The Final Care Coordination Plan Discussion Paper

The Final Care Coordination Plan Discussion Paper

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 all strata of society and, therefore, requires the input of professionals from different fields to manage the disorder. The goal of care coordination is to collaborate services to meet the personal healthcare needs of people with substance use disorder, using Psychosocial and Cultural aspects of the 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 works with current evidence-based literature and the objectives prepared for Healthy People 2030. This plan emphasizes the use of empirical practices and community assets to increase patient quality and offer a comprehensive care plan that is individualized, comprehensive, and tailored around the many 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 The Final Care Coordination Plan Discussion Paper.

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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 some of the available community resources to ensure that follow-up to the intervention is firmly anchored.

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)The Final Care Coordination Plan Discussion Paper. 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 twelve weeks and, after that, attend the session every fortnight for the next twelve weeks. Community Resources here include Mental Health clinics, Psychologists, and Tele-Health Services.
2. Support Groups: Encourage the attendance of peer support groups like Alcoholics Anonymous (A. A. ) and Narcotics Anonymous (N. A. ) 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 are 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 are vocational rehab programs, employment agencies, and community colleges.

Cultural Health Interventions: The Final Care Coordination Plan Discussion Paper

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 (Grant et al., 2021). 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.The Final Care Coordination Plan Discussion Paper

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 be a moral complacency in order to meet the various needs of a patient with substance dependency disorders. Informed consent involves ascertaining that a patient has all the necessary information regarding treatment and has the mobility to choose whatever therapy they want. It consists of informing the patient of the possible advantages and disadvantages of a treatment plan, as well as available options for treatment, in a language that the patient will understand. The practical impact has more benefits to the patient since it means that patients will be able to participate in the doctors’ decision-making process, hence 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 and guaranteeing that all activities in care integration are confidential. This principle is crucial in establishing the patients’ trust in healthcare providers since it guarantees the patient 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 givers who are supposed to be attending to the same patient to ensure that they receive holistic attention fits well under the ethical dilemma. The question arises: How can we both share patent data with other health care providers as needed so that the patients receive proper care while at the same time respecting patient’s rights and privacy? The Final Care Coordination Plan Discussion Paper

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 important to reflect on possible risks and advantages of the planned interventions in order for the interventions that are implemented to be more beneficial than non-beneficial. 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 to be incurred are reduced to the lowest possible to maximize the potential rewards in terms of patient benefit. This leads to the ethical question: What risks and benefits are associated with the proposed interventions, and how can we guarantee that the positive impact of the changes surpasses the undesirable consequences that may ensue from the implementation of the suggested changes?

Health Policy Implications for Care Coordination

Coordination and continuity of care are significant areas of concern in healthcare policies that 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 people get the required treatment and care to help them live with these conditions (Baumgartner et al., 2020).

The Health Insurance Portability and Accountability Act manages patient information privacy and data integrity, which is crucial in 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. Through promoting continuity and coordination across treatment settings, these policies ensure that all individuals, irrespective of their means, are afforded appropriate levels of care (Centers for Medicare & Medicaid Services, 2021)The Final Care Coordination Plan Discussion Paper. Hence, those provisions in the approved health policy greatly determine the efficiency of care coordination and guarantee cooperation in dispensing appropriate health services that are integrated and sensitive to the patient’s needs.

Priorities in Discussing the Plan with Patients and Families

Regarding interactions with the patients and families during the care coordination session, the care coordinators must set priorities to realize and achieve a common understanding of the care coordination plan among the 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 families in making care plans to fulfill all their requirements and wishes. This engagement encourages individuals to have a vested self-interest in the activity outcomes, hence an essential aspect for success. It is agreed that incorporating the family into the support group meetings helps strengthen the support framework for the patients, explicitly offering emotional and practical help 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 the 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 also makes sure that the patient and the families understand all the care plans and roles required of them (SAMHSA, 2023)The Final Care Coordination Plan Discussion Paper.
• Continuous Monitoring: One of the factors that must be observed for the care plan to work is having follow-ups and modifications of the care plan according to 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 the patients and families as a way of making sure that the care plan is both appropriate and functioning optimally. This feedback loop assists in altering the care based on information analysis, enhancing the general 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 such as health clinics and vocational rehabilitation programs to improve 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 The Final Care Coordination Plan Discussion Paper.

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 expands upon prior care coordination initiatives, is supported by findings from current research and is in line with Healthy People 2030 objectives, with an emphasis on individualized, recovery-oriented, person-centered care. Thus, this plan focuses on using patient-centered health interventions that involve community resources to improve the general 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.

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References

Amin, M., Irani, R. D., Fattahi, P., & Pakseresht, S. (2023). Effects of brief cognitive behavioral therapy on mental health in substansce-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 The Final Care Coordination Plan Discussion Paper

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 The Final Care Coordination Plan Discussion Paper