NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Name

Capella university

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Final Care Coordination Strategy

Care coordination is an essential framework that ensures patients receive continuous, comprehensive, and integrated services across different points of the healthcare system. It is particularly significant for individuals with complex conditions such as mental illness, where fragmentation of care can worsen outcomes. Effective coordination fosters improved health status, reduces inequities, minimizes duplication of services, and enhances patient satisfaction (Garfin et al., 2022).

This paper presents a care coordination strategy designed for adults living with mental illness in Florida, a state where approximately 2.9 million adults are impacted by psychiatric conditions (Garfin et al., 2022). The strategy focuses on patient-centered interventions, community partnerships, ethical dilemmas, relevant policy frameworks, and alignment with the Healthy People 2030 objectives.

Patient-Centered Health Interventions and Timelines

Adults with mental illness in Florida frequently experience comorbid physical conditions, cultural barriers, and psychosocial challenges that hinder recovery. Addressing these concerns requires interventions that are patient-focused, evidence-based, and supported by local resources. Below are three major strategies with community support and measurable timelines.

Comorbid Physical Illnesses

Adults with serious mental illness (SMI) often suffer from chronic diseases such as diabetes and cardiovascular problems, leading to a reduced life expectancy of 15–20 years (Nielsen et al., 2021). Integrating physical screenings into mental health care is vital to improving overall health.

Intervention Plan for Physical Health Screening

Focus Area	Action Steps	Community Partners	Timeline
Physical Health Monitoring	BMI, blood pressure, blood glucose, lipid profile, and smoking status measured regularly	Care Resource (sliding-scale services); Caron Florida (integrated screenings); MHACF (linkage to providers)	Initiated at intake; follow-up every 3 months
Lifestyle Modification	Nutrition counseling, exercise planning, and smoking cessation support	Care Resource wellness programs	Begins within 1 month; ongoing throughout treatment

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Cultural Stigma and Mental Health Literacy

Stigma remains a major barrier to care, particularly in diverse communities where cultural and linguistic barriers discourage treatment (Ahad et al., 2023). Addressing stigma through culturally relevant education promotes early care-seeking and treatment adherence.

Intervention Plan for Cultural Stigma Reduction

Focus Area	Action Steps	Community Partners	Timeline
Culturally Tailored Education	Biweekly workshops with multilingual materials and culturally relatable examples	NAMI Florida (public awareness programs); MHACF (community outreach); Care Resource (awareness campaigns)	Start 2 weeks after diagnosis; every 2 weeks for 6 months
Evaluation	Pre- and post-session surveys to measure change in knowledge and stigma reduction	Program facilitators and peer educators	Ongoing during 6-month cycle

Emotional Dysregulation

Conditions such as depression and anxiety often involve emotional dysregulation. Mindfulness-Based Cognitive Therapy (MBCT) has proven effective in reducing symptoms and preventing relapse.

Intervention Plan for Emotional Regulation

Focus Area	Action Steps	Community Partners	Timeline
MBCT Sessions	Weekly group sessions combined with cognitive-behavioral tools	Caron Florida (psychological programs); MHACF Outlook Clinic (free MBCT); NAMI Florida (mindfulness initiatives)	Initiate within 1 month of diagnosis; weekly for 6 months
Outcome Tracking	Monitor PHQ-9 depression scores for measurable progress	Coordinated care team	Goal: 40% improvement over 6 months

Ethical Decisions in Designing Patient-Centered Health Interventions

Designing interventions for individuals with mental illness requires balancing ethical principles of autonomy, cultural respect, and justice.

How do we ensure truly informed consent in individuals who may struggle with comprehension due to their mental state?

Patients with psychiatric conditions may have impaired judgment. To maintain autonomy, providers should use simplified language, decision aids, and ongoing consent checks. This ensures patients understand their care choices before agreeing to MBCT, screenings, or lifestyle modifications (Nagaoka et al., 2023).

How do we make interventions culturally competent and respectful in a way that does not make patients feel labeled or marginalized?

While culturally tailored programs reduce stigma, they may also unintentionally reinforce stereotypes. To avoid this, providers must include patient perspectives in planning, employ peer educators, and adapt programs to local community needs (Ahad et al., 2023).

How do we ensure equitable access for all patients?

Justice requires that uninsured and underinsured individuals have equal access to care. Partnerships with organizations like Care Resource and MHACF, which offer services on a sliding scale or free of charge, ensure inclusivity and reduce inequities (Care Resource, 2025; MHACF, 2025).

Relevant Health Policy Implications

Supportive policies reinforce coordinated care:

• Mental Health Parity and Addiction Equity Act (MHPAEA): Requires mental health coverage equal to physical health care, reducing financial barriers for services like therapy and MBCT (CMS, 2024).
• Affordable Care Act (ACA): Classifies mental health and substance use treatment as essential benefits, encouraging routine physical screenings for individuals with SMI (Nielsen et al., 2021).
• Healthy People 2030: Prioritizes mental health promotion, stigma reduction, and equitable access, directly aligning with the outlined care strategy (Healthy People 2030, 2020).

Priorities for Care Coordinators in Patient and Family Discussions on Mental Illness

Care coordinators should emphasize:

1. Transparent Communication: Explain diagnosis, prognosis, and the importance of routine physical health checks (Nielsen et al., 2021).
2. Cultural Sensitivity: Address cultural stigma respectfully and provide translated educational resources (Ahad et al., 2023).
3. Patient Empowerment: Set measurable goals such as MBCT attendance or stigma-reduction participation, while tracking improvement using tools like PHQ-9 (Liu et al., 2024).

Learning Session Content with Best Practices and Healthy People 2030

Learning sessions such as MBCT and stigma-reduction workshops reflect best practices in care. Research recommends supplementing sessions with follow-ups and peer facilitators to improve sustainability (Gkintoni et al., 2025).

Cultural relevance is strengthened by peer-led education, where individuals from similar backgrounds share lived experiences, reducing stigma more effectively (Ahad et al., 2023). These methods align with Healthy People 2030 objectives of promoting equity, reducing disparities, and enhancing mental health literacy.

Need for Change

The initial plan lacks structured feedback systems and peer-led facilitation. Without these, interventions risk being less culturally responsive. Incorporating community-based peer leaders, routine surveys, and open feedback forums will improve patient engagement and ensure alignment with Healthy People 2030 goals (Healthy People 2030, 2020).

Conclusion

This care coordination strategy for adults with mental illness in Florida emphasizes holistic wellness through physical health integration, stigma reduction, and emotional regulation. By leveraging policies like the ACA and MHPAEA and aligning with Healthy People 2030, the plan ensures ethical, equitable, and sustainable care. Adding peer-led support and continuous evaluation further strengthens cultural sensitivity and long-term effectiveness.

References

Ahad, A. A., Sanchez-Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(7), e39549. https://doi.org/10.7759/cureus.39549

Care Resource. (2025). Behavioral health. Care Resource. https://careresource.org/services/behavioral-health/

Caron Florida. (2024). Mental health program. Caron Transformational Care. https://www.caron.org/treatment-programs/mental-health-program

Centers for Medicare & Medicaid Services (CMS). (2024, September 10). The Mental Health Parity and Addiction Equity Act (MHPAEA). https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15(2), 37–70. https://doi.org/10.1177/1529100614531398

Garfin, D. R., Thompson, R. R., Holman, E. A., Wong-Parodi, G., & Silver, R. C. (2022). Association between repeated exposure to hurricanes and mental health in a representative sample of Florida residents. JAMA Network Open, 5(6), e2217251. https://doi.org/10.1001/jamanetworkopen.2022.17251

Gkintoni, E., Vassilopoulos, S. P., & Nikolaou, G. (2025). Mindfulness-based cognitive therapy in clinical practice: A systematic review of neurocognitive outcomes and applications for mental health and well-being. Journal of Clinical Medicine, 14(5), 1703. https://doi.org/10.3390/jcm14051703

Healthy People 2030. (2020). Mental health and mental disorders. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives-and-data/browse-objectives/mental-health-and-mental-disorders

Liu, W., Yuan, J., Wu, Y., Xu, L., Wang, X., Meng, J., Wei, Y., Zhang, Y., Kang, C.-Y., & Yang, J.-Z. (2024). A randomized controlled trial of mindfulness-based cognitive therapy for major depressive disorder in undergraduate students: Dose–response effect, inflammatory markers and BDNF. Psychiatry Research, 331, 115671. https://doi.org/10.1016/j.psychres.2023.115671

Mental Health Association of Central Florida (MHACF). (2025). About us. https://mhacf.org/learn-more/

Nagaoka, M., Koreki, A., Kosugi, T., Ninomiya, A., Mimura, M., & Sado, M. (2023). Economic evaluation alongside a randomized controlled trial of mindfulness-based cognitive therapy in healthy adults. Psychology Research and Behavior Management, 16, 2767–2785. https://doi.org/10.2147/prbm.S406347

National Alliance on Mental Illness (NAMI) Florida. (2025). Mission. https://namiflorida.org/about-nami-florida/mission/

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Nielsen, R. E., Banner, J., & Jensen, S. E. (2021). Cardiovascular disease in patients with severe mental illness. Nature Reviews Cardiology, 18(2), 136–145. https://doi.org/10.1038/s41569-020-00463-7

Substance Abuse and Mental Health Services Administration (SAMHSA). (2022). Cultural competence in mental health care. U.S. Department of Health and Human Services. https://www.samhsa.gov/behavioral-health-equity/cultural-competence