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Final Care Coordination Plan

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Final Care Coordination Plan

Mental illness is among the most prevalent disorders in the United States. A patient-

centred care practice is required for any healthcare practice. The methods guarantee the

patient's optimal health restoration result. To lower the number of persons with mental

illness, care coordination strategies must be in place to assure treatment for mental health

patients and prevent stigmatization of those with mental health disorders.

Although it can be challenging to establish a schedule for a patient's recovery, nurses

must implement a patient-centred approach with attainable timelines to enhance a patient's

health. A patient-centred strategy and intervention entail providing considerate care to all

mentally ill individuals. (Grassi, Wise, & Riba, 2019) This plan for care coordination will

emphasize mental health, designpatient-centred interventions using evidence-based practice

as a guide, and make ethical considerations for patient-centred health care intervention

design. Intensive coordinated planning and a continuum of care are crucial for a nurse to

comprehend a patient's needs and perspective. A benefit of excellent planning and patient-

centred care is the active participation of patients in their treatment.

Patient-Centred Interventions

When planning care for individuals with mental diseases, it is necessary to identify

and address cultural difficulties. To correctly manage mental health illnesses, the patient must

be willing to participate in treatment. Providers should be aware of their cultural biases and

refrain from transmitting them to patients. Providing an open communication channel through

which care personnel inquire about patient knowledge of mental health diagnoses has been

proven to be the optimal method. If necessary, hospital-provided cultural sensitivity training

may be attended by healthcare professionals. The clients should be encouraged to seek out

resources that will assist them in processing their diagnosis-related thoughts. In the event of
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suicidal ideation, suicide hotlines are available. Bipolar disorder, dementia, and mental health

stigma are three mental health issues in this plan.

Bipolar Disorder (BD)

BD is a recurrent, chronic condition marred with changes in moods (Grande, Berk,

Birmaher, & Vieta, 2016). One of the leading causes of disability in youth is BD, which can

cause both mental and physical impairments, as well as an increased risk of death by suicide.

Bipolar disorders (BDs) are frequent mental health conditions that afflict 1–5% of the

population, have a chronic course, and are associated with a significantly raised risk of

premature death (Dome, Rihmer, & Gonda, 2019). Suicide is a component of the lower life

expectancy in BD. BD is a highly heritable mental illness that affects an estimated 50 million

people globally (O'Connell & Coombes, 2021).

In primary care, collaborative approaches improve mental and physical healthcare

outcomes for patients with mental diseases, including bipolar disorder. Due to the recurrent

and persistent nature of the BD, maintenance treatment is crucial (Carvalho, Firth, & Vieta,

2020). Often, a combination of pharmacologic, psychological, and lifestyle therapies is

necessary to prevent the formation of affective episodes and onerous affective symptoms.

Implementing early intervention measures may assist in altering the course of the illness and

preventing irreversible harm to bipolar disorder patients. Initial stages may be more

responsive to treatment and necessitate less aggressive drugs. (Vieta, et al., 2018).

Psychotherapy such as cognitive-behavioural therapy (CBT), patient education, and setting a

regular schedule for sleep, nutrition, and exercise are among the interventions that would aid

the patient in managing the disease. Antidepressants such as SSRIs will be used. Lithium

remains one of the most effective medications for preventing manic and depressive relapses

in bipolar illness. The Mayo Clinic, the Cleveland Clinic, the Depression and Bipolar Support

Alliance (DBSA), and the Mental health foundation are community resources for BD.
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Dementia

Dementia is a medical disorder defined by the progressive or chronic decline of

intellectual capacities such as memory, abstract thought, and personality (Emmady & Tadi,

2022). An intervention may involve a nurse providing frequent, simple, and straightforward

explanations. Even when forgetting is unavoidable, frequent reminders lessen the likelihood

of forgetting. Also essential is the frequent orientation of items in a room, ensuring that the

patient understands the purpose of each item. In addition, providing positive comments

enhances a patient's self-esteem and mental wellness. There are typically solutions that could

assist with any mental health issue. Informing the patient of their problem, treatment options,

and alternatives in a manner they can fully comprehend. Involving them in decision-making

makes them feel in charge of their lives, enhancing their confidence. Inform them of any

modifications to their coordinated care plans before implementation to avoid confusion and

conflicts of interest.

The interventions incorporate good communication and guarantee that patients and

nurses comprehend better care for optimal health. In addition, when patients can make

decisions about their care, they acquire trust in the treatment plan and the caregiver, which

improves their health. Some community resources include local peer groups. Additionally,

some facilities manage all aspects of individuals with mental problems. Mental Health

America (MHA) and the National Alliance for Mental Health are examples of available

resources. Professionally, they resolve anxiety disorders, dementia, and even sleeping

abnormalities.

Mental health stigma

Multiple stigmas are related to mental health (Vargas, Huey , & Miranda, 2020).

Mental illness-related stigma, prejudice, and discrimination may be overt or covert.

Discrimination manifests itself in numerous forms, and stigmas stem from ignorance and
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fear. Although the public may acknowledge that a mental disease has a physical cause, there

is still a negative attitude toward it. A social stigma consists of others' unfavourable or

discriminating views toward mental illness (Brouwers, 2020). The term "self-stigma" is used

to describe the unfavorable beliefs and feelings that people with mental illness have about

themselves and their illness. (Tzouvara, Papadopoulos, & Randhawa, 2018). Institutional

stigma includes government and private organizations' policies that purposefully or

accidentally restrict possibilities for those with mental illness (Krupchanka & Thornicroft,

2017). Participating in a rally alongside those with mental illness is a strategy to combat the

stigmas they experience. Encourage communication, demonstrate compassion, promote

equality, educate yourself and others, and choose self-determination above shame. Speak

freely about mental health and be the voice required by those with mental illness. Counselling

or participation in groups with comparable family or friend dynamics might assist in

overcoming stigma. Community resources are available to assist. NAMI's Stigma Free

campaign aims to end stigma and provide hope for those affected by mental illness: it is

called Stigma-Free, and there is a website with a quiz to learn how to become stigma-free.

Ethical Implications

Ethical decision-making is essential to care coordination and provides nurses with a

moral framework. As nurses, we have a moral obligation to organize care according to the

ethical principles of beneficence, justice, autonomy, and nonmaleficence (Podgorica,

Flatscher-Thöni, Deufert, Siebert, & Ganner, 2021). Care for individuals with mental illness

can be challenging from an ethical standpoint. Decisions should be made in the best interest

of the patient's health, although it may be necessary to consider inevitable consequences. Due

to ethical concerns, healthcare professionals may ask themselves, "Is the care coordinated in

the patient's best interests?" Is the patient's safety guaranteed during treatment? Would you
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alter specific ethically sound interventions in any way? Would you administer the same

treatments to another patient? The responses should be consistent with ethical standards.

Healthcare Policies

The government is responsible for developing health policies to provide citizens with

the best healthcare. The Americans with Disabilities Act (ADA) of 1990 outlawed

discrimination against disabled people (Ross, 2022). Mental disorders have been added to the

list of diseases. In addition to being required to provide reasonable accommodations for

disabled employees, employers are prohibited by law from discriminating against them

during the recruitment process. Mental health treatments must be included in health insurance

companies' care plans. The Affordable Care Act is among the most influential healthcare-

related programs in recent history. In addition, it has been the subject of political contention,

which has threatened to impede its implementation. As a result of the Affordable Care Act,

healthcare has become more affordable, allowing for greater accessibility.

As the number of patients increases, care coordination becomes increasingly

important to meet their needs. The Hospital Readmission Reduction Policy is an additional

strategy that supports care coordination. The policy ensures that patients recover rapidly and

are not readmitted for recurrences or other medical issues. The Health Insurance Portability

and Accountability Act (HIPAA) is a renowned law that enhances the protection of patient

information and permits the acceptance of insurance for various healthcare needs. Essential to

the healthcare process is patient confidentiality, and healthcare institutions must be able to

safeguard patient information.

Establishing Priorities When Making Changes

Priority should be placed on stabilizing a mental health patient. Together with

community resources, the care coordination and interdisciplinary team will connect the

continuum of care. Utilizing any available data from external sources to promote
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comprehension of mental health and mental illness disorders. Children's vulnerability to

depression can be mitigated and parenting abilities can be improved through interventions

directed at families experiencing adversity like parental depression or divorce. Academic

performance can benefit from preventative measures taken at school with the aim of

enhancing students' social and emotional well-being. Since mental health can occur at any

age, interventions beginning in childhood are necessary for lifelong effects. Healthy People

2030 has ambitious mental health goals for people of all ages (Reitz & Scaffa, 2020). Healthy

People 2030 focuses on screening for depression with primary care providers at all ages and

increasing the proportion of individuals receiving treatment for substance abuse and mental

health disorders. Reducing the suicide rate and attempts, increasing the number of destitute

adults with mental health issues receiving treatment, and reducing emergency department

visits related to the nonmedical use of opioid medications will reduce the suicide rate and

suicide attempts.

Teaching Lessons

Evidence-Based PracticePractice is crucial for patient safety (Horntvedt, Nordsteien,

Fermann, & Severinsson, 2018). In coordinated care, consideration of patients' preferences is

emphasized. Healthy People 2030 was enacted in 2020, providing public health leaders with

new strategies to improve health by 2030. Including this in learning sessions improves the

management of mental health problems. For example, it identifies the most significant threats

to mental health and establishes reduction goals. Four of the objectives of Healthy People

2030 are concerned with promoting and enhancing a high quality of life and eliminating

disparities for all groups. Therefore, patients with mental illness are included in the plan,

which will be evaluated in 2030.

Literature on Evaluation
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Evaluation is the process of determining a program's or intervention's efficacy.

Evaluation entails collecting data and evaluating the data to determine if an intervention is

efficient or not. Evaluation is a complicated procedure, and literature is abundant on the

subject. The evaluation literature includes recommendations on undertaking evaluations and

utilizing evaluation results to make program and intervention decisions. The evaluation

literature may be utilized to evaluate the quality of learning sessions using best practices.

Using the literature on evaluation, the subject of learning sessions can be compared to

evidence-based practices for mental health. Healthy People 2030 focuses on preventing,

screening, and treating mental and behavioral illnesses (Healthy People 2030, 2020).

According to the Healthy People 2030 website's research-based resources, a collaborative

approach is essential for the optimal treatment of mental health disorders, and more

community resources exist. Patients must learn about the symptoms and indicators of mental

disease. To accomplish effective care coordination, it is necessary to provide patients and

their families with training. The training should enhance care coordination and comply with

Healthy People 2030. Concerning care coordination, training will ensure that all parties

collaborate to reach a unified objective. The training sessions should emphasize the

significance of these health-related elements and goals and ensure that the specified

objectives are compatible with the training sessions. Mental health training sessions can be

evaluated using the traditional behavioural change model, in which a rise in understanding

and positive attitudes results in a behaviour change (Anderson, et al., 2019). Training

programs are useful for enhancing mental health knowledge and attitudes.

Conclusion

A registered nurse's role as a care coordinator is crucial to delivering optimal care and

achieving desired results for patients. Nurses are educated in the code of ethics and are

expected to uphold it at all times. Improved patient outcomes can be achieved through the
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timely treatment of disease symptoms by implementing a care coordination plan. There is a

dire need for increased resources dedicated to mental health care, and healthcare providers

need additional training in responding to mental health crises. A better diagnosis can be

expected when a patient is surrounded by caring people, whether they are relatives, friends,

co-workers, or members of the community at large. A strong interdisciplinary team is crucial

for care coordination since it will be the factor that determines the patient's success and

improvement.
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References

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Mental Health Training Programs for Secondary School Teachers: A Systematic

Review. School Mental Health, 11(3), 489-508.

Brouwers, E. P. (2020). Social Stigma Is an Underestimated Contributing Factor to

Unemployment in People With Mental Illness or Mental Health Issues: Position Paper

and Future Directions. BMC Psychology, 8(1), 1-7.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. New England Journal of

Medicine, 383(1), 58-66.

Dome, P., Rihmer, Z., & Gonda, X. (2019). Suicide Risk in Bipolar Disorder: A Brief

Review. Medicina, 55(8), 403.

Emmady, P. D., & Tadi, P. (2022). Dementia. In StatPearls [Internet]. StatPearls Publishing.

Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar Disorder. The Lancet,

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Grassi, L., Wise, T., & Riba, M. B. (2019). The Role of Patient-Centered and Recovery-

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Horntvedt, M.-E. T., Nordsteien, A., Fermann, T., & Severinsson, E. (2018). Strategies for

Teaching Evidence-Based Practice in Nursing Education: A Thematic Literature

Review. BMC Medical Education, 18(1), 1-11.

Krupchanka, D., & Thornicroft, G. (2017). Discrimination and Stigma. In The Stigma of

Mental Illness-End of the Story? (pp. 123-139). Springer.

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O'Connell, K. S., & Coombes, B. J. (2021). Genetic Contributions to Bipolar Disorder:

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Podgorica, N., Flatscher-Thöni, M., Deufert, D., Siebert, U., & Ganner, M. (2021). Nursing

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Reitz, S. M., & Scaffa, M. E. (2020). Occupational Therapy in the Promotion of Health and

Well-Being. AJOT: American Journal of Occupational Therapy, 74(3), 7403420010-

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