Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

I have included the scoring guide and the supplement with available topics. Please use mental health disorders.

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement. Preliminary Care Coordination Plan

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Scenario

Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

• Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
• Allow plenty of time to plan your chosen health care concern.

Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan Preliminary Care Coordination Plan

Complete the following:

• Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF] Download Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
• Identify available community resources for a safe and effective continuum of care.

Document Format and Length

• Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
  • Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
• In your paper include possible community resources that can be used.
• Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
  • Study the subtle differences between basic, proficient, and distinguished.

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary 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. Preliminary Care Coordination Plan

• Analyze your selected health concern and the associated best practices for health improvement.
  • Cite supporting evidence for best practices.
  • Consider underlying assumptions and points of uncertainty in your analysis.
• Describe specific goals that should be established to address the health care problem.
• Identify available community resources for a safe and effective continuum of care.
• Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
• Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
  • Write with a specific purpose with your patient in mind.
  • Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

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.
  • Analyze a health concern and the associated best practices for health improvement.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
  • Describe specific goals that should be established to address a selected health care problem.
• Competency 3: Create a satisfying patient experience.
  • Identify available community resources for a safe and effective continuum of care.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Preliminary Care Coordination Plan

The aim of care coordination is the inclusion of services that would address the needs of an individual. Its goal centers on providing recovery-oriented and integrated services to assist people in accessing healthcare services. Substance abuse is a significant public health concern with a plethora of physical, psychosocial, and cultural dimensions (Lo et al., 2020). It impacts everyone from diverse age groups and income levels, demanding complex and multi-disciplinary efforts in care coordination. Care coordination for this issue must be addressed within the community environment, especially with a Budget shortage and a shortage of case management staff. This anticipatory care coordination plan is intended to meet the physical, psychosocial, and cultural needs of individuals with substance abuse disorders and to delineate community resources to provide a continuum of care effectively.

Physical Considerations

One of the significant impacts of drug addiction is the rapid deterioration of health. For instance, chronic alcohol abuse may lead to liver or heart disease or pancreatitis, whereas the use of illicit drugs may cause cardiovascular or respiratory diseases or neurological disorders (NIDA, 2022). Intravenous drug users are at risk of acquiring infectious diseases like HIV, hepatitis B and C viruses, and other blood-borne viruses (National Institute on Drug Abuse, 2021). Furthermore, substance abuse significantly interferes with feeding schedules, leading to malnourishment and other related health problems. Long-term exposure to any substance also has the potential for worsening pre-existing pain or causing additional pain. These conditions need constant medical management and treatment to avoid further decline.

For physical health issues, the care coordination plan includes a thorough diagnostic examination to identify comorbidities and a practical approach to treating opioid use disorder, nutritional support, and appropriate pain management strategies. Best practices for physical health improvement in substance abuse include:

1. Regular Medical Check-ups: Regular screenings are essential to track the health of the liver and heart and the functioning of respiratory organ systems. Such check-ups offer a chance to identify and address any illness or diseases resulting from substance abuse in time.
2. Medication Management: Methadone, Buprenorphine, and Naltrexone are some of the most popular drug therapies used to treat withdrawal and cravings Substance Abuse and Mental Health Services Administration (2023). These medications form part of more expansive Medication Assisted Treatment (MAT), which combines medication with counseling and behavioral therapies as a ‘whole-patient’ approach.
3. Nutritional Support: Malnutrition is thus a resultant problem of substance abuse. This is why offering dietary plans that increase physical healing and health is essential. These plans can include vitamin and mineral supplements, a weight-control diet, planned meals, and a nutritionist refresher course to meet patients’ nutrient needs.

Psychosocial Considerations

Mental illnesses like depression, anxiety, and PTSD often co-occur with substance abuse, compounding the problems associated with addiction and making recovery more complex. Those addicted to drugs and alcohol may also become socially withdrawn as existing relationships change and they stop participating in social events (SAMHSA, 2023). Addiction often comes with economic costs such as losing a job, becoming homeless, and other economic challenges; legal implications are also common, with people with an addiction often ending up in jail. To meet these psychosocial requirements, the care coordination plan advocates for mental health assessment and treatment of co-occurring disorders.

Counseling and Therapy involving the services of psychologists or counselors aid in dealing with emotional problems and providing coping mechanisms. Cognitive-behavioral Therapy (CBT) is especially useful in getting people to alter unconscionable behaviors and thought processes that may contribute to substance misuse (Amin et al., 2023). participation in mutual support groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), vocational rehabilitation to improve financial stability and self-esteem, and access to legal aid to navigate legal issues and reduce the risk of recidivism. Also, including the family in the recovery and therapy process fosters trust and improves family social relations. Substance abuse disorders cannot be fully managed without attending to psychosocial needs.

Cultural Considerations

Cultural beliefs and practices have a profound impact on the willingness of an individual to engage in substance abuse treatment. Acknowledging and valuing these cultural considerations is essential for care coordination (Weinandy & Grubbs, 2021). Care coordinators must show cultural competence and adapt the interventions to display awareness and respect for cultures and beliefs. This may involve understanding cultural attitudes toward substance abuse so that the nurses can see the patients without any prejudice or discrimination. They should bridge the language gap by giving access to services in the language the individual understands and approach the culture of the individuals about substance abuse to reduce fear of stigmatization. They should incorporate cultural values and practices in developing individual treatment programs to improve care. Preliminary Care Coordination Plan

Specific Goals

To address the healthcare problem of substance abuse, the following specific goals should be established:

1. Physical Health Improvement: Within six months, restore stable liver, cardiovascular, and respiratory function. This includes frequent medical check-ups, the use of medications as prescribed, and adequate nutrition.
2. Emotional Stability: Within three months, emotional and mental health will be improved, and coping skills will be enhanced. This can be managed through regular counseling, attendance at support groups, and personal life skills management approaches.
3. Social Reintegration: Reestablish social networks and return to activities of daily living within six months. This encompasses family therapy, community developmental activities, and employment or vocation development opportunities.
4. Cultural Acceptance: Enhance cultural endorsement and compliance with the treatment regimen in three months. This includes culturally competent care, community partnership, and culturally specific care, including the understanding and adapting of the individual’s cultural values and practices into their care plan.

Available Community Resource

Many resources are available in the community that can be used to promote the individual’s recovery. Substance abuse treatment centers provide detoxification, inpatient programs, and outpatient services, as well as aftercare services. These centers offer the client care and services within a formal setting that fosters recovery. Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) offer peer accountability and regularly scheduled meetings for recovery. These groups are essential in preventing a relapse to addiction. Community health centers offer primary care and mental and substance abuse facilities in a culturally and linguistically appropriate setting.

Primary health care clinics are often the primary outlet for ongoing care and assistance. Crisis Hotlines Services such as the Substance Abuse and Mental Health Services Administration (SAMHSA) hotline offer immediate support and a referral to local resources. Crisis hotlines are open round the clock to support those who need help due to a crisis. Vocational rehabilitation programs help people find and keep jobs; legal aid organizations offer legal services for people who cannot afford a lawyer. Job-related assistance is crucial for restoring a lost sense of productivity and financial stability upon completing recovery. Preliminary Care Coordination Plan

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Conclusion

Addressing physical, emotional, and cultural requirements and leveraging accessible community resources are essential components of effective substance abuse care coordination. Healthcare providers can enhance the health outcomes of people suffering from substance use disorders by setting clear, quantifiable, and attainable goals. This primary care coordination plan is the foundation for comprehensive and culturally responsive care, ensuring a safe and effective community care continuum.

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

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

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 Preliminary Care Coordination Plan