NURS FPX 4905 Assessment 5

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Student Name

Capella University

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name:

Date

Final Care Coordination Strategy

Care coordination represents a structured and patient-focused approach that ensures continuity of care across multiple healthcare systems. It is particularly crucial for individuals with complex needs, such as adults living with mental illness, where fragmented care often results in poor outcomes. Effective coordination enhances quality of life, reduces health disparities, and builds trust between patients and providers (Garfin et al., 2022).

This strategy emphasizes the development of a comprehensive care coordination model for adults with mental illness in Florida. The plan integrates patient-centered interventions, ethical considerations, policy frameworks, and Healthy People 2030 objectives to strengthen mental health services. It also highlights community resources and timelines for interventions that improve access, reduce stigma, and promote holistic wellness.

Patient-Centered Health Interventions and Timelines

Florida has one of the highest rates of adult mental illness, with approximately 2.9 million individuals affected. These patients often face additional challenges such as comorbid physical conditions, stigma, and emotional instability (Garfin et al., 2022). A patient-centered approach demands interventions that are multidimensional, evidence-based, and sensitive to cultural and psychosocial needs.

Patient-Centered Interventions, Community Resources, and Timelines

• Barrier Addressed: Physical Comorbidities (e.g., diabetes, cardiovascular disease) Intervention: Routine health screenings such as BMI, blood pressure, glucose, and lipid levels; counseling on lifestyle modification. Community Resources: Care Resource, Caron Florida, Mental Health Association of Central Florida (MHACF). Timeline & Evaluation: Begin at intake; screenings every three months; lifestyle counseling initiated in the first month and continued throughout care.

• Barrier Addressed: Cultural Stigma and Low Mental Health Literacy Intervention: Biweekly culturally sensitive education sessions with multilingual resources, peer educators, and stigma-reduction workshops. Community Resources: NAMI Florida, MHACF, Care Resource. Timeline & Evaluation: Start two weeks post-diagnosis; sessions every two weeks for six months; pre- and post-session surveys to measure awareness and stigma reduction.

• Barrier Addressed: Emotional Dysregulation Intervention: Weekly Mindfulness-Based Cognitive Therapy (MBCT) to improve resilience and prevent relapse. Community Resources: Caron Florida, MHACF’s Outlook Clinic, NAMI Florida. Timeline & Evaluation: Begin within one month of diagnosis; continue weekly for six months; target 40% reduction in PHQ-9 scores.

Comorbid Physical Illnesses

Adults with severe mental illness frequently suffer from comorbid conditions such as diabetes and cardiovascular disease, which reduce their life expectancy by 15–20 years (Nielsen et al., 2021). Integrating preventive and routine physical check-ups into psychiatric care allows for early detection and intervention. Care Resource and Caron Florida provide combined behavioral and physical health services, while MHACF ensures patients are linked to appropriate providers for follow-up.

Cultural Stigma and Mental Health Literacy

Stigma remains a major barrier to mental health treatment, particularly in culturally diverse populations. Patients may avoid services due to fear of judgment or discrimination (Ahad et al., 2023). Biweekly educational interventions, such as community workshops and peer-led discussions, can promote awareness, improve literacy, and encourage early treatment. NAMI Florida and MHACF play central roles in delivering outreach initiatives, while Care Resource expands access through minority-focused education programs.

Emotional Dysregulation

Emotional instability, including recurrent depressive or anxious episodes, is prevalent among adults with mental illness. Mindfulness-Based Cognitive Therapy (MBCT) has demonstrated effectiveness in enhancing emotional regulation and decreasing relapse risk (Gkintoni et al., 2025). Caron Florida and MHACF offer structured MBCT programs, while NAMI Florida partners with mental health professionals to increase access. Monitoring PHQ-9 scores over six months provides measurable indicators of success.

Ethical Decisions in Designing Patient-Centered Health Interventions

How do we ensure informed consent for individuals with impaired judgment? Respect for autonomy requires adapting informed consent processes to the patient’s needs. Simplified explanations, caregiver involvement, and repeated clarification ensure patients understand and consent appropriately (Nagaoka et al., 2023).

How do we ensure cultural competence without reinforcing stigma? Cultural education should avoid labeling or marginalizing patients. Co-designing programs with patient input and using peer educators from similar cultural backgrounds enhances acceptance and minimizes perceived bias (Ahad et al., 2023).

How do we address health equity and access? Equity requires fair access to care regardless of financial status. Organizations such as Care Resource and MHACF bridge the gap by offering sliding-scale and free services, ensuring that vulnerable populations receive necessary support (MHACF, 2025).

Relevant Health Policy Implications

Policy frameworks form the backbone of effective care coordination:

• The Mental Health Parity and Addiction Equity Act (MHPAEA) ensures mental health benefits are equal to physical health coverage, reducing barriers to ongoing treatments such as therapy and medication (CMS, 2024).
• The Affordable Care Act (ACA) designates mental health and substance use treatment as essential health benefits, expanding coverage for preventive screenings and education (Nielsen et al., 2021).
• Healthy People 2030 emphasizes reducing stigma, enhancing mental health literacy, and improving equity, aligning closely with this strategy (Healthy People 2030, 2020).

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

Care coordinators should emphasize:

1. Transparency and Trust: Clearly communicate diagnosis, prognosis, and treatment options, including comorbidity risks (Nielsen et al., 2021).
2. Cultural Sensitivity: Incorporate cultural beliefs, provide translated materials, and utilize community-based education to reduce stigma (Ahad et al., 2023).
3. Active Engagement: Encourage patients and families to participate in measurable goals, such as weekly MBCT sessions, with progress tracked using tools like the PHQ-9 (Liu et al., 2024).

Learning Session Content with Best Practices and Healthy People 2030

Best practices in mental health care align with the proposed interventions:

• Mindfulness-Based Cognitive Therapy (MBCT): Proven to reduce relapse in depression and enhance well-being when paired with follow-up care (Gkintoni et al., 2025).
• Culturally Tailored Education: Peer-led sessions using culturally relevant examples improve literacy and reduce stigma, supporting community-based recovery (Ahad et al., 2023).

These practices reinforce Healthy People 2030 goals, including reducing disparities, improving access, and enhancing patient empowerment.

Need for Change

The original strategy requires greater integration of feedback mechanisms and peer support systems. Implementing regular patient surveys, community feedback forums, and peer-led facilitation will strengthen cultural relevance and responsiveness. Such changes ensure ongoing adaptability while aligning with Healthy People 2030 goals to improve behavioral health outcomes and equity (Healthy People 2030, 2020).

Conclusion

This care coordination strategy outlines a holistic approach for addressing the needs of adults with mental illness in Florida. By integrating interventions that address comorbidities, stigma, and emotional instability, the plan strengthens patient-centered care. Supportive policies such as ACA and MHPAEA ensure access, while Healthy People 2030 reinforces long-term equity and inclusion. Enhancements such as peer-led support and systematic feedback ensure cultural responsiveness, patient empowerment, and sustainable health outcomes.

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. https://doi.org/10.7759/cureus.39549

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

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

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

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

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. https://odphp.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

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

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

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

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

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