Final Care Coordination Plan

Final Care Coordination Plan

Proper coordination of care requires robust control of patient activities, along with the sharing of information from the various stakeholders involved in the care provision process. The primary goal is to create a foundation for the effectiveness and safety of patient care. Thus, a healthcare provider should identify the particular needs of a patient and his/her preferences and then communicate them to the right parties, including the patient and his family, to create an efficient plan of care.

Patient-Centered Health Intervention

A patient-centered approach to care has gained popularity in the modern healthcare setting. This model is focused more on the particular needs of a patient than the perception of the physician (Delaney, 2018). In this way, patients develop trust and a connection with the healthcare providers.

The case patient, Kenneth, suffers from a mental condition and demonstrates several health issues. Firstly, the patient has developed depression out of difficulties in meeting the needs of his family. His capacity to carry on with life has been limited by this condition. He seems not to enjoy his time with family, friends, or at work. The patient cannot even have enough sleep. Secondly, Kenneth is a victim of substance abuse, from tobacco to alcohol and hard drugs. This trend might have grown out of depression, but it has consumed his ability to function with these substances. Lastly, Kenneth has developed suicidal thoughts. He complains that he feels pressured to meet the demands of life. A proper intervention is needed to address each of these issues that the patient is facing.

Kenneth is an African American, and the appropriate intervention should meet the particular needs of this community. This community is likely to accept antidepressants or seek assistance for depression (Nicolaidis, McKeever & Meucci, 2013). However, the patient can enroll in a culturally-customized, psycho-educational fitness and exercise endorsement program for six months. Such an initiative can help in managing depressive symptoms. In this intervention, Kenneth sets his activity goals and acquires depression self-management skills. The African-American Health Coalition (AAHC) is one community resource that can help Kenneth in his fight against depression through education and advocacy.

Drug addiction is another problem that the patient exhibits. He wishes to be able to work independently on drugs. In managing this issue, it is crucial that Kenneth undergoes behavioral counseling for six months. This plan should run concurrently with the program suggested above. Along with counseling, the patient should receive medication and clinical devices used to manage withdrawal symptoms. Likewise, an evaluation is important, as well as continued treatment for depression. A follow-up program can be developed to avoid relapse. In accessing help, Kenneth can use the behavioral health treatment services locator offered by the Substance Abuse and Mental Health Services Administration (SAMHSA). This resource provides a confidential source of information to anyone seeking medical assistance in the US (SAMHSA, n.d.). Thus, the client has no reason not to pursue clinical help as he can do it remotely.

While suicide is complex and often hard to envisage, it is preventable. Thus, it is essential to help Kenneth overcome these thoughts and proceed with life as normal. It is not that Kenneth wishes to die; he just wants to get rid of issues that are hurting him. Making the patient talk about his concerns is the best approach to this problem. As a healthcare provider, it is important to listen to Kenneth, be sympathetic, offer hope, and take him seriously. This discussion should be held weekly for six months to ensure that the patient develops a positive mindset about his life. If Kenneth feels uncomfortable expressing himself, he can seek help from the National Suicide Prevention Lifeline, which offers 24/7 help through a toll-free helpline, 1-800-273-8255 (Murphy, 2013). Thus, the patient can access various resources, and if he adheres to the above interventions, he can recover within six months.

Ethical Considerations

Morals are the foundation of healthcare practice. They guide the behavior and conduct during the provision of care. The main goal is to realize the right and wrong of particular actions and entails the decision-making process of identifying the fundamental implications of those events. Kenneth, being an African American, has complex issues and demands that create an ethical dilemma, which conflicts with the values of the practice. Also, he is worried about the confidentiality of his information, justice in treatment, and the potential of being harmed. He seems not to trust anyone in his life.

A patient-centered approach was adopted to assure Kenneth that care is provided according to his needs and preferences. In this way, he is offered the autonomy to make decisions per his beliefs and values. Initially, Kenneth was resistant to medication, and that right was respected despite conflicting with the views of the healthcare provider. Also, he is treated equally, just like other patients in the country. Lastly, the patient is treated with the respect that he deserves, and care is tailored according to his preferences.

Health Policy Implications

The patient-centered approach to care has been emphasized by various global healthcare frameworks as well as national policies. The World Health Organization (WHO) provides a guideline for integrated people-centered health services (IPCHS). This framework proposes five strategies, including engagement and empowerment of communities, strengthening governance and responsibility, reorienting the plan of care, coordinating services across sectors, and creating and supporting the environment (WHO, 2018). The US Department of Health has implemented this structure and enacted laws to ensure that patients are accessing care.

The Patient Protection and Affordable Care Act (ACA) remains active to ensure the safety of and access to care by patients. This policy was developed to address the rising number of uninsured individuals. It is through ACA that access to quality care has increased, even for low-income households (Kominski, Nonzee & Sorensen, 2017). The provision requires that healthcare professionals offer high-standard services, in which case patients should not return to the facility within thirty days after treatment and discharge. Kenneth is set to recover after six months, after which follow-up will be conducted to prevent a relapse.

Learning Session Outcomes and Attainment of Goals

Kenneth had set unrealistic goals that included preserving much of his savings and protecting his income. However, through discussions, he agreed to set objectives aligning with his health, as he cannot work while sick. The patient appreciates the plan of enrolling in the depression treatment program as he is able to meet positive people who encourage him to adopt a stress-free life. The wellness training and exercises seem to be working in relieving the thoughts that have been disturbing Kenneth. Currently, he is struggling with the goal of valuing his self-worth. He still criticizes himself on the basis of not being able to meet the needs of his family satisfactorily. It is hoped that this trend will decline with time as he continues with the treatment. In the future, an intervention should be tailored to help such a patient learn ways of diversifying his income to avoid financial constraints.

Patient Satisfaction

Mental health describes a state in which an individual shows proper mental function, which enables him/her to engage in productive pursuits, cope with challenges, and develop positive relationships with other individuals. Kenneth feels contented in the way he is able to connect with other people, unlike before. Similarly, it was a huge step for him to seek medical assistance. Also, he appears to be focused while talking to someone, which shows that he is regaining his mental health.

A majority of the observations noted with Kenneth’s improvements are consistent with the Healthy People 2020 goals on mental health. The framework aims to minimize suicidal rates the number of persons with major depressive disorders, and increase the number of adults seeking medical services related to mental health (Healthy People 2020, n.d.). Also, mental health patients should be treated fairly as other people, even at work. The current intervention can be improved by incorporating a program that would improve the patient’s ability to return to work.

In conclusion, patient care should be tailored to the particular needs of the patient to ensure coordination and continuum of care. The report has detailed the case of a mental health patient who is suffering from depression, substance abuse, and suicidal thoughts. An intervention has been developed to address each of these issues based on the preferences of the patient. Ethical concerns are prevalent in a patient-centered approach to care as a patient may be hesitant towards treatment. However, the rights of the patient must be observed. Kenneth appears to be satisfied with the intervention as he is regaining his mental health. However, the study has recommended a few adjustments to align the intervention with Healthy People 2020 goals.

References

Delaney, L. (2018). Patient-centered care as an approach to improving health care in Australia. Collegian, 25(1), 119-123. doi: 10.1016/j.colegn.2017.02.005

Healthy People 2020. Mental Health and Mental Disorders. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental- disorders/objectives

Kominski, G., Nonzee, N., & Sorensen, A. (2017). The Affordable Care Act’s Impacts on Access to Insurance and Health Care for Low-Income Populations. Annual Review Of Public Health, 38(1), 489-505. doi: 10.1146/annual-publhealth-031816-044555

Murphy, G. (2013). The National Suicide Prevention Lifeline and New Technologies in Suicide Prevention: Crisis Chat and Social Media Initiatives. In B. Mishara & A. Kerkhof, Suicide Prevention and New Technologies. (1st ed., pp. 111-122). London, LDN: Palgrave Macmillan.

Nicolaidis, C., McKeever, C., & Meucci, S. (2013). A Community-Based Wellness Program to Reduce Depression in African Americans: Results From a Pilot Intervention. Progress In Community Health Partnerships: Research, Education, And Action, 7(2), 145-152. doi: 10.1353/cpr.2013.0017

SAMHSA. Behavioral Health Treatment Services Locator. Retrieved from https://findtreatment.samhsa.gov/

WHO. (2018). Continuity and coordination of care: A practice brief to support implementation of the WHO Framework on integrated people-centred health services. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?ua=1

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Assessment 4

Final Care Coordination Plan

INTRODUCTION- For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

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.

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.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including a title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

· Design patient-centered health interventions and timelines for a selected healthcare problem.

· Address three healthcare issues.

· Design an intervention for each health issue.

· Identify three community resources for each health intervention.

· Consider ethical decisions in designing patient-centered health interventions.

· Consider the practical effects of specific decisions.

· Include the ethical questions that generate uncertainty about the decisions you have made.

· Identify relevant health policy implications for the coordination and continuum of care.

· Cite specific health policy provisions.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

· Clearly explain the need for changes to the plan.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

· Use the literature on evaluation as a guide to compare learning session content with best practices.

· Align teaching sessions to the Healthy People 2030 document.

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

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

Additional Requirements- Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Context- Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

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

· Competency 1: Adapt care based on patient-centered and person-focused factors.

· Design patient-centered health interventions and timelines for a selected healthcare problem.

· Competency 2: Collaborate with patients and family to achieve desired outcomes.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

· Competency 3: Create a satisfying patient experience.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

· Competency 4: Defend decisions based on the code of ethics for nursing.

· Consider ethical decisions in designing patient-centered health interventions.

· Competency 5: Explain how healthcare policies affect patient-centered care.

· Identify relevant health policy implications for the coordination and continuum of care.

· Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

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

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

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

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

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