NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Name

Capella university

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Preliminary Care Coordination Plan

A preliminary care coordination strategy is a structured approach to address a specific health condition by considering physical, psychological, and cultural factors. This assessment focuses on mental health disorders in Houston, Texas. As a staff nurse at a community care facility, I have supervised care approaches that help bridge gaps within the case management framework. This plan will outline key health challenges, establish clear objectives and highlight available community resources to support patient needs. The goal is to enhance patient outcomes through informed decision-making and personalized intervention plans.

Analysis of Mental Health Disorders and Best Practices for Improvement

Mental health disorders are the most common illnesses in the United States (U.S). Major depressive disorder, attention deficit hyperactivity disorder (ADHD) and panic disorder have become common problems. The Centers for Disease Control and Prevention (CDC) reported that one in four U.S. adults experienced a mental health condition (58.7 million) (CDC, 2024). These conditions have multi-faceted root causes based on genetic, environmental, psychological, social, lifestyle and neurological factors. Psychiatric illness will affect patients physical well-being through disturbances of normal physiological function.

It raises the risk for diseases such as diabetes and heart disease. In psychosocial terms, individuals experience stress, depression and anxiety that create financial hardship. Moreover, cultural perspectives influence how mental illnesses are perceived and diagnosed, influencing stigma, care-seeking behaviors and coping mechanisms. Mental health conditions require comprehensive, patient-centered approaches integrating medical, psychological and social support systems to enhance well-being.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

An effective management approach of mental illness is integrating the evidence-based strategy to reduce future risks and to decrease symptoms. Key components in this approach are lifestyle adjustments, seeking expert support, adherence to treatment plans, a strong social network and engaging in physical activity. The Flexible Assertive Community Treatment (FACT) model integrates diverse healthcare experts within a collaborative care team and supports self-management more effectively than the traditional single-provider model (Nielsen et al., 2021).

Mobile health solutions are preferred for ongoing, remote monitoring, leveraging technologies like telehealth. Research shows mobile health systems provide prompt counseling services, drug adherence, and regular symptom monitoring. It enables patients to actively participate in their treatment through continuous follow-up and intervention (Frank et al., 2021). Additionally, a study explores how incorporating healthy lifestyle habits like diet, smoking, and physical activity into an encompassing health score improves mental health. It reduces the chances of worsening and increases health outcomes (Hautekiet et al., 2022).

The efficiency of mental disorder care approaches may depend on several key assumptions. For example, it is assumed that patients can access health services, possess health literacy, are capable of managing their treatment, and have the financial means to afford treatments and resources. However, challenges arise from inconsistencies in patient responses to care and problems within community settings that may hinder adherence to care plans. Cultural beliefs and stigma may prevent persons from seeking help or disclosing their mental issues (Ran et al., 2021). Addressing these uncertainties requires more adaptable interventions that consider the unique characteristics of patients and communities, promoting inclusivity in care delivery.

SMART Goals to Address Mental Health Disorders

The SMART framework is a valuable tool for setting clear and actionable aims by ensuring that goals are Specific, Measurable, Achievable, Relevant, and Time-bound. It offers a structured plan and tracks progress, leading to effective outcomes in managing mental disorders. Below are three SMART goals designed to enhance the management of mental health conditions.

Goal 1: Enhance Patient Education

The first goal is to improve patient education with awareness about mental health illness and the need to change their lifestyles by adopting healthy diets, exercise, and medication regimens in persons with mental diseases in the adult population (S). This will be done by conducting educational sessions for at least 60 patients within three months, with records of attendance and patients’ feedback available (M). To make it achievable, collaboration with the psychiatrist, dietitian, psychiatric nurse, social worker, and physical therapist will be supported to mutually develop resources and materials for the sessions (A). Educating patients will help prevent mental health disorders and help them self-manage through better understanding and self-regulation (R) (Ran et al., 2021). Due to time constraints, the sessions will be done every 14 days for three months, starting from February 2025 (T).

Goal 2: Improve Patient Adherence to Treatment Plans

The second goal is improving patient compliance with the care plan through a uniform follow-up system (S). Even though the projected percentage of adherence equals 75%, the main indicators that will be used to monitor the level of adherence include follow-up visits, medicine refill ratios, and patient-reported mood-tracking questionnaires (M). This will be attained through daily/Weekly SMS/WhatsApp reminders and client follow-up to ensure they use them as planned (A). If care plans are followed carefully, patient hospitalization rates will be reduced, and patients’ mental health will be enhanced (R) (Lappalainen et al., 2021). The plan will be executed within two months, and adherence rates shall be evaluated within six months (T).

Goal 3: Train Health Professionals for Enhanced Care Coordination

The third goal is training healthcare professionals on care coordination interventions and models for managing mental health disorders using collaborative care management, patient involvement, and technology (S). It will be employed through at least four workshops and 40 healthcare workers and pre- and post-training tests to increase knowledge by at least 65% (M). It will be achievable since integrating professional mental health trainers and using sourced training materials guarantee that the training is systematic and relevant (A). Training is essential to improve knowledge of care coordination among workers, improve patient outcomes, and drive more efficient mental illness management (R) (Nielsen et al., 2021). Training sessions will be accomplished in three months starting in March 2025 (M).

Community Resources and Care Coordination

This segment focuses on identifying local resources that can be leveraged to assist individuals with mental health challenges. It ensures that individuals receive the necessary services, treatment, and support to improve their mental well-being.

• • NAMI Greater Houston Mental Health Initiatives: The department provides programs to support people with mental illnesses, fostering the development of a grassroots organization to strengthen their voices within the mental health community. It offers wellness workshops, essential education, timely screenings, and community outreach initiatives to empower those affected by mental health conditions to lead healthier lives. For further details, visit NAMIWalks 2025, walk@namigreaterhouston.org, or call 713-970-4464.
  • The Harris Center for Mental Health and IDD: The Harris Center is dedicated to supporting the most vulnerable populations, striving to empower individuals with behavioral health and intellectual and developmental disabilities (IDD) to lead transformative lives. It offers a complete range of housing services, including outreach for the homeless and rehabilitative care (The Harris Center for Mental Health and IDD, 2023). These initiatives focus on enhancing mental health outcomes through education. For assistance, call 713-970-7000 or visit theharriscenter.org/

• NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

  • National Alliance on Mental Illness (NAMI): NAMI’s guidelines equip persons with mental health states by offering educational materials, peer support groups, and advocacy programs (NAMI, 2022). Its initiatives emphasize raising awareness and equipping people with skills for self-care and management. To learn more, call 1-800-950-6264 or visit www.nami.org/
  • The Montrose Center Houston, TX: The center offers mental health education and training based on the real-world experiences and responsibilities of the current workforce. Through interactive programs, it reinforces public health’s ability to tackle mental health and substance use issues in Houston, offering workshops and coordinated care services. For more information, call 202-684-7457 or visit thenationalcouncil.orgE

• U.S. Department of Veterans Affairs: The VA Houston health care delivers a robust behavioral health program focused on veteran community outreach, research, and mental health disease prevention and management. It provides inclusive, inpatient, outpatient, and community-based services (U.S department of Veterans Affairs, 2022). Utilizing evidence-based approaches, we strive to improve health outcomes and address veterans’ unique challenges. For more details, visit va. govhouston mental healthcare/ or call 713-794-7561.

Conclusion

Effective care coordination for mental health disorders requires an approach that integrates evidence-based approaches, patient-centered goals, and community resources. This preliminary plan emphasizes improving patient education, enhancing treatment adherence, and strengthening healthcare provider training to optimize mental health outcomes. By leveraging community resources, individuals can access tailored support and interventions. Implementing structured care coordination strategies will help bridge healthcare gaps, reduce stigma, and empower individuals to manage their mental health.

References

CDC. (2024, October 7). About Mental Health. Mental Health. 

https://www.cdc.gov/mental-health/about/index.html

Frank, H. E., Grumbach, N. M., Conrad, S. M., Wheeler, J., & Wolff, J. (2021). Mental health services in primary care: Evidence for the feasibility of telehealth during the COVID-19 pandemic. Journal of Affective Disorders Reports, 5, 100146. https://doi.org/10.1016/j.jadr.2021.100146

Hautekiet, P., Saenen, N. D., Martens, D. S., Debay, M., Van der Heyden, J., Nawrot, T. S., & De Clercq, E. M. (2022). A healthy lifestyle is positively associated with mental health and well-being and core markers in ageing. BioMed Central Medicine, 20(1). https://doi.org/10.1186/s12916-022-02524-9

Lappalainen, R., Lappalainen, P., Puolakanaho, A., Hirvonen, R., Eklund, K., Ahonen, T., Muotka, J., & Kiuru, N. (2021). The Youth Compass -the effectiveness of an online acceptance and commitment therapy program to promote adolescent mental health: A randomized controlled trial. Journal of Contextual Behavioral Science, 20, 1–12. https://doi.org/10.1016/j.jcbs.2021.01.007

NAMI Greater Houston. (2024). NAMI Greater Houston – 501 (c)(3) Nonprofit – You are not alone! NAMI Greater Houston. 

https://www.namigreaterhouston.org/

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

NAMI. (2022). NAMI: National Alliance on Mental Illness. NAMI: National Alliance on Mental Illness. 

https://www.nami.org/

Nielsen, C., Hjorthøj, C., Nordentoft, M., & Christensen, U. (2021). A qualitative study on the implementation of flexible assertive community treatment – An integrated community-based treatment model for patients with severe mental illness. International Journal of Integrated Care, 21(2), 13. https://doi.org/10.5334/ijic.5540

Ran, M.-S., Hall, B. J., Su, T. T., Prawira, B., Petersen, M., Li, X.-H., & Zhang, T.-M. (2021). Stigma of mental illness and cultural factors in Pacific Rim region: A systematic review. BioMed Central Psychiatry, 21(1). https://doi.org/10.1186/s12888-020-02991-5

The Harris Center for Mental Health and IDD. (2023). Transform the lives of people with behavioral health and IDD needs. Www.theharriscenter.org. https://www.theharriscenter.org/

U.S department of Veterans Affairs. (2022, October 12). Mental health care. Veterans Affairs. https://www.va.gov/houston-health-care/health-services/mental-health-care/