Final Care Coordination Plan

A care coordination plan aims to provide exceptional quality healthcare services to patients and it also improves the communication between healthcare providers and patients (Karam et al., 2021). As a care coordination plan is rooted in providing exceptional healthcare facilities and improving patient satisfaction, the plan incorporates patient care workshops to attain the goal. Healthcare professionals form interdisciplinary teams to develop an understanding of patient’s needs in a better way. Furthermore, effective communication and awareness among healthcare providers, their patients, and families improves patient trust, satisfaction, and overall well-being (Schot et al., 2020). Nurses can develop customized treatment plans using all the strategies of this plan. This assessment focuses on providing evidence that using effective communication strategies, personalized care, empathetic listening, and mental health support can eliminate psychosocial complications in patients. 

Patient-Centered Health Interventions & Timelines

Patient-centered interventions allow healthcare providers to provide care to patients suffering from different psychosocial problems. In the U.S., only 9% of people receive psychosocial care such as enhanced self-management skills regarding their unique health issues (Terlizzi & Zablotsky, 2020). An effective patient-centered technique will be effective in providing patient-centered care. One of these strategies is organizing educational workshops that have resources and pamphlets in different languages (Young & Guo, 2020).  This will help eliminate cultural barriers to patient care. Another strategy is to organize training workshops for healthcare providers on developing the skills of cultural competency and empathetic listening as well (Young & Guo, 2020). As interdisciplinary teams are proven to be effective in achieving patient care goals, collaborating with community health workers can also be beneficial in providing culturally relevant education and emotional support to patients. Another strategy is to provide regular screening of anxiety and depression levels. Patients with higher rates of anxiety or depression should be advised to see their relevant healthcare professionals (Pinho et al., 2021). All of these interventions can help patients reduce their fear of medical procedures by educating them and improving their emotional well-being by providing empathetic healthcare providers. 

Timeline

The timeline for effective patient-centered healthcare interventions is as follows.

• Week 1-2 The introductory week starts with accessing patients’ needs, identifying their language and the issues they face due to it, and learning culturally sensitive materials. 

•  Week 3-4 The second two weeks will focus on patients visiting psychologists and getting assessments for any symptoms done. The patient will get a personalized treatment plan from the clinical psychologist and develop mutually agreed-upon goals for both the patient and clinical psychologist. 

• Week 5-6 This week is about developing patients who will get a revised treatment plan if they face any complications or want to make required adjustments. The new proposed treatment plan will be implemented by the patient. 

Ethical Decisions in Designing Patient-Centered Healthcare Interventions

All healthcare providers have ethical guidelines that act as their values when providing healthcare services to patients. These values include justice, honesty, autonomy, integrity, and dignity for everyone. All these values are provided to nurses by the American Nurses Association (ANA). The ethical guideline of justice is to provide equal and fair treatment to all people regardless of their color, race, ethnicity, and religion (Cheraghi et al., 2023). Non-maleficence is to ensure that a patient’s autonomy is protected which means that patients have the right to decide the best treatment for themselves regardless of any pressure. Healthcare providers can provide information on all of the treatment options the patient has but it is the right of the patient to decide which treatment they want to go for and that is autonomy (Cheraghi et al., 2023). That is why a care-coordinated plan based on ethical decision-making is important to ensure the rights of the patients and their well-being as well. Enhancing patient satisfaction, trust, shared decision-making, and quality of treatment are the essence of ethical choices. All ethics are rooted in providing exceptional care to patients and for this purpose a healthcare provider can withhold a clinical treatment if it goes against the patient’s best interests. 

Policy Implications for the Coordination and Continuum of Care

Healthcare policies are important to eliminate the psychosocial barriers that stand in the way of patients getting the best possible treatment for their health condition. To overcome these challenges, it is important to incorporate culturally competent care and patient-centered communication strategies as well. The Affordable Care Act (ACA) vouches for the value of justice and enables healthcare centers to provide language assistance services for patients speaking different languages to eradicate the language barrier (Baumgartner et al., 2020) Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) provides psychological safety and engagement policies for patients. Such policies with enhanced healthcare provider training can pave the way to better healthcare services and treatment, especially for people with psychosocial stressors. Furthermore, the Mental Health Parity and Addiction Equity Act (MHPAEA) allows psychological services to reach those in need especially those with chronic diseases (Presskreischer et al., 2023). To manage chronic illnesses, patient-centered care initiatives are introduced such as holistic healthcare, that ensures the care reaches those in need. The policy models such as Patient-Centered Medical Homes (PCMH) provide psychological support to patients with chronic illnesses. 

Care Coordinator Priorities to Discuss the Plan

The care coordinator must be mindful of some factors while discussing the care coordination plan with the patient and their family. These factors include empathetic communication, active listening, awareness in a way they can understand, and addressing their concerns. The priorities of the care coordinator must include realistic and SMART goals based on the patient’s unique psychosocial factors. Moreover, the care coordinator must empathetically address the patient’s and their family’s fears, apprehensions, and language barriers (Weintraub et al., 2021). The care coordinator can hire an interpreter with them if they feel like they are not able to understand their language and concerns. Furthermore, collaborative decision-making should be achieved by the care coordinator to increase the patient and their family’s satisfaction, trust, and treatment outcomes. The care coordinator must inform the patient and family about every possible treatment and must also give the patient the right of autonomy to choose what the patient wants. However, understanding patients’ needs and concerns is the top priority of the care coordinator in developing a customized treatment plan.

Need for Changes in the Plan

The need for change in the plan is required when treating different patients from diverse backgrounds and specific needs. For example, if a patient with a chronic disease is experiencing emotional distress and anxiety, healthcare professionals such as, clinical psychologists can use stress management techniques and mindfulness therapy to reduce emotional distress and anxiety. Stress management techniques and mindfulness therapy are both evidence-based practices and that is why incorporating them in the patient’s treatment can help evolve the plan into one that addresses the needs of patients. 

Learning Session Content Evaluation with Best Practices

Healthy People 2030 offers a guideline to enhance patient well-being (Gomez et al., 2021) and the specific objectives are as follows 

• Improve the quality and accessibility of prevention plans. 
• Increase the availability of healthcare services, especially to those in need. 
• Elimination of health disparities by providing health equity and treatment interventions.
• Enhance healthcare quality and reduce the risk factors that cause multiple diseases.
• Development of interdisciplinary teams that cater to the psychosocial needs of a patient.

The goals of training workshops for nurses include the following.

• The sessions should be devoted to the elimination of health disparities that occur due to language barriers. Moreover, the topic of workshops must emphasize the needs of patients and potential means to address them.
• The educational workshop should also address the prevention and lifestyle modification, especially behavioral changes, that are needed to overcome psychosocial issues. 
• Possible follow-up sessions, regular checkups, and most importantly, getting detailed checks of symptoms. 
• The ethical guidelines must be revised to remind nurses about their moral duty and values. 
•  Incorporating role plays in workshops among healthcare professionals and patients to educate them aabout providing awareness of the disease, diagnosis, and possible treatments can be helpful for them to understand the psychosocial needs of patients. 

Need for Revision 

The care coordination plan entails the tools that nurses can use to overcome the language barrier and healthcare differences. Moreover, it helps them to address the psychosocial needs of patients. These sessions give details about training and managing patients’ concerns to enhance treatment results. 

Conclusion

All of these practices have a primary aim of offering improved treatment and healthcare to patients. Nurses must get skills training on developing empathetic communication and active listening to understand what their patients are going through. Moreover, nurses should always remind themselves of the ethical guidelines of justice, autonomy, and protection of patients. Collaborative teams need to enhance the patient care quality as well. Collaboration is the essence of developing a care coordination plan for patients and providing them with the healthcare services they need.

References

Baumgartner, J., Collins, S., Radley, D., & Hayes, S. (2020). How the Affordable Care Act (ACA) has narrowed racial and ethnic disparities in insurance coverage and access to health care, 2013‐18. Health Services Research, 55, 56-57. https://doi.org/10.1111/1475-6773.13406 

Gómez, C. A., Kleinman, D. V., Pronk, N., Gordon, G. L. W., Ochiai, E., Blakey, C., & Brewer, K. H. (2021). Addressing health equity and social determinants of health through Healthy People 2030. Journal of Public Health Management and Practice, 27(6). https://doi.org/10.1097/PHH.0000000000001297

Karam, M., Chouinard, M. C., Poitras, M. E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: a scoping review. International Journal of Integrated Care, 21(1). https://doi.org/10.5334%2Fijic.5518 

Pinho, L. G. D., Lopes, M. J., Correia, T., Sampaio, F., Arco, H. R. D., Mendes, A., & Fonseca, C. (2021). Patient-centered care for patients with depression or anxiety disorder: an integrative review. Journal of Personalized Medicine, 11(8), 776. https://doi.org/10.3390/jpm11080776 

Presskreischer, R., Barry, C. L., Lawrence, A. K., McCourt, A., Mojtabai, R., & McGinty, E. E. (2023). Enforcement of the mental health parity and addiction equity act: state insurance commissioners’ statutory capacity. Psychiatric Services, 74(6), 652-655.https://doi.org/10.1176/appi.ps.20220210  

Schot, E., Tummers, L., & Noordegraaf, M. (2020). Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. Journal of Interprofessional Care, 34(3), 332-342. https://doi.org/10.1080/13561820.2019.1636007 

Terlizzi, E. P., & Zablotsky, B. (2020). Mental health treatment among adults: United States, 2019. https://stacks.cdc.gov/view/cdc/111879/cdc_111879_DS1.pdf 

Weintraub, J., Cassell, D., & DePatie, T. P. (2021). Nudging flow through ‘SMART’goal setting to decrease stress, increase engagement, and increase performance at work. Journal of Occupational and Organizational Psychology, 94(2), 230-258. https://doi.org/10.1111/joop.12347 

Young, S., & Guo, K. L. (2020). Cultural diversity training: the necessity of cultural competence for health care providers and in nursing practice. The Health Care Manager, 39(2), /2020/04000