Preliminary Care Coordination Plan

Providing the best quality treatment and improving patients’ health is the goal of every healthcare organization in the world. A preliminary care coordination plan is an important part of this goal because it helps to provide excellent and timely care to patients (Karam et al., 2021). The first step in developing a preliminary care plan is to identify the healthcare needs of a patient. This will help healthcare centers focus on evaluating the currently used medications, treatment strategies, and also patient satisfaction. It is a cost-effective method because it provides tailored services to the patient’s unique needs. That is why it neglects all of the unnecessary healthcare facilities and adds to cost-effectiveness. This plan is focused on the implementation and evaluation of the treatment strategies used to improve patient concerns. This assessment will focus on developing a preliminary care coordination plan for psychosocial health issues. 

Analysis of Health Concerns and Associated Best Practices

Lack of access to healthcare is a crucial issue that leads to health disparities and poor healthcare conditions. Timely care is the essence of a successful treatment however, psychosocial fears such as mistrust in healthcare staff, fear of medical treatments, and in some cases, language barriers restrict patients from getting the care they need. These issues can lead to poor adherence to treatment due to mistrust, more complicated disease, and treatment delays as well. Research by Escobedo et al. (2023) showed that language barriers have increased the mistrust in Latinx people after getting the wrong treatment due to the language barrier. It is crucial to address this issue to provide the best treatment and patient care.  However, there are other ways of informing healthcare providers about culturally competent care and patient care so that the language barrier is eliminated. 

Chronic illness management also entails the same psychosocial problems like stress, anxiety, and depressive disorders, which are a result of other diseases like diabetes, and heart illness, among others. These conditions may decrease the patient’s compliance with the prescribed treatment regimens thus worsening the disease outcome and deterioration of quality of life. Psychosocial support and patient care techniques can be effective in overcoming these challenges. Attention to mental health, an individualized approach to patients, and enhanced awareness about disease will imply better health outcomes and increased patient involvement (Katon et al., 2020). Thus, the consideration of psychosocial factors of chronic disease management is crucial in enhancing healthcare. 

Credible Evidence for Best Practices

The most promising practices in the elimination of barriers and chronic disease care consist of cultural sensitivity in the delivery of care and psychosocial services. For instance, patient navigation programs have been valued as strategies that assist patients in navigating healthcare and closing gaps in access to treatments (DeGroff et al., 2022). Moreover, the integration of behavioral health services for patients with chronic illnesses in the primary care setting promotes mental health, decreases illness burden, and enhances medication compliance, and overall health outcomes (Aragonga et al., 2021). These strategies show the effectiveness of patient-centered interventions that address their barriers and include psychosocial support as an effective strategy to increase access to health care and management of chronic illnesses.

Assumptions and Points of Uncertainty

An important assumption of care coordination aims that more access to culturally sensitive care leads to better health status of patients. Although this has been backed up by research, their effectiveness depends on individual differences and community characteristics which raises questions on the external validity of such interventions. Additionally, the blending of behavioral health in chronic illness treatment expects that patients will use these services regularly. Nevertheless, challenges such as cultural perceptions towards mental health still prove to be a barrier in such interventions, and willingness to change behavior at different levels also limits the impact of these interventions (Kleinman, 2021). The second concern is whether the patient engagement initiatives remain financially viable in the long term and whether they are assignable to different types of facilities. Although some benefits have been observed in the short term, questions regarding sustainability and cost remain pertinent to the use of the method in wider clinical practice.

Realistic, Measurable, and Attainable Goals to Address the Selected Health Care Problem

Enhancing the care coordination plan can be achieved by setting realistic, measurable, and attainable goals. It is important to keep in mind the psychosocial factors like fear of medical procedures, mistrust, and language barriers while developing goals, 

Specific Goals

Increase Healthcare Accessibility Through Community Health Initiatives

The primary goal is to improve access by utilizing mobile health clinics and telemedicine in areas that constitute the population with limited access. This serves to enable patients to go for their treatment at a location that is close to them and without having to go to healthcare facilities that might create fear or mistrust in their minds (Tabaac et al., 2020). The goal can be measured based on the reach of the community members with quality services from the program and the uptake rates of the services over six months.

Address Language Barriers and Improve Communication

It is crucial to work to eliminate language barriers, including providing culturally sensitive, multilingual education programs. This can be promoted by training healthcare providers on issues of cultural sensitivity and by providing services of interpretation. This goal can be evaluated by the data obtained from the surveys and feedback from the patients (Nápoles et al., 2021). This should be accomplished in the next one year time. 

Build Trust and Alleviate Fear of Medical Procedures

There is a need to implement teamwork-based patient care systems in efforts to erase patient fears and mistrust. Clear communication of medical interventions and clients’ detailed treatment plans are effective approaches. Quantitative data consists of patients’ scale self-reported trust in the healthcare providers and the achievement of the care plan in the first year of treatment alternatively (Rahman et al., 2023).

Chronic Disease Management Goals

Improve Emotional Well-being for Patients with Chronic Diseases

The aim is to combine strategies aimed at promoting mental health with strategies for caring for chronic diseases by providing the possibility of weekly counseling, support groups, and stress management information. This is measurable and attainable as lower anxiety and depression scores shall be observed from the participants using valid tools such as the Patient Health Questionnaire (PHQ-9) in six months (Archer et al., 2020).

Enhance Self-Management Skills Among Patients

Patient education plays a major role whereby patients are taught how to self-manage through the correct use of medications, and diets and observing their signs and symptoms. Where possible, improvement can be gauged using the self-efficacy scores from preferred and evidence-based scales and the clinical status of patients, all within a year frame (Piette et al., 2022).

Significant and Available Community Resources 

Two community assets that can eliminate or reduce healthcare disparities are Federally Qualified Health Centers (FQHCs) and mobile health clinics. FQHCs offer primary and preventive care, which is more focused on the needs of populations that have little to no access to care, and offer services at a reduced cost scale depending on the patient’s income, making them both a financial and access solution (National Association of Community Health Centers, 2022). Mobile health clinics serve as a supplement to FQHCs since they directly reach out to the affected communities, if not for the transport barrier, and perceived compromise in trust since community-based, culturally sensitive services are provided by these clinics (Attipoe et al., 2020). These resources sustain people in receiving services that may otherwise have gaps in service delivery most often for individuals with chronic illnesses and psychosocial problems.

Credible Evidence of Contribution

Other important critical centers are the CHWs and telehealth services. It is noted that CHWs help in community mobilization, education, overcoming language barriers, and gaining people’s trust, thereby improving care coordination (Miller et al., 2021). Patients with chronic illness can benefit from telehealth services as they provide a convenient way of attending to their chronic conditions and also address psychosocial problems such as fear and anxiety through consultation as well as mental health support respectively (Kruse et al., 2021). Two resources have used effectiveness in increasing access to health care, enhancing compliance with medical prescriptions, and addressing health disparities.

Conclusion

The preliminary care coordination plan considers the primary health concerns of a patient, mainly psychosocial factors associated with chronic diseases. By highlighting areas like mistrust, language disparities, and reduced healthcare access, this plan shows the efficient practices for overcoming these challenges. The plan ensures community resources like Federally Qualified Health Centers are incorporated to fill gaps within the delivery of care. Due to these reasons, the evidence-based strategies when practiced in conjunction with CAC and mental health care services are likely to help improve the health of the patients engaged and the coordination of their care for the culturally diverse.

References

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Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., Coventry, P. (2020). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 20(1). https://doi.org/10.1002/14651858.CD006525.pub2 

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