be a part of a multidisciplinary approach in relation to provision of care. Hence as a result, the issue on chronically ill patients is not one that can be handled by a single profession but rather one that requires a multidisciplinary approach and a care coordination plan to best deal with the health concerns (Hannigan et. al., 2018). Chronic Obstructive Pulmonary Disease (COPD) COPD is a type of obstructive lung disease often characterized by long-term breathing problems and poor airflow resulting in difficulties when breathing. It tends to be characterized by shortness of breath as well as coughs accompanied with sputum production. Therefore, patients with COPD tend to present various complex health issues that demand for immediate pharmacological interventions (Hanania et. al., 2018). Care coordination assists in solving these complexities and in providing alternatives to quality health care. By offering a collaborative approach it is possible to address not only the patient’s needs in relation to the respiratory aspect of the disease but also in addressing the systemic effects and comorbidities associated with the illness (Hanania et. al., 2018). According to the Journal of Chronic Pulmonary Diseases, the most appropriate practices for care coordination for COPD include pulmonary rehabilitation, care integration, a holistic approach and an inclusion of a care transition model. These practices help to meet the complex needs of managing COPD. However, regardless of the clear goals in managing COPD, there still exist certain challenges (Hanania et. al., 2018). One such challenge is dealing with the hopelessness of the condition. Often physicians face uncertainties in diagnosing the disease, identifying its medications and hospitalizations. Even worse, patients in the past have shown non-compliance as a result of the disease’s complexity (Hanania et. al., 2018). All in all, an effective care coordination plan would help to effectively manage the condition of COPD. Care Coordination Plan To help attain success in the care coordination for Mr. Andrew Anderson a team of fifteen professionals will be selected. Although this team seems large, past research shows that a big number of people is important when c.

1. Running Head: CARE COORDINATION 1
CARE COORDINATION 8
Preliminary Care Coordination Plan
Capella University
Alexander Ruche
Introduction
The role of care coordination is to ensure that there exists
integrated services that meet the needs of individuals. The focus
of care coordination lies in the delivery of recovery-focused and
collaborative services that connect people to healthcare
services. A key necessity for care coordination is the
management of chronically sick patients. Chronically ill
patients are a part of interconnected problems as they affect the
social circles around them (Hannigan et. al., 2018). Just as it is
complicated to the patients, so is it on service provision, hence
mandating for family and friend to be a part of a
multidisciplinary approach in relation to provision of care.
Hence as a result, the issue on chronically ill patients is not one
that can be handled by a single profession but rather one that

2. requires a multidisciplinary approach and a care coordination
plan to best deal with the health concerns (Hannigan et. al.,
2018).
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a type of obstructive lung disease often characterized
by long-term breathing problems and poor airflow resulting in
difficulties when breathing. It tends to be characterized by
shortness of breath as well as coughs accompanied with sputum
production. Therefore, patients with COPD tend to present
various complex health issues that demand for immediate
pharmacological interventions (Hanania et. al., 2018). Care
coordination assists in solving these complexities and in
providing alternatives to quality health care. By offering a
collaborative approach it is possible to address not only the
patient’s needs in relation to the respiratory aspect of the
disease but also in addressing the systemic effects and
comorbidities associated with the illness (Hanania et. al., 2018).
According to the Journal of Chronic Pulmonary Diseases, the
most appropriate practices for care coordination for COPD
include pulmonary rehabilitation, care integration, a holistic
approach and an inclusion of a care transition model. These
practices help to meet the complex needs of managing COPD.
However, regardless of the clear goals in managing COPD,
there still exist certain challenges (Hanania et. al., 2018). One
such challenge is dealing with the hopelessness of the
condition. Often physicians face uncertainties in diagnosing the
disease, identifying its medications and hospitalizations. Even
worse, patients in the past have shown non-compliance as a
result of the disease’s complexity (Hanania et. al., 2018). All in
all, an effective care coordination plan would help to effectively
manage the condition of COPD.
Care Coordination Plan
To help attain success in the care coordination for Mr. Andrew
Anderson a team of fifteen professionals will be selected.
Although this team seems large, past research shows that a big
number of people is important when creating diversity and

3. expertise in COPD management. This team will compromise of
nurses, pulmonologists and general experts all with a specific
interest in COPD (Korpershoek et. al., 2017). The goal of the
plan will be to create awareness around the disease, to offer a
guideline based management, rehabilitation and self-
management support program. The plan is also aimed at
improving patient outcomes as evidenced in the attachment
below:
PATIENTS NAME: Mr. Anderson
CONTACT: Private
ADDRESS: Private
1. Self-management behavior
a. Adherence to pharmacology- Consume prednisolone 30mg
every day. Helps in reducing instances of exacerbation, failure
of treatment, admission, and improves hypoxemia.
· Adhere to using albuterol (Combivent) 100 mcg/20 mcg after
every 6 hours and must not exceed 6 actuations daily. Such
helps to boost instances of dyspnea and activity tolerance
during the daily exercise regimens (Korpershoek et. al., 2017).
· Take ciprofloxacin twice every day because it lowers instances
of treatment failure
● Please note that medications will be collected at Walgreens
Pharmacy located in Cutler Bay.
SCORE OF ADHERANCE
Excellent
Moderate
Poor
2. Patient Education
a. Mr. Anderson will attend a smoking cessation program at

4. Primax Rehabilitation Program. After the end of six months Mr.
Anderson will have managed his smoking habits. By being part
of the rehabilitation program, you will have modified the
occurrence of the disease and lowered instances of contracting
myocardial infarction and lung cancer. It is paramount to note
that the effects of quitting smoking will not be evidenced until
after several months of quitting (Jiménez-Ruiz et. al., 2015).
b. Enroll in a muscle relaxation program at the Pembroke
Resource Center. Such will promote Mr. Anderson’s respiratory
and psychological well-being. The center will offer activities
like yoga, muscle relaxation and deep breathing exercises
(Volpato, et. al., 2015).These exercises will be aimed at
improving his breathing capacity and will be done every
Monday and Friday.
c. Take part in the training of early detection of exacerbation at
the Porta General Hospital as directed by the program
coordinator. In the event of an exacerbation contact the care
coordinator. While at the training you will be looked after by
the lead physician and community nurse (May et. al., 2016).
Write date, day and time of attendance.
Smoking cessation program
Relaxation techniques
Early detection of exacerbation
●Rate the usefulness of every program in a percentage score:
(e.g. 20%, 50%, 100%)
- Smoking cessation program:
- Relaxation technique
- Early detection of exacerbation
3. Influenza Vaccination
After the first week, you will get the influenza vaccine from

5. South Miami Hospital. The vaccine is very useful since
influenza is termed as the second most common cause of COPD
exacerbations. The vaccination will help reduce instances of
attacks (Nici & ZuWallack, 2018).
4. Involvement by the family
For effective management of COPD management, family
intervention is important. Family will help in offering emotional
support during the journey. They will also help in supporting
smoking cessation and facilitate drug adherence. Mr. Anderson
will involve his spouse in the training programs while attending
the monthly COPD clinics with him. Such ensures not just
support but will make it easier for the care coordinator to
monitor the patient for best outcomes.
CONTACTS Signature
Care Coordinator: 734-755-602
Walgreens Pharmacy: 965-546-8300
Lead physician: 953-493-398
Local clinic: 955-412-0134
Pembroke Resource Center: 308-680-5075
Ambulance: 720-119-3647
References
Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A.
(2018). Care coordination as imagined, care coordination as
done: findings from a cross-national mental health systems
study. International Journal of Integrated Care, 18(3).
Hanania, N. A., Hawken, N., Gilbert, I., Martinez, F. J., Fox, K.
M., Ross, M. M., ... & Tervonen, T. (2018). What Symptomatic
Patients with Asthma and Chronic Obstructive Pulmonary
Disease (COPD) Find Important in Their Maintenance Inhaler
Therapy: A Focus Group Study. In C37. OPTIMIZING

6. ASTHMA CARE ACROSS DIVERSE PATIENTS (pp. A4863-
A4863). American Thoracic Society.
Jiménez-Ruiz, C. A., Andreas, S., Lewis, K. E., Tonnesen, P.,
Van Schayck, C., Hajek, P., … Gratziou, C. (2015). Statement
on smoking cessation in COPD and other pulmonary diseases
and in smokers with comorbidities who find it difficult to quit.
European Respiratory Journal, 46(1), 61-79.
doi:10.1183/09031936.00092614
Korpershoek, Y., Bruins Slot, J., Effing, T., Schuurmans, M., &
Trappenburg, J. (2017). Self-management behaviors to reduce
exacerbation impact in COPD patients: a Delphi study.
International Journal of Chronic Obstructive Pulmonary
Disease, Volume 12, 2735-2746. doi:10.2147/copd.s138867
May, C. R., Cummings, A., Myall, M., Harvey, J., Pope, C.,
Griffiths, P., … Richardson, A. (2016). Experiences of long-
term life-limiting conditions among patients and carers: what
can we learn from a meta-review of systematic reviews of
qualitative studies of chronic heart failure, chronic obstructive
pulmonary disease and chronic kidney disease? BMJ Open,
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Nici, L., & ZuWallack, R. (2018). Integrated care in chronic
obstructive pulmonary disease and rehabilitation. COPD:
Journal of Chronic Obstructive Pulmonary Disease, 15(3), 223-
230.
Volpato, E., Banfi, P., Rogers, S. M., & Pagnini, F. (2015).
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Evidence-Based Complementary and Alternative Medicine,
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