NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Preliminary Care Coordination Plan

The early phases of a patient’s healthcare journey are crucially organized and initiated by the preliminary care coordination plan. This fundamental plan delineates the patient’s care objectives, assembles a dedicated care team, and outlines initial procedures. Its principal aim is to provide efficient and well-coordinated medical support and assistance, ensuring the patient receives effective care (Khatri et al., 2023). This preliminary care coordination plan lays the groundwork for adequate patient support by emphasizing the critical role of addressing food insecurity in Oakwood Heights, Texas. This preamble sets the tone for evidence-based practices and SMART goals, underscoring a holistic approach to mitigating food insecurity and fostering a seamless continuum of care through community resources.

Health Concerns and Evidence-Based Practices for Health Improvement

Addressing food insecurity requires a comprehensive approach, considering physical, psychosocial, cultural, and community factors. Inadequate access to nutritious foods due to food insecurity can lead to malnutrition, weight loss, and a heightened risk of chronic diseases. Promoting access to healthy foods through initiatives like the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) is crucial. Adapting care involves recognizing individual needs, financial constraints, and cultural preferences. Additionally, addressing underlying assumptions, such as broader social determinants of health, is paramount for effective interventions. Collaborating with community organizations and government agencies boosts the impact of food assistance programs (Hawkins & Panzera, 2020).

Psychosocially, food insecurity often triggers emotional distress, anxiety, and depression, exacerbating existing mental health situations. Incorporating mental health support facilities into food assistance programs is crucial. Adapting care involves recognizing mental health needs and providing trauma-informed care. Acknowledging underlying assumptions and points of uncertainty, such as the long-term impact of food insecurity on mental health outcomes, is essential for holistic interventions. Providing access to support groups and counseling services can further aid individuals in coping with the stress of food insecurity (Pourmotabbed et al., 2020). Culturally, beliefs influence attitudes toward seeking help and dietary preferences.

Tailoring food assistance programs to accommodate cultural dietary preferences and engaging community leaders is crucial. Providing culturally sensitive support services and acknowledging cultural differences are essential for effective care. Recognizing underlying assumptions, such as the influence of cultural beliefs on help-seeking behaviors, is critical for developing culturally appropriate interventions. Building trust and partnerships within diverse communities can facilitate the delivery of culturally competent care (Domingo et al., 2021). Addressing food insecurity demands holistic interventions, recognizing individual needs, cultural preferences, and broader social determinants of health. Collaboration with community stakeholders, mental health support services provision, and cultural sensitivity are vital aspects of effective intervention strategies.

Goals Established to Address Food Insecurity

To address food insecurity effectively, it is crucial to establish SMART (specific, realistic, measurable, and attainable) goals. This comprehensive approach lays the groundwork for developing impactful and sustainable strategies to combat food insecurity. The following goals have been thoughtfully crafted to target the multifaceted aspects of food insecurity, emphasizing measurable outcomes. The healthcare initiative endeavors to improve access to nutritious food and nutritional knowledge within the community by adhering to these goals.

Goal 1: Establish a monthly community food distribution program called “Nourish Now” in partnership with local food banks, targeting households in low-income neighborhoods (Specific). Increase the number of families “Nourish Now” served by 25% within six months, tracked through registrations and distribution logs (Measurable). Secure partnerships with at least two local grocery stores to donate surplus perishable food items, ensuring a varied supply of nutritious food options (Attainable). Implement “Nourish Now” within three months to address immediate food assistance needs and promote sustainable health equity (Relevant) (Miller, 2020).

Goal 2: Launch bi-weekly nutrition education workshops titled “Healthy Eats” in collaboration with local health clinics, targeting food-insecure individuals and families (Specific). Increase participants’ knowledge of healthy eating habits by 30% as assessed through pre- and post-workshop surveys (Measurable). Recruit certified nutritionists and community health educators to facilitate workshops covering meal planning, budgeting, and cooking tips (Attainable). Conduct workshops over six months with quarterly evaluations to empower participants in making informed dietary choices within financial constraints (Relevant) (Norris et al., 2023).

Goal 3: Establish a volunteer-driven community garden initiative named “Grow Together” in vacant lots within targeted neighborhoods (Specific). Increase garden yield by 50% within one year, tracked through regular harvest assessments (Measurable). Mobilize community members for garden planning, planting, and maintenance with support from local horticultural experts (Attainable). Promote food sovereignty and self-sufficiency, fostering community resilience and reducing dependence on external food sources. Establish and launch “Grow Together” within three months, ensuring sustainability through ongoing monitoring and evaluation (Relevant) (Jurkowski et al., 2021).

Community Resources for an Effective Continuum of Care

Addressing food insecurity and ensuring a satisfying patient experience is essential to identifying and utilizing significant community resources. They support an efficient and safe continuum of care. In Oakwood Heights, Texas, food banks and pantries like the Community Food Pantry serve as critical immediate food assistance sources, offering diverse nutritious options to bridge nutritional gaps for individuals and families facing food insecurity. Government assistance programs like SNAP and WIC provide financial aid and access to healthy foods, addressing food insecurity and promoting better nutrition among vulnerable populations (Serchen et al., 2022). Additionally, community gardens supported by Green Life Initiatives and Urban Growers Collective offer sustainable solutions by empowering residents to grow fresh produce locally, fostering healthy eating habits and neighborhood social cohesion (Mejia et al., 2020).

Nutrition education programs provided by Regional Health Services and Healthy Living Institute equip individuals with the knowledge and skills to make healthy dietary choices within budget constraints. Mobile food markets operated in partnership with Fresh Harvest Express and Transportation Access Network play a crucial role in enhancing access to nutritious options, particularly in areas with limited grocery store accessibility, thus addressing transportation barriers (Downer et al., 2020). Community health centers offer holistic care, including primary care and nutrition counseling, addressing medical needs and social determinants of health like food insecurity.

Furthermore, social services agencies like Community Housing Solutions and Job Assistance Network provide support with housing, employment, and access to benefits, addressing underlying causes of food insecurity and promoting long-term stability and well-being (DeHaven et al., 2020). By effectively leveraging these community resources and fostering stakeholder collaboration, healthcare providers can establish a safe and effective continuum of care for individuals experiencing food insecurity. By working together, patients can get the help and resources they need to enhance their general health and food security, leading to a positive patient experience in the community.

Conclusion

In conclusion, the preliminary care coordination plan underscores the importance of addressing food insecurity through evidence-based practices and SMART goals. Collaborative efforts with community resources, such as food banks, nutrition education workshops, and community gardens, facilitate a holistic approach to healthcare delivery. By integrating mental health support, cultural sensitivity, and stakeholder collaboration, healthcare providers can ensure effective interventions. It satisfies patient experience and fosters sustainable health equity and well-being.

References

DeHaven, M. J., Gimpel, N. A., Gutierrez, D., Carmichael, H. K., & Revens, K. (2020). Designing health care: A community health science solution for reducing health disparities by integrating social determinants and the effects of place. Journal of Evaluation in Clinical Practice, 26(5). https://doi.org/10.1111/jep.13366

Domingo, A., Charles, K.-A., Jacobs, M., Brooker, D., & Hanning, R. M. (2021). Indigenous community perspectives of food security, sustainable food systems and strategies to enhance access to local and traditional healthy food for partnering Williams treaties first nations (Ontario, Canada). International Journal of Environmental Research and Public Health, 18(9), 4404. https://doi.org/10.3390/ijerph18094404

Downer, S., Berkowitz, S. A., Harlan, T. S., Olstad, D. L., & Mozaffarian, D. (2020). Food is medicine: Actions to integrate food and nutrition into healthcare. The BMJ, 369(369). https://doi.org/10.1136/bmj.m2482

Hawkins, M., & Panzera, A. (2020). Food insecurity: A key determinant of health. Archives of Psychiatric Nursing, 35(1). https://doi.org/10.1016/j.apnu.2020.10.011

Jurkowski, J., Udo, T., & Hackstadt, A. (2021). Food insecurity in NY state. Solutions to address the multifaceted problem. Understanding and Eliminating Minority Health Disparities in a 21st-Century Pandemic: A White Paper Collection. https://scholarsarchive.library.albany.edu/covid_mhd_nys_white_papers/10/

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Mejia, A., Bhattacharya, M., & Miraglia, J. (2020). Community gardening as a way to build cross-cultural community resilience in intersectionally-diverse gardeners: A community-based participatory research and campus-community partnered proposal (Preprint). JMIR Research Protocols, 9(10). https://doi.org/10.2196/21218

Miller, H. A. E. (2020). A review of the food security, diet and health outcomes of food pantry clients and the potential for their improvement through food pantry interventions in the United States. Physiology & Behavior, 220, 112871. https://doi.org/10.1016/j.physbeh.2020.112871

Norris, K., Pitts, S. J., Reis, H., & Maslow, L. H. (2023). A systematic literature review of nutrition interventions implemented to address food insecurity as a social determinant of health. Nutrients, 15(15), 3464–3464. https://doi.org/10.3390/nu15153464

Pourmotabbed, A., Moradi, S., Babaei, A., Ghavami, A., Mohammadi, H., Jalili, C., Symonds, M. E., & Miraghajani, M. (2020). Food insecurity and mental health: A systematic review and meta-analysis. Public Health Nutrition, 23(10), 1778–1790. https://doi.org/10.1017/s136898001900435x

Serchen, J., Atiq, O., Hilden, D., Serchen, J., Atiq, O., Hilden, D., Beachy, M., Brislen, H., Curry, W., Engel, L., Hollon, M., Mathew, S., Mellacheruvu, P., Sagar, A., Shoushtari, C., Southworth, M., & Tan, M. (2022). Strengthening food and nutrition security to promote public health in the United States: A position paper from the American College of Physicians. Annals of Internal Medicine, 175(8), 1170–1171. https://doi.org/10.7326/m22-0390