Preliminary Care Coordination Plan

 

 

Preliminary Care Coordination Plan
1. For this assessment, you will develop a 3–4-page preliminary care coordination plan for a
selected health care problem. Include physical, psychosocial, and cultural considerations for this
health care problem. Identify and list available community resources for a safe and effective
continuum of care.
2. Before you complete the instructions detailed in the course room, first select one of the following health care problems or issues:
 Health Literacy
• Physical considerations: Low health literacy can lead to poor health outcomes and difficulty managing chronic diseases.
• Psychosocial considerations: Low health literacy can cause emotional distress, anxiety, and depression.
• Cultural considerations: Cultural beliefs and practices may influence an individual.
• Community resources: Health literacy programs, patient education materials, and health navigators can provide resources and support for individuals with low health literacy.
 Environmental Health
• Physical considerations: Environmental hazards such as air pollution, lead exposure, and toxic waste can cause physical health problems.
• Psychosocial considerations: Environmental hazards can cause emotional distress, anxiety, and depression.
• Cultural considerations: Cultural beliefs and practices may influence an individual’s exposure to environmental hazards.
• Community resources: Environmental health clinics, community clean-up programs, and advocacy groups can provide resources and support for individuals affected by environmental hazards.
After you have selected one of the problems/issues from the list above, return to the detailed instructions in the course room to complete your assessment.
Scenario
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 in addressing the specific health concerns of community residents.
Instructions
Develop the Preliminary Care Coordination Plan
Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF] Download Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
Identify available community resources for a safe and effective continuum of care.

 

Sample Solution

Introduction:

As a community care center nurse stepping into the role of care coordinator, I understand the importance of effective patient management. Environmental health is a complex issue with profound impacts on physical, psychosocial, and cultural well-being, making it a crucial focus for care coordination. This plan outlines a multi-faceted approach to address environmental health concerns in our community, ensuring safe and effective care for all residents.

Physical Considerations:

Exposure to environmental hazards can significantly impact residents’ physical health. Air pollution, lead contamination, and toxic waste can trigger respiratory issues, cardiovascular problems, neurological disorders, and even cancer. Children, pregnant women, and older adults are particularly vulnerable. Our care coordination plan will prioritize:

  • Early identification: Conducting comprehensive health assessments to identify potential environmental exposures and their health effects.
  • Education and prevention: Providing residents with clear information about local environmental risks, safe practices, and available resources. This includes collaborating with environmental agencies to conduct community outreach campaigns and educational workshops.
  • Advocacy and policy change: Working with community leaders and environmental advocacy groups to push for stricter regulations, improved environmental monitoring, and remediation efforts in at-risk areas.
  • Medical intervention: Referring residents with confirmed environmental health problems to appropriate medical specialists for diagnosis, treatment, and ongoing monitoring.

Psychosocial Considerations:

Environmental health concerns can have a profound impact on residents’ mental and emotional well-being. Anxiety, depression, and stress are common responses to living in polluted or contaminated environments. The plan will address these challenges through:

  • Individualized counseling: Providing emotional support and counseling to residents struggling with anxiety, depression, or other mental health issues related to environmental factors.
  • Peer support groups: Facilitating support groups where residents can share experiences, learn coping mechanisms, and build resilience together.
  • Community-based resources: Connecting residents to existing community resources such as mental health clinics, hotlines, and social support services.

Cultural Considerations:

Cultural beliefs and practices can influence residents’ exposure to environmental hazards and their responses to them. Our plan will recognize and respect these differences by:

  • Cultural competency training: Providing care team members with training on cultural sensitivities and approaches to effectively engage diverse community members.
  • Multicultural outreach and education: Developing culturally appropriate education materials and outreach programs that resonate with different cultural groups within the community.
  • Community partnerships: Collaborating with cultural and religious leaders to promote environmental awareness and safe practices within their communities.

Community Resources:

To ensure a safe and effective continuum of care, the plan will leverage available community resources. These include:

  • Environmental health agencies: Partnering with local environmental agencies for air quality monitoring, lead testing, and remediation programs.
  • Public health departments: Collaborating with public health departments for disease prevention, health education initiatives, and access to medical care for residents with environmental health problems.
  • Community organizations: Partnering with environmental advocacy groups, community gardens, and other non-profit organizations to promote environmental awareness, provide resources, and support community clean-up efforts.
  • Faith-based organizations: Collaborating with local churches, mosques, and other faith-based institutions to mobilize communities, provide support services, and advocate for environmental justice.

Conclusion:

This preliminary care coordination plan outlines a comprehensive approach to address environmental health concerns in our community. By focusing on physical, psychosocial, and cultural needs, leveraging available resources, and fostering collaboration, we can work towards a healthier and more sustainable environment for all residents. This plan is a starting point and will be continuously reviewed and updated based on community needs, available resources, and ongoing research. Through effective care coordination, we can empower residents to make informed choices, advocate for change, and build a healthier future for themselves and their families.

 

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