Evaluating a Preliminary Care Coordination Plan- Best Practices and Insights from the Literature
This final care coordination plan builds upon the preliminary plan developed in Assessment 1, addressing the complex issue of food insecurity. The plan aspires to be patient-centric and holistically designed. This entails developing patient-centered health interventions, addressing ethical issues, considering health policy matters, prioritizing care coordination items, and identifying teaching sessions to meet the best practices and the Healthy People 2030 goals. This program plan aims to fulfill the need to align community resources and evidence-based strategies to have an effective continuum of care benefiting individuals and families facing food insecurity.
Patient-Centered Health Interventions and Timelines
Healthcare Issue One: Improving Access to Affordable, Nutritious Foods
Multi-faceted intervention is suggested to address restricted access to affordable and nutritious meals. Community efforts should increase food pantries, Supplemental Nutrition Assistance Program (SNAP) membership, urban agriculture, and community gardens. This intervention entails working with local food banks, government agencies, and community groups to open new food pantries and SNAP enrollment campaigns the following year. Within 18 months, urban farming and community gardens will cooperate to open at least two more locations, enhancing fresh food availability.
Healthcare Issue Two: Providing Nutrition Education and Cooking Classes
Teaching house individuals and families the basics of a balanced diet, meal planning, and food preparation is the number one way of eradicating the problem of food insecurity. The solution to the problem includes learning a nutrition education program, including cooking classes in community centers and schools. The timeline encompasses the program’s debut in the next six months, with the educative stages planned to occur regularly or biweekly. Community resources for this program need to involve nutritionists and local culinary schools for teachers, space rentals, and community colleges in terms of instructors and places for training.
Healthcare Issue Three: Addressing Social Determinants of Health
Recognizing that food insecurity is a symptom of structural factors under which many people live, education and awareness contributions are needed. This intervention requires teaming up with local government entities and well-meaning non-profit organizations to solve poverty, unemployment, and transportation problems. The schedule in the second part comprises a social determinants evaluation that takes place over the next six months, followed by the implementation of the targeted solution that will be realized within the next 24 months. Community resources for this intervention would embrace connections with employment schemes, including those from the social sector, post-secondary education, workforce development programs, and public transportation authorities.
Ethical Decisions in Designing Patient-Centered Health Interventions
Ethical considerations must be carefully evaluated when designing patient-centered health interventions for food insecurity.
Practical Effects of Specific Decisions
The question of equal distribution of resources between expanding two food assistance programs (SNAP and food pantries) raises concerns about potential stigmatization and discrimination towards the needy population. Enhancing access to cheap food is only a part of the solution. It is equally important to make sure these programs exist without involving humiliation or discrimination.
Healthy eating promotion through nutrition education and cooking classes can be critical to their ability to make more informed choices and possess functional skills to eat healthier. On the other hand, the risk remains that neglect of cultural sensitizing may occur, or the imposition of societal norms may be encouraged on the ethnically diverse. Proper attention should be paid to ensure that the educational content is culturally acceptable and has no stereotypical notion or discrimination that covers up underlying beliefs. Further, tackling social determinants of health (like poverty and unemployment) is also necessary to eliminate food insecurity’s source causes (Dubowitz et al., 2021; Pourmotabbed et al., 2020). However, ethical issues about resource allocation, stigma, and intervention sustainability may emerge.
Ethical Questions Generating Uncertainty
While setting up food assistance programs, questions arise about how fairly the resources within the different communities would be shared and what kind of hidden bias or discrimination could happen during site selection or eligibility criteria. There is a question of how one can cope with nutrition education requirements if healthy eating habits often contradict the traditional dietary preferences of various cultures, traditions, and groups. Articulating the right balance between the culture-sensitive curriculum and the adaptability level may be crossed to the point of ethical issues. Moreover, taking into account social determinants of health involves some ethical controversy about what groups of people should receive priority for resources and interventions simultaneously and/or in different geographical regions. Also, questions weighing the moral duty to all the stakeholders—government agencies, private entities, individuals, and so on—arise due to the complexity of these social problems.
Health Policy Implications for the Coordination and Continuum of Care
Coordinating and sustaining care for food-insecure households requires alignment with health policies and services. Many policies shape the care landscape and support suggested solutions.
Supplemental Nutrition Assistance Program
The USDA administers SNAP, previously the Food Stamp Program. Economically disadvantaged households get food aid. SNAP participation and accessibility support the intervention to increase affordable, healthy food access.
Hunger-Free Kids Act
The 2010 HHFKA enhanced school lunch nutrition and community access to healthy foods. This policy promotes nutrition and cookery programs to encourage healthy eating and education.
Farm Bill
The US Farm Bill covers agricultural and food policy. Many Farm Bill sections support the intervention to improve fresh food availability via urban agriculture and community gardening.
The Affordable Care Act (ACA)
Although primarily focused on healthcare reform, ACA also addresses socioeconomic determinants of health by creating the Prevention and Public Health Fund. Similar to the planned intervention targeting socioeconomic determinants of health, this fund promotes programs that address poverty and resource scarcity as fundamental causes of health inequalities.
The Older Americans Act (OAA)
The OAA funds community-based nutrition and food delivery initiatives for older individuals. This approach helps older people avoid food poverty and maintain care.
Priorities for Care Coordination with Patients and Families
When discussing the care coordination plan with patients and families, the care coordinator should set the following evidence-based priorities:
Encouraging Food Assistance Program Enrollment
The care coordinator should emphasize enrolling people and families in food assistance programs like SNAP and local food banks. This supports evidence-based policies emphasizing increasing access to inexpensive, nutritious meals to reduce food insecurity (Eicher-Miller et al., 2020).
Education and Skill-Building in Nutrition
Nutrition education and cooking workshops may help families make better food choices and learn meal preparation skills, even with limited resources (Eicher-Miller et al., 2020). Patients should be enrolled in these educational programs and encouraged to participate by the care coordinator.
Addressing Socioeconomic Barriers
Since socioeconomic problems frequently cause food insecurity, the care coordinator should focus on poverty, unemployment, and transportation. This supports evidence-based strategies that stress addressing socioeconomic determinants of health for sustained food security (Nigusso & Mavhandu-Mudzusi, 2020).
Fostering Community Partnerships and Resource Utilization
The care coordinator should link patients and families with community resources and local food insecurity groups. Evidence-based practices emphasize collaboration and community-based treatments for long-term solutions (Nigusso & Mavhandu-Mudzusi, 2020).
Explanation of Changes Based on Evidence-Based Practice
As new evidence emerges or existing interventions are evaluated, the care coordinator should be prepared to change the care coordination plan. For example, if the care coordinator finds out that something helped increase the number of people participating in SNAP or if cultural peculiarities need to be considered in nutrition education programs, the plan should be adapted accordingly. Furthermore, the care coordinator has to do a steady assessment of the achievements of the treatment plan and, if necessary, modify them based on patients’ feedback and their progress. It is essential to emphasize the constant process of re-evaluation of the care coordination plan and its adaptability to unpredictable situations that may occur and complicate the lives of families and individuals affected by food insecurity.
Aligning Teaching Sessions with Best Practices and Healthy People 2030
The care coordinator should compare food insecurity training sessions to literature and evidence-based standards to verify efficacy and best practices. Concerning nutrition activities, especially interactive cooking classes, the key is to involve people in learning through practice, adjust the information to cultural needs and diets, and develop teachers’ capacity to create supportive and non-discriminatory learning ambiance (Eicher-Miller et al., 2020). The care coordinator should effectively promote those principles in every session of the teaching program, thus encouraging participants to engage in practical food preparation activities actively and allowing them to feel free to share their thoughts and feedback.
Moreover, the class sessions should be planned according to the goals that the Healthy People 2030 movement wants to achieve. Lover-specialized targets for nutrition and weight status, including improving the number of adults who follow a healthy diet and reducing the prevalence of food insufficiency in the community, should be built into the curriculum, according to the Office of Disease Prevention and Health Promotion (2023). The care coordinator can have some related activities that show the consequences of food insecurity, help an individual eat healthily, and give them tools to find and employ community resources more efficiently. Essentially, the assessment of the subject matter of teaching sessions against proven teaching methods and synergizing them with the food security and national health objectives of Healthy People 2030 is an effective way to define evidence-based, culturally sensitive, and food-security-promoting teaching materials.
Conclusion
This final care coordination plan presents a complete framework for dealing with food insecurity, which is a complex issue. This scheme intends to take into account patient-centered health intervention design, ethical implications, identification of relevant health policies, setting of priorities for care coordination, and arranging teaching sessions in line with best practices and Healthy People 2030 objectives; therefore, it can provide safe and able provision of care range for families and people who do not have enough income. Accordingly, this plan empowers individuals and families to achieve and maintain food security by increasing access to affordable, nutritious foods, providing nutrition education and cooking classes, addressing social determinants of health, and fostering community partnerships. In addition, this care coordination plan can improve food insecurity outcomes and community well-being by prioritizing evidence-based practices, respecting cultural diversity, and encouraging collaboration.
References
Dubowitz, T., Dastidar, M. G., Troxel, W. M., Beckman, R., Nugroho, A., Siddiqi, S., Cantor, J., Baird, M., Richardson, A. S., Hunter, G. P., Mendoza-Graf, A., & Collins, R. L. (2021). Food insecurity in a low-income, predominantly African American cohort following the COVID-19 pandemic. American Journal of Public Health, 111(3), 494–497. https://doi.org/10.2105/ajph.2020.306041
Eicher-Miller, H. A., Rivera, R. L., Sun, H., Zhang, Y., Maulding, M. K., & Abbott, A. R. (2020). Supplemental Nutrition Assistance Program-Education improves food security independent of food assistance and program characteristics. Nutrients, 12(9), 2636. https://doi.org/10.3390/nu12092636
Nigusso, F. T., & Mavhandu-Mudzusi, A. H. (2020). High magnitude of food insecurity and malnutrition among people living with HIV/AIDS in Ethiopia: A call for integration of food and nutrition security with HIV treatment and care program. Nutrition and Health, 26(1), 51–57. https://doi.org/10.1177/0260106020971855
Office of Disease Prevention and Health Promotion. (2023). Nutrition and healthy eating. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/nutrition-and-healthy-eating
Pourmotabbed, A., Moradi, S., Babaei, A., Ghavami, A., Mohammadi, H., Jalili, C., Symonds, M. E., & Miraghajani, M. (2020). Food insecurity and mental health: A systematic review and meta-analysis. Public Health Nutrition, 23(10), 1778–1790. https://doi.org/10.1017/
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Question 
For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.
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Introduction
This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected healthcare problem.
Evaluating a Preliminary Care Coordination Plan- Best Practices and Insights from the Literature
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
Preparation
You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessments.
In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.
To prepare for your assessment, you will research the literature on your selected healthcare problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based on EBP and discuss how the plan includes elements of Healthy People 2030.
Instructions
Note: You are required to complete Assessment 1 before this assessment.
For this assessment:
- Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.