Capella 4050 Assessment 4 Final Care Coordination Plan

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Final Care Coordination Plan

Substance abuse is a common healthcare problem in West Virginia. According to the reports by the National Center for Drug Abuse Statistics (n.d.), West Virginia has the highest prevalence of substance abuse, with a 51.5% death rate due to this deadly healthcare issue. For this purpose, as a care coordinator at South Charleston Community Center, I developed a preliminary care coordination plan. This assessment is the evaluation of that care coordination plan, which presents patient-centered health interventions to deal with substance abuse issues. Furthermore, it presents the ethical implications of these interventions and healthcare policies related to the concern. Lastly, the plan evaluates the teaching and learning sessions on evidence-based best practices and Healthy People 2030 objectives. 

Health Interventions for Substance Abuse 

Several issues are identified in West Virginia communities associated with substance abuse. These include physical damage to body organs, emotional distress that affects psychological well-being, and stigma associated with help-seeking behaviors. To mitigate these issues, the three best practices and patient-centered health interventions are health screening and monitoring programs, collaborative care models, and community education and awareness programs. 

Health Screening and Monitoring Programs

According to Woodward et al. (2023), comprehensive health screening and medical intervention programs in community settings are significant in addressing physical health issues and preventing further organ damage through preventive measures. This patient-centered intervention includes patients’ regular checkups, diagnostic testing, and consultations to manage health conditions associated with substance abuse. The timeline to implement this intervention is 10-12 months, including program development, recruitment of trained healthcare professionals, onsite execution, and evaluation of the effectiveness for ongoing improvement. We can utilize community resources such as financial and human resources from the West Virginia Department of Health and Human Resources (WVDHHR), training and technical support from the West Virginia Primary Care Association (WVPCA), and facilitation from local health departments to enhance accessibility. 

Collaborative Care Models

Another issue identified is poor psychological well-being. Collaborative care models establish a collaboration among multidisciplinary members such as mental health specialists, healthcare providers, counselors, and social workers to address co-occurring mental health and substance abuse disorders (Fishbein & Sloboda, 2023). Moreover, these models encourage patient engagement to improve health outcomes, eventually improving psychosocial well-being. The timeframe for this intervention is 6-8 months, which includes stages like provider training, implementing integrated behavioral health services in primary care settings, and evaluation for optimal success. Community resources such as the Substance Abuse and Mental Health Services Administration (SAMHSA) will help with funding and technical assistance. Moreover, the West Virginia Psychological Association (WVPA) offers training resources for professionals, and community health centers can be used as spaces for counseling and psychiatric services. 

Community Education and Awareness Programs 

To mitigate the stigma associated with help-seeking behaviors among substance abusers, educational and awareness campaigns are crucial. Through interactive workshops and peer networking, we can integrate preventive services within the communities (Fishbein & Sloboda, 2023). This patient-centered health intervention will offer culturally sensitive education for patients and their families to reduce stigma and promote help-seeking behaviors. The timeline for this intervention is 7-9 months, including the development of culturally sensitive education materials and media resources and partnering with community organizations to promote anti-stigma campaigns within religious places, schools, and community centers. Moreover, this timeframe includes the implementation of community events, workshops, and support groups and the conducting evaluation of the campaigns. Community resources such as the National Alliance on Mental Illness (NAMI) West Virginia, West Virginia Office of Drug Control Policy (ODCP), and Recovery Community Organizations (RCOs) offer support like advocacy, collaboration, policy development, peer support, and community engagement opportunities. 

Ethical Considerations and Patient-centered Health Interventions

In designing patient-centered health interventions, several ethical principles are considered and prioritized to ensure the provision of ethically sound healthcare services. Regular screening and monitoring programs should balance the need for early detection and intervention and patient privacy and autonomy. This ethical consideration is imperative to building patients’ trust in healthcare providers encouraging patients’ participation in screening programs and early intervention (Zhang et al., 2021). Ethical conflicts between patient confidentiality and public health priorities can become a point of uncertainty. Secondly, the collaborative care models should prioritize patient-centeredness, patient autonomy, and patient involvement in decision-making. Inefficient collaboration among healthcare providers can lead to potential uncertainties. Lastly, community education and awareness programs must ensure cultural sensitivity while disseminating information. These awareness programs must respect individuals’ cultural beliefs and practices to mitigate stigmatization and individuals’ attitudes toward substance abuse services (Bo et al., 2023). Uncertainties regarding systemic barriers to healthcare accessibility must be addressed. 

Health Policies and Coordination and Continuum of Care 

Two relevant health policies that have a significant impact on the coordination and continuum of care for substance abuse issues are the Affordable Care Act (ACA) and the Comprehensive Addiction and Recovery Act (CARA). The ACA has several policy provisions, one of which aims to expand healthcare access for substance abuse treatment and care coordination. Through this policy, low-income individuals are able to access substance abuse treatment and rehabilitation services by Medicaid eligibility (Olfson et al., 2021). This policy provides health insurance coverage without yearly limits. Thus improving care coordination through extensive preventive care and reducing financial barriers. 

Similarly, CARA is a federal law that aims to address addiction by promoting preventive and treatment services and rehabilitation for substance abuse-affected individuals. This policy is used to promote evidence-based treatment practices and law enforcement and reduce the stigma associated with substance abuse (Sharp et al., 2023). Both policies emphasize the importance of integrating substance abuse services into mainstream healthcare and fostering partnerships to address the complex needs of individuals with substance abuse disorders, thereby improving the continuum of care and outcomes for affected individuals. 

Priorities of a Care Coordinator and Evidence-based Practices

While discussing this final care coordination plan with the patients and their family members, the care coordinator must set some priorities to ensure the plan is tailored to patients’ needs. Moreover, changes in the care plan should be based on Evidence-Based Practices (EBP), providing the care plans are based on the latest and justified evidence. Priorities for plan discussion include: 

1. Clear communication channels must be established to facilitate shared decision-making and address patients’ and their family members’ concerns regarding the effectiveness of the plan. Open communication between providers and patients fosters trust and collaboration, enhancing patient engagement and adherence to the care plan (Kwame & Petrucka, 2021). 
2. Secondly, the care coordinator would prioritize personalized goal-setting based on evidence-based interventions. By aligning treatment goals with the patient’s preferences, values, and unique circumstances, the care plan becomes more meaningful and achievable.
3. Lastly, they should prioritize patients’ understanding of the plan, which requires clear and easy-to-comprehend language. Using non-medical terms and culturally sensitive concepts is essential to discuss the plan with the clients and their families, guaranteeing their engagement in the healthcare journey (Ranjan et al., 2020). 

Need for the Changes in the Plan

Incorporating EBP into the care plan is essential to ensure the plan is effective, safe, and aligned with the best available scientific knowledge. In the preliminary care coordination plan, we only added best practices like collaborative care models and community education. However, the final care coordination plan includes health screening and monitoring programs along with two other patient-centered interventions. This change to the plan is based on EBP to optimize outcomes by integrating interventions that have been rigorously evaluated and shown to produce positive results in substance abuse patients. 

Alignment of Learning Sessions 

While evaluating the learning sessions’ content against the best practices, it is imperative to prepare the evidence-based content, ensuring its accuracy and effectiveness. For example, the education and awareness sessions for the communities must include evidence-based coping strategies for substance abuse survivors to provide appropriate and established guidelines (Fishbein & Sloboda, 2023). Moreover, the content should be learner-centered, taking into account the diverse needs, preferences, and learning styles of affected individuals in the West Virginia community. These learner-centric sessions enhance engagement and knowledge retention among participants (Bo et al., 2023). 

Incorporating Healthy People 2030 objectives into the outline of teaching sessions will help align these sessions with Healthy People 2030. For example, the learning session with a focus on substance abuse prevention should address specific objectives related to reducing substance abuse prevalence, promoting healthy behaviors, and improving access to treatment and recovery services as outlined in Healthy People 2030 (U.S. Department of Health and Human Services, n.d.). The need for revisions lies in the constantly updating scientific knowledge. As evidence advances, it is imperative to update teaching materials to ensure accuracy and relevance. Moreover, revisions are needed to incorporate feedback from learners and evaluations of previous sessions. By soliciting input from participants and systematically assessing the impact of the learning sessions, educators can identify areas of improvement in the existing content and make targeted revisions to enhance the overall learning experience.

References

Bo, A., Goings, T. C., Evans, C. B. R., Sharma, A., Jennings, Z., Durand, B., Bardeen, A., & Murray-Lichtman, A. (2023). Culturally sensitive prevention programs for substance use among adolescents of color: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 99, 102233. https://doi.org/10.1016/j.cpr.2022.102233 

Fishbein, D. H., & Sloboda, Z. (2023). A national strategy for preventing substance and opioid use disorders through evidence-based prevention programming that fosters healthy outcomes in our youth. Clinical Child and Family Psychology Review, 26(1), 1–16. https://doi.org/10.1007/s10567-022-00420-5 

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158. https://doi.org/10.1186/s12912-021-00684-2 

Capella 4050 Assessment 4

NCDAS. (n.d.). Drug abuse statistics. https://drugabusestatistics.org/ 

Olfson, M., Wall, M., Barry, C. L., Mauro, C., Choi, C. J., & Mojtabai, R. (2021). Effects of the ACA on health care coverage for adults with substance use disorders. Psychiatric Services (Washington, D.C.), 72(8), 905–911. https://doi.org/10.1176/appi.ps.202000377 

Ranjan, P., Kumari, A., & Arora, C. (2020). The value of communicating with patients in their first language. Expert Review of Pharmacoeconomics & Outcomes Research, 20(6), 559–561. https://doi.org/10.1080/14737167.2020.1835474 

Sharp, N., Fuchs, J., & Drake, A. (2023). An implementation evaluation of the Comprehensive Addiction Recovery Act (CARA) policy in New Mexico. Maternal and Child Health Journal, 27(1), 113–121. https://doi.org/10.1007/s10995-023-03787-1 

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U.S. Department of Health and Human Services. (n.d.). Addiction—Healthy People 2030 | health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/addiction 

Woodward, D., Wilens, T. E., Glantz, M., Rao, V., Burke, C., & Yule, A. M. (2023). A systematic review of substance use screening in outpatient behavioral health settings. Addiction Science & Clinical Practice, 18, 18. https://doi.org/10.1186/s13722-023-00376-z 

Zhang, H., Zhang, H., Zhang, Z., & Wang, Y. (2021). Patient privacy and autonomy: A comparative analysis of cases of ethical dilemmas in China and the United States. BMC Medical Ethics, 22(1), 8. https://doi.org/10.1186/s12910-021-00579-6 

Capella 4050 Assessment 3 Care Coordination Presentation to Colleagues

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Care Coordination Presentation to Colleagues

Welcome colleagues. My name is ________, and today’s presentation is about fundamental concepts and aspects of care coordination. Initially, we will delve into evidence-based, culturally sensitive strategies for effective collaboration with patients and their families. Furthermore, I will discuss some implications of change management on patient experience, providing a comprehensive explanation of patient experience and patient satisfaction. Then, I will highlight the importance of ethically sound care coordinated plans and the consequences of an ethical approach to care. Additionally, we will cover some healthcare policies that influence patient outcomes and care experience. Lastly, I will raise awareness regarding nurses’ role in care coordination and continuum. 

Evidence-based and Culturally-Sensitive Collaboration Strategies 

The literature presents several strategies that are essential for collaborating with patients and their families. However, drug-specific education interventions and cultural competence strategies are topmost. Tailoring educational materials according to patients’ needs, preferences, and cultural beliefs is an imperative collaborative strategy that promotes easy comprehension and maintains cultural sensitivity. This strategy allows healthcare professionals to provide patient-centered care, enhancing their engagement in the healthcare journey to achieve optimal outcomes (Ricci et al., 2021). For instance, visuals, diagrams, and culturally appropriate language can be used to explain medication instructions, potential side effects, and the importance of adherence. 

Additionally, employing cultural competence through culturally tailored care plans is an effective strategy to collaborate with patients and their families. This involves incorporating traditional healing practices, dietary preferences, and religious beliefs into the treatment plan to enhance patient engagement and adherence to the care plans (Joo, 2023). Moroever, partnerships with community organizations, cultural groups, and religious leaders are essential to gain patients’ trust, collaborate with the patients and their families, and improve access to healthcare services. By implementing these strategies, healthcare providers can collaborate with patients and their families to achieve optimal health outcomes while valuing their cultural beliefs and practices. 

Change Management, Patient Satisfaction, and Patient Experience 

To understand the impact of change management on patient experiences and outcomes, let us first recognize and comprehend the difference between patient experience and patient satisfaction, as these aspects are substantially connected with quality assurance. While patient experience refers to the patient’s overall interaction and perceptions about the healthcare services, patient satisfaction is defined as the measure to which patients’ expectations are met from the care received (Friedel et al., 2023). 

Two critical aspects of change management that influence patient experience are – effective communication and training and education. Clear and transparent communication is essential to address patients’ concerns and build a trustworthy relationship between patients and healthcare providers. This change management aspect encourages patients and their family members’ engagement in healthcare changes, helping organizations to understand patients’ needs and preferences. Ultimately, it leads to patient-centered care, enhancing patient experiences and satisfaction (Kwame & Petrucka, 2021). Additionally, comprehensive training and education programs for healthcare staff equip them with the necessary knowledge, skills, and attitudes to deliver high-quality, patient-centered care. Emphasizing the importance of empathy, communication, and cultural competence, these training programs prepare well-trained healthcare professionals to address patients’ concerns, provide easy-to-understand information, and engage patients in shared decision-making, ultimately contributing to improved patient experiences and outcomes (Mirzaei Maghsud et al., 2020). 

Coordinated Care Plans and Ethical Decision Making

Care coordination plans based on ethical principles play a pivotal role in improving patient experiences and outcomes. Coordinated care plans prioritize patient autonomy, beneficence, and justice as fundamental moral principles. Healthcare providers collaborating for comprehensive patient care respect patients’ autonomy by involving them in decision-making (Lewis & Holm, 2022). Furthermore, these plans aim to benefit patients and reduce harm by preventing medical errors and expanding healthcare accessibility. This indicates the adherence to the ethical principles of beneficence and non-maleficence. Lastly, these plans uphold ethical principles of justice and equity by reducing healthcare disparities and enhancing adequate resource allocation. 

An ethical approach to care results in several positive consequences, such as fostering trustworthy relationships between patients and providers, improved patient satisfaction, and enhanced adherence to treatment plans. Moreover, this approach helps healthcare providers deliver ethically sound care by ensuring decisions are made in the patient’s best interests, improving the quality of care. Considering legal and financial aspects along with ethical care contributes to a positive organizational reputation and reduces legal repercussions associated with patient dissatisfaction (Alshawish & Benbenishty, 2023). This approach to care coordination is based on several underlying assumptions, such as the assumption that patients have the right to autonomy, which requires respect during healthcare decisions. Moreover, ethical decision-making is guided by the assumption of a commitment to beneficence, an essential obligation for healthcare professionals to strive for patients’ benefits. Lastly, it assumes that healthcare professionals must follow integrity and honesty in all interactions with patients and their families. 

Capella 4050 Assessment 3

Health Care Policies – Patient Experience and Outcomes

Several healthcare policy provisions have significant impacts on patient experiences and health outcomes. One of the most influential policies is the Affordable Care Act (ACA). This policy aims to improve healthcare accessibility by establishing adequate health insurance opportunities for low-income individuals and underserved populations. This policy emphasizes preventive care and care coordination, which further enhances patient experiences and health outcomes (Levine et al., 2022). Another policy, the Health Information Technology for Economic and Clinical Health (HITECH), promotes the adoption and meaningful use of Electronic Health Records (EHRs) by healthcare providers. This policy impacts patient experiences and health outcomes by enhancing communication and coordination among healthcare providers, leading to smooth care transitions and decreased medical errors. Through the development of health information-sharing channels, the HITECH policy enables healthcare providers to share patient information securely, enhancing care coordination and preserving patient safety (Trout et al., 2022). 

Nurses Role in Coordination of Care 

Nurses play a crucial role in coordinating care and maintaining its continuum. One of the critical roles is patient advocacy. Being frontline healthcare providers, nurses are most aware of patients’ needs and preferences, allowing them to collaborate with other healthcare professionals to provide care that is patient-centered (American Nurses Association, n.d.). Nurses can facilitate communication and collaboration among multidisciplinary healthcare teams to provide holistic patient care, develop individualized care plans, and monitor patient progress. This role is essential to prevent fragmentation of care and maintain care continuity. Moreover,  nurses’ expertise extends beyond clinical tasks. Their holistic approach to care empowers patients and improves adherence to treatment plans. Thus, nurses’ role in care coordination and continuum of care leads to better patient experiences and improved health outcomes. 

Conclusion

I would like to conclude my presentation by revising the fundamental concepts of care coordination discussed throughout. We addressed some collaboration strategies that can be employed to engage patients and their families effectively. These include tailored education and cultural competence. Moreover, we discussed that change management aspects, such as effective communication and training and development, are essential as they impact patient experiences and health outcomes. Next, we elaborated on the positive consequences and importance of ethical decision-making in care coordination. Furthermore, we highlighted the impact of health policies, including the Affordable Care Act and the Health Information Technology for Economic and Clinical Health, on patient experiences and health outcomes. Lastly, we discussed nurses’ role in care coordination, such as patient advocacy, patient-centered care, interprofessional collaboration, and holistic approach to care to improve patient outcomes and patient experiences with healthcare services. 

References

Alshawish, E., & Benbenishty, J. (2023). Global Nurse Involvement in ethical decision-making during pandemics: A concept analysis. Journal of Research in Nursing, 28(2), 92–101. https://doi.org/10.1177/17449871231159612 

American Nurses Association (ANA). (n.d.). Care coordination and the essential role of nurses. https://www.nursingworld.org/practice-policy/health-policy/care-coordination/ 

Friedel, A. L., Siegel, S., Kirstein, C. F., Gerigk, M., Bingel, U., Diehl, A., Steidle, O., Haupeltshofer, S., Andermahr, B., Chmielewski, W., & Kreitschmann-Andermahr, I. (2023). Measuring patient experience and patient satisfaction—how are we doing it and why does it matter? A comparison of European and US. American approaches. Healthcare, 11(6), 797. https://doi.org/10.3390/healthcare11060797 

Capella 4050 Assessment 3

Joo, J. Y. (2023). Fragmented care and chronic illness patient outcomes: A systematic review. Nursing Open, 10(6), 3460–3473. https://doi.org/10.1002/nop2.1607 

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158. https://doi.org/10.1186/s12912-021-00684-2 

Levine, D. M., Chalasani, R., Linder, J. A., & Landon, B. E. (2022). Association of the patient protection and Affordable Care Act with ambulatory quality, patient experience, utilization, and cost, 2014-2016. JAMA Network Open, 5(6), e2218167. https://doi.org/10.1001/jamanetworkopen.2022.18167 

Lewis, J., & Holm, S. (2022). Patient autonomy, clinical decision making, and the phenomenological reduction. Medicine, Health Care, and Philosophy, 25(4), 615–627. https://doi.org/10.1007/s11019-022-10102-2 

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Mirzaei Maghsud, A., Abazari, F., Miri, S., & Sadat Nematollahi, M. (2020). The effectiveness of empathy training on the empathy skills of nurses working in intensive care units. Journal of Research in Nursing: JRN, 25(8), 722–731. https://doi.org/10.1177/1744987120902827 

Ricci, L., Villegente, J., Loyal, D., Ayav, C., Kivits, J., & Rat, A. (2021). Tailored patient therapeutic educational interventions: A patient‐centred communication model. Health Expectations, 25(1). https://doi.org/10.1111/hex.13377 

Trout, K. E., Chen, L.-W., Wilson, F. A., Tak, H. J., & Palm, D. (2022). The impact of meaningful use and electronic health records on hospital patient safety. International Journal of Environmental Research and Public Health, 19(19), 12525. https://doi.org/10.3390/ijerph191912525 

Capella 4050 Assessment 2 Ethical and Policy Factors in Care Coordination

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Ethical and Policy Factors in Care Coordination

Hello. I _______, as a care coordinator at Hilltown Community Health Center, Huntington, Massachusetts, would like to welcome you to today’s presentation. This presentation focuses on the ethical and policy factors influencing patient care coordination and health outcomes. As the representatives of the American Heart Association (AHA), a prestigious organization working to improve cardiovascular health for diverse communities, you must understand these ethical and policy implications to improve your services and provide better, coordinated care to the communities served. 

Presentation Roadmap

This presentation will cover: 

1. The concept of care coordination and its importance. 
2. Impact of health and safety policies established by the government on care coordination. 
3. The ethical dilemmas for care coordination and their implications interlinked with national, state, or local-level policies 
4. Influence of nursing code of ethics on coordination and continuum of care. 

Care Coordination 

Patient care coordination is the systematic arrangement of healthcare practices and communication among all stakeholders for sharing information related to patient care. This coordinated effort helps stakeholders achieve desired patient outcomes (Agency for Healthcare Research and Quality, n.d.). It ensures that patients receive appropriate care through proper measures, avoiding the duplication of services and fragmentation of care and preventing medical errors. Patients with complex healthcare needs, such as those suffering from chronic diseases or elderly patients with extensive therapies, benefit from coordinated care, as it enhances communication between healthcare providers. This effective communication streamlines care transitions and promotes patient engagement. 

AHA and Care Coordination

The American Heart Association (AHA) is vital in coordinating patient care. They provide education, resources, and standardized guidelines for healthcare professionals and patients regarding cardiovascular diseases and stroke. Moreover, they advocate for international forums for healthcare policies and provisions to improve patient health and outcomes, especially cardiovascular health. Through various initiatives, AHA promotes evidence-based practices and quality improvement in managing heart-related conditions, enhancing care coordination among healthcare teams. By fostering interprofessional collaboration and patient encouragement in managing heart health effectively, the AHA contributes to better cardiovascular care delivery and improved patient outcomes (Warner et al., 2020). 

Policies Affecting the Care Coordination

Several governmental policies related to communities’ health and safety impact care coordination. The Affordable Care Act (ACA) significantly influences care coordination as it emphasizes preventive care, accessibility of healthcare services, care quality, and cost-effectiveness. Through various initiatives like Accountable Care Organizations (ACOs) and bundled payments, this policy encourages healthcare facilities to coordinate care across multiple healthcare settings and provide healthcare services to all individuals, regardless of socioeconomic status (Navathe et al., 2021). These initiatives promote better health outcomes and effectiveness of care through collaboration and integration of various team members. The ACA’s provisions permit AHA to promote evidence-based cardiovascular care practices by encouraging cooperation between healthcare providers. It facilitates the adoption of standardized protocols and guidelines, enhancing care coordination to ensure patients receive optimal cardiovascular care across various settings. 

Another governmental policy that impacts care coordination is the Medicare Access and CHIP Reauthorization Act (MACRA). This policy initiated value-based payment models, such as the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), to incentivize healthcare professionals for top-notch quality of care. This policy encourages teamwork among providers, standardization of protocols, and focus on patient-centered care, aligning with care coordination goals (Abodunde et al., 2021). This team collaboration and standardization of protocols is connected with the mission of AHA to provide effective cardiovascular care to achieve better patient outcomes. 

Finally, the Health Insurance Portability and Accountability Act (HIPAA) is another influential policy that obligates the protection of patients’ privacy and security of health information. This policy provides guidelines for coordinated care teams during information sharing (U.S. Department of Health and Human Services, 2023). AHA must comply with HIPAA guidelines while disseminating educational resources, collaborating with various teams, and sharing patient information. Thus, implementing secure communication channels and data-sharing practices while safeguarding patients’ confidentiality and privacy should be a priority. 

Ethical Dilemmas for Care Coordination

Various US-based, state-based, and local-level policy provisions generate moral questions/concerns for care coordination. These ethical dilemmas impact the role of AHA, requiring comprehensive efforts to mitigate the concerns for patient safety and better health outcomes. The HIPAA guidelines, as the national-level policy, raise ethical questions regarding patient privacy and information sharing in care coordination. While HIPAA postulates the protection of patient confidentiality and privacy of sensitive health information, its strict regulations impede efficient communication among healthcare providers.

These regulations potentially compromise the quality of care as healthcare professionals may encounter challenges while sharing vital patient information, leading to fragmented care (Qin, 2019). The American Heart Association plays a crucial role in addressing the ethical dilemma of patient privacy and information sharing by advocating for procedures and policies that balance both aspects, emphasizing effective care coordination. AHA can help healthcare providers with guidance and resources for navigating HIPAA rules by secure information-sharing channels, promoting ethical practices, and patient-centered care coordination.

Capella 4050 Assessment 2

On a state level, the Certificate of Need (CON) program, known as Determination of Need (DoN) in Massachusetts, births ethical questions regarding the allocation of resources and healthcare accessibility. The CON programs are developed for states to obtain approval before expanding or establishing new healthcare facilities or services. Thus preventing duplication of services and promoting effective care coordination (National Conference of State Legislatures, 2023). While CON aims to control healthcare costs and ensure equitable distribution of resources, it also limits innovation and patient’s preferences for access to specialized care. Therefore, AHA plays a crucial role by collaborating with stakeholders to ensure CON regulations promote fair competition, innovation, and equitable access to cardiovascular care services. 

Policies at the local level, such as zoning regulations, can pose ethical dilemmas for care coordination regarding the placement and accessibility of healthcare services. These laws may restrict the location of healthcare facilities, affecting patients’ ability to access timely and convenient care and increasing healthcare disparities. AHA can address these ethical dilemmas by advocating for equitable access to cardiovascular care facilities and services in the local community. Engaging with local authorities and community stakeholders, AHA can promote establishing cardiovascular care facilities in areas of significant need, ensuring all residents have access to quality care.

Code of Ethics and its Role in Care Coordination and Continuum of Care 

Patient advocacy, cultural sensitivity, patient-centered care, privacy and confidentiality, patient beneficence, and justice and equity are some core principles in the nursing code of ethics. These principles help nurses and other healthcare professionals deliver effective patient care, maintaining care coordination and continuity of care. As frontline healthcare providers, nurses are significant care coordinators, ensuring seamless transitions between healthcare settings and addressing patients’ diverse needs along the continuum of care. For patients with complex healthcare needs, such as cardiovascular problems, nurses play a crucial role in safeguarding their rights and delivering patient-centered care to make the healthcare journey less harmful and more beneficial (Karam et al., 2021). 

Nurses perform these actions under the guidance of a code of ethics. Moreover, nurses, guided by the code of ethics, advocate for equitable access to healthcare services by addressing factors that lead to healthcare disparities. These factors are named Social Determinants of Health (SDoH) by the Healthy People 2030 initiative. These include socioeconomic status, education, healthcare accessibility, and environmental factors (U.S. Department of Health and Human Services, n.d.). Nurses collaborate with interdisciplinary teams to identify and mitigate these barriers to care, promoting health equity and reducing healthcare disparities. Additionally, the nursing code of ethics emphasizes cultural competence and patient-centered care. While integrating SDoH into their nursing practices, nurses address patients’ unique needs through comprehensive patient care to promote coordination and a continuum of care. 

Conclusion

Therefore, we conclude that care coordination is an essential aspect of patient care and requires a systematic approach to address the implications of ethical and policy factors. The American Heart Association plays a crucial role in mitigating the negative impacts of the policies and ethical dilemmas generated to provide effective, patient-centered, and coordinated care to promote cardiovascular health and wellness in communities. I hope this presentation was helpful for you as the representatives of AHA and you will further disseminate the information within the organization. We’re hopeful that AHA will perform its vital role in advocating for patients’ benefits. Thank you for listening patiently to my presentation. 

References

Abodunde, B., Slater, C., & Coustasse, A. (2021). MACRA and Accountable Care Organizations: Is it working? The Journal of Ambulatory Care Management, 44(2), 148. https://doi.org/10.1097/JAC.0000000000000350 

Agency for Healthcare Research and Quality. (n.d.). Care coordination. https://www.ahrq.gov/ncepcr/care/coordination.html

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), 16. https://doi.org/10.5334/ijic.5518 

National Conference of State Legislatures. (2023, January 1). Certificate of Need state laws. Www.ncsl.org. https://www.ncsl.org/health/certificate-of-need-state-laws 

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Navathe, A. S., Liao, J. M., Wang, E., Isidro, U., Zhu, J., Cousins, D. S., & Werner, R. M. (2021). Association of patient outcomes with bundled payments among hospitalized patients attributed to accountable care organizations. JAMA Health Forum, 2(8), e212131. https://doi.org/10.1001/jamahealthforum.2021.2131 

Qin, F. (2019). The debilitating scope of care coordination under HIPAA. UNC School of Law. NCL Rev., 98, 1395. https://scholarship.law.unc.edu/cgi/viewcontent.cgi?article=6809&context=nclr 

U.S. Department of Health and Human Services. (2023, February 27). HIPAA privacy rule and care coordination. https://www.hhs.gov/hipaa/for-professionals/regulatory-initiatives/hipaa-care-coordination/index.html 

U.S. Department of Health and Human Services. (n.d.). Social determinants of health—Healthy people 2030 | health.gov. https://health.gov/healthypeople/priority-areas/social-determinants-health 

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Warner, J. J., Benjamin, I. J., Churchwell, K., Firestone, G., Gardner, T. J., Johnson, J. C., Ng-Osorio, J., Rodriguez, C. J., Todman, L., Yaffe, K., Yancy, C. W., Harrington, R. A., & On behalf of the American Heart Association Advocacy Coordinating Committee. (2020). Advancing healthcare reform: The American Heart Association’s 2020 statement of principles for adequate, accessible, and affordable health care: A presidential advisory from the American Heart Association. Circulation, 141(10). https://doi.org/10.1161/CIR.0000000000000759 

Capella 4050 Assessment 1 Preliminary Care Coordination Plan

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Preliminary Care Coordination Plan

Substance abuse is the excessive use of harmful substances, leading to physical and psychosocial implications. This preliminary care coordination plan is established for the population around South Charleston Community Center, West Virginia, engaged in unhealthy behaviors of substance abuse. As a care coordinator, I have personalized this care coordination plan, elaborating on substance abuse and its consequences for communities. Furthermore, this plan presents evidence-based best practices to address the concern and develop SMART goals for the concerned population. Finally, the plan lists the available community resources that affected and high-risk individuals can use to improve health outcomes and mitigate substance abuse in the community.

Analysis of Substance Abuse and Evidence-based Best Practices 

According to the American Psychological Association (APA) (2024), substance abuse is described as the continued use of harmful substances such as alcohol, tobacco, prescription drugs, illegal drugs, inhalants, and Performance-Enhancing Drugs (PED). Young adults are most commonly engaged in such activities, accounting for 6.2% in 2019 in the United States (Lu et al., 2023). Additional statistics reveal that 50% of people aged 12 and above have used these substances once in their lifetime, leading to approximately 1 million deaths associated with substance use disorder in the US. West Virginia is at the top of all other states, leading with a 51.5 death rate among 100,000 people (NCDAS, n.d.). 

Substance abuse has several physical consequences, including damage to the vital body organs, leading to morbidity and mortality. Simultaneously, the health concern leads to emotional distress, inability to perform daily activities, and social isolation, damaging an individual’s psychosocial well-being. Thus, these statistics and poor consequences advocate for comprehensive care coordination to eradicate the issue from the communities. However, various socio-cultural norms, beliefs, and traditions prevent individuals from seeking substance abuse services (Razaghi et al., 2023). Evidence-based best practices to address the issue among the population served by South Charleston Community Center include community-based educational programs and collaborative care models.

• Community-based Educational Programs: Educational programs, through workshops, peer support groups, and multimedia campaigns, play a crucial role in spreading awareness and promoting prevention among communities (Fishbein & Sloboda, 2023). Through these programs, our community center will employ evidence-based strategies to offer targeted educational interventions for West Virginia adolescents, adults, parents, and community leaders. 
• Collaborative Care Models: Collaboration among primary care providers and community care individuals such as healthcare professionals, mental health specialists, counselors, and social workers is a paramount practice to deliver comprehensive and coordinated care to individuals with substance abuse disorders (Fishbein & Sloboda, 2023). These models aim to enhance healthcare access, minimize stigma, and improve patient engagement to improve health outcomes for affected individuals and their families. 

This analysis assumes that our concerned community members will show positive attitudes while collaborating for better patient outcomes. Moreover, the analysis presupposes that integrating healthcare services through collaborative models and raising awareness through education will improve health outcomes and reduce substance abuse rates. Nevertheless, the effectiveness of implementation strategies, variations in community needs and resources, long-term sustainability, and the impact of socio-cultural disparities may generate uncertainties within the care coordination plan. 

SMART Goals for Substance Abuse

SMART goals are necessary to address substance abuse and reduce its prevalence rate in West Virginia. These goals are to enhance access to healthcare services and implement substance abuse prevention programs in schools. 

Goal # 1

The goal is to expand the number of healthcare facilities and rehabilitation providers in West Virginia (S) within the next 12-18 months (T). We aim to establish three more rehabilitation centers within the community and integrate substance abuse and mental health services within all community centers and hospitals nearby (A). This goal will be measured by the 20% increase in individuals receiving substance abuse treatment (M). The goal is relevant (R) as it addresses the need for healthcare disparities due to inaccessible healthcare services in West Virginia. 

Goal # 2

Another goal is collaborating with local schools and educational institutions to implement substance abuse prevention programs and policies (S). We aim to decrease the prevalence of substance abuse among adolescents and young adults by 50% within a year (M, T). The goal is attainable through teachers’ training and development, awareness programs, mental health screening, substance abuse screening, and “SAY NO TO SUBSTANCE” policies within the schools (A). Since adolescents are a high-risk population for substance abuse, this goal is relevant to prevent future generations from this harmful behavior and minimize the risk of morbidities and mortality (R).

Capella 4050 Assessment 1

Community Resources and Care Coordination

Several community resources are available in the United States, specifically in West Virginia, for patient safety and the continuum of care related to substance abuse. These include the Substance Abuse and Mental Health Services Administration (SAMHSA), which provides financial resources, training programs, and logistical resources to support substance abuse prevention, treatment, and recovery services across the United States (SAMHSA, n.d.). They also provide a 24/7 helpline service through 1-800-662-HELP (4357) for substance abuse treatment and mental health services. Furthermore, the West Virginia Department of Health and Human Resources (WVDHHR) oversees public health programs in West Virginia, including substance abuse prevention, treatment, and recovery services. Along with it, the West Virginia Office of Drug Control Policy (ODCP) coordinates efforts to address substance abuse issues, including law enforcement initiatives.

The collaboration among these organizations has led to several beneficial initiatives, such as the Prescription Drug Monitoring Program, that addressed the drug overdose epidemic in West Virginia, resulting in positive health outcomes for the communities (Wood et al., 2023). Additionally, many universities and colleges in West Virginia offer Collegiate Recovery Programs (CRPs) to support students and young adults in recovery from substance abuse disorders. An example is the Collegiate Recovery Community at West Virginia University (West Virginia University, n.d.). Other resources include local support groups. Telehealth services, educational programs, and counseling services within the community. Collectively, these resources contribute to improving community health by providing access to prevention, treatment, and recovery services for substance abuse survivors in the state. 

References

American Psychological Association (APA). (2024, February). Substance use, abuse, and addiction. https://www.apa.org/topics/substance-use-abuse-addiction 

Fishbein, D. H., & Sloboda, Z. (2023). A national strategy for preventing substance and opioid use disorders through evidence-based prevention programming that fosters healthy outcomes in our youth. Clinical Child and Family Psychology Review, 26(1), 1–16. https://doi.org/10.1007/s10567-022-00420-5 

Lu, W., Lopez-Castro, T., & Vu, T. (2023). Population-based examination of substance use disorders and treatment use among US young adults in the National Survey on Drug Use and Health, 2011–2019. Drug and Alcohol Dependence Reports, 8, 100181. https://doi.org/10.1016/j.dadr.2023.100181 

NCDAS. (n.d.). Drug abuse statistics. https://drugabusestatistics.org/ 

Capella 4050 Assessment 1

Razaghi, E., Farhoudian, A., Pilevari, A., Noroozi, A., Hooshyari, Z., Radfar, R., & Malekinejad, M. (2023). Identification of the socio-cultural barriers of drug addiction treatment in Iran. Heliyon, 9(5), e15566. https://doi.org/10.1016/j.heliyon.2023.e15566 

SAMHSA. (n.d.). SAMHSA – The Substance Abuse Mental Health Services Administration. https://www.samhsa.gov/node 

West Virginia University. (n.d.). Collegiate Recovery Program | Home. https://recovery.wvu.edu/home 

Capella 4050 Assessment 1

Wood, N., Mells, J., Dotson, T., & Jeffries, J. E. (2023). Enhancing and leveraging the West Virginia’s Prescription Drug Monitoring Program (PDMP) for public health surveillance and clinical decision making: A case study. Journal of Public Health Management and Practice : JPHMP, 29(2), E37–E43. https://doi.org/10.1097/PHH.0000000000001660 

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

Crafted with meticulous planning and community engagement, this comprehensive healthcare intervention plan targets food insecurity with a multi-faceted approach. By integrating patient-centered interventions focusing on access to nutritious food, psychosocial support, and the Supplemental Nutrition Assistance Program (SNAP) enrollment, the initiative aims to address the underlying social determinants impacting health. Ethical considerations are woven into each intervention, ensuring equity, confidentiality, and empowerment for all participants. Leveraging national health policies such as the Healthy Food Financing Initiatives (HFFI) and SNAP, the plan aligns with the objectives outlined in Healthy People 2030, promoting improved health outcomes and equity in healthcare access. Through transparent communication and continuous evaluation, the plan endeavors to bridge gaps in health literacy, empower individuals, and foster a sustainable healthcare ecosystem. By prioritizing evidence-based practices and community involvement, this initiative strives to create a lasting impact on the well-being of communities, shaping a path toward a more informed, engaged, and equitable healthcare landscape.

Interventions and Timelines for Food Insecurity

To effectively address food insecurity, three key health concerns will be targeted, each with a patient-centered intervention accompanied by timelines and community resources.

Access to Nutritious Food

To tackle the challenge of access to nutritious food, we propose the establishment of a community garden project modeled after “City Green.” Over twelve months, our initiative will unfold in carefully planned stages. In the initial three months, we will diligently work on securing suitable land and necessary resources through collaborative partnerships. By the sixth month, our focus will shift to recruiting volunteers who will actively engage in planting and maintaining the garden, ensuring its sustainability. As we progress into the ninth month, our efforts will culminate in providing comprehensive gardening workshops to empower community members with essential skills for sustainable cultivation. Leveraging community resources such as Community Food Assistance, Urban Harvest, and the Farmer’s Cooperative will be pivotal in ensuring the success and longevity of this intervention, promoting food security and dietary diversity within our community (Bahn et al., 2021).

Psychosocial Support

Recognizing the profound psychosocial impact of food insecurity, our intervention centers around the development of a peer support program inspired by the successful “Food for All” initiative. Over twelve months, our approach will unfold in meticulously planned phases. Within the first three months, our focus will be on recruiting and training peer mentors from within the community who possess lived experiences with food insecurity. By the sixth month, the peer support program will be fully operational, offering a safe and empathetic space for individuals to share experiences, access emotional support, and engage in group activities. Over twelve months, we will measure the program’s impact on participants’ mental well-being through pre- and post-program surveys, ensuring continuous improvement. Collaborating with resources such as Community Food Assistance, Local Mental Health Services, and Social Service Agencies will enrich the program, providing comprehensive support services alongside peer-based assistance (Henderson et al., 2023).

SNAP Enrollment

Addressing the imperative to increase SNAP enrollment among eligible individuals, our intervention aims to achieve a 20% increase within twelve months through strategic outreach efforts and personalized assistance. Over the next twelve months, we have meticulously outlined a strategic timeline to execute this intervention effectively. Within the first month, we will forge partnerships with local agencies to streamline SNAP application processes, ensuring accessibility for all eligible individuals. By the third month, we will intensify our outreach efforts through community events and targeted social media campaigns, shedding light on SNAP benefits and eligibility criteria. Throughout the sixth month and beyond, we will diligently track and analyze SNAP enrollment metrics monthly to gauge the effectiveness of our intervention, making necessary adjustments as required. Leveraging resources such as Local Agencies, Community Events, and Social Media Platforms will be instrumental in reaching our target population and facilitating SNAP enrollment within the community (Bleich et al., 2020). Through these meticulously planned and community-engaged interventions, we aim to holistically address the multifaceted challenges of food insecurity, fostering resilience and well-being within our community.

Designing Patient-Centered Health Interventions Based on Ethical Decisions

In the realm of healthcare interventions aimed at addressing food insecurity, the integration of ethical considerations is paramount. Each intervention must be meticulously examined for potential ethical dilemmas, ensuring that they align with ethical principles while also meeting the needs of the community. Establishing a community garden project necessitates careful ethical deliberation when contemplating access to nutritious food. Questions regarding the fair distribution of resources and the project’s long-term sustainability arise. It’s imperative to guarantee equitable access to resources and consider the environmental implications of such initiatives. Leveraging community resources like Community Food Assistance, Urban Harvest, and the Farmer’s Cooperative supports the objective of promoting food security and dietary diversity (Burt et al., 2020). Similarly, ethical considerations play a central role in the development of psychosocial support programs. Confidentiality, privacy, and empowerment are pivotal factors that must be taken into account. Ensuring that participants feel safe, respected, and empowered is crucial for the success and effectiveness of such programs. Collaboration with local mental health services and social service agencies is essential, as it provides the necessary support for individuals facing psychosocial challenges related to food insecurity (Higashi et al., 2021).

Furthermore, when aiming to increase SNAP enrollment, ethical decision-making becomes imperative. Addressing issues of eligibility, accessibility, and stigma is crucial to ensure that eligible individuals have equitable access to benefits without facing discrimination or judgment. Collaborating with local agencies and utilizing community events and social media platforms facilitates outreach and education about SNAP benefits and eligibility criteria, thereby promoting equity and fairness in access to resources (Schanzenbach, 2023). By incorporating these ethical considerations into the design of patient-centered interventions, nurses can navigate the complexities of addressing food insecurity while upholding ethical principles of beneficence, justice, and respect for autonomy. This approach ensures that interventions are not only effective but also ethically sound, ultimately leading to improved health outcomes and well-being within the community.

Health Policies Implications for Continuum and Coordination Care

Healthcare policies, such as the HFFI and the SNAP, play critical roles in shaping the coordination and continuum of care, particularly concerning food insecurity. Specifically, HFFI provides financial and technical assistance to attract grocery stores, farmers’ markets, and other sources of fresh, nutritious food to underserved communities. By addressing food deserts and improving access to healthy food options, HFFI policies contribute to the continuum of care by addressing the social determinants of health. Individuals who have access to nutritious food are more likely to experience better health outcomes and require fewer medical interventions, thereby promoting patient-centered care (Foster, 2022).

Similarly, SNAP offers financial assistance to low-income individuals and families to purchase food. SNAP policies directly impact the continuum of care by ensuring that vulnerable populations have access to essential nutrition. By alleviating food insecurity, SNAP helps prevent and manage chronic health conditions associated with poor diet quality. This, in turn, reduces the need for costly medical interventions and fosters patient-centered care by addressing underlying health issues (Whitmire et al., 2021). Policies like HFFI and SNAP have significant implications for the coordination and continuum of care. By addressing food insecurity and promoting access to nutritious food options, these policies contribute to improved health outcomes, reduced healthcare costs, and patient-centered care initiatives.

Priorities of Care Coordinator for Plan Discussion

The care coordinator would prioritize discussions centered around ensuring access to nutritious food and addressing the social determinants impacting food security. The care coordinator would emphasize the importance of addressing immediate food needs to alleviate hunger and prevent malnutrition. This could involve connecting the patient and family with resources like food banks, SNAP enrollment assistance, or community meal programs. Promoting education and empowerment regarding healthy eating habits becomes crucial. Educating patients and families about budget-friendly nutritious food options, meal planning strategies, and food preparation techniques empower them to make healthier choices within their means. Facilitating access to supportive services beyond food provision is essential. This could include referrals to social services for housing assistance, job training programs, or mental health support to address underlying factors contributing to food insecurity (Arensberg et al., 2022).

During discussions, the care coordinator would transparently explain any proposed changes to the care plan based on evidence-based practices related to addressing food insecurity. For instance, if new resources or programs become available in the community to support food-insecure individuals, the care coordinator would discuss the potential benefits and reasons for incorporating these changes into the care plan. Additionally, modifications to the plan to accommodate emerging needs or preferences would be communicated clearly. This could involve adjustments in accessing food assistance programs or incorporating new strategies for improving food security tailored to the patient’s circumstances. By fostering open communication and collaboration with patients and families, the care coordinator ensures that changes to the plan align with their specific needs and preferences. This ultimately promotes patient-centered care and better outcomes in addressing food insecurity (Bernhardt et al., 2021).

Healthy People 2030 and Evaluation Learning Session with Best Practices

Utilizing evaluation literature as a guide, educators meticulously compare learning session content with best practices, drawing insights from specific interventions proven effective in addressing food insecurity. This involves critically assessing the effectiveness of teaching methods and materials in alignment with evidence-based strategies. The data highlights interventions such as SNAP enrollment assistance and community gardens as practical approaches. By referencing these specific interventions, educators can identify strategies that have been proven to be successful. Incorporating interactive activities, culturally sensitive materials, and community engagement initiatives ensures participant engagement and knowledge retention, aligning with established best practices (McKay et al., 2022). Aligning teaching sessions with the Healthy People 2030 document involves integrating its objectives into the curriculum. Healthy People 2030 objectives related to food security and nutrition, such as reducing food insecurity and promoting healthy eating behaviors, serve as guiding principles for educators. By incorporating these objectives into the curriculum, educators ensure that their teaching sessions contribute to overarching public health goals and address specific needs identified in the community (Guzman & Hatton, 2024).

When explaining the need for revisions to the plan, educators rely on evidence from evaluations and data collected. Transparent communication with stakeholders is essential in this process, as it fosters collaboration and ensures that the revised plan effectively meets the needs of the target audience. By soliciting input from participants and stakeholders, educators can make informed decisions and tailor their teaching sessions to address specific challenges related to food insecurity identified in the community (Nur et al., 2021). By utilizing evaluation literature, aligning with evidence-based strategies, and integrating data and Healthy People 2030 objectives, educators can create impactful learning sessions that address food insecurity comprehensively. This approach promotes participant engagement, fosters knowledge acquisition, and contributes to advancing public health goals in the community.

Conclusion

In conclusion, the multifaceted approach presented addresses food insecurity through community-driven interventions targeting access to nutritious food, psychosocial support, and SNAP enrollment. Each intervention integrates ethical considerations, aligning with principles of equity, confidentiality, and empowerment. Health policies like HFFI and SNAP bolster the continuum of care by addressing social determinants of health. The care coordinator prioritizes discussions on access to nutritious food, transparently incorporating evidence-based practices into care plans. Education sessions align with Healthy People 2030 objectives, utilizing evaluation data to refine interventions and promote community engagement.

References

Arensberg, M. B., Ridpath, K. S., Kerr, K., & Phillips, W. (2022). Opportunities to improve quality outcomes: Integrating nutrition care into medicare advantage to address malnutrition and support social determinants of health. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 59, 004695802210814. https://doi.org/10.1177/00469580221081431 

Bahn, R. A., Hwalla, N., & Labban, S. E. (2021). Chapter 1 – Leveraging nutrition for food security: The integration of nutrition in the four pillars of food security (C. M. Galanakis, Ed.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128205211000010 

Bernhardt, C., Hou, S.-I., King, C., & Miller, A. (2021). Identifying barriers to effective patient-provider communication about food insecurity screenings in outpatient clinical settings in central Florida. Journal of Public Health Management and Practice, Publish Ahead of Print. https://doi.org/10.1097/phh.0000000000001449 

Bleich, S. N., Moran, A. J., Vercammen, K. A., Frelier, J. M., Dunn, C. G., Zhong, A., & Fleischhacker, S. E. (2020). Strengthening the public health impacts of the supplemental nutrition assistance program through policy. Annual Review of Public Health, 41(1), 453–480. https://doi.org/10.1146/annurev-publhealth-040119-094143 

Burt, K. G., Mayer, G., & Paul, R. (2020). A systematic, mixed studies review of the outcomes of community garden participation related to food justice. Local Environment, 26(1), 17–42. https://doi.org/10.1080/13549839.2020.1861589 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Foster, N. H. (2022). Food systems financing action plan. Master of Urban and Regional Planning Capstone Projects. https://scholarscompass.vcu.edu/murp_capstone/62/ 

Guzman, M. R. T. de, & Hatton, H. (2024). Extension education and the social sciences: Uplifting children, youth, families, and communities. In Google Books. Cambridge University Press. https://books.google.com/books?hl=en&lr=&id=Wv_5EAAAQBAJ&oi=fnd&pg=PA166&dq=+Healthy+People+2030+objectives+related+to+food+security+and+nutrition 

Henderson, C. G., Hiestand, E., Schluter, E., Olson, E., Tacheny, J., Crusan, A., & Hearst, M. O. (2023). A campus-based community clinic and food-shelf join efforts to reduce food insecurity using a one health approach toward building a vibrant living system. Journal of American College Health, 1–5. https://doi.org/10.1080/07448481.2023.2232461 

Higashi, R. T., Sood, A., Conrado, A. B., Shahan, K. L., Leonard, T., & Pruitt, S. L. (2021). Experiences of increased food insecurity, economic and psychological distress during the COVID-19 pandemic among supplemental nutrition assistance program-enrolled food pantry clients. Public Health Nutrition, 1–11. https://doi.org/10.1017/s1368980021004717 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

McKay, F. H., Spiteri, S., Zinga, J., Sulemani, K., Jacobs, S. E., Ranjan, N., Ralph, L., Raeburn, E., Threlfall, S., Bergmeier, M. L., & Pligt, P. van der . (2022). Systematic review of interventions addressing food insecurity in pregnant women and new mothers. Current Nutrition Reports. https://doi.org/10.1007/s13668-022-00418-z 

Nur, H. A., Atoloye, A. T., Wengreen, H., Archuleta, M., Roskos, M. R. S., Wille, C., & Jewkes, M. (2021). A scoping review and assessing the evidence for nutrition education delivery strategies for refugees in high-income countries. Advances in Nutrition, 12(6), 2508–2524. https://doi.org/10.1093/advances/nmab080 

Schanzenbach, D. W. (2023). Understanding SNAP: An overview of recent research. Food Policy, 114, 102397. https://doi.org/10.1016/j.foodpol.2022.102397 

Whitmire, M., Arensberg, M. B., Ashbrook, A., & Blancato, R. (2021). Nutrition-related policy fundamentals for supporting older adults in the community during a pandemic: Lessons from COVID-19. Journal of Elder Policy, 1(3). https://doi.org/10.18278/jep.1.3.9 

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Care Coordination Presentation to Colleagues

Hi, my name is ______, and today I am pleased to address you on the vital role of nurses in care coordination, a cornerstone of patient-centered healthcare delivery. Nurses serve as essentials in composing collaboration among patients, families, and healthcare teams to optimize health outcomes. Through effective medication management, ethical decision-making, and engagement in change management initiatives. Nurses ensure seamless care transitions, foster patient empowerment and promote positive patient experiences. At the heart of their practice lies a commitment to personalized care, advocacy, and continuous improvement, all essential elements in enhancing the coordination and continuum of care for every individual under their charge.

Evidence-Based Strategies of Nurses for Collaborating with Patients

Nurses serve as linchpins in orchestrating collaboration among patients, families, and healthcare teams to optimize health outcomes. In facilitating effective medication management, nurses employ simplified communication techniques, ensuring clear, concise explanations of medication regimens, including dosage, side effects, and interactions. Utilizing plain language and visual aids enhances comprehension, while personalized education tailored to individual patient needs, considering literacy levels, language proficiency, and learning preferences, reinforces understanding and fosters patient empowerment. Regular medication reconciliation, conducted collaboratively with patients and families, helps identify discrepancies and address concerns, ensuring accuracy and consistency in medication management (Alrabadi et al., 2021).

Cultural sensitivity lies at the core of nursing practice, necessitating acknowledgment and respect for diverse cultural backgrounds and perspectives. Nurses engage in culturally sensitive communication, employing active listening and non-judgmental approaches. Customizing care plans to align with cultural beliefs, practices, and preferences, along with utilizing interpreters or cultural mediators as needed, facilitates effective communication and promotes patient trust. Collaborative decision-making processes integrate cultural values and preferences, foster patient involvement in treatment decisions, and enhance treatment acceptance (Larsen et al., 2020). Empowering patient advocacy is paramount, with nurses equipping patients and families with resources to advocate for their healthcare needs. This includes fostering autonomy and self-efficacy in decision-making processes. Creating a supportive environment that respects diversity and offers access to services such as social work or counseling addresses psychosocial needs and enhances patient well-being. Continuous education ensures nurses stay updated on cultural competence and evidence-based practices while seeking feedback from patients and families, facilitating ongoing improvement in care delivery (Almeida et al., 2024).

Enhancing Patient Experience through Change Management

Change management is essential in shaping the patient experience of superior, patient-centered care within healthcare settings. Effective communication stands as a cornerstone during periods of change. Transparent communication ensures patients are informed about modifications in care delivery, fostering trust and understanding. Nurses play a central role in conveying these changes to patients, addressing concerns, and providing reassurance. Additionally, staff training and competency development programs are vital. Well-trained nurses are better equipped to deliver new care processes or technologies, thereby contributing to a positive patient experience. They also serve as educators, guiding patients through changes in care delivery and offering support as patients adapt (Kwame & Petrucka, 2020). Furthermore, patient engagement and empowerment are crucial. Involving patients in decision-making processes empowers them and enhances their sense of control. Change management initiatives that prioritize patient input and feedback lead to care models better aligned with patient needs and preferences. Nurses act as advocates for patient engagement, facilitating communication among patients, families, and healthcare teams to ensure patient voices are valued and integrated into care plans (Schroeder et al., 2022). Differentiating between patient experience and satisfaction is crucial. Patient satisfaction reflects contentment with specific care aspects, while patient experience includes all interactions throughout the healthcare journey. A satisfying patient experience extends beyond expectations, focusing on meaningful connections, emotional well-being, and trust in the healthcare system. Nurses ensure satisfaction by providing empathetic, respectful, and personalized care (Ferreira et al., 2022).

 Coordinated Care Plans Rationale Founded on Ethical Decisions

Care coordinated plans, rooted in ethical decision-making, are foundational to nursing practice, embodying the core principles of patient-centered care and advocacy. Nurses, as frontline caregivers, are uniquely positioned to implement and uphold these ethical standards in their daily interactions with patients, families, and interdisciplinary teams. In nursing, ethical decision-making guides the development and implementation of care plans that prioritize the holistic needs of patients. Nurses integrate ethical principles such as beneficence, no maleficence, and justice into their practice, ensuring that care is delivered with compassion, respect, and cultural sensitivity. By considering the reasonable implications and consequences of each decision, nurses strive to promote the well-being and autonomy of their patients while upholding ethical standards (Tawili et al., 2023). Furthermore, nurses play a crucial role in facilitating patient involvement in care planning processes. They act as supporters for patients, safeguarding that their opinions are heard and their first choice is respected. Through effective communication and collaboration with interdisciplinary teams, nurses tailor care plans to meet the individual needs and preferences of patients, promoting trust and enhancing patient satisfaction (Kuipers et al., 2021). Additionally, nurses navigate complex ethical dilemmas within the healthcare environment, balancing the needs of individual patients with broader considerations of resource allocation and societal impact. They engage in critical reflection and ethical deliberation to address these challenges, always prioritizing the best interests of their patients (Haahr et al., 2020).

Policy Provisions of Health Care on Patient Experiences and Outcomes

Healthcare policy provisions profoundly affect patient consequences and experiences within the healthcare system. The Health Insurance Portability and Accountability Act (HIPAA) prioritizes the confidentiality of patient health data, ensuring that sensitive data remains protected. This provision fosters trust between patients and healthcare providers, facilitating open communication and collaboration. Patients feel more comfortable disclosing sensitive information, which enhances accuracy in diagnoses, tailoring treatment plans, and ultimately improving health outcomes. Moreover, HIPAA permits patients to have greater control over their health information, thereby supporting autonomy and confidence in healthcare resolutions (Krzyzanowski & Manson, 2022). The logical implications of HIPAA’s emphasis on patient privacy and security are profound. By safeguarding patient confidentiality, HIPAA fosters trust and enhances patient-provider relationships. Patients feel more comfortable disclosing sensitive information, which in turn improves accuracy in diagnoses and treatment planning. However, it’s crucial to recognize that violations of HIPAA can erode patient trust and compromise the quality of care provided, potentially resulting in adverse health outcomes and experiences (Stadler, 2021).

The Affordable Care Act (ACA) has had a multifaceted influence on patient outcomes and experiences. One of its primary objectives is to expand contact to affordable well-being coverage for many of Americans. The ACA achieves this through various mechanisms, including Medicaid eligibility expansions and the establishment of health insurance marketplaces. By increasing access to healthcare services, the ACA enables patients to receive timely preventive care, better manage chronic conditions, and access necessary treatments without financial barriers. Additionally, the ACA mandates vital health benefits, such as defensive services and mental health exposure, contributing to improved health consequences and patient experiences (Ercia, 2021). The logical effects of the ACA’s focus on expanding access to affordable coverage and essential benefits are also profound. Increased access to healthcare services under the ACA enables patients to receive timely preventive care, better manage chronic conditions, and access necessary treatments without financial barriers. (Glied et al., 2020). Overall, both HIPAA and the ACA play critical roles in shaping patient outcomes and experiences within the healthcare system, emphasizing the importance of evidence-based policy analysis and thoughtful implementation to ensure continued advancements in patient-centered care.

Vital Role of Nurses in the Continuum and Coordination of Care

Rising awareness of the nurse’s dynamic role in the continuum and coordination of care is paramount for optimizing patient outcomes and experiences. Nurses, as advocated by the American Nurses Association (ANA), are the cornerstones in orchestrating seamless care transitions and ensuring continuity across various healthcare settings. Their expertise spans from conducting comprehensive assessments to coordinating interdisciplinary teams, advocating for patient needs, and facilitating effective communication among healthcare professionals. Nurses serve as educators, empowering patients and their families with the knowledge needed to manage their health effectively (Rekha, 2020). Moreover, they play a critical role in promoting preventive care, managing chronic conditions, and addressing psychosocial needs, thus contributing significantly to positive health outcomes. By acknowledging and promoting the importance and significance of the nurse’s role, stakeholders can gain a deeper understanding of the multifaceted contributions nurses make to healthcare delivery. This heightened awareness fosters greater collaboration and appreciation for nurses’ expertise, ultimately enhancing patient-centered care and improving overall healthcare quality (Flaubert et al., 2021).

Conclusion

In conclusion, nurses play a pivotal role in orchestrating collaboration, cultural sensitivity, and ethical decision-making to optimize patient outcomes and experiences. Their expertise in medication management, communication, and advocacy ensures tailored care plans that prioritize patient needs and preferences. Additionally, nurses are integral in navigating healthcare policy provisions, such as HIPAA and the ACA, to uphold patient confidentiality and expand access to essential services. Recognizing the vital role of nurses in coordinating care transitions and promoting continuity across settings is crucial in fostering patient-centered care and improving overall healthcare value.

References

Almeida, A. S., Paguia, A., & Neves, A. P. (2024). Nursing interventions to empower family caregivers to manage the risk of falling in older adults: A scoping review. International Journal of Environmental Research and Public Health, 21(3), 246–246. https://doi.org/10.3390/ijerph21030246 

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., rabadi, D. A., Farha, R. A., AlRabadi, S., & Faouri, I. A. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025 

Ercia, A. (2021). The impact of the affordable care act on patient coverage and access to care: Perspectives from FQHC administrators in Arizona, California and Texas. BMC Health Services Research, 21(1), 1–9. https://doi.org/10.1186/s12913-021-06961-9

Ferreira, J., Patel, P., Guadagno, E., Ow, N., Wray, J., Emil, S., & Poenaru, D. (2023). Patient experience or patient satisfaction? A systematic review of child- and family-reported experience measures in pediatric surgery. Journal of Pediatric Surgery. https://doi.org/10.1016/j.jpedsurg.2023.01.015 

Flaubert, J. L., Menestrel, S. L., Williams, D. R., & Wakefield, M. K. (2021). The role of nurses in improving health care access and quality. In www.ncbi.nlm.nih.gov. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK573910/ 

Glied, S. A., Collins, S. R., & Lin, S. (2020). Did the ACA lower Americans’ financial barriers to health care? Health Affairs, 39(3), 379–386. https://doi.org/10.1377/hlthaff.2019.01448 

Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing Ethics, 27(1), 258–272. https://doi.org/10.1177/0969733019832941 

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Krzyzanowski, B., & Manson, S. M. (2022). Twenty years of the HIPAA safe harbor provision: Unsolved challenges and ways forward (Preprint). JMIR Medical Informatics, 10(8). https://doi.org/10.2196/37756 

Kuipers, S. J., Nieboer, A. P., & Cramm, J. M. (2021). Making care more patient centered; Experiences of healthcare professionals and patients with multimorbidity in the primary care setting. BMC Family Practice, 22(1). https://doi.org/10.1186/s12875-021-01420-0 

Kwame, A., & Petrucka, P. M. (2022). Universal healthcare coverage, patients’ rights, and nurse-patient communication: A critical review of the evidence. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-00833-1 

Larsen, R., Mangrio, E., & Persson, K. (2020). Interpersonal communication in transcultural nursing care in India: A descriptive qualitative study. Journal of Transcultural Nursing, 32(4), 310–317. https://doi.org/10.1177/1043659620920693 

Rekha, S. G. (2020). The future of nursing: Leading change, advancing health. IP Journal of Paediatrics and Nursing Science, 3(3), 60–63. https://doi.org/10.18231/j.ijpns.2020.013 

Schroeder, K., Bertelsen, N., Scott, J., Deane, K., Dormer, L., Nair, D., Elliott, J., Krug, S., Sargeant, I., Chapman, H., & Brooke, N. (2022). Building from patient experiences to deliver patient-focused healthcare systems in collaboration with patients: A call to action. Therapeutic Innovation & Regulatory Science, 56(5), 848–858. https://doi.org/10.1007/s43441-022-00432-x 

Stadler, A. (2021). The health insurance portability and accountability act and its impact on privacy and confidentiality in healthcare. Senior Honors Theses. https://digitalcommons.liberty.edu/honors/1084/ 

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Tawili, G. A., Znati, N. S. A., Albishri, H. S. M., Khudhayr, W. A. J. A., AlAmri, B. A. H., Alamri, S. A. H., Suwaydi, A. A., Alzanbaqi, M. O. H., Alshehri, S. A. F., Alsahfi, R. A. R. H., & Aloufi, A. O. S. (2023). Ethical Considerations in nursing practice: A review of the literature. Migration Letters, 20(S1), 2222–2232. https://migrationletters.com/index.php/ml/article/view/8723 

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

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

 Policy and Ethical Factors in Care Coordination

Greetings, I am Harman, a nurse at City Health Systems. Effective care coordination is crucial for providing comprehensive care to individuals with chronic conditions like diabetes. We align our coordination efforts with governmental policies such as HIPAA, the Health Insurance Portability and Accountability Act, and the Affordable Care Act (ACA), ensuring patient privacy and navigating coverage parameters. Initiatives like the National Diabetes Prevention Program support our efforts. Ethical considerations arise, balancing patient privacy with timely care. Upholding the nursing Code of Ethics, we prioritize equity and patient-centered care in our coordination efforts. We collaborate closely with organizations like the American Diabetes Association (ADA), leveraging resources and expertise to optimize care delivery and support for individuals with diabetes in our community. By integrating these principles, we strive to maximize health outcomes for individuals with diabetes while navigating regulatory requirements and promoting inclusivity.

Care Coordination

In order to guarantee thorough and patient-centered care, effective care coordination requires the smooth administration of healthcare services across several providers and settings. Enhancing the overall effectiveness and quality of patient care requires collaboration, communication, and integration of healthcare struggles (Khatri et al., 2023). The ADA emphasizes the importance of coordinated care in meeting the unique healthcare needs of individuals with diabetes. Care coordination within the ADA framework aims to deliver culturally competent and supportive care, reducing disparities and enhancing health outcomes for individuals living with diabetes by fostering communication and collaboration among healthcare professionals.

Governmental Policies Affecting the Care Coordination

The ADA and other organizations that coordinate care are significantly impacted by health and safety policies of the government HIPAA is a significant policy that guards patient privacy and health information security. HIPAA compliance affects how the ADA coordinates care by setting standards for the exchange of patient data among healthcare providers, insurers, and other entities involved in care delivery. For example, ADA staff must ensure that they adhere to HIPAA regulations when communicating with healthcare providers about a patient’s treatment plan or sharing medical records to ensure confidentiality and protect patient privacy (ElSayed et al., 2022). Moreover, policies stemming from the ACA play a significant role in shaping care coordination efforts.

ACA policies dictate coverage parameters and reimbursement mechanisms, directly impacting the availability and affordability of services for individuals with diabetes. For example, ACA provisions expand access to preventive services and essential health benefits, ensuring that patients receive comprehensive care. However, fluctuations in ACA regulations or funding allocations can affect the ADA’s ability to provide seamless care coordination, especially if specific treatments or services become ineligible for coverage or experience reimbursement limitations (Lee & Hale, 2020).

Furthermore, policies related to public health initiatives and chronic disease management also influence care coordination efforts. One example of such a program is the National Diabetes Prevention Program (DPP), which is funded by the Centers for Disease Control and Prevention (CDC). The objective of the DPP is to postpone or prevent the onset of type 2 diabetes by implementing lifestyle modifications like eating less, exercising more, and losing weight. By providing funding and resources to organizations like the ADA, the DPP supports efforts to implement evidence-based diabetes prevention programs within communities, thereby facilitating early intervention and reducing the burden of diabetes on the healthcare system (Ritchie et al.,2020). 

Overall, governmental policies related to health and safety, including HIPAA regulations, ACA provisions, and public health initiatives, significantly impact the coordination of care within the ADA. Compliance with privacy standards, navigating coverage requirements, and leveraging resources from public health programs are essential components of effective care coordination for individuals with diabetes. By aligning with these policies and leveraging available resources, the ADA can ensure that patients receive comprehensive, patient-centered care while navigating regulatory requirements and promoting health equity within the community. 

Care Coordination Ethical Questions or Dilemmas 

Finding particular federal, state, and local policy regulations that raise moral concerns or provide challenges for care coordination within the ADA is necessary for navigating the complicated world of healthcare regulations.  One policy is the HIPAA, which serves to safeguard privacy of patients and data safety. While HIPAA is essential for protecting patient confidentiality, its stringent requirements, such as obtaining patient consent before sharing medical information, can sometimes pose ethical dilemmas. This might lead to delays in urgent treatment decisions, potentially compromising patient outcomes.

Moreover, the intricate nature of HIPAA regulations may inadvertently result in breaches, raising ethical concerns despite organizational efforts to comply (Weitzman et al., 2021). Additionally, the provisions outlined in the ACA significantly impact care coordination efforts within the ADA. ACA policies expand access to preventive services and essential health benefits, promoting comprehensive care for individuals with diabetes. However, fluctuations in ACA regulations or funding allocations can introduce ethical dilemmas. For instance, changes in coverage parameters may lead to certain diabetes treatments or services being excluded, thereby creating barriers to accessing necessary care and exacerbating health disparities (Kelley et al., 2020).

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

Furthermore, public health initiatives like the DPP, funded by the CDC, contribute to care coordination efforts. Even though the goal of these programs is to use changes in lifestyle to prevent or postpone the onset of type 2 diabetes, concerns about equity and resource allocation may come up. Limited funding or resources may disproportionately affect underserved communities with higher diabetes prevalence rates, exacerbating health disparities. Additionally, ethical considerations arise regarding the sustainability and scalability of these programs, particularly in resource-constrained environments (Williams et al., 2021). These policy provisions raise ethical questions about balancing patient privacy with the need for timely information sharing, ensuring equitable access to care, and effectively allocating resources to address the burden of diabetes within communities.

The consequences of these ethical dilemmas include potential compromises in patient care, exacerbation of health disparities, and challenges in achieving optimal health outcomes for individuals with diabetes. The upper studies provide evidence of the ethical associations and concerns of particular policy provisions on care coordination within the ADA. They underscore the importance of navigating regulatory requirements while addressing the multifaceted challenges posed by diabetes management within evolving healthcare policies.

The Nurses Code of Ethics on the Coordination and Continuum of Care

The code of ethics for nurses plays a vital role in managing decision-making and actions within the healthcare system, including within organizations like the ADA. Nurses, as frontline healthcare providers, are often involved in the coordination and continuum of care for individuals with diabetes. By adhering to the principles outlined in the code of ethics, nurses contribute significantly to the provision of high-quality, patient-centered care. The coordination of treatment under the ADA is one crucial area where the code of ethics has an impact. Ethical precepts, including beneficence, non-maleficence, and respect for patient autonomy, adhere to nurses. These principles guide nurses in advocating for the best interests of patients, ensuring their safety and well-being, and respecting their preferences and choices regarding diabetes management.

As a result, the coordination of care within the ADA is influenced by nurses’ commitment to upholding these ethical standards, promoting collaboration among healthcare team members, and prioritizing the needs of individuals with diabetes (Hübner et al., 2022). Moreover, the ethics code for nurses also affects the care continuum provided by the ADA. Nurses are advocates for health equity and access to services for all individuals, including those affected by diabetes. They identify and deal with the social determinants of health that lead to inequalities in health and obstacles to receiving care. An individual’s capacity to effectively manage their diabetes can be significantly impacted by variables like their socioeconomic status, degree of education, and geographic location. Nurses, guided by the code of ethics, work to address these disparities by advocating for resources and services that promote health equity and empower individuals to overcome barriers to care access (Rogers & Schill, 2021).

Healthy People 2020 identifies social factors of health as critical factors influencing health outcomes and disparities. Nurses, through their adherence to the code of ethics, recognize the importance of addressing these determinants in the provision of care to individuals with diabetes. Nurses improve health outcomes and lessen disparities among people with diabetes by supporting laws and programs that address social factors like food insecurity, income inequality, and access to healthcare services (Briggs et al., 2020). The nursing code of ethics significantly impacts the ADA’s care continuum and coordination. Nurses address health disparities, support patient-centered care, and facilitate access to services for people with diabetes, all while adhering to ethical principles. Through their commitment to upholding the code of ethics and addressing social determinants of health, nurses play a vibrant role in improving health outcomes and enhancing the quality of care provided by the ADA.

Conclusion

In conclusion, effective care coordination for individuals with diabetes necessitates alignment with governmental policies like HIPAA and ACA while balancing ethical considerations such as patient privacy and equitable access. Collaboration with organizations like the ADA optimizes resources and expertise to enhance patient-centered care. Nurses, guided by the Code of Ethics, advocate for health equity and address social determinants of health, thereby improving outcomes within the continuum of care. Overall, navigating regulatory requirements, promoting inclusivity, and upholding ethical principles are integral to optimizing health consequences for people with diabetes.

References

Briggs, F. H., Adler, N. E., Berkowitz, S. A., Chin, M. H., Webb, T. L. G., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2020). Social determinants of health and diabetes: A scientific review. Diabetes Care, 44(1), 258–279. https://doi.org/10.2337/dci20-0053 

ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B. S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A. (2022). 7. Diabetes technology: Standards of care in diabetes—2023. Diabetes Care, 46(Supplement_1), S111–S127. https://doi.org/10.2337/dc23-s007 

Hübner, U. H., Egbert, N., & Schulte, G. (2022). Ethical issues: Patients, providers, and systems. Health Informatics, 465–483. https://doi.org/10.1007/978-3-030-91237-6_31 

Kelley, A. T., Nocon, R. S., & Brien, M. J. O. (2020). Diabetes management in community health centers: A review of policies and programs. Current Diabetes Reports, 20(2). https://doi.org/10.1007/s11892-020-1289-0 

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8 

Lee, J., & Hale, N. (2022). Evidence and implications of the affordable care act for racial/ethnic disparities in diabetes health during and beyond the pandemic. Population Health Management, 25(2), 235–243. https://doi.org/10.1089/pop.2021.0248 

Ritchie, N. D., Baucom, K. J., & Sauder, K. A. (2020). Current perspectives on the impact of the national diabetes prevention program: Building on successes and overcoming challenges. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 13, 2949–2957. https://doi.org/10.2147/dmso.s218334 

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

Rogers, B., & Schill, A. L. (2021). Ethics and total worker health®: Constructs for ethical decision-making and competencies for professional practice. International Journal of Environmental Research and Public Health, 18(19), 10030. https://doi.org/10.3390/ijerph181910030 

Weitzman, E. R., & Floyd, M. (2022). Chapter 6 – Privacy and diabetes digital technologies and telehealth services (D. C. Klonoff, D. Kerr, & E. R. Weitzman, Eds.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B978032390557200011X 

Williams, J., Sachdev, N., Kirley, K., Moin, T., Duru, O. K., Brunisholz, K. D., Sill, K., Joy, E., Aquino, G. C., Brown, A. R., O’Connell, C., Rea, B., Craig-Buckholtz, H., Witherspoon, P. W., & Bruett, C. (2021). Implementation of diabetes prevention in health care organizations: Best practice recommendations. Population Health Management, 25(1). https://doi.org/10.1089/pop.2021.0044 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Preliminary Care Coordination Plan

The early phases of a patient’s healthcare journey are crucially organized and initiated by the preliminary care coordination plan. This fundamental plan delineates the patient’s care objectives, assembles a dedicated care team, and outlines initial procedures. Its principal aim is to provide efficient and well-coordinated medical support and assistance, ensuring the patient receives effective care (Khatri et al., 2023). This preliminary care coordination plan lays the groundwork for adequate patient support by emphasizing the critical role of addressing food insecurity in Oakwood Heights, Texas. This preamble sets the tone for evidence-based practices and SMART goals, underscoring a holistic approach to mitigating food insecurity and fostering a seamless continuum of care through community resources.

Health Concerns and Evidence-Based Practices for Health Improvement

Addressing food insecurity requires a comprehensive approach, considering physical, psychosocial, cultural, and community factors. Inadequate access to nutritious foods due to food insecurity can lead to malnutrition, weight loss, and a heightened risk of chronic diseases. Promoting access to healthy foods through initiatives like the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) is crucial. Adapting care involves recognizing individual needs, financial constraints, and cultural preferences. Additionally, addressing underlying assumptions, such as broader social determinants of health, is paramount for effective interventions. Collaborating with community organizations and government agencies boosts the impact of food assistance programs (Hawkins & Panzera, 2020).

Psychosocially, food insecurity often triggers emotional distress, anxiety, and depression, exacerbating existing mental health situations. Incorporating mental health support facilities into food assistance programs is crucial. Adapting care involves recognizing mental health needs and providing trauma-informed care. Acknowledging underlying assumptions and points of uncertainty, such as the long-term impact of food insecurity on mental health outcomes, is essential for holistic interventions. Providing access to support groups and counseling services can further aid individuals in coping with the stress of food insecurity (Pourmotabbed et al., 2020). Culturally, beliefs influence attitudes toward seeking help and dietary preferences.

Tailoring food assistance programs to accommodate cultural dietary preferences and engaging community leaders is crucial. Providing culturally sensitive support services and acknowledging cultural differences are essential for effective care. Recognizing underlying assumptions, such as the influence of cultural beliefs on help-seeking behaviors, is critical for developing culturally appropriate interventions. Building trust and partnerships within diverse communities can facilitate the delivery of culturally competent care (Domingo et al., 2021). Addressing food insecurity demands holistic interventions, recognizing individual needs, cultural preferences, and broader social determinants of health. Collaboration with community stakeholders, mental health support services provision, and cultural sensitivity are vital aspects of effective intervention strategies.

Goals Established to Address Food Insecurity

To address food insecurity effectively, it is crucial to establish SMART (specific, realistic, measurable, and attainable) goals. This comprehensive approach lays the groundwork for developing impactful and sustainable strategies to combat food insecurity. The following goals have been thoughtfully crafted to target the multifaceted aspects of food insecurity, emphasizing measurable outcomes. The healthcare initiative endeavors to improve access to nutritious food and nutritional knowledge within the community by adhering to these goals.

Goal 1: Establish a monthly community food distribution program called “Nourish Now” in partnership with local food banks, targeting households in low-income neighborhoods (Specific). Increase the number of families “Nourish Now” served by 25% within six months, tracked through registrations and distribution logs (Measurable). Secure partnerships with at least two local grocery stores to donate surplus perishable food items, ensuring a varied supply of nutritious food options (Attainable). Implement “Nourish Now” within three months to address immediate food assistance needs and promote sustainable health equity (Relevant) (Miller, 2020).

Goal 2: Launch bi-weekly nutrition education workshops titled “Healthy Eats” in collaboration with local health clinics, targeting food-insecure individuals and families (Specific). Increase participants’ knowledge of healthy eating habits by 30% as assessed through pre- and post-workshop surveys (Measurable). Recruit certified nutritionists and community health educators to facilitate workshops covering meal planning, budgeting, and cooking tips (Attainable). Conduct workshops over six months with quarterly evaluations to empower participants in making informed dietary choices within financial constraints (Relevant) (Norris et al., 2023).

Goal 3: Establish a volunteer-driven community garden initiative named “Grow Together” in vacant lots within targeted neighborhoods (Specific). Increase garden yield by 50% within one year, tracked through regular harvest assessments (Measurable). Mobilize community members for garden planning, planting, and maintenance with support from local horticultural experts (Attainable). Promote food sovereignty and self-sufficiency, fostering community resilience and reducing dependence on external food sources. Establish and launch “Grow Together” within three months, ensuring sustainability through ongoing monitoring and evaluation (Relevant) (Jurkowski et al., 2021).

Community Resources for an Effective Continuum of Care

Addressing food insecurity and ensuring a satisfying patient experience is essential to identifying and utilizing significant community resources. They support an efficient and safe continuum of care. In Oakwood Heights, Texas, food banks and pantries like the Community Food Pantry serve as critical immediate food assistance sources, offering diverse nutritious options to bridge nutritional gaps for individuals and families facing food insecurity. Government assistance programs like SNAP and WIC  provide financial aid and access to healthy foods, addressing food insecurity and promoting better nutrition among vulnerable populations (Serchen et al., 2022). Additionally, community gardens supported by Green Life Initiatives and Urban Growers Collective offer sustainable solutions by empowering residents to grow fresh produce locally, fostering healthy eating habits and neighborhood social cohesion (Mejia et al., 2020).

Nutrition education programs provided by Regional Health Services and Healthy Living Institute equip individuals with the knowledge and skills to make healthy dietary choices within budget constraints. Mobile food markets operated in partnership with Fresh Harvest Express and Transportation Access Network play a crucial role in enhancing access to nutritious options, particularly in areas with limited grocery store accessibility, thus addressing transportation barriers (Downer et al., 2020). Community health centers offer holistic care, including primary care and nutrition counseling, addressing medical needs and social determinants of health like food insecurity.

Furthermore, social services agencies like Community Housing Solutions and Job Assistance Network provide support with housing, employment, and access to benefits, addressing underlying causes of food insecurity and promoting long-term stability and well-being (DeHaven et al., 2020). By effectively leveraging these community resources and fostering stakeholder collaboration, healthcare providers can establish a safe and effective continuum of care for individuals experiencing food insecurity. By working together, patients can get the help and resources they need to enhance their general health and food security, leading to a positive patient experience in the community.

Conclusion

In conclusion, the preliminary care coordination plan underscores the importance of addressing food insecurity through evidence-based practices and SMART goals. Collaborative efforts with community resources, such as food banks, nutrition education workshops, and community gardens, facilitate a holistic approach to healthcare delivery. By integrating mental health support, cultural sensitivity, and stakeholder collaboration, healthcare providers can ensure effective interventions. It satisfies patient experience and fosters sustainable health equity and well-being.

References

DeHaven, M. J., Gimpel, N. A., Gutierrez, D., Carmichael, H. K., & Revens, K. (2020). Designing health care: A community health science solution for reducing health disparities by integrating social determinants and the effects of place. Journal of Evaluation in Clinical Practice, 26(5). https://doi.org/10.1111/jep.13366 

Domingo, A., Charles, K.-A., Jacobs, M., Brooker, D., & Hanning, R. M. (2021). Indigenous community perspectives of food security, sustainable food systems and strategies to enhance access to local and traditional healthy food for partnering Williams treaties first nations (Ontario, Canada). International Journal of Environmental Research and Public Health, 18(9), 4404. https://doi.org/10.3390/ijerph18094404 

Downer, S., Berkowitz, S. A., Harlan, T. S., Olstad, D. L., & Mozaffarian, D. (2020). Food is medicine: Actions to integrate food and nutrition into healthcare. The BMJ, 369(369). https://doi.org/10.1136/bmj.m2482 

Hawkins, M., & Panzera, A. (2020). Food insecurity: A key determinant of health. Archives of Psychiatric Nursing, 35(1). https://doi.org/10.1016/j.apnu.2020.10.011 

Jurkowski, J., Udo, T., & Hackstadt, A. (2021). Food insecurity in NY state. Solutions to address the multifaceted problem. Understanding and Eliminating Minority Health Disparities in a 21st-Century Pandemic: A White Paper Collection. https://scholarsarchive.library.albany.edu/covid_mhd_nys_white_papers/10/ 

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Mejia, A., Bhattacharya, M., & Miraglia, J. (2020). Community gardening as a way to build cross-cultural community resilience in intersectionally-diverse gardeners: A community-based participatory research and campus-community partnered proposal (Preprint). JMIR Research Protocols, 9(10). https://doi.org/10.2196/21218 

Miller, H. A. E. (2020). A review of the food security, diet and health outcomes of food pantry clients and the potential for their improvement through food pantry interventions in the United States. Physiology & Behavior, 220, 112871. https://doi.org/10.1016/j.physbeh.2020.112871 

Norris, K., Pitts, S. J., Reis, H., & Maslow, L. H. (2023). A systematic literature review of nutrition interventions implemented to address food insecurity as a social determinant of health. Nutrients, 15(15), 3464–3464. https://doi.org/10.3390/nu15153464 

Pourmotabbed, A., Moradi, S., Babaei, A., Ghavami, A., Mohammadi, H., Jalili, C., Symonds, M. E., & Miraghajani, M. (2020). Food insecurity and mental health: A systematic review and meta-analysis. Public Health Nutrition, 23(10), 1778–1790. https://doi.org/10.1017/s136898001900435x 

Serchen, J., Atiq, O., Hilden, D., Serchen, J., Atiq, O., Hilden, D., Beachy, M., Brislen, H., Curry, W., Engel, L., Hollon, M., Mathew, S., Mellacheruvu, P., Sagar, A., Shoushtari, C., Southworth, M., & Tan, M. (2022). Strengthening food and nutrition security to promote public health in the United States: A position paper from the American College of Physicians. Annals of Internal Medicine, 175(8), 1170–1171. https://doi.org/10.7326/m22-0390