Category: NURS-FPX4065

NURS FPX 4065 Assessment 6 Name Capella university NURS-FPX4065 Patient-Centered Care Coordination Prof. Name Date

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 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: Transparent Communication: Explain diagnosis, prognosis, and the importance of routine physical health checks (Nielsen et al., 2021). Cultural Sensitivity: Address cultural stigma respectfully and provide translated educational resources (Ahad et al., 2023). 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,

NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues Name Capella university NURS-FPX4065 Patient-Centered Care Coordination Prof. Name Date Care Coordination Presentation to Colleagues Care Coordination (CC) plays a vital role in enhancing patient outcomes and ensuring smooth healthcare delivery across different settings. Nurses act as the connecting link between patients, families, and healthcare teams, fostering communication and continuity of care (Karam et al., 2021). This presentation highlights evidence-based strategies that strengthen collaboration with patients and families, promote positive experiences, and ensure ethically sound care. Nurses remain at the forefront of patient-centered approaches, and CC enables fair, safe, and effective treatment across diverse populations. Evidence-Based Strategies Shared Decision-Making One of the central evidence-based practices in CC is Shared Decision-Making (SDM). This process allows patients and providers to work together when choosing treatment plans. According to Resnicow et al. (2021), SDM requires flexibility since patients differ in how much guidance they need from healthcare providers. Nurses can support SDM by applying practical tools such as: Strategy Nursing Role Patient Impact Decision aids Guide patients through treatment choices Improves clarity and understanding Teach-back method Ensure patients can repeat care instructions Reduces errors and builds confidence Plain language communication Simplify medical information Enhances autonomy and engagement These methods not only foster patient independence but also encourage them to be active participants in their care journey. Cultural Competence in Care Cultural competence is another key factor in effective CC. Nurses must be aware of how cultural traditions, beliefs, and language barriers influence patients’ healthcare behaviors. The U.S. Department of Health and Human Services (HHS) has established standards for addressing the needs of Culturally and Linguistically Diverse (CALD) groups, ensuring equity in healthcare delivery. Examples include: By tailoring care to cultural values, nurses reduce disparities and foster stronger patient-provider relationships. Family-Centered Approaches Family involvement is especially important for patients with chronic conditions such as diabetes, heart failure, or asthma. Nurses can empower families by teaching them disease management, self-care techniques, and preventive strategies. When families receive culturally relevant and easy-to-understand education materials, they can provide consistent support at home, reducing complications and hospital readmissions (Karam et al., 2021). Collaboration with community health workers further enhances the sustainability of this education. Change Management Applying Lewin’s Model Change management in CC is about preparing healthcare teams, especially nurses, to lead improvements that directly benefit patients. Lewin’s Change Model consists of three stages: Phase Description Nursing Application Unfreezing Recognizing the need for change Identify gaps in transitions and prepare staff Changing Implementing new practices Introduce team care models and revise discharge protocols Refreezing Embedding the new norm Ensure permanent adoption through policies and training This model enables nurses to lead change with confidence while maintaining patient safety (Barrow, 2022). Improving Patient Transitions One of the most frequent problems during transitions is poor communication, leading to missed instructions, medication errors, and repeated diagnostic tests. To address this, nurses use tools like SBAR (Situation, Background, Assessment, Recommendation) and provide discharge instructions early in the care process. Unlike older models that focused on satisfaction surveys alone, coordinated care now considers patients’ lived experiences—such as clarity of instructions, pain control, and responsiveness of providers. Small but impactful changes—like simplifying scheduling systems, reducing call-back delays, and ensuring follow-up calls—have been shown to enhance trust and satisfaction more effectively than large organizational overhauls. Rationale for Coordinated Care Coordinated care is grounded in ethical nursing values that emphasize justice, safety, respect, and dignity. The American Nurses Association (ANA) Code of Ethics obliges nurses to safeguard patient rights while providing compassionate, evidence-based care (ANA, 2025). Key ethical principles in CC include: Nurses address barriers such as transportation challenges and language differences by arranging interpreter services, providing accessible discharge instructions, and connecting patients with community resources. Such strategies promote patient compliance, minimize errors, and align care with personal values (Ilori et al., 2024). Ethical decision-making also strengthens trust, reduces conflicts, and builds integrity in nursing practice. Nurses feel more confident and less morally distressed when guided by clear ethical frameworks. Impact of Health Care Policy Provisions Affordable Care Act (ACA) The ACA has transformed healthcare access by expanding Medicaid, requiring coverage for preventive services, and supporting Accountable Care Organizations (ACOs). These changes have allowed more patients to receive care earlier, reducing hospitalizations and improving chronic disease management (Ercia, 2021). Nurses in ACOs coordinate discharge planning, provide patient education, and ensure effective follow-up. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) provides patients with privacy protection. For nurses, HIPAA ensures secure communication while maintaining patient trust. Clear boundaries in data sharing promote respect, encourage patient openness, and enhance coordinated care efforts. Telehealth Policies Following the COVID-19 pandemic, telehealth policies expanded access to care, especially for patients in rural or underserved areas. Nurses now use telehealth for remote symptom monitoring, medication support, and chronic disease follow-ups. This model increases accessibility and strengthens the nurse-patient relationship (Moulaei et al., 2023). Nurse’s Role in Coordination Nurses are the backbone of CC, ensuring patients transition smoothly across care settings. Their responsibilities include: Policy initiatives, such as value-based care models and the CMS Chronic Care Management (CCM) program, place nurses at the center of coordinated efforts. These programs not only improve patient health outcomes but also reduce costs by supporting long-term, nurse-led interventions (Karam et al., 2021). Conclusion Care coordination ensures safer, more effective, and patient-centered care. Nurses serve as leaders in managing transitions and applying evidence-based strategies that enhance quality outcomes. Change management frameworks support sustainable improvements. Ethical principles ensure dignity and autonomy, while policies like the ACA, HIPAA, and telehealth reforms expand access and trust. Ultimately, effective CC empowers patients, strengthens families, and positions nurses as vital advocates within an evolving healthcare system. References ANA. (2025). Ethics and human rights. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ Barrow, J. M., & Annamaraju, P. (2022). Change management in health care. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459380/ 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 NURS FPX 4065 Assessment 4 Care

NURS FPX 4065 Assessment 3 Ethical and Policy Factors in Care Coordination Name Capella university NURS-FPX4065 Patient-Centered Care Coordination Prof. Name Date Ethical and Policy Factors in Care Coordination Hello, I am ——-, and I am honored to present today. I currently work as a care coordinator at the Longevity Center, where we provide education, psychosocial support, and access to essential services for individuals living with mental health conditions. Agenda This discussion explores ethical and policy considerations in coordinating mental health care at the Longevity Center. It covers the significance of multidisciplinary teamwork, examines federal and state policies such as the Baker Act and HIPAA, and highlights the ethical framework provided by the American Nurses Association (ANA) Code of Ethics. Ethical dilemmas, including equity in access and cultural sensitivity, are also examined. Furthermore, the importance of reducing disparities through community collaboration and developing sustainable systems of care is emphasized. Significance of Care Coordination in Chronic Disease Management Care coordination plays a pivotal role in the management of mental health conditions at the Longevity Center. It ensures that patients receive timely, comprehensive, and continuous care across different service areas. Adults with psychiatric conditions often require services from multiple professionals and community-based organizations (Bury et al., 2022). When care is fragmented, patients face increased risks such as worsening symptoms, recurring crises, and elevated healthcare expenditures. In Florida alone, approximately 2.8 million adults are affected by mental illness, and in 2021, nearly 40.9% reported symptoms of depression (NAMI, n.d.). This highlights the pressing need for structured and coordinated interventions. At the Longevity Center, care coordination strengthens access to care, enhances treatment adherence, and reduces avoidable hospitalizations. Governmental Policies’ Effect on Care Coordination Government policies at both state and federal levels shape how mental health care is coordinated at the Longevity Center. Key Policy Influences Policy/Act Purpose Impact on Care Coordination Florida Mental Health Act (Baker Act) Provides crisis intervention and guidelines for psychiatric care Protects patient rights during involuntary psychiatric treatment (Florida DCF, 2024) HIPAA Protects patient health information privacy Allows secure sharing of patient records across care teams (Subbian et al., 2021) Value-Based Care Reforms Promotes preventive care and cost efficiency Encourages early intervention and coordinated behavioral health (Pincus & Fleet, 2022) Additionally, community organizations such as NAMI Florida support patients by offering education, peer navigation, and advocacy services, complementing the work of the Longevity Center. Ethical Questions or Dilemmas for Care Coordination National Policy Provision The Affordable Care Act (ACA) expanded healthcare access and improved quality of care nationwide. However, ethical challenges arise when financial limitations and standardized pathways compromise patient autonomy. For example, value-based models emphasize cost-effectiveness, which may restrict individualized interventions crucial for complex psychiatric cases (Braun et al., 2023). This creates a tension between cost control and personalized care. State Provision Policy Florida’s Medicaid behavioral health programs provide coverage for low-income populations. While they expand access, they also create challenges: delays in referrals, limited specialist availability, and administrative barriers. These issues compromise beneficence and result in health disparities, particularly for Medicaid recipients compared to privately insured patients (Patel et al., 2025). At the Longevity Center, provider shortages exacerbate this ethical dilemma. Local Provision Policy At the local level, community-based initiatives aim to expand access through free screenings, peer counseling, and educational programs (NAMI Florida, 2025). However, the issue of resource allocation persists. When demand outweighs resources, decisions about who receives support raise questions of justice and fairness. Inconsistent funding for community programs often leads to fragmented services, diminishing public trust. Impact of the Code of Ethics for Nurses The ANA Code of Ethics guides ethical mental health practice at the Longevity Center. Provision 2: Emphasizes the nurse’s duty to advocate for patient dignity and individualized needs. Provision 8: Highlights collaboration to promote human rights, cultural sensitivity, and equity (ANA, 2025). Core ethical principles—justice, beneficence, non-maleficence, and autonomy—guide decision-making. For example, when facing staff shortages, nurses are still obligated to ensure equitable distribution of available services. By adhering to these provisions, nurses foster trust and strengthen care continuity. Social Determinants of Health and Health Equity Social determinants significantly shape health outcomes at the Longevity Center. Determinant Challenge Ethical Concern Economic Stability Low income and unemployment Barriers to accessing continuous care Transportation Access Limited mobility to clinics Inequitable service access Health Literacy Limited patient understanding of conditions Reduced treatment adherence Housing Security Unstable living conditions Stressors worsen psychiatric symptoms Nurses guided by the ANA Code of Ethics are expected to address these inequities by providing culturally responsive and socially tailored care, thus advancing equity and improving adherence. Recommendations for Support and Collaboration To strengthen ethical coordination at the Longevity Center: Expand partnerships with NAMI Florida and the Mental Health Association of Central Florida (MHACF) to enhance patient navigation and peer support (MHACF, 2025). Advocate for equitable policies that reduce disparities in Medicaid behavioral health coverage. Promote culturally sensitive training among staff to address diverse community needs. Leverage technology (telehealth, electronic health records) to reduce barriers in communication and access. By aligning these strategies with the ANA Code of Ethics, nurses can ensure patient-centered and ethically sound care. Conclusion Ethical and policy-driven coordination is indispensable in addressing mental health challenges at the Longevity Center. By leveraging laws, community partnerships, and the ANA Code of Ethics, nurses can navigate ethical dilemmas, reduce disparities, and advocate for equitable access. The integration of culturally sensitive practices and policy reforms ensures that mental health care is not only clinically effective but also ethically just and socially inclusive. References ANA. (2025). Code of ethics for nurses. American Nurses Association. https://codeofethics.ana.org/home Braun, E., Scholten, M., & Vollmann, J. (2023). Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence‐ and autonomy‐based eligibility criteria? Bioethics, 38(1), 61–68. https://doi.org/10.1111/bioe.13243 Bury, D., Hendrick, D., Smith, T., Metcalf, J., & Drake, R. E. (2022). The psychiatric nurse care coordinator on a multi-disciplinary, community mental health treatment team. Community Mental Health Journal, 58(7), 1354–1360. https://doi.org/10.1007/s10597-022-00945-7 NURS FPX 4065 Assessment 3 Ethical and Policy Factors in Care Coordination Florida Department of Children and Families. (2024). Baker act | Florida DCF. Www.myflfamilies.com. https://www.myflfamilies.com/crisis-services/baker-act MHACF. (2025). About us. Mental Health Association of Central Florida. https://mhacf.org/learn-more/ NAMI Florida. (2025). Mission. National Alliance on Mental Illness Florida. https://namiflorida.org/about-nami-florida/mission/ National Alliance on Mental Illness. (n.d.). Mental health in Florida. National Alliance on Mental Illness.org. https://www.nami.org/wp-content/uploads/2023/07/FloridaStateFactSheet.pdf Patel, R., Baser, O., Waters, H. C.,