NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Name

Capella university

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Final Care Coordination Plan

Homelessness is a widespread and pressing public health issue in the United States (U.S). This final care coordination plan aims to address key healthcare concerns associated with homelessness by outlining data-driven interventions, relevant community resources, and ethical and policy considerations. The plan aims to improve health outcomes for this at-risk population by implementing a comprehensive, evidence-based approach.

Patient-Centered Health Interventions

Intervention 1: Mobile Health Clinics to Improve Access to Care  

In Maricopa County, Arizona, where an estimated 9,700 individuals are experiencing homelessness, a lack of access to healthcare exacerbates chronic illnesses and acute medical conditions, often leading to costly emergency room visits (Maricopa County, n.d.). A mobile health clinic initiative will be implemented to address this gap in healthcare access, targeting high-density areas such as Central Phoenix, Mesa, and Tempe. These mobile units will deliver primary care, preventive screenings, vaccinations, and chronic disease management services directly to unsheltered individuals (Bensken et al., 2021).

The program will consist of five fully equipped mobile health units, each staffed with a nurse practitioner, a mental health professional, and a social worker. Additionally, bilingual staff will be employed to address language barriers, particularly for the significant Hispanic population (31% of Maricopa’s homeless population), ensuring culturally competent care.

Timeline and Community Resources for Mobile Health Clinics  

The mobile health clinic program will launch within 6 months, starting with acquiring mobile units and staffing by month 3. The first two units will be operational by month 4, with full deployment of all five units by month 6. Community partnerships will include the Arizona Alliance for Community Health Centers (AACHC) for staffing support, local food banks to provide nutritional services, and Arizona Complete Health for insurance navigation and enrollment assistance (Arizona Alliance for Community Health Centers, 2023).

Intervention 2: Mental Health and Substance Use Disorder Support  

Maricopa County’s homeless population faces significant mental health and substance use challenges, with approximately 40% experiencing severe mental illness or substance use disorders. In response, a comprehensive mental health and addiction support program will be launched, incorporating on-site mental health assessments, psychiatric care, and addiction counseling at key homeless shelters like the Human Services Campus in Phoenix and the East Valley Men’s Center in Mesa (Maricopa County, 2024). The program will partner with local mental health providers, such as Terros Health, and will deploy 10 behavioral health specialists to provide services directly at shelters.

Timeline and Community Resources for Mental Health and Substance Use Disorder Support  

The program will roll out in 12 months, with initial partnerships and funding secured within three months. Behavioral health specialists will begin providing services at key shelters by month six, with full-scale implementation across multiple sites by twelve months. Key community resources include Terros Health and Copa Health for mental health care, the Arizona Behavioral Health Corporation for housing coordination, and the Phoenix Rescue Mission for addiction support services (Terros Health, 2023).

Intervention 3: Transitional Housing with Integrated Healthcare  

To combat the rising number of homeless individuals in Arizona, particularly in Maricopa County, a transitional housing program will be developed that integrates healthcare and social services. Currently, only 45% of homeless individuals in the county have access to shelter, leaving thousands unsheltered and without access to essential health services (Maricopa County, 2022). The initiative will partner with healthcare providers like Circle the City and Native Health to offer on-site medical and behavioral health care within the transitional housing facilities. Nutritional support and chronic disease management programs will also be provided, with a focus on improving health outcomes for individuals who have been on the streets for extended periods.

Timeline and Community Resources for Transitional Housing with Integrated Healthcare  

The transitional housing project will be phased over 18 months, with property acquisition and partnerships finalized by month 6. The first facility will be operational by month 12, and all planned units will be occupied by month 18. Community resources include Circle the City for medical services, Native Health for culturally competent care, and the Arizona Department of Housing for housing subsidies and grants (Circle the City, 2023).

Ethical Considerations and Patient-centered Health Interventions

Ethical principles are crucial in crafting interventions that are effective, morally sound, and considerate of diverse needs. Key ethical concepts like beneficence, non-maleficence, justice, and respect for autonomy are fundamental to creating patient-centered healthcare. These principles ensure that interventions prioritize patient well-being, minimize harm, promote equitable care, and honor patients’ rights and choices (Zimmerman, 2024). Firstly, the mobile health clinic initiative demonstrates the principle of beneficence by ensuring that homeless individuals receive vital medical services, vaccinations, and screenings, supporting their health (Zimmerman, 2024). The initiative fosters a supportive atmosphere by operating in familiar environments and providing care without judgment. 

The mental health support intervention aligns with the principle of justice with local mental health organizations, offering culturally sensitive counseling and support groups. This approach ensures fair access to mental health resources while accommodating the unique needs of the homeless community (Johnsen et al., 2020). Finally, the nutritional support initiative reflects respect for autonomy and non-maleficence by addressing food insecurity with nutritious meals prepared to honor the dignity and health of recipients (Johnsen et al., 2020). Despite these ethical groundworks, challenges persist. For example, there are questions about whether mobile health clinics can adequately meet the diverse health needs of the homeless seeking assistance.

Health Policies and Coordination and Continuum of Care

Multiple health policies are crucial in shaping the coordination and continuity of care for the homeless population, aiming to improve access, equity, and quality of services. Two significant policies in this setting are the Affordable Care Act (ACA) and the McKinney-Vento Homeless Assistance Act. The ACA is a transformative law that seeks to broaden health insurance coverage and enhance the quality of healthcare across the U.S. A vital feature of the ACA is its expansion of Medicaid eligibility, which increases healthcare access for low-income individuals, including those experiencing homelessness.

This expansion helps facilitate engagement in necessary health services and makes rehabilitation programs more affordable, supporting regular and preventive care (U.S. Centers for Medicare & Medicaid Services, 2024).The McKinney-Vento Homeless Assistance Act, established in 1987, serves as a foundational federal framework addressing homelessness in the U.S. This legislation offers comprehensive support to homeless individuals and families through a range of programs that fund emergency shelters, transitional housing, and job training. It aimed at fostering long-term stability and self-sufficiency.

One important aspect of the McKinney-Vento Act is the Education for Homeless Children and Youth (EHCY) program, which ensures that homeless children and teens have equal access to public education by removing barriers related to enrollment, transportation, and attendance (Hatch et al., 2022). This legislation addresses both the immediate and long-term needs of the homeless population through coordinated and accessible services.

Priorities of a Care Coordinator and Evidence-based Practices

When discussing the care coordination plan for individuals facing homelessness, care coordinators must prioritize effective communication, empathy, and collaboration. The initial step should involve establishing trust by recognizing the distinct challenges that patients face (Mosley, 2021). Homeless individuals deal with unstable living situations, limited resources, and the routine stress associated with their circumstances.

The provision of culturally sensitive care ensures that language barriers impede understanding and access to services. It is important to highlight how the suggested interventions will meet their immediate and long-term needs, tailored to fit their unique situations (Mosley, 2021). Involving patients and their families in the decision-making process is vital. It allows them to share their preferences, promoting a sense of ownership and empowerment regarding their care. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

The preliminary plan emphasized primary healthcare needs through mobile clinics, mental health services, and nutritional support but fell short in incorporating specific cultural sensitivity measures for the homeless population. The revised plan improves cultural sensitivity across all interventions, addressing the diverse needs of the homeless population. Literature indicates that overcoming language barriers through the use of bilingual staff and translation services enhances effective communication and improves health outcomes during medical visits (Thorndike et al., 2022).

The plan aims to achieve better health outcomes and minimize errors by adopting a strategy that prioritizes culturally sensitive communication. Furthermore, executing non-judgmental practices, such as providing confidential and culturally respectful counseling in mental health support, fosters a more inclusive environment for discussing mental health concerns. In the nutritional support component, the plan includes culturally appropriate foods and practices, honoring individual dietary preferences, and tackling food insecurity (Thorndike et al., 2022).

Evaluating Learning Sessions and Aligning Teaching Sessions

It is crucial to incorporate a variety of strategies to ensure that our learning sessions adhere to best practices. First, effective learning environments foster open discussions that encourage participant involvement and facilitate real-time responses to their inquiries (Usera, 2023). Clear and concise communication improves individuals experiencing homelessness’ understanding of key resources and services and their practical applications in addressing their immediate needs. Additionally, incorporating brief quizzes during the session provides immediate feedback and allows for assessment of comprehension enabling necessary adjustments and support of the material (Usera, 2023).

Aligning teaching goals with Healthy People 2030 requires a focus on specific aims such as improving access to care, offering essential mental health services, and addressing social determinants like nutrition. These goals aim to reduce health disparities and enhance the quality of care for underserved homeless populations (National Institute of Health, 2023).

The session will highlight resources that improve access to healthcare, mental health support, stable housing, and nutritional assistance, directly involving Healthy People 2030 objectives for the homeless community. Future updates will include the latest data and emerging research to ensure the training remains relevant to the evolving needs of the community and adheres to best practices. These revisions will keep the session content aligned with the specific goals of Healthy People 2030, reflecting changes in data and community provisions (National Institute of Health, 2023).

Conclusion

The care coordination plan emphasizes the importance of addressing homelessness through targeted healthcare interventions, mental health support, and stable housing solutions. By integrating ethical principles and aligning with relevant policies, the plan aims to improve health outcomes for this vulnerable population. The focus on culturally sensitive practices and community partnerships enhances accessibility and effectiveness. Continuous evaluation and adaptation will ensure that the initiatives remain responsive to the evolving needs of homeless individuals, fostering their well-being and self-sufficiency.

References

Arizona Alliance for Community Health Centers. (2023). AACHC. https://aachc.org/ 

Bensken, W. P., Krieger, N. I., Berg, K. A., Einstadter, D., Dalton, J. E., & Perzynski, A. T. (2021). Health status and chronic disease burden of the homeless population: An analysis of two decades of multi-institutional electronic medical records. Journal of Health Care for the Poor and Underserved, 32(3), 1619–1634. https://doi.org/10.1353/hpu.2021.0153 

Circle the City. (2023). Healthcare services for the homeless. https://circlethecity.org/ 

Hatch, E., Villagrana, K., Wu, Q., Lawler, S., & Ferguson, K. (2022). Predictors of secondary completion among homeless youth in three U.S. cities and the potential application of national policies. Child & Adolescent Social Work Journal, 39(3), 347–359. https://doi.org/10.1007/s10560-022-00826-8

Johnsen, S., Watts, B., & Fitzpatrick, S. (2020). Rebalancing the rhetoric: A normative analysis of enforcement in street homelessness policy. Urban Studies, 58(2), 355–371. https://doi.org/10.1177/0042098019898369

Maricopa County. (n.d.). Wellness | Maricopa County, AZ. Www.maricopa.gov. Retrieved July 23, 2024, from https://www.maricopa.gov/1385/Wellness 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Maricopa County. (2022). Maricopa County Invests $3 Million in Funding to Provide Housing for Veterans in Glendale. Maricopa County, AZ. https://www.maricopa.gov/CivicAlerts.aspx?AID=2860 

Maricopa County. (2024). Mental Health and Substance Use Data | Maricopa County, AZ. Www.maricopa.gov.
https://www.maricopa.gov/5079/Mental-Health-and-Substance-Use-Data 

Mosley, J. E. (2021). Cross-sector collaboration to improve homeless services: Addressing capacity, innovation, and equity challenges. The ANNALS of the American Academy of Political and Social Science, 693(1), 246–263. https://doi.org/10.1177/0002716221994464

National Institute of Health. (2023, July 11). Healthy People 2030 research objectives. Office of Disease Prevention.
https://prevention.nih.gov/research-priorities/research-needs-and-gaps/healthy-people-2030-research-objectives#topic-substance-use

Terros Health. (2023). Terros Health | Whole Health, Integrated Care. https://www.terroshealth.org/ 

Thorndike, A. L., Yetman, H. E., Thorndike, A. N., Jeffrys, M., & Rowe, M. (2022). Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco’s Mission District: a qualitative study. BMC Public Health, 22(1). https://doi.org/10.1186/s12889-022-13499-w

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

U.S. Centers for Medicare & Medicaid Services. (2024). Health coverage options for consumers experiencing homelessness. https://www.cms.gov/marketplace/technical-assistance-resources/coverage-options-consumers-experiencing-homelessness.pdf

Usera, D. (2023). Audience engagement techniques in oral presentations. Business and Professional Communication Quarterly. https://doi.org/10.1177/23294906231190575

Zimmerman, A. (2024). Homelessness and mental illness: Medicalizing a housing crisis. Journal of Human Rights and Social Work, 9, 117–128. https://doi.org/10.1007/s41134-024-00294-3