NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan NR

Preliminary Care Coordination Plan

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan 

Care coordination is a model of healthcare delivery created out of the growing awareness of the prevalence and cost of chronic conditions among patient populations and the fragmentation and limitations of a healthcare system organized around fee-for-service and acute care (Williams et al., 2019). Care coordination requires meticulous planning, coordination, and collaboration between experts of various fields with the common goal of providing safer and substantially better care. When properly implemented, care coordination effectively reduces hospital admissions, re-admissions, and safety incidents. Throughout this paper, I will discuss the implications of proper care coordination related to stroke patients.


According to data from the CDC 2021, more than 795,000 people in the United States have a stroke every year. The primary cause of a stroke is high blood pressure which often goes undetected hence known as “the silent killer.” Two primary types of strokes occur: ischemic and hemorrhagic. Ischemic stroke stems from the brain’s deficient blood and oxygen supply; hemorrhagic stroke stems from bleeding or leaky blood vessels (Kyriakos & Xiao, 2020). The common risk factors for contracting the disease include family history, reduced physical activity, morbid obesity, smoking, alcoholism, and uncontrolled diabetes. While one in every six deaths from cardiovascular disease was due to stroke in 2018 (CDC, 2021), survivors are often left with physical and mental deficits that require care coordination between multiple specialties to improve their quality of life.

Post-Stroke Care Coordination


NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan NR

The process of rehabilitation for a stroke patient is often long and taxing. The needs of each patient will vary according to the extent of damage sustained and the patient’s physical and mental fortitude to recover. Lifestyle changes will typically include the prescription of new medications, dietary modification, physical activity requirements, and follow-up checkups. Due to the functional deficits caused by a stroke, optimal care requires a multidisciplinary approach, including physiotherapy, occupational therapy, speech therapy, and nursing care (Deutschbein et al., 2020).

In the aftermath of a stroke, it is common to see a patient sustain speech and language recognition deficits. In addressing these deficits, the role of the speech therapist becomes vital. The speech therapist will work closely with the patient to help reduce the deficits as much as possible while also coming up with new solutions to aid communication (Deutschbein et al., 2020). This rehabilitation process works synergistically in collaboration with the occupational therapist. The occupational therapists’ goal is to help the patient recover as much of their pre-stroke independence as physically and mentally achievable. While it may not be possible for the patient to revert to pre-stroke functionality, the goal is to pursue as much independence as possible while working hand in hand with the other care team members.

The services provided by the physiotherapist further supports the combined efforts of the speech and occupational therapists. The physiotherapist’s job is to help the patient regain overall bodily strength and mobility through continued exercise sessions. This rehabilitation is implemented through carefully planned exercises based on the patients’ needs and abilities. Through a combination of retraining speech, swallowing, communication, independence, and mobility, the patient may achieve a significant improvement to their quality of life. Given stroke’s high societal and economic burden, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers (Duncan et al., 2017).

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan 

Besides the therapists above, stroke survivors may also require the assistance of a nurse or multiple nurses. Depending on the severity of the stroke, bedridden patients may require constant care and supervision to avoid things like skin breakdown or unintentional falls that could cause secondary and tertiary problems. The mental stress of going from independence to partial or even complete dependence often requires survivors to consult with a mental health professional to deal with things like depression and suicidal ideation. The good news is that research by Deutschbein et al. (2020) shows the utilization rate of essential health services increased, and the rate of hospital readmissions decreased due to careful care coordination.

As evidenced above, every post-stroke intervention is crucial in determining the overall quality of life that a survivor will have. Carefully coordinated patient-centered care by the various teams of experts will play a pivotal role in improving the physical and mental health of a survivor. Stroke patients will generally have the support of at least one family member in addition to the professionals listed. Careful care coordination can also alleviate the burden placed on the family member responsible for caring for the patient. Without careful coordination, the new responsibilities undertaken by the family caregiver can often lead to overwhelming physical and emotional strain, depressive symptoms, a decline in physical and mental health, reduced quality of life, and isolation (Duncan et al., 2017).

Community Resources

Besides the immediate care team specifically assigned to the patient, community resources play a more prominent role in helping survivors around a specific area. One of the most important forms of community resources is patient education. Access to educational materials focused on helping patients, caregivers, and providers understand stroke recovery and prevention (Duncan et al., 2017) can not only help post-stroke but also reduce the number of stroke victims overall. Respite care facilities allow for overwhelmed family caregivers to attain temporary relief to relax and recoup while providing stroke survivors with a safe environment. On the other hand, support groups enable survivors to meet each other, which creates a new form of community and social life. The importance of these community resources cannot be overstated in the overall care coordination plan.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan 


While stroke remains a terrible life-altering disease that impacts patients in a significant way, careful care coordination can certainly bring back some form of independence and happiness to the lives of survivors. Not only does the patient benefit from enhanced quality of life, but also the patients’ family and the community at large. A complex intervention study by Deutschbein et al. (2020) revealed that care coordination is an effective instrument to support stroke survivors as they organize and utilize the necessary and available health services in the community in a coherent way.


NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan NR

Williams, M. D., Asiedu, G. B., Finnie, D., Neely, C., Egginton, J., Finney Rutten, L. J., & Jacobson, R. M. (2019, February 1). Sustainable care coordination: A qualitative study of primary care provider, administrator, and insurer perspectives. BMC health services research. Retrieved March 9, 2022, from 

CDC. (2021, May 25). Stroke facts. Centers for Disease Control and Prevention. Retrieved March 9, 2022, from 

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International journal of molecular sciences21(20), 7609.

Deutschbein, J., Grittner, U., Schneider, A., & Schenk, L. (2020). Community care coordination for stroke survivors: results of a complex intervention study. BMC health services research20(1), 1143.

Duncan, P.W., Bushnell, C.D., Rosamond, W.D. et al. The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial. BMC Neurol 17, 133 (2017).

Local Community Resources

  • Granny Nannies Home Care
  • (239) 277 7188
    • 4300 Ford Street, Suite 106, Ft. Myers, FL 33916
  • Lee Health – Stroke and Aneurysm Care
    • (239) 343 3900 – Rehabilitation Hospital
    • (239) 343 3390 – Skilled Nursing Facility
  • Stroke Recovery Foundation
    • (239) 254 8266
    • Education and resources
  • Fort Myers Nursing and Rehabilitation – Respite Care
    • (239) 936 0203
    • Short-term and long-term care


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