NURS-FPX4050 Assessment 4 Final Care Coordination Plan

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NURS-FPX4050 Assessment 4 Final Care Coordination Plan – Step-by-Step Guide

The first step before starting to write the NURS-FPX4050 Assessment 4 Final Care Coordination Plan, it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment. 

It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.

How to Research and Prepare for NURS-FPX4050 Assessment 4 Final Care Coordination Plan

The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list. 

You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.

How to Write the Introduction for NURS-FPX4050 Assessment 4 Final Care Coordination Plan

The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.

How to Write the Body for NURS-FPX4050 Assessment 4 Final Care Coordination Plan

The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.

How to Write the In-text Citations for NURS-FPX4050 Assessment 4 Final Care Coordination Plan

In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:

The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.

How to Write the Conclusion for NURS-FPX4050 Assessment 4 Final Care Coordination Plan

When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.

How to Format the Reference List for NURS-FPX4050 Assessment 4 Final Care Coordination Plan

The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication. 

Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:

References

Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456

Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.

NURS-FPX4050 Assessment 4 Final Care Coordination Plan Instructions

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

Introduction

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem. Have a look at NURS-FPX4060 Assessment 1 Health Promotion Plan.

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Preparation

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030. (https://health.gov/healthypeople)

Instructions

Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Design patient-centered health interventions and timelines for a selected health care problem.

Address three health care issues.

Design an intervention for each health issue

Identify three community resources for each health intervention.

Consider ethical decisions in designing patient-centered health interventions.           

Consider the practical effects of specific decisions.    

Include the ethical questions that generate uncertainty about the decisions you have made.

Identify relevant health policy implications for the coordination and continuum of care.          

Cite specific health policy provisions.

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

Clearly explain the need for changes to the plan.

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

Use the literature on evaluation as guide to compare learning session content with best practices.

Align teaching sessions to the Healthy People 2030 document.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course

Context

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

Course Competencies

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.  

Design patient-centered health interventions and timelines for a selected health care problem.

Competency 2: Collaborate with patients and family to achieve desired outcomes.

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

Competency 3: Create a satisfying patient experience.

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

Competency 4: Defend decisions based on the code of ethics for nursing.                       

Consider ethical decisions in designing patient-centered health interventions.

Competency 5: Explain how health care policies affect patient-centered care.  

Identify relevant health policy implications for the coordination and continuum of care.

Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.     

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

NURS-FPX4050 Assessment 4 Final Care Coordination Plan Example

Final Care Coordination Plan

Substance abuse is a significant public health concern that requires a comprehensive and coordinated approach to address its multifaceted dimensions. It occurs in all age groups and across all strata of society, and therefore requires the input of professionals from various fields to manage the disorder. The goal of care coordination is to collaborate on services that meet the personal healthcare needs of individuals with substance use disorder, utilizing the Psychosocial and cultural aspects of each individual to provide recovery and Person-centered care services (Karam et al., 2021).

This elaborate care coordination plan is the next step in developing the previous plan. It aligns with current evidence-based literature and the objectives outlined in Healthy People 2030. This plan emphasizes the use of empirical practices and community assets to enhance patient quality and provide a comprehensive, individualized care plan tailored to the various issues related to substance abuse. The subsequent sections of this article will describe specific approaches, the ethical issues and concerns of health policies, and patient and family involvement in care coordination.

Patient-Centered Health Interventions and timelines for Substance abuse

The most common health problems for people with substance use disorder include physical health decline, mental illness comorbidity, and social integration difficulties. Every issue requires an individualized, targeted approach considering the patient’s needs. Substance abuse concerns necessitate more specific strategies aimed at managing the medical, psychological, and sociocultural needs of individuals. For each intervention, it is essential to have access to some of the available community resources to ensure that follow-up to the intervention is firmly established.

Physical Health Interventions
  1. Regular Medical Check-ups: Conduct thorough diagnostic examinations to identify comorbidities and track the health of vital organs affected by substance abuse (National Institute on Drug Abuse, 2021). Schedule bi-monthly medical check-ups for the first six months, followed by quarterly visits to monitor progress. Community Resources include Local health clinics, hospital outpatient departments, and mobile health units.
  2. Medication Management: Utilize medications like Methadone, Buprenorphine, and Naltrexone as part of Medication-Assisted Treatment (MAT) to treat withdrawal and cravings (Substance Abuse and Mental Health Services Administration, 2023). Implement a structured medication plan with continuous assessment and adjustment during bi-monthly check-ups. Community Resources include Substance abuse treatment centers, pharmacies, and telemedicine services.
  3. Nutritional Support: Provide dietary plans and nutritional supplements to address malnutrition and support physical healing (National Institute on Drug Abuse, 2022). Develop a personalized nutrition plan with an initial consultation and monthly follow-ups with a nutritionist. Community Resources include community health centers, nutritionists, and food banks.
Psychosocial Health Interventions:
  1. Mental Health Assessment and Treatment: Provide primary mental health care and support with counseling and therapy sessions to those with dual diagnosis issues like depression, anxiety, and post-traumatic stress disorder (SAMHSA, 2023). To complete an initial psychiatric evaluation, the patient should attend counseling sessions on a weekly basis for the first 12 weeks and then attend sessions every other week for the next 12 weeks. Community resources include Mental Health clinics, Psychologists, and Telehealth Services.
  2. Support Groups: Encourage attendance at peer support groups, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), to promote support and accountability (Amin et al., 2023). Explain the importance of attending weekly support group sessions and educate the patient on the recommended weekly sessions for the recovery process. Here, resources include local A.A. and N.A. chapters, community centers, and online support groups.
  3. Vocational Rehabilitation: Provide vocational rehabilitation services to improve financial stability and self-esteem (SAMHSA, 2023). Conduct an initial vocational assessment, followed by bi-monthly sessions for job training and placement support. Community resources include vocational rehabilitation programs, employment agencies, and community colleges.
Cultural Health Interventions:
  1. Culturally Competent Care: Ensure care plans are adapted to respect and incorporate the individual’s cultural values and practices (Weinandy & Grubbs, 2021). Conduct continuous cultural assessments and adjust care plans to align with cultural preferences and practices. Community Resources: Cultural competence training programs, community cultural organizations, and language translation services.
  2. Community Partnership: Engage with community leaders and organizations to build trust and facilitate culturally appropriate care (Lo et al., 2020). Establish ongoing partnerships with community leaders to ensure culturally relevant care delivery. Local cultural organizations, faith-based groups, and community leaders Serve as advocates and intermediaries between patients and healthcare providers.
  3. Education and Outreach: Conduct community education and outreach programs to reduce stigmatization and encourage treatment. Organize monthly community outreach events to educate the public about substance abuse and available resources. The Public Health Department will lead community health education initiatives. Non-profit organizations support outreach and educational programs aimed at reducing stigma. Community Health Workers act as liaisons, providing education and connecting individuals to resources.
Ethical Considerations in Designing Patient-Centered Health Interventions

It is essential to highlight ethical considerations to avoid deviating from clients’ interests and to ensure the new health interventions developed are fair and for the greater good of the targeted patients. A clear understanding of the consequences of some decisions is required to avoid moral complacency in order to meet the various needs of a patient with substance dependency disorders. Informed consent involves ensuring that a patient has all the necessary information about their treatment and has the capacity to choose the therapy they want.

It involves informing the patient of the possible advantages and disadvantages of a treatment plan, as well as available treatment options, in a language that the patient can understand. The practical impact has numerous benefits for the patient, as it enables them to participate in the doctor’s decision-making process, thereby promoting patient compliance with the doctor’s recommended treatment plan. However, this raises the ethical question: In what ways might information provided by patients enhance their engagement in their treatment process and decisions, particularly regarding matters of medical complexity where patients need to understand treatment choices and the costs and benefits of treatment?

Confidentiality entails keeping the patient’s details confidential and ensuring that all activities related to care integration are handled confidentially. This principle is crucial in establishing patients’ trust in healthcare providers, as it guarantees that their information will be protected from being shared with anyone without their consent (Tariq & Hackert, 2023). On the other hand, the challenge of sharing patient information between the various healthcare providers who are supposed to attend to the same patient to ensure they receive holistic attention fits well under the ethical dilemma. The question arises: How can we both share patent data with other healthcare providers as needed, so that patients receive proper care while at the same time respecting patients’ rights and privacy?

Two other essential ethical concepts in patient care include nonmaleficence and beneficence. Nonmaleficence means that a healthcare provider has no right to harm the patient, whereas beneficence entails a duty to do good for the patient and work for their benefit. It is essential to consider the potential risks and benefits of the planned interventions to ensure that the implemented interventions are more beneficial than detrimental.

For example, the use of medicine in the treatment of substance abuse comes with side effects, but the main aim of managing withdrawal symptoms and the risk of relapse is an important one to be achieved. The definable consequence of these decisions is that the potential risks incurred are reduced to the lowest possible level, thereby maximizing the potential rewards in terms of patient benefit. This raises the ethical question: What risks and benefits are associated with the proposed interventions, and how can we ensure that the positive impact of the changes outweighs the undesirable consequences that may result from their implementation?

Health Policy Implications for Care Coordination

Coordination and continuity of care are significant areas of concern in healthcare policies, which offer frameworks and guidelines for providing comprehensive, patient-centered services. The Affordable Care Act (ACA) emphasizes patient-centered care and preventive services, supporting integrated care models. The ACA also ensures substance abuse is addressed by requiring coverage of essential health benefits, which include mental health and substance use disorder services, therefore advancing comprehensive clinical care of patients with substance abuse disorders. This policy ensures that individuals receive the necessary treatment and care to help them manage these conditions (Baumgartner et al., 2020).

The Health Insurance Portability and Accountability Act (HIPAA) ensures the privacy and integrity of patient information, which is crucial for effective care coordination. HIPAA enables the exchange of information between healthcare providers to improve the health of individual patients and ensure adequate information sharing to avoid compromising the Patient’s identity. It helps to build up the patient-provider relationship and also helps maintain the credibility of the healthcare sector.

Medicaid and Medicare offer guidelines and reimbursement patterns to coordinate care for frail populations. These regulations enhance the basic health needs of infamous persons by incorporating them into healthcare services to be supported through well-coordinated care efforts. By promoting continuity and coordination across treatment settings, these policies ensure that all individuals, regardless of their financial means, are afforded appropriate levels of care (Centers for Medicare & Medicaid Services, 2021). Hence, those provisions in the approved health policy significantly determine the efficiency of care coordination and ensure cooperation in delivering integrated and patient-centered health services.

Priorities in Discussing the Plan with Patients and Families

Regarding interactions with patients and families during the care coordination session, care coordinators must set priorities to achieve a common understanding of the care coordination plan among patients and families. The following care coordination priorities and related changes based on evidence-based practice are critical for the effective coordination of care:

  • Patient and Family Engagement: It is crucial to include patients and their families in developing care plans to meet all their needs and wishes. This engagement encourages individuals to have a vested interest in the activity outcomes, which is an essential aspect for success. It is agreed that incorporating the family into support group meetings helps strengthen the support framework for patients, offering both emotional and practical support during the recovery process (Amin et al., 2023). As such, the plan required the structured involvement of the family in such sessions to enhance a sound support system.
  • Clear Communication: It is crucial to reiterate and explain all aspects of the care plan to patients and families, as they may have questions and concerns to ask. Communication is essential in ensuring that all parties have a shared understanding, and therefore, trust is developed. The use of graphics, illustrative written text, or any other media that can augment the spoken word can help improve comprehension and recall. Ongoing and clear communication ensures that the patient and their family understand all the care plans and roles required of them (SAMHSA, 2023).
  • Continuous Monitoring: One of the key factors that must be observed for the care plan to be effective is regular follow-ups and modifications of the care plan based on the patient’s outcome. Continuous monitoring enables the detection of problems, if any and the subsequent adoption of changes where necessary. It is also recommended that a feedback mechanism be instituted to gather periodic data from patients and their families, ensuring that the care plan is both appropriate and functioning optimally. This feedback loop helps adjust care based on information analysis, thereby enhancing the overall quality of care (National Institute on Drug Abuse, 2021).
Alignment with Healthy People 2030

The care coordination plan aligns with Healthy People 2030 goals by addressing key health issues and promoting comprehensive, patient-centered care.

Healthy People 2030 Objectives:

  • Objective: Reduce drug overdose deaths and improve mental health. The plan includes interventions for regular medical check-ups, mental health assessments, and support groups, addressing both physical and mental health needs.
  • Objective: Increase access to healthcare services. The plan leverages community resources, including health clinics and vocational rehabilitation programs, to enhance access to comprehensive care.
  • Objective: Enhance health equity. The plan incorporates culturally competent care and community partnerships to ensure that care is equitable and respects cultural values.
Conclusion

It is imperative to emphasize that substance abuse is a significant problem that requires a multi-disciplinary and cohesive model of care targeting the physical, psychosocial, and cultural aspects. This care coordination plan is the next step. It builds upon prior care coordination initiatives, is supported by findings from current research, and aligns with Healthy People 2030 objectives, with an emphasis on individualized, recovery-oriented, and person-centered care.

Thus, this plan focuses on utilizing patient-centered health interventions that incorporate community resources to enhance the overall patient experience. The culture of care coordination, patient engagement, and relevant policy issues shall incorporate ethical aspects that foster the effectiveness and continuity of care delivery. Through ongoing assessment and modifications of the care plan, substance use healthcare professionals can implement comprehensive, coordinated care that targets the complex factors related to substance use.

References

Amin, M., Irani, R. D., Fattahi, P., & Pakseresht, S. (2023). Effects of brief cognitive behavioral therapy on mental health in substance-related disorder: A randomized controlled trial. BMC Psychiatry, 23(1). https://doi.org/10.1186/s12888-023-05413-4

Baumgartner, J., Collins, S., Radley, D., & Hayes, S. (2020). How the Affordable Care Act (ACA) has narrowed racial and ethnic disparities in insurance coverage and access to health care, 2013‐18. Health Services Research, 55(S1), 56–57. https://doi.org/10.1111/1475-6773.13406

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), 1–21. https://doi.org/10.5334/ijic.5518

Lo, T. W., Yeung, J. W. K., & Tam, C. H. L. (2020). Substance abuse and public health: A multilevel perspective and multiple responses. International Journal of Environmental Research and Public Health, 17(7), 2610. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177685/

National Institute on Drug Abuse. (2021, December 1). HIV. National Institute on Drug Abuse. https://nida.nih.gov/research-topics/hiv

National Institute on Drug Abuse. (2022, March 22). Addiction and health. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/addiction-health

SAMHSA. (2023, February 7). Mental health and substance use co-occurring disorders. Www.samhsa.gov. https://www.samhsa.gov/mental-health/mental-health-substance-use-co-occurring-disorders

Substance Abuse and Mental Health Services Administration. (2023). Medications for Substance Use Disorders. Www.samhsa.gov. https://www.samhsa.gov/medications-substance-use-disorders

Tariq, R. A., & Hackert, P. B. (2023). Patient confidentiality. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519540/

Weinandy, J. T. G., & Grubbs, J. B. (2021). Religious and spiritual beliefs and attitudes towards addiction and addiction treatment: A scoping review. Addictive Behaviors Reports, 14, 100393. https://doi.org/10.1016/j.abrep.2021.100393