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Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

Health Concern

One of the growing health concerns in American society is increased cases of mental illness. As a result, there is increasing focus on mental illness and evaluation of the best approaches to intervene for mental illness in the American population. In a study conducted by Crowley and Kirschner (2015), 43.8% of the American population do developmental illnesses annually. This prevalence rate is high and demands the integration of effective preventive and management strategies to treat mental illnesses. Individuals diagnosed with mental illnesses result in poor emotional, behavioral, and social well-being. Therefore, there is a need to develop a care coordination plan since interventions for mental illnesses are likely to be handled from an interdisciplinary collaborative approach (Munson & Jaccard, 2018). From the insuperability, individuals affected by poor mental health development experience challenges in mental and cognitive processes leading to impairment in judgment and negative thought development. In other cases, poor mental health development also has an impact on physical health outcomes due to impairment in body systems that result in physiological symptoms of mental illnesses.

The main mental illnesses that have significant impacts on patients and their overall well-being are depression and anxiety. Daily experiences in life result in the development of stress, depression, and anxiety arise when a person is exposed to a significant level of stress that results in negative thoughts and emotional disturbances that generate physiological and emotional symptoms (Crowley & Kirschner, 2015). Treatment of depression and anxiety requires a combination of psychological, cognitive-behavioral, pharmacological, and social interventions, which attracts multiple professionals in care and management, such as social workers, nurses, physicians, and psychiatrists. These professionals form a collaborative team that can help the patients in recovery from mental illness and restores health and well-being (Lyon & Bruns, 2019). Therefore, there is a need for an effective approach to the coordination of care for the treatment and management of patients with mental illness.

Facts about Mental Health Issues in the United States Population

Patients with mental illness have some invincible disabilities which harm their ability to perform their daily activities. Affected individuals usually consider their conditions not severe, unlike other physiological diseases exposing them to serious behavior and physiological deteriorations. Mental health patients do experience assumptions that influence the concentration of most general public from their concerns (Crowley & Kirschner, 2015). While mental illnesses and associated health issues could be detrimental to a successful life, management of these illnesses is dependent on the availability and access to resources and support mechanisms to enhance the recovery process. Canady’s (2016) study on mental illnesses identified that over 40% of mental health patients do not seek support and treatment. This type of trend reduces the efficacy of set interventions resulting in a significant number of patients deteriorating to more severe conditions and cases of suicide (Munson & Jaccard, 2018). Additionally, a study conducted by Canady (2016) found that $193 billion are usually lost annually in the United States alone due to incapacitation and reduced productivity of working patients with mental illness. These results indicate that mental health illnesses like depression, anxiety, and bipolar conditions are the main cause of hospitalization for people aged 18-44 years. This indicates the gravity of mental illnesses in the American population.

Elements of Consideration in Mental Health Illnesses Care Coordination

Mental health illnesses are diverse and result in a significant impact on the well-being and quality of life of patients. One area of concentration for patients is emotional, psychological, social, and physiological processes. For instance, Munson and Jaccard (2018) claim that long periods of exposure to depression and anxiety result in the emergence of physiological symptoms like gastrointestinal problems, headache, and in some severe cases, increased risk of other non-communicable diseases. In the intervention, patients with mental illness require a holistic approach to care, which brings a team of professionals from different levels and care settings to enhance the recovery of the patients.

For instance, a case of depression in a patient could attract nursing interventions, psychiatrist therapies, cognitive-behavioral therapies, social interventions and community involvement, pharmacological interventions, and treatment by physicians (Lyon & Bruns, 2019). All these professionals must collaboratively work together to restore the health and well-being of patients with mental illness. Therefore, there is a need to adopt an interdisciplinary collaborative team in addressing and coordinating care for patients with mental illnesses since the approach helps to address the myriad of risk factors, including social, emotional, behavioral, cognitive, physiological, and environmental factors that could play a part in the recovery process of the patients (Munson & Jaccard, 2018). This is implemented through an effective care coordination plan.

Mental Illnesses Care Coordination Plan Goals

Care coordination is the process aimed at helping patients with mental illness to access a broad range of services that help them to become better and work positively towards recovery. During this process, the patients do interact with different clinicians and healthcare providers, primary carers, family members, and the community (Lyon & Bruns, 2019). The main goal of integrating a collaborative care team comprising of an interdisciplinary approach is helping to ensure coordination of care is enhanced to improve the health and functioning of patients recovering from mental illness by meeting the complex mental health, physical health, and living in long-term care settings. Care coordination in mental health illnesses treatment requires a multidisciplinary team involving psychosocial support providers, self-management education and resources, a clinical treatment team comprising nurses, pharmacists and physicians, and cognitive-behavioral therapists (Munson & Jaccard, 2018). The care coordination plan aims at meeting the needs of a mentally sick patient. During the assessment, the patient has significant family and friends’ support but requires additional support from professionals due to financial constraints, stress burden, long period of exposure to mental health problems, and strained ability to meet family needs.

Resources Available in the Community for Effective Continuum of Care Assessment of the patient’s community environment indicates that he may benefit from different support programs that are aimed at assisting such patients with mental wellness problems for optimum recovery. One of these resources is Mental Health America (MHA) which offers an affiliate network of mental health organizations that are meant to address public policies on mental health and ensure effective care delivery to mental health patients in American society (Mental Health America, 2020). MHA is available in over 200 affiliates and is highly committed to providing support and advocacy for mental health needs. The affiliates do have active services and programs that can benefit the patients in meeting their needs for a smooth recovery, including rehabilitative programs. Other resources include the Substance Abuse Treatment Facility Locator, which offers guidance to mental health patients for programs in their local community setting (Munson & Jaccard, 2018). Another resource accessible to the community is the National Suicide Prevention Lifeline offers help to mental health patients by linking local crisis centers for immediate assistance to mental health patients. Patients with mental health issues can evaluate the best option for addressing their healthcare needs during the treatment and care process.

Care Coordination Plan

Due to the sensitive nature of mental health problems, patients are required to be evaluated for holistic health approaches due to the diverse nature of mental health issues in the patient’s emotional, psychological, social, and physiological well-being (Lyon & Bruns, 2019). Therefore, effective evidence-based interventions have been required that cover the holistic health and well-being of the patients. The goal of care coordination is to ensure that each member of the interdisciplinary team takes an active role collaboratively to help in restoring the health and well-being of patients (Lyon & Bruns, 2019). An effective strategy for coordination of care in mental illness patients requires an interdisciplinary collaborative team approach to ensure all aspects of care are delivered. Through collaboration, each member of the interdisciplinary team has an active role in influencing positive outcomes for patients, including restoring well-being holistically. In the current scenario, the patient is an African American residing in Houston city in Texas. The care coordination plan began with a familiarization session that is scheduled for January 8, 2021. The patient must be assessed for suitability of his home and household, evaluate the family-level support systems, friends and community involvement, and the interdisciplinary team involved in helping in the recovery and treatment process.


Canady, V. (2016). NAMI report calls for a cultural shift to promote engagement in MH care. Mental Health Weekly, 26(30), 1-3. Doi: 10.1002/mhw.30698

Crowley, R., & Kirschner, N. (2015). The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Annals of Internal Medicine, 163(4), 298-299. Doi: 10.7326/M15-0510

Lyon, A., & Bruns, E. (2019). From evidence to impact: joining our best school mental health practices with our best implementation strategies. School Mental Health, 11(1), 106–114. Doi: 10.1007/s12310-018-09306-w

Mental Health America. MHA (2020), Affiliate Network. Retrieved from

Munson, M., & Jaccard, J. (2018). Mental health service use among young adults: communication framework for program development. Adm Policy Ment Health, 45(1),

62-80. Doi: 10.1007/s10488-016-0765-y


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Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

NOTE: You are required to complete this assessment before Assessment 4.

Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular healthcare problem.

Include physical, psychosocial, and cultural considerations for this healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.

Analyze a health concern and the associated best practices for health improvement.

Competency 2: Collaborate with patients and families to achieve desired outcomes.

Describe specific goals that should be established to address a selected healthcare problem.

Competency 3: Create a satisfying patient experience.

Identify available community resources for a safe and effective continuum of care.

Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

Organize content so ideas flow logically with smooth transitions; contain few errors in grammar/punctuation, word choice, and spelling.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.


Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts, and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively to address the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.

Allow plenty of time to plan your chosen healthcare concern.

Note: Remember that you can submit all or a portion of your draft plan to Smarthinking Tutoring for feedback before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.


Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan

Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:


Heart disease (high blood pressure, stroke, or heart failure).

Home safety.

Pulmonary disease (COPD or fibrotic lung disease).

Orthopedic concerns (hip replacement or knee replacement).

Cognitive impairment (Alzheimer’s disease or dementia).

Pain management.

Mental health.


Identify available community resources for a safe and effective continuum of care.

Document Format and Length

Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.

Remember to use active voice, which means being direct and writing concisely, as opposed to passive voice, which means writing with a tendency to wordiness.

In your paper, including possible community resources that can be used.

Be sure to review the scoring guide to make sure all criteria are addressed in your paper.

Study the subtle differences between basic, proficient, and distinguished.

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Preliminary Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Analyze your selected health concern and the associated best practices for health improvement.

Cite supporting evidence for best practices.

Consider underlying assumptions and points of uncertainty in your analysis.

Describe specific goals that should be established to address the healthcare problem.

Identify available community resources for a safe and effective continuum of care.

Organize content so ideas flow logically with smooth transitions; contain few errors in grammar/punctuation, word choice, and spelling.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Write with a specific purpose with your patient in mind.

Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

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