Final Care Coordination Plan

1 Running Head: FINAL CARE COORDINATION PLAN

Final Care Coordination Plan

NURS-FPX4050

Capella University

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Final Care Coordination Plan

According to McWilliams (2016), care coordination is a vital healthcare process that

synchronizes healthcare delivery from several healthcare providers and specialists. Care

coordination is performed to help to improve health outcomes by ensuring that care from

different healthcare providers is provided as one. Additionally, by eliminating redundant tests

and procedures, care coordination helps in reducing healthcare costs. According to studies, care

coordination cannot be successful without effective healthcare policies, utilization of community

resources, and nurses' American Nurses Association (ANA) code of ethics. This final care

coordination has taken into consideration all these aspects and utilized them alongside what was

gathered during the preliminary care coordination plan for a mental health illness patient.

Mental illness, also known as mental health disorders, comprises a wide range of mental

health conditions affecting an individual's moods, behavior, and thinking. Many people have

mental health issues from time to time (Baruah & Vasudevan, 2019). However, such a concern

becomes an illness when the signs and symptoms of the illness cause the individual to become

frequently stressed and when their ability to function are significantly affected. An individual

with mental illness can become miserable and other problems in one's daily life, such as in

relationships or at school, or at work. Most of the time, symptoms of mental health illness can be

managed using a combination of medications and talk therapy (Baruah & Vasudevan, 2019). The

preliminary care coordination was prepared face-to-face with the patient. The outcomes and

areas of interventions are going to be presented to the patient and his family.

Design patient-centered health interventions and timelines for a selected health care

problem

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According to David et al. (2018), patient-centered care is about providing care that

respects and responds to the individual patient's preferences, needs, and values. Additionally,

patient-centered care is about ensuring that the patient values guide all clinical decisions. Patient-

centered care cannot be performed without individuals partnering with their healthcare providers,

and in such a partnership, the healthcare decisions and measuring of outcomes are driven by the

individual's needs and aspirations (David et al., 2018). Unlike the hospital-centered model, the

patient-centered model has healthcare teams working towards knowing and treating the patient

thoroughly. This comprises the team developing individualized, comprehensive care plans

whereby mental health and social needs are given equal attention as traditional medical

treatment.

The burden of mental health illnesses continues to grow while significantly impacting

health and significant social, human rights, and economic consequences everywhere in the

world. For example, 19% of the adults in the United States experience mental illness in some

form while 4.1% has a serious mental illness. These statistics and the fact that the patient in

question is among the 4.1% in the United States have necessitated the care coordination plan.

Additionally, a care coordination plan was necessary because the mental illness significantly

affected the patient's life and relationships, and health. With a care coordination plan, the patient

will partner with the healthcare providers, and the providers will treat the patient from the

clinical, emotional, mental, spiritual, social, and financial perspective (Gusmano et al., 2019).

The patient is a 67-year old male of Asian origin who has been with mental disorders

since 2016. The patient's details are; Blood pressure 151/81, HR 105 bpm, temperature 35.9

degrees Celcius, and RR 36 bpm. The patient was highly interested in the entire process and was

also looking forward to being part of the care coordination plan. Furthermore, the patient pointed

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out that his family was going to be involved in the process. The patient also identified three

health issues related to mental health illness, as will be shown.

Depression

Depression is a common mental illness and one of the primary causes of disability

globally. According to estimations, more than 260 million people globally are affected by

depression, with women being more than men. The patient identified depression as one of the

mental illnesses he had suffered from symptoms such as sadness, loss of interest or pleasure,

feelings of guilt and low self-worth, disturbed sleep and appetite, tiredness, and poor

concentration. Additionally, the patient indicated that he had had multiple physical complaints

with no apparent physical cause (Jokela et al., 2016). Depression is severe and is one of the

major mental disorders. Therefore, the patient must be taught about the disorder and how simple

it is to become depressed, and what one should do to ensure that he is not severely affected by

the illness.

Intervention programs have been shown to reduce depression and its effects significantly.

An essential intervention would be psychosocial assistance following conflicts and disasters.

Additionally, effective treatments for depression include talking therapies such as cognitive

behavioral therapy or psychotherapy. Depression can also be effectively treated via

antidepressants for moderate to severe depressions (Jokela et al., 2016). However,

antidepressants should not be used as the first line of depression treatment, especially for cases of

mild depression. Managing the patient depression should include psychosocial aspects whereby

healthcare providers should identify the stress factors in the patient such as financial problems,

difficulties at the workplace or physical or mental abuse, and sources of support, including

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friends and family members. Additionally, the importance of maintenance of social networks and

social activities cannot be underestimated (Jokela et al., 2016).

Bipolar Disorder

Bipolar disorder is a severe mental illness that affects more than 40 million people

globally. Indeed, the patient has indicated that he has suffered manic and depressive episodes

separated by periods of normal moods in the last two years. Manic episodes involve the patient

having elevated or irritable mood, rapid speech, over-activity, inflated self-esteem, and a reduced

need for sleep. Although the patient did not have depressive episodes, he cannot be classified as

not having bipolar disorder (Lopez-Munoz et al., 2016).

Bipolar disorder patient-centered interventions are also necessary to effectively treat the

acute phase of bipolar disorder and the prevention of relapse. The patient can use medicines to

stabilize moods. Additionally, similar to depression, psychosocial support can be a critical

component for treating bipolar disorder. Other patient-centered interventions include cognitive

behavioral therapy. The goal of these interventions is to help alter harmful thoughts and

behavioral patterns that could make it difficult for the patient to deal with the illness (Lopez-

Munoz et al., 2016).

Schizophrenia

Schizophrenia is one of the severest mental illnesses and affects more than 20 million

people globally. Distortions characterize schizophrenia in thinking, perception, emotions,

language, sense of self, and behavior. Additionally, the patient has indicated to having

hallucinations (seeing and hearing nonexistent things) and delusions (fixed false beliefs).

Schizophrenia has made it difficult for the patient to work normally. People with schizophrenia

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are highly stigmatized and discriminated against, which can lead to such people being unable to

access health and social services (McCurtcheon et al., 2020).

Schizophrenia can be effectively treated using both medicines and psychosocial support.

With the patient treated appropriately and receiving appropriate social support, he can lead a

productive life and integrate into society. Additionally, facilitating assisted living and supported

housing and employment can act as the base from which the patient can easily achieve multiple

recovery goals as they find it challenging to obtain or retain normal jobs and a place to live

(McCurtcheon et al., 2020).

Consider ethical decisions in designing patient-centered health interventions.

Ethics and ethical decisions are essential in providing healthcare. Therefore, healthcare

providers should make ethical decisions during the process of care. According to the Institute of

Medicine, ethics in healthcare comprises applying core principles of bioethics (autonomy,

beneficence, nonmaleficence, justice) while making medical and healthcare decisions. Basically,

ethics in healthcare is a multidisciplinary lens through which healthcare providers can view

complex health issues and make recommendations regarding what should be done (Iserson,

2020). The ANA Nursing Code of Ethics is a significant policy guideline that can be helpful to

nurses regarding working within ethical confines during the coordination of care plans.

Ethical issues will arise in the coordination of care when there are decisions that need to

be made. The answers may not be clear, and the solutions are not ideal. During the coordination

of care plan, ethical decisions will include honesty vs. withholding information when providing

care. According to ANA, truth should always prevail. Another ethical decision will come in the

form of science vs. spirituality, whereby science-based healthcare will impede the patient's

religious beliefs. Other ethical decisions and considerations will comprise healthcare providers

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deciding whether coordination of care is for the patient's best welfare and whether it guarantees

patient safety. Additionally, healthcare providers will have to determine whether they will change

some interventions that do not conform to ethical guidelines.

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

Health policies are major determinants of decisions, plans, and actions needed to ensure

healthcare delivery most appropriately based on patient safety and healthcare standards. It is the

responsibility of the government to create health policies to provide people with high-quality

healthcare (Thomson et al., 2018). One such policy is the Affordable Care Act (ACA) which has

significantly affected healthcare in recent times. With the implementation of ACA, healthcare has

become more affordable, thereby increasing the number of people with access to healthcare. The

increasing number of people and, therefore, patients have increased the need for coordination of

care to deal with patient needs.

The Hospital Readmission Reduction Policy has also significantly affected coordination

of care. The implementation of the policy has helped ensure that patients recover in the best way

and are not re-hospitalized for healthcare issues (McGarry et al., 2016). Note that the aim of

coordination of care is to ensure patients get the best care in the hospital and at home and, in

doing that, reduces patient readmission. The Health Insurance Portability Accountability Act

(HIPAA) has also impacted coordination of care. HIPAA ensures patient privacy and

confidentiality, which are critical aspects of the healthcare process. Patient information must be

protected and safeguarded during maintenance.

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.

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Learning sessions help in strengthening coordination of care plans. With sessions done

regularly, it will ensure that all participating parties understand their roles in the coordination of

the care plan. Having learning sessions is also essential as it makes it possible to realize several

things. For example, healthcare providers understand patient expectations from the plan. The

healthcare providers would understand whether the patient is excited or worried by the plan and,

therefore, what the providers would have to do concerning this. Additionally, the information

from the patient would determine how the providers will react and whether there is anything that

needs to be changed or improved.

Learning sessions also indicate areas that need to clarify or revised. For example, through

the learning sessions, the patient would indicate whether they can handle the amount of

information generated from the sessions or add more information to what is already being

provided by the providers. Basically, holding learning sessions is helpful to both patients and

healthcare providers. To the healthcare provider, it enables the healthcare providers to know the

multidisciplinary approach that should be employed to better explain to the patient some

interventions that may be difficult for the patient to grasp. Following this, therefore, there was a

need for including nutritionists and dieticians, counselors, and trainers in the learning sessions to

the final care plan. The addition of these parties would help enhance understanding and care

coordination for the patient's needs.

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.

Coordination of care plan should aim at ensuring the patient is delighted. With the

learning sessions, the patient and other stakeholders in the plan were able to indicate their level

of satisfaction concerning the coordination of the care plan. The patient was delighted and

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encouraged the coordination of care to proceed. To ensure the patient is satisfied further, the

revisions identified will be incorporated in the final coordination of the care plan. There were

many indications that coordination of care was in line with the objectives of Healthy People

2030.

Healthy People 2030 was created to help achieve specific healthcare goals. One of the

features of Healthy People 2030 is mental health which are featured as significant disorders that

affect moods, thinking, and behaviors of people and, therefore, should be handled as stipulated in

the Healthy People 2030 framework (Griffith, 2021). Indeed, there are several mentions of

coordination of care as an effective way through which mental illnesses can be handled. This is

an indication that caring for the patient is well within the initiative requirements.

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References

Baruah, J., & Vasudevan, A. (2019). The vessels shaping mental health or illness. The Open

Neurology Journal, 13, 1.

David, G., Saynisch, P. A., & Smith-McLallen, A. (2018). The economics of patient-centered

care. Journal of Health Economics, 59, 60-77.

Griffith, D. M. (2021). Well-being in Healthy People 2030: A missed opportunity. Health

Education & Behavior, 48(2), 115-117.

Gusmano, M. K., Maschke, K. J., & Solomon, M. Z. (2019). Patient-centered care, yes; patients

as consumers, no. Health Affairs, 38(3), 368-373.

Iserson, K. V. (2020). Healthcare ethics during a pandemic. Western Journal of Emergency

Medicine, 21(3), 477.

Jokela, M., Virtanen, M., Batty, G. D., & Kivimaki, M. (2016). Inflammation and specific

symptoms of depression. JAMA Psychiatry, 73(1), 87-88.

Lopez-Munoz, F., Shen, W. W., D'ocon, P., Romero, A., & Alamo, C. (2016). A history of the

pharmacological treatment of bipolar disorder. International Journal of Molecular

Sciences, 19(7), 2143.

McCurtcheon, R. A., Marques, T. R., & Howes, O. D. (2020). Schizophrenia - an overview.

JAMA Psychiatry, 77(2), 201-210.

McGarry, B. E., Blankley, A. A., & Li, Y. (2016). The impact of the Medicare hospital

readmission reduction program in New York State. Medical Care, 54(2), 162-171.

McWilliams, J. M. (2016). Cost containment and the convenient tale of care coordination. The

New England Journal of Medicine, 375(23), 2218.

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Thomson, K., Hillier-Brown, F., Todd, A., McNamara, C., Hujts, T., & Bambra, C. (2018). The

effects of public health policies on health inequalities in high-income countries: An

umbrella review. BMC Public Health, 18(1), 1-21.