Care Coordination Plan for Patients with Heart Failure Disease

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Heart failure’s three main health care issues are abnormal heart rhythms, fluid overload, and hypertrophy. As time progresses, there will be more factors that lead to exacerbation or worsening of these symptoms. It is important to plan for the care of patients diagnosed with heart failure now that they have been discharged from the hospital after successfully treating an episode of heart failure. Care planning also requires involving the patient’s family to take on their role as part-time caregivers for the patient. Ultimately, care coordination that is customized may result in better results for patients, caregivers, and funders.

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Abnormal Heart Rhythms

One common intervention for abnormal heart rhythms is medication. There are many different types of medications that can be prescribed to help regulate heart rhythm. Some of these medications include beta-blockers, calcium channel blockers, and digoxin. If medications do not work, or if the patient cannot tolerate them, another option is electrical cardioversion (Oyanguren et al., 2016). Its procedure uses electricity to shock the heart and reset the rhythm. If these interventions do not work, a pacemaker may be necessary. Additionally, a pacemaker, a device implanted in the chest to help regulate the heartbeat can be used to regulate heart rhythm.

Community Resources

The first community resource is patient education/knowledge about the disease and treatment provided by nurses or physicians, or other team members. The patients should have a basic knowledge about the treatment provided and how to take it. They should also have a better understanding of what they can do to take care of themselves. Patients can participate in their healthcare by becoming educated, asking questions, and working closely with their health team as partners in care (Comín-Colet et al., 2016). When patients understand their heart failure and the treatments available to them, they can better manage their condition and improve their quality of life.

The second community resource is support groups which offer emotional support and information about heart failure and its treatment. Patients with heart failure can feel isolated and may find it helpful to talk with others going through the same thing. The third community resource is case managers who work with patients to develop a care plan. A case manager can help understand heart failure, how it might progress, and what treatments are available (Hanlon et al., 2017). Case managers can also connect patients with other resources in their community, such as support groups or therapists.

Fluid Overload

One of the main ways to correct fluid overload in heart failure is by developing a care coordination plan. It includes working with healthcare providers to create a personalized care plan that outlines the best way to manage fluids and medications. It is also important to have regular follow-up appointments to ensure an effective plan. If patients have problems with fluid overload, it is important to speak with their healthcare provider. They can help them develop a care coordination plan that best meets their needs.

It is important for the patient to stick to the plan and follow up with the provider as scheduled. According to Kavalieratos et al., (2017), this will help ensure that patients get the best possible care for the condition. If there are problems with fluid overload, it is important to speak with the healthcare provider. They can help develop a care coordination plan that will best meet the patient’s needs. Remember, it is important to stick to the plan and follow up with the provider as scheduled. It will help ensure that the patients get the best possible care for their condition.

Community Resources

A few different community resources can help those suffering from fluid overload in heart failure disease intervention. The first is the American Heart Association (AHA). The AHA has several different programs and services available to help heart failure patients. They offer patient education materials, support groups, and wellness programs. The second community resource is the National Heart, Lung, and Blood Institute (NHLBI). The NHLBI offers a wide variety of information on heart failure, including fact sheets, treatment guidelines, and an index of clinical trials (Hanlon et al., 2017). They also have a helpline available to answer any questions about heart failure. The third community resource is the Centers for Medicare and Medicaid Services (CMS). CMS offers a wide variety of resources, including information about payment options and coverage, tools to help measure the quality of care the patient is getting, and various types of counseling (Centers for Medicare & Medicaid Services, 2020). These resources can lower the cost of managing fluid overload.

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Hypertrophy refers to the enlargement of the heart muscle, which causes the heart to beat faster than usual to circulate blood, eventually leading to heart failure. There are many ways that hypertrophic cardiomyopathy (HCM) can be intervened or corrected. Suppose a patient has not been diagnosed with hypertrophic cardiomyopathy but has been experiencing symptoms like chest pain, shortness of breath, and fatigue. In that case, they should reach out to their family physician and explain these symptoms to them (Kavalieratos et al., 2017). The doctor will likely perform an assessment to check the heart’s electrical activity. If this test shows a problem with the electrical activity in their heart, they may be referred to a cardiologist for further testing like an echocardiogram. It would be considered diagnostic testing, and it would generally occur before the patient is given a diagnosis.

Community Resources

In heart failure, three community resources for Hypertrophy disease intervention are family members, physicians, and pharmacies. In hypertrophic heart disease patients, there is a need for ongoing monitoring by a physician and ongoing medication. The patient’s family should be involved in the patient’s care because they have to monitor symptoms and ensure that the patient is taking their medication (Hoying & Zadvinskis, 2021). Pharmacies can provide help by educating patients on different drugs and by having programs that allow physicians to monitor clinical outcomes for hypertrophic disease patients.

Ethical decisions in designing patient-centered health interventions.

Patient-centered care is influenced by the ethical concept of autonomy and takes into account patients’ traditional values, individual preferences, beliefs, family circumstances, and habits. There are practical effects of specific decisions that need to be considered when designing a care plan for patients with heart failure. For example, incorporating shared decision-making into patient education may result in improved self-care behaviors and better health outcomes (Hoying & Zadvinskis, 2021). In addition, providing educational resources in various formats can better meet the individual needs of patients.

Ethical questions that generate uncertainty about decisions include:

  • What are some ethical issues/ethical theories in care coordination?
  • How should health care professionals balance family needs with patient autonomy?
  • What are some possible outcomes of shared decision-making?
  • Does the use of patient-reported outcome measurement (PROM) improve shared decision-making?
  • How do we ethically address cultural differences regarding care coordination and health literacy?

Health policy implications for the coordination and continuum of care

Health policy concerns for heart failure illness management and continuity of care encompass the requirement for an integrated care strategy to guarantee that individuals get timely and adequate treatment. This plan should include communication among healthcare providers, patient self-care education, and follow-up care (Hanlon et al., 2017). Additionally, patients with heart failure disease should be monitored to meet certain criteria for follow-up exams. There are also national policies to ensure that patients with heart failure disease receive priority access to transplantation programs. Specific health policy provisions include the following:

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  • Health care providers should help coordinate patient care through designated referral sources, improve communication among healthcare providers, and provide educational materials to patients (Hoying & Zadvinskis, 2021).
  • Patients with heart failure disease should be monitored to ensure they meet certain criteria for follow-up exams, including blood pressure and weight checks and assessment of their symptoms.
  • National policies that prioritize patients with heart failure disease for access to transplantation programs exist.
  • Priorities to be established by a care coordinator in addressing the plan
  • The care coordinator should ensure that all health care team members are aware of the patient’s current condition and treatment plan.
  • The care coordinator should also work with the patient and family to create a care plan tailored to meet the individual’s needs. The plan should include goals for treatment, including medications and physical activity.
  • The care coordinator must work closely with the patient and family to create a care plan that meets the individual’s needs. The plan should be tailored to the specific patient.


Care coordination among all parties involved in in a client’s treatment facilitates proper treatment planning. The primary goal of care coordination plan is to accommodate patients’ requirements and choices in the provision of better, cost-effective medical services. This requires that the patient’s requirements and choices be identified and conveyed to the relevant individuals at the opportune moment, and that this knowledge be utilized to direct all care practices and decision making.


Centers for Medicare & Medicaid Services (2020). Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. Web.

Comín-Colet, J., Enjuanes, C., Lupón, J., Cainzos-Achirica, M., Badosa, N., & Verdú, J. M. (2016). Transitions of care between acute and chronic heart failure: Critical steps in the design of a multidisciplinary care model for the prevention of rehospitalization. Revista espanola de cardiologia (English ed.), 69(10), 951–961. Web.

Hanlon, P., Daines, L., Campbell, C., McKinstry, B., Weller, D., & Pinnock, H. (2017). Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer. Journal of medical Internet research, 19(5), e172. Web.

Hoying, J., & Zadvinskis, I. (2021). The Fuld Institute for EBP Community Core: Supporting the Patient Perspective in EBP for Optimal Health and Wellness. Worldviews on evidence-based nursing, 18(5), 244–246. Web.

Kavalieratos, D., Gelfman, L. P., Tycon, L. E., Riegel, B., Bekelman, D. B., Ikejiani, D. Z., Goldstein, N., Kimmel, S. E., Bakitas, M. A., & Arnold, R. M. (2017). Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities. Journal of the American College of Cardiology, 70(15), 1919–1930. Web.

Oyanguren, J., Latorre García, P. M., Torcal Laguna, J., Lekuona Goya, I., Rubio Martín, S., Maull Lafuente, E., & Grandes, G. (2016). Effectiveness and Factors Determining the Success of Management Programs for Patients With Heart Failure: A Systematic Review and Meta-analysis. Revista espanola de cardiologia (English ed.), 69(10), 900–914. Web.

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NursingBird. (2022, November 15). Care Coordination Plan for Patients with Heart Failure Disease. Retrieved from


NursingBird. (2022, November 15). Care Coordination Plan for Patients with Heart Failure Disease.

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"Care Coordination Plan for Patients with Heart Failure Disease." NursingBird, 15 Nov. 2022,


NursingBird. (2022) 'Care Coordination Plan for Patients with Heart Failure Disease'. 15 November.


NursingBird. 2022. "Care Coordination Plan for Patients with Heart Failure Disease." November 15, 2022.

1. NursingBird. "Care Coordination Plan for Patients with Heart Failure Disease." November 15, 2022.


NursingBird. "Care Coordination Plan for Patients with Heart Failure Disease." November 15, 2022.