Post-Stroke Depression in Older Adults (65+) Following Ischemic Stroke

 

Build on your preliminary care infographic and selected health concern and population and create a detailed comprehensive final care coordination strategy.
It is suggested that you use the following outline to organize your 5–7 page paper, including headings:
• Design patient-centered health interventions and timelines for your selected healthcare problem. 
o Address three patient healthcare issues related to your selected healthcare problem and patient population
o Design an intervention for each health issue.
o Identify three community resources for each health intervention.
o Establish timelines for implementing these interventions.
o Include evidence to support your ideas.
• Consider the ethical decisions in designing patient-centered health interventions for your selected healthcare problem.
o Include the ethical questions that generate uncertainty about the decisions you have made.
o Include evidence to support your ideas.
• Identify relevant health policy implications for the coordination and continuum of care of your selected healthcare problem and population.
o Cite specific health policy provisions.
o Include evidence to support your ideas.
• Describe the priorities a care coordinator would establish when discussing the plan with a patient and family members.
o Include evidence to support your ideas
• Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.
o Clearly explain the need for the changes to the plan.

Sample Answer

 

 

 

 

 

 

  • Problem: Cost of medications and supplies, lack of understanding of medication regimen, forgetfulness, fear of hypoglycemia, and lack of immediate feedback on lifestyle changes contribute to poor adherence and infrequent SMBG.
  • Intervention: Medication Adherence and SMBG Support Program.
    • Components:
      • Initial medication reconciliation and education session with the care coordinator and primary care provider (PCP).
      • Use of pill organizers and/or medication reminder apps (e.g., MyMedSchedule, Dosecast) provided or subsidized.
      • Simplification of medication regimen where clinically appropriate (e.g., fixed-dose combinations, once-daily agents).
      • Education on the importance of SMBG, target ranges, and how to interpret results.
      • Provision of affordable or free SMBG supplies (e.g., through pharmaceutical assistance programs, community health centers).
      • Regular (monthly) follow-up calls/texts from the care coordinator to check adherence, address barriers, and troubleshoot issues.
      • Linkage to financial assistance programs for medications (e.g., PAPs - Patient Assistance Programs).

 

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