NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS
NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

Primary Care Coordination Plan

Being a staff nurse in a patient care centre is not a comfortable job. Recently due to the pandemic effects and economic downturn, the centre had to cut down its budgets and reallocate inpatient settings. The fact remains that nursing mental health care quality is a big concern for the patients and healthcare provider Elliott (2021). Care coordination plan is important in this context because it helps nurses and other practitioners better manage the current patients. I am being assigned the role of a care coordination nurse by the manager because I am familiar with difficult tasks. The focus of my care plan for the nursing centre is “mental health” due to the rising mental health patients amidst the global pandemic. This coordination plan will consider social, physical, and cultural needs of patients and will also help to identify the community resources available for safe and effective continuity of the care (Kuo, 2018). Moreover, the current plan will also identify the best practices for improving patients’ mental health in the nursing centre to achieve wellness goals. 

Specific Goals and Practices for Mental Health Improvement in Nursing Centre

Mental health disorders are becoming a common issue worldwide, yet, there is a pressing need to enhance quality of care of these mental health patients other than dementia. According to evidence-based research conducted by McAllister (2018), a framework or plan for promoting the quality of mental health care is vital in the nursing settings. Since individuals diagnosed with a depressive disorder or other anxiety disorders develop stereotypes and are perceived negatively by most of the population. This leads to even greater suffering for these mental health patients in nursing homes and hospitals as many tend to deny their diagnosis for the fear of being judged by their community (Nguyen, 2019). As a part of my nursing training for mental health patients, I also spent time with young chronic psychiatric population. This population has changed my whole practice because I discovered some best practices to improve the mental healthcare outcomes in such patients. Since nurses face several challenges while treating patients of chronic mental illness such as confusion about utilizing medications, inadequate understanding of psychoanalysis and interventions, and elongated patient care time, scholars argue that nurses should use alternate strategies to fully embrace the best practices. The best practices can include: 

NURS FPX 4050 Assessment 2 Ethical and Policy Factors in Care Coordination TS

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

  • Don’t Exceed Number of Patients: Nurses should only allow the hospital to admit patients easily treatable without creating overwhelm and confusion. 
  • Understand Care Guidelines: Nurses should familiarize them with psychotherapy and psychotropic medication guidelines to provide adequate doses to patients and reduce doses over time (Ross, 2019). 
  • Using a Proactive Approach: Nurses should use a proactive approach to lead the mental illness patients with responsibility. They should use behaviroal techniques to treat in-house patients effectively.
  • Building Relationships: The most important aspect of success is building strong relationships with emergency rooms and private psychiatric hospitals and also builds relationships with hospital’s staff (Palimaru, 2019). 
  • Telehealth Use: Nurses should ensure the use of telemedicine into nursing home settings to ensure better long-term communication and patient care related to mental illness. 
  • Use Evidence-based Frameworks: Since many mental health patients struggle to deal with their conditions, nursing leaders in evidence-based mental health services nursing homes should use their knowledge to support the recovery of behavioural health patients. 
  • Collaborative Communication: Nurses should ensure communication with interdisciplinary teams, families, clinicians, and other caregivers to double-check all patient care needs. They should know names of patients by heart and find more information about their mental health disorders and treatments. 

Physical, Psychosocial, and Cultural Needs of Mentally Sick Patients

In the United States, almost 24 million people suffer from Schizophrenia and 37 million face dementia issues. The fact remains that nurses and mental health professionals often have to work with patients of diverse backgrounds and cultures with different values and psychological needs (Ross, 2019). This multi-cultural practice in the nursing home is filled with several issues such as difference in class, religion, language, gender, and social status. Culture provides a set of values form a sociological perspective and describes social norms of mentally ill patients, refugees, and immigrants. As they face higher levels of income inequality in the country, they often feel depressed that adversely impacts their overall mental health condition and wellbeing. Much of the psychiatry theory has emerged from Western cultures and traditions which help to provide frameworks and tools for the elimination of mental illness in nursing settings. Therefore, family care for mental illness provides several benefits to patients; however, they also pose some psychological and social challenges over nurses that are important for both caregivers and patients. This means that such psychological issues need collaborative care approach between nurses and the government to meet the social and cultural needs of patients and nurses (Palimaru, 2021). 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

Awareness of patients’ ethnic background is vital to all settings because nurses often deal with their culture that varies from patient to patient. This means nurses should recognize patient’s cultural beliefs in delivery of effective nursing care. They should refrain from creating a judgemental attitude or stance and view their behaviour if it stands in the way of effective care. Many evidence-bases researches state that mental illnesses cause psychosocial problems such as deteriorated life quality and increased social distances from relatives. This shows that some mentally ill patients engage in frightening behaviours. Such issues can result in relapse of mental illness in patients from diverse backgrounds and religions. Nurses can easily feel overwhelmed by such disturbing behaviors. Therefore, social support is vital for patients and their families by including collaborative plans and strategies to assist people dealing with stigma (Nguyen, 2019). Therefore, nurses should ensure such patients are treated with respect, dignity, and empathy to mitigate the adverse experiences. Such a collaborative plan can help nurses and patients to manage stressful circumstances. 

Another study conducted by McAllister, (2018) explains that many mentally ill patients feel left out and feel less fit in the world around them. With the context of working environment, work-related stress and demand/control mechanism has a great impact on mental health. Care coordination is a vital process of assisting such mentally stressed individuals to access services to become well. Therefore, the goal of care coordination planning and services should be to improve the condition of patients, especially for customers, who have complex physical and mental needs. Therefore, nurses should always work hand in hand with the multidisciplinary teams and psychotherapists to facilitate and integrate the best mental health treatment. This implies that nurses should respect patient’s values and build therapeutic relationships to address patients’ holistic needs. Moreover, nurses should also show a sense of accountability and ownership of their duties. 

The recent advancement in psychotherapy reveals that depression is a mental health disorder that generates anguish and leads to an array of physical problems such as causing chronic fatigue, heart problems, and decreased appetite in patients (Kuo, 2018). Nurses should not overlook these signs and consider physical needs of patients as important end the vicious cycle of illnesses such as stroke, diabetes, and kidney diseases. Moreover, nurses should also set overall goals to know the sad and angry feelings of patients to have better control over their situation. They should practice forgiveness and accept their mistakes to provide the best therapy.  

Available Community Resources for a Safe and Effective Continuum of Care.

The treatment offered by nurses in our nursing home often does not work properly when mental health issues are long-lasting and severe. This calls for the need of using the best available community-based resources to provide safe and effective care services. Our psychiatric nurses should work in community-based settings to engage with customers and their family members to empower them to make the right decisions (Elliott, 2021). This means that there should be an integration of general medical care and behavioural health care in primary nursing settings to achieve improved healthcare outcomes. The following resources can help nurses to better deal with mental health patients:

  1. American Nurses Association (ANA)
  2. Anxiety and Depression Association of  America (ADAA) 
  3. Community mental health teams (CMHTs) 
  4. Residential Care 

For instance, residential care allows higher support for patients with several mental-related problems. Social and community care health teams can help to manage finances, housing issues, and transport for mental health patients. Nurses can collaborate with them as a care coordinator to improve the care plan. CMHTs support people with nurses, therapists, and psychologists to help with the care plan. Moreover, a registered nurse with an associate degree or a diploma can also obtain the ANA certification to improve nursing practices for mental health. Another promising approach is home visiting that connects nurses with their families (Bellon, 2019). 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS


Bellon, J. E., Bilderback, A., Ahuja‐Yende, N. S., Wilson, C., Altieri Dunn, S. C., Brodine, D., & Boninger, M. L. (2019). University of Pittsburgh Medical Center home transitions multidisciplinary care coordination reduces readmissions for older adults. Journal of the American Geriatrics Society67(1), 156-163.

Elliott, M. N., Adams, J. L., Klein, D. J., Haviland, A. M., Beckett, M. K., Hays, R. D., … & Schneider, E. C. (2021). Patient-Reported Care Coordination is Associated with Better Performance on Clinical Care Measures. Journal of General Internal Medicine, 1-7.

Kuo, D. Z., McAllister, J. W., Rossignol, L., Turchi, R. M., & Stille, C. J. (2018). Care coordination for children with medical complexity: whose care is it, anyway?. Pediatrics141(Supplement 3), S224-S232.

McAllister, J. W., Keehn, R. M., Rodgers, R., & Lock, T. M. (2018). Implementation of a shared plan of care: a pilot approach to care coordination with children with neurodevelopmental disabilities. J Nurs Res Pract [Internet]2(2), 1-5.

Nguyen, T., Ng, Y., Lehenaff, R., McCoy, D., Laughrey, M., Grigg, J., … & Hardt, N. S. (2019). A mobile clinic care coordination program: Enhancing patient care with innovative roles for undergraduate students. Journal of health care for the poor and underserved30(2), 510-518.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan TS

Palimaru, A. I., McBain, R. K., McDonald, K., Batra, P., & Hunter, S. B. (2021). Perceived care coordination among permanent supportive housing participants: Evidence from a managed care plan in the United States. Health & Social Care in the Community.

Ross, A., Arnold, J., Gormley, A., Locke, S., Shanske, S., & Tardiff, C. (2019). Care coordination in pediatric health care settings: the critical role of social work. Social work in health care58(1), 1-13.

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