NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Name

Capella university

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Final Care Coordination Strategy

Coordinating care is an essential healthcare function that ensures patients receive continuous and connected services across different health settings. It is particularly critical for individuals with complex health needs, such as adults living with mental illness. Effective care coordination improves health outcomes, reduces disparities, and fosters patient engagement and satisfaction (Garfin et al., 2022).

This strategy proposes a comprehensive plan for adults with mental illness in Florida, where mental health challenges are widespread and often co-exist with physical and social concerns. The plan incorporates patient-centered interventions, use of community resources, ethical considerations, policy frameworks, and alignment with Healthy People 2030 goals.

Patient-Centered Health Interventions and Timelines

Mental illness affects approximately 2.9 million adults in Florida, many of whom face difficulties including comorbid physical illnesses, cultural stigma, and emotional instability (Garfin et al., 2022). Addressing these concerns requires evidence-based, individualized interventions supported by community partners and guided by measurable timelines.

Comorbid Physical Illnesses

Adults with serious mental illness (SMI) often experience physical conditions such as cardiovascular disease or diabetes, which can shorten life expectancy by up to 20 years (Nielsen et al., 2021). Integrating regular physical health screenings into mental health treatment is crucial.

Table 1. Intervention for Comorbid Physical Illnesses

Strategy	Community Partners	Timeline	Expected Outcome
Routine screenings (BMI, blood pressure, glucose, lipids, smoking status) integrated into therapy	Care Resource (2025), Caron Florida (2024), MHACF (2025)	At intake, 3-month follow-up; lifestyle counseling begins in Month 1	Early identification and management of comorbid conditions; improved overall health

Cultural Stigma and Mental Health Literacy

Cultural stigma often delays treatment and prevents many adults from seeking care. Biweekly culturally adapted educational programs can improve awareness, reduce stigma, and promote treatment engagement (Ahad et al., 2023).

Table 2. Intervention for Reducing Stigma and Improving Literacy

Strategy	Community Partners	Timeline	Evaluation Method
Culturally sensitive education (booklets, workshops, outreach)	NAMI Florida (2025), MHACF (2025), Care Resource (2025)	Start 2 weeks post-diagnosis; biweekly for 6 months	Pre- and post-session surveys assessing stigma reduction and knowledge gain

Emotional Dysregulation

Recurring anxiety, depression, or emotional instability are common in this population. Mindfulness-Based Cognitive Therapy (MBCT) is effective in enhancing resilience and preventing relapse (Gkintoni et al., 2025).

Table 3. Intervention for Emotional Dysregulation

Strategy	Community Partners	Timeline	Expected Outcome
Weekly MBCT sessions integrated with therapy	Caron Florida (2024), MHACF Outlook Clinic (2025), NAMI Florida (2025)	Begin within first month of diagnosis; weekly for 6 months	40% improvement in PHQ-9 depression scores; enhanced emotional regulation

Ethical Decisions in Designing Patient-Centered Interventions

Designing interventions for adults with mental illness raises several ethical challenges.

Informed Consent

Question: How do we ensure truly informed consent in individuals with compromised decision-making abilities? Even when patients face cognitive or emotional impairments, autonomy must be respected. Coordinators should use simplified explanations, repeated discussions, and ensure comprehension before obtaining consent (Nagaoka et al., 2023).

Cultural Sensitivity

Question: How do we ensure interventions remain respectful without labeling patients? Cultural stigma can worsen with poorly delivered programs. Interventions should be co-created with patients, involving them in planning and ensuring cultural beliefs are honored (Ahad et al., 2023).

Equity in Access

Question: How can care be made equitable for uninsured or low-income patients? Justice in healthcare requires fair access. Sliding-scale and free services from programs such as Care Resource and MHACF expand care to underserved populations (Care Resource, 2025; MHACF, 2025).

Relevant Health Policy Implications

Supportive health policies shape the success of coordinated care. The Mental Health Parity and Addiction Equity Act (MHPAEA) ensures mental health benefits are comparable to physical health, reducing financial barriers to therapies like MBCT and medication management (CMS, 2024). The Affordable Care Act (ACA) requires insurance plans to cover essential mental health and substance use services, supporting screenings and preventive interventions (Nielsen et al., 2021). Healthy People 2030 emphasizes reducing stigma, increasing access, and promoting health equity, aligning directly with this care strategy (Healthy People 2030, 2020).

Priorities for Care Coordinators in Patient and Family Discussions

Care coordinators should focus on communication, empowerment, and culturally competent strategies.

1. Transparency in communication: Explain diagnoses, treatment options, and the importance of physical screenings to address comorbidities.
2. Cultural sensitivity: Incorporate patient and family beliefs, provide translated material, and use culturally adapted education to build trust.
3. Patient engagement: Establish measurable goals such as attending MBCT sessions or stigma-reduction programs. Monitor progress using PHQ-9 or similar tools (Liu et al., 2024).

Learning Session Content with Best Practices and Healthy People 2030

Learning sessions such as MBCT and culturally sensitive education align with best practices and national health goals. MBCT sessions, when combined with individual follow-ups, improve treatment outcomes and prevent relapse (Gkintoni et al., 2025). Similarly, culturally relevant peer-led education helps reduce stigma and promote care-seeking behaviors (Ahad et al., 2023). These practices directly support Healthy People 2030 goals of improving access, reducing disparities, and enhancing health literacy.

Need for Change

The initial plan lacks strong feedback systems and peer-led support. Without continuous evaluation and community-driven facilitators, cultural relevance and engagement may decline. Integrating regular surveys, feedback sessions, and peer educators will enhance patient-centeredness and ensure alignment with Healthy People 2030 (Healthy People 2030, 2020).

Conclusion

This care coordination plan for adults with mental illness in Florida integrates interventions for physical, cultural, and emotional health challenges. Evidence-based approaches such as MBCT, lifestyle changes, and stigma-reduction strategies improve patient outcomes. Supportive policies including the ACA and MHPAEA strengthen access to care, while Healthy People 2030 provides a guiding framework. Continuous evaluation and peer engagement will ensure the strategy remains ethical, effective, and patient-centered.

References

Ahad, A. A., Sanchez-Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus. https://doi.org/10.7759/cureus.39549

Care Resource. (2025). Behavioral health. Care Resource. https://careresource.org/services/behavioral-health/

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Caron Florida. (2024). Mental health program. Caron Transformational Care. https://www.caron.org/treatment-programs/mental-health-program

CMS. (2024, September 10). The mental health parity and addiction equity act (MHPAEA). Centers for Medicare & Medicaid Services. https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity

Garfin, D. R., Thompson, R. R., Holman, E. A., Wong-Parodi, G., & Silver, R. C. (2022). Association between repeated exposure to hurricanes and mental health in a representative sample of Florida residents. JAMA Network Open, 5(6), e2217251. https://doi.org/10.1001/jamanetworkopen.2022.17251

Gkintoni, E., Vassilopoulos, S. P., & Nikolaou, G. (2025). Mindfulness-based cognitive therapy in clinical practice: A systematic review of neurocognitive outcomes and applications for mental health and well-being. Journal of Clinical Medicine, 14(5), 1703. https://doi.org/10.3390/jcm14051703

Healthy People 2030. (2020). Mental health and mental disorders. Office of Disease Prevention and Health Promotion. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/mental-health-and-mental-disorders

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Liu, W., Yuan, J., Wu, Y., Xu, L., Wang, X., Meng, J., Wei, Y., Zhang, Y., Kang, C.-Y., & Yang, J.-Z. (2024). A randomized controlled trial of mindfulness-based cognitive therapy for major depressive disorder in undergraduate students: Dose-response effect, inflammatory markers and BDNF. Psychiatry Research, 331, 115671. https://doi.org/10.1016/j.psychres.2023.115671

MHACF. (2025). About us. Mental Health Association of Central Florida. https://mhacf.org/learn-more/

Nagaoka, M., Koreki, A., Kosugi, T., Ninomiya, A., Mimura, M., & Sado, M. (2023). Economic evaluation alongside a randomized controlled trial of mindfulness-based cognitive therapy in healthy adults. Psychology Research and Behavior Management, 16, 2767–2785. https://doi.org/10.2147/prbm.s406347

NAMI Florida. (2025). Mission. National Alliance on Mental Illness Florida. https://namiflorida.org/about-nami-florida/mission/

Nielsen, R. E., Banner, J., & Jensen, S. E. (2021). Cardiovascular disease in patients with severe mental illness. Nature Reviews Cardiology, 18(2), 136–145. https://doi.org/10.1038/s41569-020-00463-7