Final Care Coordination Plan

Final Care Coordination Plan

WHO estimates suggest that mental health illnesses will be a leading cause of morbidity in developed countries. With the increasing prevalence of these disorders in these countries, specific, prompt, and aggressive addresses of these health issues are warranted. There is a call for intensified efforts toward improving the efficacy of treatment approaches utilized in the management of these disorders. Patient-centered approaches and comprehensive care remain valuable in this regard. These approaches enable the utilization of patient-specific goals in their care processes. Their effectiveness in realizing better clinical outcomes underpins their necessity in mental healthcare management.

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Patient-Centered Health Interventions and Timelines for Mental Health Illnesses

Mental health illnesses present considerable management challenges to healthcare providers. This is because of the diverse nature of these illnesses, symptom similarities, and their chronic nature. Accurate diagnosis is required to enable the detection of the actual underlying mental health problem as well as any predisposing factor and any apparent comorbidity to ensure the adequate address of these illnesses. Specific issues that are apparent in mental health management, in general, include inadequate access to mental healthcare, poor quality of life of persons living with mental health illnesses, and identification of these illnesses.

Issue 1: Access to Mental Healthcare

Access to mental healthcare has remained a topic for discussion in the U.S. for a long time. Despite all this, access to healthcare remains an issue in the country, with many Americans unable to receive basic healthcare due to constraints in their financial and physical resources. The issue is particularly worse in mental healthcare since the issue is compounded by the scarcity of resources required for mental health management and the lingering societal stigmas still associated with mental health illnesses. According to Coombs et al. (2021), accessibility to care and perceived barriers to accessing basic healthcare can be viewed as a multidimensional concept encompassing approachability, availability, affordability, accessibility, and appropriateness. Approachability of mental healthcare details the ability of communities to perceive and seek mental healthcare services. This concept defines the community’s health-seeking behavior, their literacy levels on health, and willingness to utilize the available healthcare resources. Approachability to mental healthcare services remains an issue. Barriers to approachability include poor health-seeking behavior, accustomed to cultural impediments, mental healthcare literacy, and the lingering societal stigmas surrounding mental health illness (Coombs et al., 2021).

The availability of mental healthcare services defines the ability of communities to get mental health services. The availability of mental healthcare services remains a challenge. Impediments to the availability of mental healthcare services include scarcity of healthcare institutions offering comprehensive mental healthcare, inadequate healthcare professionals offering mental health services, and inadequate health resources used to manage these illnesses. Affordability is the ability of communities to pay for mental health services. As it stands, mental health care is a component of advanced care, often requiring higher acuity and specialty care. The Affordable Care Act was landmark legislation that considerably expanded healthcare accessibility to many Americans. Even with this expansion, some states are yet to roll out this program. Additionally, this program does not cover all healthcare costs used in mental healthcare management. Many Americans still fall short of the funds required to facilitate their treatment, such as transport costs to healthcare facilities.

Addressing the issue of accessibility is key to the overall enhancement of the health of the communities. Enhancing access to healthcare is an elaborate process that draws the participation of the community members, the healthcare system, and the governments. The role of the communities is to embrace positive health-seeking behaviors that enable them to appreciate the role of the healthcare providers and their fundamental responsibility of seeking healthcare whenever they fall ill. The role of the government is to improvise policies in the healthcare system that will enhance the affordability, accessibility, and availability of mental healthcare services. In this regard, the government should ensure healthcare system expansion to remote areas where healthcare provision centers are scarce and enhance affordability by further expanding insurance coverages for Americans. The healthcare system should ensure that healthcare provision centers offering mental healthcare have the required treatment equipment and experienced healthcare professionals required for mental healthcare management.

Community resources that can assist community members in accessing mental healthcare services include community groups, the American Psychiatric Association (APA), and federal online tools such as the CDC. Federal online tools such as the CDC offer valuable information on mental health illnesses and may enable the debunking of myths about these illnesses and, therefore, eliminate stigmas concerning these disorders. The APA is another organization that offers information on mental health illnesses. This organization champions for effective treatment of mentally ill patients. Community groups such as the Jet Foundation also advocate for mental health care accessibility and quality treatment.

Issue 2: Early Detection and Identification of Mental Health Illnesses

The effectiveness of management plans on mental health illness and the subsequent excellent prognosis is dependent on the early detection of these disorders. Early detection of mental health illnesses is fundamental in preventing the morbidity and mortality of these illnesses. This is especially because early detection enables the prompt initiation of therapy, thereby preventing complications attributable to these illnesses implicated in their suffering. Early detection also ensures patient surveillance, thus ensuring that any risks to the patients are identified and curtailed. It also enables the identification of comorbidities or predisposing factors that may contribute to the psychological suffering of the patient.

Intense community outreach programs can be carried out to ensure early detection of mental health illnesses. These programs should focus on creating community awareness of the disorders and encouraging community members who are at risk and those suspected of having the disease to be screened for mental health illnesses. Additionally, these community outreach programs should educate the communities about the benefits of managing these disorders and the harmful effects that these disorders may have on their lives. Kohrt et al. (2018) reinforce the significance of community outreach programs in creating mental health awareness and promoting the health of communities. The vitality of community programs in educational programs on mental health and coordinated care underpins their significance in overall care processes for mentally ill patients.

Community groups, faith-based organizations, and hospitals are valuable in ensuring the early detection of mental health illnesses. Community groups are local associations within communities that ensure the psychosocial well-being of other community members. They can promote earlier detection of mental illness by observing behavioral patterns and apparent changes in behavior that may indicate a mental illness. Faith-based and community-based organizations are involved in community outreach programs on mental health awareness. The hospital conducts screening exercises for these illnesses.

Issue 3: Improving the Quality of Life of Mentally Ill Patients

Mental illnesses are associated with significant morbidities, functional losses, and consequential suffering attributable to incarceration. These problems are amplified in the absence of mental health care and support. Due to functional losses, these patients may also require close monitoring and support in executing routine self-care activities. Any apparent comorbidity should be treated aggressively to prevent them from adding to the patient’s suffering. The goal of mental health management is to improve the quality of life of these individuals.

Aggressive treatment of mental health disorders upon diagnosis is pivotal in improving the quality of life of these individuals. Effective treatment approaches in mental health illnesses utilize collaborative approaches, drawing multiple healthcare providers. Psychotherapeutic and pharmacological approaches have been used in this regard. Adjunctive treatment with psychotherapy and pharmacotherapy remains superior to either modality used solely. Aggressive treatment enables symptomatic relief and slows the progression of these disorders.

Community groups, federal organizations such as the CDC, and the Association for Behavioral Health & Wellness (ABHW) are community resources that can help in the overall management of psych patients. Community groups and families support the patients during their treatment processes. The CDC offers valuable information on effective therapeutic modalities that can be utilized in these interventions. In addition, ABHW champions specialty care for mental health illnesses necessary for the care processes.

Ethical Decisions in Patient-Centered Approach

The patient-centered approach in mental healthcare involves the patients and their families in the provision of care. It involves respecting the patient’s values and preferences, enhancing their access to care, and care continuity (Davis et al., 2017). Healthcare decisions during the management of mentally ill patients sometimes present considerable ethical challenges. Common ethical challenges apparent in mental health care are those on informed consent, confidentiality, and disclosure, among others. Healthcare providers offering mental healthcare are often tasked with making ethical decisions when designing patient-centered treatment plans. In this regard, they must always utilize the provisions of the ethical principles of autonomy, non-maleficence, justice, and beneficence in making their clinical decisions.

Further, informed consent in mental health care may sometimes be challenging. This is especially where the patients cannot make informed decisions due to cognitive decline. In this regard, clinicians should act to the benefit of the patients. They should ensure that the decisions they make are those that promote the overall health of the patients.

Relevant Health Policies

Several healthcare policies enhance access and promote the quality of mental healthcare provision. The Affordable Care Act (ACA) was landmark legislation that expanded insurance coverage to Americans of low socioeconomic status. This provision ensured that Americans who would have otherwise not had access to mental healthcare received care in various healthcare institutions. The Medicare program has also enabled care access to older Americans aged 65 years and above and those with disabilities. The Mental Healthcare Act is another provision that defines the standards of mental healthcare practice. This provision also safeguards the welfare of the patients and protects their rights.

Priorities in Care Coordination

Care coordination is an elaborate process that requires specific input from the patients. The healthcare givers usually make special considerations when discussing the healthcare plan with the patients. Priorities in mental healthcare management involve the suppression of symptoms and ensuring the safety of the patients (Mascherek & Schwappach, 2017). Suppression of symptoms requires medications and aggressive treatment of the underlying causal factors. Therefore, it is important that the healthcare plan designed for these patients be accurate and address the causal factors for the patient’s suffering. In this regard, the healthcare provider should tailor the management plan to suit the patient’s preference to improve their compliance with treatment. Since safety is paramount in mental healthcare, healthcare providers and other patient caregivers, such as family members, should be involved in care discussions involving their kin. They should be told the importance of patient monitoring as a measure that enables the identification of any threat to their health. Mentally ill patients have the propensity to indulge in risky behaviors such as violence, crime, and suicide. Therefore, monitoring these patients for any exacerbations may be helpful in safety enhancements.

Change in treatment plans is often necessitated by ineffectiveness in the initial therapeutic plan. An ineffective plan can be exhibited by frequent symptom recurrences, disease exacerbations, and safety risks. Ineffectiveness in treatment usually results from poor medication compliance and inadequate monitoring of the patients. Any change in the treatment should be evidence-based and should address the likely causes of deficiencies in the treatment processes. A medication review can be necessary in case of poor patient response. Surveillance intensification may also be necessary where the patient is at a high safety risk. The patient may also be referred to institutionalized care facilities when home-based care cannot offer adequate surveillance of the patients.

Literature Evaluation

Literature findings on the best practices in mental health care reinforce the need for intense mental awareness campaigns, early detection of these disorders, and aggressive treatment as strategies for managing these disorders (Priebe et al., 2018). These findings recommend community outreach programs that provide educational programs on mental health as vital tools for creating awareness. Findings also emphasize the need for early detection and initiation of therapeutic interventions to suppress symptoms of these disorders and improve the quality of living of these individuals.

The provisions of Healthy People 2030 are in concert with these literature findings. The Healthy People 2030 reinforces the need to prevent these disorders. It recommends community awareness campaigns as the strategy of choice for preventing these disorders. It also aimed to increase the proportion of persons with mental disorders who get treatment, screen for common mental disorders such as depression, and increase the quality of mental healthcare provision (“Mental Health and Mental Disorders – Healthy People 2030 | health.gov”, 2022). Healthy People 2030 also champions enhanced access to mental healthcare by highlighting vulnerable groups that should be at the forefront of mental healthcare.

Conclusion

Comprehensive mental healthcare remains pivotal in the preservation of the lives of persons presenting with mental illnesses. Comprehensive mental health care focuses on prevention, treatment of welfare of the patients. Preventive strategies seek to reduce the incidence of mental health illnesses. Community awareness programs are valuable in preventing mental health disorders. The treatment plan for mental illnesses utilizes a collaborative approach that draws multiple healthcare providers. Aggressive and effective treatment prevents the development of other morbidities and ensures symptomatic relief. Care coordination is a key component of mental health management. It is important to note that all providers involved should make ethically sound decisions that ensure the safety of the patients. The welfare of the patients can be ensured by surveilling them and involving other stakeholders, such as community groups and the patients’ families, in their care plan.

References

Coombs, N., Meriwether, W., Caringi, J., & Newcomer, S. (2021). Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM – Population Health, 15, 100847. https://doi.org/10.1016/j.ssmph.2021.100847

Davis, K., Schoenbaum, S., & Audet, A. (2017). A 2020 vision of patient-centered primary care. Journal of General Internal Medicine, 20(10), 953-957. https://doi.org/10.1111/j.1525-1497.2005.0178.x

Kohrt, B., Asher, L., Bhardwaj, A., Fazel, M., Jordans, M., & Mutamba, B. et al. (2018). The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies. International Journal Of Environmental Research And Public Health, 15(6), 1279. https://doi.org/10.3390/ijerph15061279

Mascherek, A., & Schwappach, D. (2017). Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study. BMJ Open, 6(8), e011494. https://doi.org/10.1136/bmjopen-2016-011494

Mental Health and Mental Disorders – Healthy People 2030 | health.gov. Health.gov. (2022). Retrieved 7 June 2022, from https://health.gov/healthypeople/objectives-and-data/browse-objectives/mental-health-and-mental-disorders.

Priebe, S., Matanov, A., Schor, R., Straßmayr, C., Barros, H., & Barry, M. et al. (2018). Good practice in mental health care for socially marginalized groups in Europe: a qualitative study of expert views in 14 countries. BMC Public Health, 12(1). https://doi.org/10.1186/1471-2458-12-248

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

Introduction
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

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.

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 health care problem.

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 assessment.

Preparation
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 health care 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 upon EBP and discuss how the plan includes elements of Healthy People 2030.

Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.

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 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 health care problem.
Address three health care 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 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; contains 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.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment 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 health care 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 health care 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; contains few errors in grammar/punctuation, word choice, and spelling.
SCORING GUIDE