I need help Building on my preliminary plan

Final Care Coordination Plan Thanh Nguyen Capella University NURS-FPX 4050: Coordinating Patient-Centered Care Dr. Dalesandro March 2024

Final Care Coordination Plan

Homelessness is a critical issue in public health, affecting people and communities worldwide. Those who are homeless encounter a wide range of health problems (Synovec, 2020). The impermanent circumstances of homelessness, along with restricted access to healthcare, intensify these health challenges, resulting in increased rates of illness and death in this demographic when compared to the broader population. This final care coordination plan will enhance the foundational structure established by the initial care coordination plan. It will focus on developing patient-centered interventions, employing ethical principles for decision-making on interventions, and examining healthcare policies and provisions that influence care coordination and the continuum of healthcare. The plan will prioritize actions for care coordinators when partnering with families to implement changes and underscore educational sessions that align with the objectives of Healthy People 2030.

Patient-Centered Health Interventions

One major health issue facing the homeless population is the high incidence of chronic diseases, such as hypertension, diabetes, and respiratory conditions. To address this, an intervention could involve the establishment of mobile health clinics that provide regular screening, disease management education, and medication distribution directly within communities where homeless populations are known to reside. Community resources that could support this intervention include local public health departments for medical supplies and personnel, non-profit organizations focused on homelessness for logistical support and patient outreach, and pharmacies willing to participate in prescription drug donation programs.

Mental health issues, including depression, anxiety, and substance abuse, are disproportionately prevalent among the homeless (Padgett, 2020). An effective intervention for this health issue could be the implementation of a collaborative program that integrates mental health services with existing shelters and temporary housing solutions. This program would offer on-site mental health evaluations, counseling, and treatment plans, along with referrals to longer-term mental health services as needed. Supporting community resources could include mental health advocacy groups providing trained volunteers or funding, local government social services offering additional case management support, and faith-based organizations supplying venues and additional volunteers for program activities.

Lastly, the lack of access to basic hygiene facilities is a significant health risk for the homeless, contributing to skin diseases, infections, and overall poor health. An intervention to tackle this issue could be the creation of portable shower and laundry facilities that move between high-density homeless areas on a scheduled basis. Key community resources for this intervention would include local businesses or community centers that can provide water access and space, hygiene product donations from companies or community drives, and volunteer support from community service organizations to maintain and operate the facilities.

Ethical Decision-Making in Designing Health Interventions

Designing patient-centered health interventions, especially for vulnerable populations like the homeless, necessitates careful ethical consideration to ensure that the interventions respect individual autonomy, promote justice, and do not inadvertently cause harm. One ethical decision involves determining the extent to which interventions should prioritize immediate healthcare needs over long-term solutions to homelessness. For instance, while mobile health clinics offer a practical solution to addressing chronic diseases within this population, an ethical question arises about whether these interventions might inadvertently perpetuate the cycle of homelessness by focusing resources on symptomatic treatment rather than addressing the root causes, such as the lack of affordable housing or employment opportunities. This generates uncertainty about the balance between providing essential healthcare services and the ethical responsibility to advocate for systemic changes that address the underlying determinants of health.

In mental health interventions, ethical decisions also come into play regarding patient consent and autonomy. Many individuals experiencing homelessness may suffer from mental health conditions that impair their capacity to make informed decisions about their care. This raises ethical questions about how to obtain informed consent, respect patient autonomy, and ensure that interventions do not coerce or stigmatize individuals. The practical effect of these decisions involves creating protocols that are sensitive to these concerns, such as implementing decision-making aids or involving mental health advocates. However, uncertainty remains about the extent to which interventions can be both fully respectful of autonomy and effectively address the mental health needs of a population that might sometimes be wary of institutionalized healthcare services.

Furthermore, interventions aimed at improving hygiene access confront ethical decisions related to privacy, dignity, and equity. For example, portable shower and laundry facilities must be designed and operated in ways that preserve the dignity and privacy of users, raising questions about the adequacy of such facilities and the potential for stigmatization. There's also the ethical concern of ensuring equitable access to these services among the homeless population, which may be dispersed or include individuals with limited mobility. The practical effect of addressing these concerns includes careful site selection and design of facilities, as well as outreach efforts to ensure wide accessibility. However, uncertainty arises in ensuring that these interventions do not reinforce social exclusion or fail to reach the most marginalized individuals within the homeless community, highlighting the complex ethical landscape in designing patient-centered health interventions.

Health Policies Pertinent to Care Coordination

The coordination and continuum of care are significantly influenced by health policy provisions that aim to enhance access, quality, and integration of services across the healthcare spectrum. For instance, the Affordable Care Act (ACA) has several provisions that directly impact these areas, such as the requirement for the creation of Accountable Care Organizations (ACOs). According to Blumenthal et al. (2020), ACOs are designed to foster coordination among providers to improve patient outcomes and reduce costs, thus directly affecting the continuum of care by incentivizing the provision of efficient, high-quality care across different settings. Furthermore, the ACA's expansion of Medicaid eligibility in many states has broad implications for care coordination by increasing access to healthcare services for a larger segment of the population, thereby addressing disparities in care access. Another relevant policy is the Health Information Technology for Economic and Clinical Health (HITECH) Act, which promotes the adoption and meaningful use of health information technology. By incentivizing the use of electronic health records (EHRs), the HITECH Act facilitates the seamless exchange of patient information among healthcare providers, which is a cornerstone of effective care coordination (Lin et al., 2019). These policies collectively aim to create a more integrated and patient-centered healthcare system, but they also present challenges in implementation and require ongoing adjustments to address issues such as data privacy concerns and the digital divide that can affect access to technology-enabled care coordination.

Establishing Priorities When Implementing Changes

When a care coordinator discusses a care plan with a patient and a family member, prioritizing patient-centered goals and evidence-based practices is crucial. Initially, the coordinator would prioritize understanding the patient’s and family's values, preferences, and desired health outcomes, ensuring that these guide the care plan's development. Changes to the plan, grounded in the latest evidence-based practices, might be necessary to optimize patient health outcomes, enhance the quality of care, and ensure the efficient use of resources. For instance, if new research suggests a more effective treatment or management approach for the patient's condition, the care coordinator would explain the need for altering the treatment regimen, focusing on how the change could improve health outcomes, reduce potential side effects, or enhance the patient’s quality of life. This process involves a transparent discussion about the benefits and potential risks of the new approach, ensuring the patient and family members are fully informed and involved in the decision-making process. The coordinator's ability to integrate patient preferences with the best available clinical evidence exemplifies the commitment to delivering personalized, high-quality care.

Aligning Teachings with Healthy People 2030

Healthy People 2030 has listed objectives for the homeless population such as eliminating health disparities, achieving health equity, and creating social, physical, and economic environments that promote good health for all—into the curriculum (Housing and Homes, n.d.). This can be achieved by incorporating case studies, data, and examples that reflect the initiative's priorities, and by designing learning outcomes that directly contribute to these national health objectives. Such an approach not only ensures that educational content is grounded in best practices but also fosters a learning environment that is relevant, forward-thinking, and committed to improving public health outcomes.

Conclusion

Homelessness is a critical healthcare issue that presents unique challenges and requires tailored, patient-centered interventions. By addressing these healthcare issues with targeted interventions and leveraging community resources, it is possible to significantly improve the health and well-being of the homeless population, creating pathways to more stable living conditions and access to continuous care. Ethical decision-making and adherence to evidence-based practices are paramount in ensuring these interventions respect patient autonomy, promote equity, and provide the highest quality of care. Moreover, aligning these efforts with broader health policy provisions and public health goals, such as those outlined in Healthy People 2030, enhances the effectiveness and relevance of healthcare services.

References

Blumenthal, D., Collins, S. R., & Fowler, E. J. (2020). The affordable care act at 10 years — its coverage and access provisions. The New England Journal of Medicine, 382(10), 963-969. https://doi.org/10.1056/NEJMhpr1916091

Housing and Homes. Housing and Homes - Healthy People 2030. (n.d.). https://health.gov/healthypeople/objectives-and-data/browse-objectives/housing-and-homes

Lin, Y., Lin, M., & Chen, H. (2019). Do electronic health records affect quality of care? evidence from the HITECH act . Information Systems Research, 30(1), 306-318. https://doi.org/10.1287/isre.2018.0813

Padgett, D. K. (2020). Homelessness, housing instability and mental health: Making the connections. BJPsych Bulletin, 44(5), 197-201. https://doi.org/10.1192/bjb.2020.49

Synovec, C. E. (2020). homelessness. Work (Reading, Mass.), 65(2), 233-234. https://doi.org/10.3233/WOR-203099