Preliminary Care Coordination Plan Development: Best Practices for Healthcare Problem Management and Community Resource Integration

Pain Management in Elderly Adults with End-Stage Cancer Receiving Home Hospice Care

Understanding Pain at the Edge of Life

Pain in dying older adults is both biological and existential. It resists neat boundaries. In home hospice settings, where the hospital’s structure dissolves into the rhythms of domestic life, nurses and caregivers carry a difficult balance: easing suffering without erasing personhood. The clinical question—how to control pain—often merges with the moral one—how to preserve dignity when the body yields. That intersection defines contemporary hospice nursing.

Effective pain management begins with recognizing that pain is rarely a single signal. In older adults with end-stage cancer, it interlaces with fatigue, anxiety, spiritual distress, and loss of autonomy. Pharmacologic control matters, but it is not sufficient. Palliative care frameworks increasingly emphasize a layered model—physical relief, emotional presence, and family inclusion—as the triad of humane care.

Evidence-Based Approaches to Pain Management

Over the past decade, hospice pain control has evolved toward personalized, multimodal regimens. Opioid therapy remains central, yet best practice now demands meticulous titration and monitoring rather than blanket dosing. According to Park et al. (2023), patient- and family-centered interventions significantly enhance comfort outcomes when analgesic protocols are aligned with individualized goals rather than standardized charts.

Equally crucial are non-opioid co-analgesics—such as gabapentinoids for neuropathic pain or low-dose corticosteroids for inflammatory pain—that allow reduction of opioid burden and related side effects (Alderwick & Dixon, 2019). The growing acceptance of integrated complementary methods, including massage therapy, guided imagery, and relaxation breathing, has also reshaped hospice routines. Evidence from Gittell et al. (2020) suggests that relational coordination among interdisciplinary teams—physicians, nurses, social workers, chaplains—directly correlates with improved patient outcomes and reduced symptom escalation.

Pharmacological plans, however, falter without consistent assessment. Elderly patients often underreport pain due to cognitive decline, stoicism, or fear of addiction. Regular use of validated pain scales, adapted for cognitive impairment when needed, forms the backbone of evidence-based management. Bauer et al. (2020) emphasize the operational importance of collaborative evaluation cycles, in which feedback between nurses and physicians occurs daily, not merely during scheduled reviews.

Physical Considerations in End-Stage Cancer Pain

The physical complexity of managing pain in end-stage cancer lies partly in metabolic variability. Older bodies process opioids unpredictably. Diminished renal clearance heightens risk for sedation or delirium. Therefore, protocols favor starting at half the adult dose, with upward titration guided by both patient feedback and observed function. Subcutaneous and transdermal routes often replace oral administration when swallowing becomes difficult.

Constipation, nausea, and respiratory depression remain perennial side effects. Here, anticipatory prescribing is a form of compassion. Prophylactic laxatives and antiemetics should not be afterthoughts but integral parts of the regimen. In some ways, effective pain management is less about drug escalation and more about preventing the domino of complications that magnify suffering.

Another dimension involves symptom clustering. Pain in these patients rarely isolates itself—it overlaps with dyspnea, anorexia, and insomnia. The nurse’s eye must distinguish which symptom to address first, because relief in one often lightens the others. Morphine, for example, not only controls pain but eases breathlessness, thereby reducing panic episodes that amplify perceived discomfort.

Psychosocial Considerations

Pain at the end of life is inseparable from fear. For elderly patients, the anxiety of dependency can sharpen physical pain. Hospice teams that address emotional distress directly—through active listening, reminiscence therapy, or spiritual counseling—report fewer medication escalations. The psychological safety of being heard is, paradoxically, analgesic.

Family dynamics add another layer. Adult children often oscillate between protective overinvolvement and avoidance. Their distress can infiltrate the care environment, affecting the patient’s comfort. Gittell et al. (2020) demonstrated that structured communication among staff and families reduced emotional strain and fostered a more consistent pain narrative—each party understanding what “comfort” meant to the patient.

The nurse’s task involves calibrating empathy and practicality: acknowledging despair without being consumed by it. That emotional discipline requires institutional support. Supervision and reflective practice groups help clinicians maintain resilience while facing repeated loss.

Cultural Dimensions of Pain and Hospice

Culture shapes both how pain is expressed and how it is treated. Some elderly patients from collectivist backgrounds interpret endurance as virtue; others equate pain relief with surrendering control. Ignoring these beliefs risks either undertreatment or mistrust. Vedel et al. (2019) argue that culturally informed care planning improves adherence and satisfaction, especially when interpreters or cultural mediators facilitate discussions around symptom management.

Within multicultural home hospice contexts, sensitivity extends beyond language. Dietary restrictions, spiritual rituals, and gender norms can influence medication routines and caregiver assignments. For instance, a devout patient may prefer same-gender caregivers for personal hygiene. Recognizing and integrating such preferences is not peripheral—it is central to person-centered care.

Moreover, pain assessment tools must accommodate cultural variation in verbal expression. Some patients describe pain through metaphor or silence rather than numeric scales. The attentive clinician listens beneath the words.

SMART Goals for Pain Management

Setting realistic, measurable goals provides direction amid uncertainty. Two practical SMART goals for elderly cancer patients in home hospice care include:

Goal 1: Maintain reported pain levels at or below 3 on a 0–10 scale within two weeks of initiating the individualized care plan.

• Specific: Focused on numeric pain relief.

• Measurable: Quantified through standardized pain scales.

• Achievable: Consistent with palliative guidelines for comfort thresholds.

• Relevant: Aligned with the patient’s primary aim of comfort rather than cure.

• Time-bound: Two-week interval allows for medication titration and reassessment.
  Evidence from Park et al. (2023) supports this target, showing that structured pain assessment every shift leads to sustained pain reduction within similar timeframes.

Goal 2: Enhance patient and caregiver confidence in managing breakthrough pain episodes through education and support within four weeks.
This goal shifts the focus from symptom control to empowerment. Teaching caregivers how to administer rescue doses safely, recognize early pain signs, and contact hospice nurses promptly can reduce emergency visits. According to Bauer et al. (2020), such training programs improve both patient satisfaction and caregiver coping.

Integrating Community Resources

Effective pain management extends beyond medical visits. It depends on a network of community supports that sustain care continuity. Local hospice organizations—such as Visiting Nurse Associations—offer 24-hour on-call support, home visits, and equipment provision. Community-based palliative services can bridge gaps when medications or supplies run low.

Faith-based networks often fill the emotional and cultural gaps formal systems miss. For many elderly patients, pastoral visits or chaplaincy counseling are not optional but restorative. Support groups for family caregivers—often hosted by senior centers or cancer foundations—provide shared understanding and burnout prevention.

Pharmacies specializing in palliative care ensure consistent access to controlled medications. Collaboration with these pharmacies minimizes delays that can exacerbate pain crises. Finally, local volunteer programs, such as Hospice Companions or Meals on Wheels, indirectly contribute to comfort by addressing fatigue and isolation—conditions that heighten pain perception.

Ethical Undercurrents and Professional Reflection

Managing pain at life’s end involves ethical tension. Nurses often wrestle with the thin line between adequate relief and potential sedation. The principle of double effect—where a good action may have harmful side consequences—frequently guides decisions. Yet, as clinical practice matures, the moral lens shifts from fear of hastening death to commitment to alleviating suffering.

To be fair, not all discomfort yields to medication. Existential pain—loss of meaning, unfinished goodbyes—demands presence rather than prescription. Sometimes, sitting quietly beside a patient achieves more than another milligram of morphine. That humility, difficult to teach but essential to practice, defines professional maturity in hospice nursing.

Toward a Coordinated Model of Care

Pain management in elderly home hospice care functions best within an integrated coordination model. Regular interdisciplinary meetings, shared electronic records, and transparent role definitions create coherence. Vedel et al. (2019) document that long-term integrated care systems, like those in Québec, sustain better continuity and fewer symptom crises by aligning clinical and operational priorities.

Moreover, leadership engagement is critical. Bauer et al. (2020) show that partnerships between clinical teams and health system administrators accelerate adoption of controlled implementation trials, leading to refined protocols adaptable to diverse home settings. Coordination thus becomes not a bureaucratic task but an ethical obligation—ensuring that no patient faces uncontrolled pain because one team failed to communicate with another.

Reframing the End

Pain management in hospice care is not merely about comfort; it is a quiet form of advocacy. It declares that even as life narrows, dignity remains negotiable. Each morphine titration, each gentle repositioning, affirms a person’s right to peace. For elderly adults dying of cancer at home, surrounded by familiar walls and familiar faces, effective pain control is both a clinical success and a human promise kept.

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References

Alderwick, H., & Dixon, J. (2019). The NHS long term plan. BMJ, 364, l84. https://doi.org/10.1136/bmj.l84

Bauer, M. S., Miller, C., Kim, B., Lew, R., Weaver, K., Coldwell, C., Henderson, K., Holmes, S., Seibert, M. N., Stolzmann, K., Elwy, A. R., & Kirchner, J. (2020). Partnering with health system operations leadership to develop a controlled implementation trial. Implementation Science, 15(1), 1–12. https://doi.org/10.1186/s13012-020-00996-1

Gittell, J. H., Logan, C., Cronenwett, J., Foster, T. C., Freeman, R., Godfrey, M., & Vidal, D. C. (2020). Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics. Health Care Management Review, 45(1), 12–20. https://doi.org/10.1097/HMR.0000000000000192

Park, M., Giap, T. T., Lee, M., Jeong, H., Jeong, M., & Go, Y. (2023). Patient- and family-centered care interventions for improving the quality of health care: A review of systematic reviews. International Journal of Nursing Studies, 138, 104385. https://doi.org/10.1016/j.ijnurstu.2022.104385

Vedel, I., Monette, M., Beland, F., Monette, J., & Bergman, H. (2019). Ten years of integrated care: Backwards and forwards. The case of the province of Québec, Canada. International Journal of Integrated Care, 19(1), 1–11. https://doi.org/10.5334/ijic.4216

Citation Resources

• Bauer, M. S., Miller, C., Kim, B., Lew, R., Weaver, K., Coldwell, C., Henderson, K., Holmes, S., Seibert, M. N., Stolzmann, K., Elwy, A. R., & Kirchner, J. (2020). Partnering with health system operations leadership to develop a controlled implementation trial. Implementation Science, 15(1), 1-12. https://doi.org/10.1186/s13012-020-00996-1
• Vedel, I., Monette, M., Beland, F., Monette, J., & Bergman, H. (2019). Ten years of integrated care: Backwards and forwards. The case of the province of Québec, Canada. International Journal of Integrated Care, 19(1), 1-11. https://doi.org/10.5334/ijic.4216
• Park, M., Giap, T. T., Lee, M., Jeong, H., Jeong, M., & Go, Y. (2023). Patient- and family-centered care interventions for improving the quality of health care: A review of systematic reviews. International Journal of Nursing Studies, 138, 104385. https://doi.org/10.1016/j.ijnurstu.2022.104385
• Gittell, J. H., Logan, C., Cronenwett, J., Foster, T. C., Freeman, R., Godfrey, M., & Vidal, D. C. (2020). Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics. Health Care Management Review, 45(1), 12-20. https://doi.org/10.1097/HMR.0000000000000192
• Alderwick, H., & Dixon, J. (2019). The NHS long term plan. BMJ, 364, l84. https://doi.org/10.1136/bmj.l84

Assessment 2

Develop infographic of a preliminary care coordination plan for a selected healthcare problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

Introduction

The first step in any effective project is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular healthcare problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

Note: You are required to complete this assessment before Assessment 5.

Overview

Please watch the following brief video message for an overview of what to keep in mind as you complete your Preliminary Coordination Plan Infographic.

• Preliminary Coordination Plan Infographic.

Scenario

Preparation

As you begin to prepare for this assessment, complete the virtual simulation from Sentinel U on Patient Management & Delegation. The goal of this activity is to help familiarize yourself with technology in healthcare, patient acuity, along with assigning and delegating patient care based on the acuity level and skillset of the registered nurse.

You are also encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Instructions

Note: You are required to complete this assessment before Assessment 5.

Choose a specific healthcare problem that aligns with your practicum site population and create an infographic that visually represents your care coordination plan.

1. Select one health concern and a patient population that aligns with your practicum setting. Examples include:
   • Type 2 diabetes in pediatric patients in a community healthcare setting.
   • Cognitive impairment in home health of elderly patients.
   • Mental health in adult patients in an acute health setting.
   • Pain management in adults in hospice care.
   • Falls in long-term care adults.
2. Analyze your selected health concern and the associated best practices for health improvement.
   • Address the following content elements in your analysis:
     • Best practices: Summarize evidence-based best practices related to the chosen healthcare problem.
     • Physical considerations: Address physical aspects of care (for example, medications, treatments, or monitoring).
     • Psychosocial considerations: Consider mental health, emotional support, and patient coping strategies.
     • Cultural considerations: Recognize cultural diversity and tailor care accordingly.
   • Cite supporting evidence for best practices.
3. Describe two specific SMART (specific, measurable, achievable, relevant, time-bound) goals that should be established to address the healthcare problem and the evidence to support those goals.
   • For example: “Reduce A1C levels by 10% within 6 months through lifestyle modifications.”
   • Include physical, psychosocial, and cultural considerations of your specific patient population.
   • Discuss your SMART goals with your preceptor. Document discussion of SMART goals in Capella Academic Portal.
4. Identify available community resources for a safe and effective continuum of care.
   • Compile a list of community resources relevant to the healthcare problem.
   • Include local clinics, support groups, educational programs, and social services.
   • Include physical, psychosocial, and cultural considerations of your specific patient population.
5. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

The requirements outlined above correspond to the grading criteria in the Preliminary Care Coordination Plan scoring guide, so be sure to address each point in your infographic. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Format

• Create an infographic that visually represents your care coordination plan.
• Create the infographic using a PowerPoint infographic template.
• Use clear and concise language.
• Include relevant icons, graphics, and colors to enhance readability.

Example Infographic

This is an Example Infographic [PPTX]. Feel free to use a PowerPoint infographic template and be creative in your presentation.

Practicum Hours Submission

Nursing Reflection Journal: Four Spheres of Care

Reflective Journaling

Reflective journaling serves as a powerful tool for self-reflection during your academic journey. Reflective journaling enables you to assess your performance and to develop the regular practice of self-reflection. During your practicum, you’ll complete four reflective journal entries, each aligned with one of the four spheres of care.

For your first entry, you can choose any of the four spheres, but you will need to complete all four by the end of the course. Remember that you’ll need to submit your completed nursing reflection as part of the final assessment for the course.

Instructions

Complete your first entry in 100–400 words in the Nursing Reflection Journal: Four Spheres of Care activity. You do not need to include scholarly resources or a reference list. Your reflections should be your own original thoughts. Please do not include patient or clinic identifying information.

As you complete your practicum hours (total of 40 hours required), it is good practice to complete a reflection journal entry every 10 hours. Take a moment to review the four spheres of care and the assigned readings for each assessment. This can help you focus your practicum time on specifics of learning and experiencing the courseroom content.

AACN Definition of the Four Spheres of Care

Wellness and disease prevention: This sphere emphasizes health promotion, as well as the treatment of minor uncomplicated diseases or injuries for those not experiencing chronic illness or life-limiting conditions. Prenatal care, screenings, immunizations, and health promotion are some examples of care in this sphere (AACN, 2021). Nursing knowledge and competency in disease prevention and addressing social determinants of health are vital to promoting wellness across populations.

Chronic disease management: This sphere encompasses caring for those with one or more chronic diseases and preventing adverse outcomes associated with them. Specialized nursing care is often needed for this population due to the complex needs, along with integrated interprofessional team-based care. Four in 10 Americans have two or more chronic diseases, and those diagnosed with multiple comorbidities are projected to increase.

Regenerative and restorative care: This sphere includes critical and trauma care, complex acute care, acute exacerbations of chronic disease, and care of unstable patients who are typically in acute care hospital settings (AACN, 2021). This sphere includes the acute management of illness, such as a stroke or mental health crisis, and progression through the rehabilitative phase. Nursing skills and management of these populations are resource-intensive and specialized.

Hospice and palliative care: The final sphere relates to competencies surrounding palliative care in advanced illness and hospice care at the end of life. All registered nurses provide generalist palliative care in compassionate and patient-centered care while managing pain and other symptoms associated with advanced, progressive illness. The End-of-Life Nursing Education Consortium has mapped its Competencies and Recommendations for Educating Nursing Students competencies to the new AACN Essentials to assist educators in this endeavor.

Reflection Questions

By the end of your practicum, make sure that you have answered each of these questions.

• Wellness and disease prevention: Reflect on the health promotion disease prevention interventions you witnessed in your practicum site, as it relates to the social determinants of health most prevalent in your community. What did you see? What does this time mean to you as a professional nurse in your role?
• Chronic disease management: Reflect on the integration of interprofessional team-based care as it relates to chronic disease management in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
• Regenerative and restorative care: Reflect on the acute management of illnesses such as stroke, mental illness, and falls in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
• Hospice and palliative care: Reflect on end-of-life nursing and advanced illness and hospice care in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?

Reference

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Essentials/Essentials-Executive-Summary.pdf

Completion Checklist

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

• Competency 1: Create a patient centered strategy to achieve desired health outcomes.
  • Analyze a health concern and the associated best practices for health improvement.
  • Describe specific goals that should be established to address a selected health care problem.
  • Identify available community resources for a safe and effective continuum of care addressing a specific healthcare problem.
• Competency 5: Apply professional, scholarly communication strategies to lead patient-centered care.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Transform healthcare delivery through effective care coordination planning: Learn to analyze health concerns, set SMART goals, and integrate community resources for optimal patient-centered care outcomes.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

 

 

 

 

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Criterion 1

Analyze a health concern and the associated best practices for health improvement.

Distinguished

Analyzes a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis.

Proficient

Analyzes a health concern and the associated best practices for health improvement.

Basic

Identifies a health concern and some best practices for health improvement without weighing appropriate physical, psychosocial and cultural considerations.

Non Performance

Does not analyze a health concern and the associated best practices for health improvement.

Criterion 2

Describe specific goals that should be established to address a selected health care problem. 

Distinguished

Describes specific goals that should be established to address a selected healthcare problem. Goals are realistic, measurable, and attainable.

Proficient

Describes specific goals that should be established to address a selected health care problem.

Basic

Describes undefined goals that should be established to address a selected health care problem.

Non Performance

Does not describe specific goals that should be established to address a selected health care problem.

Criterion 3

Identify available community resources for a safe and effective continuum of care addressing a specific healthcare problem.

Distinguished

Identifies available community resources for a safe and effective continuum of care addressing a specific healthcare problem. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health.

Proficient

Identifies available community resources for a safe and effective continuum of care addressing a specific healthcare problem.

Basic

Identifies available community resources.

Non Performance

Does not identify available community resources for a safe and effective continuum of care addressing a specific healthcare problem.

Criterion 4

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Distinguished

Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.

Proficient

Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Basic

Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.

Non Performance

Does not organize content for ideas. Lacks logical flow and smooth transitions.

Criterion 5

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Distinguished

Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Correctly uses quotes and paraphrasing.

Proficient

Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Basic

Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes, and/or paraphrasing.

Non Performance

Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.

Criterion 6

Complete a minimum of 10 practicum hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal. Document discussion of SMART goals in Capella Academic Portal under “Activities.”

Distinguished

Completes a minimum of 10 practicum hours. Includes detailed description of activities and discussion of SMART goals with preceptor in Capella Academic Portal. Submits all to Capella Academic Portal.

Proficient

Completes a minimum of 10 practicum hours, approved by your preceptor. Submits practicum hour documentation to Capella Academic Portal. Documents discussion of SMART goals in Capella Academic Portal under “Activities.”

Basic

Completes less than 10 practicum hours, approved by your preceptor. Submits practicum hour documentation to Capella Academic Portal.

Non Performance

Does not complete any practicum hours, approved by your preceptor. Does not submit practicum hour documentation to Capella Academic Portal.