Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

Priority Health Problem

Although the patient has four health problems, the priority issue is diabetes because it seems two of the issues, hypertension, and neuropathy, are complications of poorly managed glucose levels. Nonetheless, this does not mean that these issues will be ignored, but diabetes management will receive more attention. Apart from the current complications, the patient is also at risk of suffering from serious health problems, such as heart disease, amputations, and strokes, if the glucose levels are not regulated. A person-centered approach where the preferences and needs of the patient are known and communicated will be useful in delivering safe and valuable health care.

What is Diabetes Mellitus?

Diabetes Mellitus (DM), also known as Type 2 diabetes is a lifelong health condition characterized by the inefficient use of insulin to regulate blood sugar levels. The underutilization results in an increase in glucose levels in the bloodstream, a problem known as hyperglycemia. Typically, this type of diabetes is more common in older individuals as opposed to younger ones (Chatterjee, Khunti, & Davies, 2017). Therefore, age is a significant risk factor for the illness. The condition is also usually associated with obesity. If diabetes mellitus is not managed well, it may lead to adverse complications, including neuropathy, hypertension, heart disease, blindness, strokes, and kidney problems.

Diabetes has far-reaching implications that go beyond the symptoms and complications associated with it. At the very basic, the economic productivity of patients is adversely affected. Unlike in the past, when diabetes was majorly a disease for aging individuals, the condition is increasingly affecting middle-aged and younger adults who are at the apex of productivity. Families are affected when the providers’ economic capacity is reduced due to diabetes. Additionally, the treatment costs of diabetes are high. These patients use more drugs, have a higher likelihood of being hospitalized, have a higher probability of requiring long term and emergency care, and have more outpatient appointments compared to the people without the illness (Espeland et al., 2015). In the United States, for instance, diabetes management is a significant leader in healthcare costs, and people with the condition have between two and three times more care expenditures compared to the persons without it.

Evidence-based Treatment

With proper blood sugar management, it possible to eliminate or at least delay the health complication and financial implications associated with diabetes. Central to the management of diabetes is adherence to acclaimed health behaviors required by robust diabetes care programs (Hunter, 2016). Lifestyle changes, including dietary adjustments and enhanced levels of physical activities, can make a notable improvement in the regulation of blood sugar levels. Treatment should focus on adopting a healthy lifestyle and proper use of diabetes medication.

At the center of diabetes treatment, is self-management because patients and their families (Carpenter, DiChiacchio, & Barker, 2019) mainly achieve treatment. Self-management involves the active engagement of patients in care activities, intending to enhance one’s behaviors, and promote wellness. Activities that will be included in the patient’s self-management regimen are taking of diabetes medications, planning of meals, exercises, daily monitoring of blood glucose, and managing of episodes of hypoglycemia and hyperglycemia (Healthypeople2020, 2019). Another critical component of diabetes management is care during illness (Mooradian, 2018). The self-management treatment plan will be developed in consultation with different healthcare professionals, including nurses, pharmacists, dietitians, and physicians.

Treatment goals

The health care professional worked with the patient and established three goals that the treatment needed to attain. The goals are:

1. Attain fasting blood sugar levels of less than 6 mmol/L within two weeks of starting treatment
2. Achieve below 9 mmol/L sugar levels after meals within two weeks of commencing self-management
3. Achieve a Body Mass Index of less than 30 within four weeks treatment
4. Reduce the blood pressure systolic readings to less than 125 and diastolic reading to less than 90
5. Reduce neuropathic pain to a self-reported level of 4 out of 10

Available Resources for A Safe and Effective Continuum of Care

Apart from primary care, various resources are essential in ensuring effective and safe and continuum of care. Some specialty care resources were identified to help in handling the issues associated with diabetes. One of the specialties is an endocrinologist, Jane Walker. The professional will help in managing hyperglycemia, avoiding acute decompensation, and preventing further disease complications. The other specialist is Mary Johnson, a neurologist, who will be instrumental in managing the neuropathic pain, which the patient is experiencing, and reverse it if it is possible. A cardiologist, Zuriel Johnson, will also be monitoring the patient’s heart and give recommendations to delay or prevent the development of heart diseases. Diabetes is also associated with mental health issues, such as depression (Chatterjee, Khunti, &Davies, 2017). Therefore, a mental health provider was identified as one of the resources in the treatment of the patient. Jones Kurer, a psychotherapist, will be useful in the diagnosis and treatment of any mental issue that may arise due to diabetes.

Conclusion

The priority health issue for the patient is diabetes management. Most of the current and potential complications could be addressed if blood sugar levels are regulated. Evidence-based care for diabetes is centered on self-management activities, including exercises, dietary adjustments, the taking of diabetes drugs, and monitoring of blood sugar levels. Various healthcare professionals should work collaboratively to help the patient attain current treatment goals and contain potential complications. Specialists who should work with the patient are an endocrinologist, a neurologist, a cardiologist, and a psychotherapist.