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Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

Analysis of the Selected Concern: Mental Health

Mental health is increasingly becoming a topic for discussion in contemporary society. Many organizations and support groups have heightened their campaigns on mental health awareness solely to minimize suffering attributed to mental health illnesses. This notwithstanding, mental health illnesses remain an issue within society. The WHO (World Health Organization) defines mental health as a state of well-being in which a person realizes their abilities and can cope with presenting stressors in their lives (Galderisi et al., 2018). Mental health is one of the predictors of well-being and healthy living within society. A compromise in an individual’s mental well-being may result in mental illnesses.

Mental health illnesses encompass all disorders that affect the psychological functionalities of an individual. These disorders have been implicated in significant morbidity and mortality and are a leading cause of functional disability. In the United States alone, 21% of all adults have a form of mental illness. Even with high prevalence, mental health illnesses still receive disproportionate attention in the healthcare spectrum. This is probably due to the heavy burden of non-communicable diseases like heart disease and diabetes that kill thousands of Americans annually. Historic underappreciation of these disorders, coupled with cultural impediments to understanding and addressing mental health issues, has increased the prevalence of these disorders. Current efforts on these disorders are to increase community awareness of these disorders, encourage health-seeking behavior among communities to enhance the address of these disorders and treat these disorders to prevent their downward detrimental effects on the patients.

The most commonly occurring mental health disorders include depressive disorders, Alzheimer’s disease, schizophrenia, bipolar disorders, anxiety disorders, and obsessive-compulsive disorders. These disorders vary in intensity and presentation. In addition, their prevalence varies across age groups, with some mental illnesses being prominent among the elderly while some appear in all ages. It is important to identify these disorders early and initiate therapy to prevent or slow the disease progressions and consequent suffering resulting from these disorders.

Best Practices for Health Improvement

Best practices in mental health are to create mental health awareness to enable early detection and treatment of these disorders, enhance access to mental health care, and utilize the collaborative approach in care processes (Priebe et al., 2018). Community awareness programs on mental health awareness are pivotal in the overall management of the disease. These programs can either utilize outreach programs to the communities or community educational programs. The sole purpose is to identify and engage with members of the community who are at increased risk of developing these disorders, as well as those with undiagnosed diseases. Prompt treatment with psychotherapeutic and pharmacotherapeutic modalities is warranted in case a positive diagnosis is made.

Enhancing access to mental health care is also crucial in mental health management. Enhancing access encompasses all strategies that ensure individuals suspected of having these disorders are diagnosed and treatment initiated (Mongelli et al., 2020). In this regard, healthcare facilities handling mental health patients must have the necessary diagnostic and treatment tools as well as qualified personnel relevant to mental healthcare. Psychologists, psychiatrists, physicians, pharmacists, nurses, and social workers are all valuable in mental health management.

A collaborative approach to care provision is the gold standard in mental health care. A collaborative approach is a multidisciplinary approach that draws all healthcare professionals offering mental health care. These professionals include nurses, physicians, pharmacists, psychiatrists, and psychologists. The collaborative approach in mental health care remains effective due to its wider scope of coverage (Lake, 2017). However, the effectiveness of this approach depends on the ability of these team members to work in concert with one another in the design of therapeutic plans for mental health patients and to monitor these patients through their illness journey.

Specific Goals to Address Mental Health Problems

Current approaches in mental health care are targeted at reducing morbidity and mortality associated with these disorders, improving the quality of life of people living with these disorders, and enhancing access to care. The first goal is to enable early detection and subsequently treatment of mental health illnesses. This is the first step in reducing morbidity and mortality associated with these disorders. Early detection and treatment prevent disease exacerbations, address any underlying conditions that may have been causing the mental illness, and adequately address the symptomatic presentations of these disorders. This goal can be achieved by intensifying community outreach programs that create awareness of mental health illnesses.

The second goal is to enhance access to mental health care. Access to mental healthcare remains a challenge in the United States. Notably, nearly 60 million Americans have difficulty accessing these services. This is partly due to the scarcity of mental health services and the lingering social stigmas associated with these disorders (Coombs et al., 2021). Nevertheless, access to mental health care can be achieved by increasing the functional capacities of healthcare institutions to include mental health units. Functional capacity entails both infrastructural expansions to include diagnostic and treatment equipment and personnel expansion to include qualified healthcare professionals with expertise in handling mental health illnesses.

Another goal is to improve the quality of life of all patients with mental health illnesses. This can be achieved by aggressive treatment of these disorders upon diagnosis. Treating these disorders will slow their progression. Collaborative approaches can be used during treatment to enhance the overall effectiveness of care. Additionally, social structures such as family and community support groups are necessary for improving these individuals’ quality of life. For these reasons, the family should be involved in the care processes involving mentally ill patients.

Available Community Resources

Several community resources are valuable in mental healthcare. Their significance in improving the psychosocial well-being of these individuals underpins their necessity. Examples of community resources necessary in mental health care include the family, community groups, community- and faith-based organizations, online resources, and governmental organizations such as the CDC. Community groups and community-based organizations assist mental health patients during their illnesses. These groups promote mental health awareness, help reduce the lingering social stigmas and discrimination against these disorders, support the recovery of these patients, and help prevent these disorders (Kohrt et al., 2018). They, therefore, promote the psychosocial well-being of these individuals.

The family also plays a role in mental health care. Their role is to assist patients who cannot undertake their routine duties due to functional losses attributable to these disorders. The family also gives the patients a sense of belonging and, in combination with community groups, ensures the social inclusion of these patients in society. Several organizations aid mentally ill patients and are also involved in mental health awareness campaigns. These organizations include the American Academy of Child & Adolescent Psychiatry, Child Mind Institute, The Jed Foundation, and the National Child Traumatic Stress Network (NCTSN), among others. The CDC also provides valuable information on mental health to all community members.


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 Health15, 100847.

Galderisi, S., Heinz, A., Kastrup, M., Beezhold, J., & Sartorius, N. (2018). Toward a new definition of mental health. World Psychiatry14(2), 231-233.

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 Health15(6), 1279.

Lake, J. (2017). Urgent Need for Improved Mental Health Care and a More Collaborative Model of Care. The Permanente Journal.

Mongelli, F., Georgakopoulos, P., & Pato, M. (2020). Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States. FOCUS18(1), 16-24.

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 Health12(1).


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Develop a 3-4 page preliminary care coordination plan for a selected health care 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.

Preliminary Care Coordination Plan

Preliminary Care Coordination Plan


NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project is planning. This assignment 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.

As you begin to prepare this assessment, you are 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.


Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen healthcare concern.
Note: Remember that you can submit all, or a portion of, your draft 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.


Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan
Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
Heart disease (high blood pressure, stroke, or heart failure).
Home safety.
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
Pain management.
Mental health.
Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3-4 pages in length.
Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the health care problem.
Identify available community resources for a safe and effective continuum of 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.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

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.
Analyze a health concern and the associated best practices for health improvement.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe specific goals that should be established to address a selected health care problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: 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.





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