NURS FPX 4050 Assessment 4 Final Care Coordination Plan

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Name

Capella University

NURS-FPX 4050 Coord Patient-Centered Care

Prof. Name

Date

Final Care Coordination Plan

Crafted with meticulous planning and community engagement, this comprehensive healthcare intervention plan targets food insecurity with a multi-faceted approach. By integrating patient-centered interventions focusing on access to nutritious food, psychosocial support, and the Supplemental Nutrition Assistance Program (SNAP) enrollment, the initiative aims to address the underlying social determinants impacting health. Ethical considerations are woven into each intervention, ensuring equity, confidentiality, and empowerment for all participants. Leveraging national health policies such as the Healthy Food Financing Initiatives (HFFI) and SNAP, the plan aligns with the objectives outlined in Healthy People 2030, promoting improved health outcomes and equity in healthcare access. Through transparent communication and continuous evaluation, the plan endeavors to bridge gaps in health literacy, empower individuals, and foster a sustainable healthcare ecosystem. By prioritizing evidence-based practices and community involvement, this initiative strives to create a lasting impact on the well-being of communities, shaping a path toward a more informed, engaged, and equitable healthcare landscape.

Interventions and Timelines for Food Insecurity

To effectively address food insecurity, three key health concerns will be targeted, each with a patient-centered intervention accompanied by timelines and community resources.

Access to Nutritious Food

To tackle the challenge of access to nutritious food, we propose the establishment of a community garden project modeled after “City Green.” Over twelve months, our initiative will unfold in carefully planned stages. In the initial three months, we will diligently work on securing suitable land and necessary resources through collaborative partnerships. By the sixth month, our focus will shift to recruiting volunteers who will actively engage in planting and maintaining the garden, ensuring its sustainability. As we progress into the ninth month, our efforts will culminate in providing comprehensive gardening workshops to empower community members with essential skills for sustainable cultivation. Leveraging community resources such as Community Food Assistance, Urban Harvest, and the Farmer’s Cooperative will be pivotal in ensuring the success and longevity of this intervention, promoting food security and dietary diversity within our community (Bahn et al., 2021).

Psychosocial Support

Recognizing the profound psychosocial impact of food insecurity, our intervention centers around the development of a peer support program inspired by the successful “Food for All” initiative. Over twelve months, our approach will unfold in meticulously planned phases. Within the first three months, our focus will be on recruiting and training peer mentors from within the community who possess lived experiences with food insecurity. By the sixth month, the peer support program will be fully operational, offering a safe and empathetic space for individuals to share experiences, access emotional support, and engage in group activities. Over twelve months, we will measure the program’s impact on participants’ mental well-being through pre- and post-program surveys, ensuring continuous improvement. Collaborating with resources such as Community Food Assistance, Local Mental Health Services, and Social Service Agencies will enrich the program, providing comprehensive support services alongside peer-based assistance (Henderson et al., 2023).

SNAP Enrollment

Addressing the imperative to increase SNAP enrollment among eligible individuals, our intervention aims to achieve a 20% increase within twelve months through strategic outreach efforts and personalized assistance. Over the next twelve months, we have meticulously outlined a strategic timeline to execute this intervention effectively. Within the first month, we will forge partnerships with local agencies to streamline SNAP application processes, ensuring accessibility for all eligible individuals. By the third month, we will intensify our outreach efforts through community events and targeted social media campaigns, shedding light on SNAP benefits and eligibility criteria. Throughout the sixth month and beyond, we will diligently track and analyze SNAP enrollment metrics monthly to gauge the effectiveness of our intervention, making necessary adjustments as required. Leveraging resources such as Local Agencies, Community Events, and Social Media Platforms will be instrumental in reaching our target population and facilitating SNAP enrollment within the community (Bleich et al., 2020). Through these meticulously planned and community-engaged interventions, we aim to holistically address the multifaceted challenges of food insecurity, fostering resilience and well-being within our community.

Designing Patient-Centered Health Interventions Based on Ethical Decisions

In the realm of healthcare interventions aimed at addressing food insecurity, the integration of ethical considerations is paramount. Each intervention must be meticulously examined for potential ethical dilemmas, ensuring that they align with ethical principles while also meeting the needs of the community. Establishing a community garden project necessitates careful ethical deliberation when contemplating access to nutritious food. Questions regarding the fair distribution of resources and the project’s long-term sustainability arise. It’s imperative to guarantee equitable access to resources and consider the environmental implications of such initiatives. Leveraging community resources like Community Food Assistance, Urban Harvest, and the Farmer’s Cooperative supports the objective of promoting food security and dietary diversity (Burt et al., 2020). Similarly, ethical considerations play a central role in the development of psychosocial support programs. Confidentiality, privacy, and empowerment are pivotal factors that must be taken into account. Ensuring that participants feel safe, respected, and empowered is crucial for the success and effectiveness of such programs. Collaboration with local mental health services and social service agencies is essential, as it provides the necessary support for individuals facing psychosocial challenges related to food insecurity (Higashi et al., 2021).

Furthermore, when aiming to increase SNAP enrollment, ethical decision-making becomes imperative. Addressing issues of eligibility, accessibility, and stigma is crucial to ensure that eligible individuals have equitable access to benefits without facing discrimination or judgment. Collaborating with local agencies and utilizing community events and social media platforms facilitates outreach and education about SNAP benefits and eligibility criteria, thereby promoting equity and fairness in access to resources (Schanzenbach, 2023). By incorporating these ethical considerations into the design of patient-centered interventions, nurses can navigate the complexities of addressing food insecurity while upholding ethical principles of beneficence, justice, and respect for autonomy. This approach ensures that interventions are not only effective but also ethically sound, ultimately leading to improved health outcomes and well-being within the community.

Health Policies Implications for Continuum and Coordination Care

Healthcare policies, such as the HFFI and the SNAP, play critical roles in shaping the coordination and continuum of care, particularly concerning food insecurity. Specifically, HFFI provides financial and technical assistance to attract grocery stores, farmers’ markets, and other sources of fresh, nutritious food to underserved communities. By addressing food deserts and improving access to healthy food options, HFFI policies contribute to the continuum of care by addressing the social determinants of health. Individuals who have access to nutritious food are more likely to experience better health outcomes and require fewer medical interventions, thereby promoting patient-centered care (Foster, 2022).

Similarly, SNAP offers financial assistance to low-income individuals and families to purchase food. SNAP policies directly impact the continuum of care by ensuring that vulnerable populations have access to essential nutrition. By alleviating food insecurity, SNAP helps prevent and manage chronic health conditions associated with poor diet quality. This, in turn, reduces the need for costly medical interventions and fosters patient-centered care by addressing underlying health issues (Whitmire et al., 2021). Policies like HFFI and SNAP have significant implications for the coordination and continuum of care. By addressing food insecurity and promoting access to nutritious food options, these policies contribute to improved health outcomes, reduced healthcare costs, and patient-centered care initiatives.

Priorities of Care Coordinator for Plan Discussion

The care coordinator would prioritize discussions centered around ensuring access to nutritious food and addressing the social determinants impacting food security. The care coordinator would emphasize the importance of addressing immediate food needs to alleviate hunger and prevent malnutrition. This could involve connecting the patient and family with resources like food banks, SNAP enrollment assistance, or community meal programs. Promoting education and empowerment regarding healthy eating habits becomes crucial. Educating patients and families about budget-friendly nutritious food options, meal planning strategies, and food preparation techniques empower them to make healthier choices within their means. Facilitating access to supportive services beyond food provision is essential. This could include referrals to social services for housing assistance, job training programs, or mental health support to address underlying factors contributing to food insecurity (Arensberg et al., 2022).

During discussions, the care coordinator would transparently explain any proposed changes to the care plan based on evidence-based practices related to addressing food insecurity. For instance, if new resources or programs become available in the community to support food-insecure individuals, the care coordinator would discuss the potential benefits and reasons for incorporating these changes into the care plan. Additionally, modifications to the plan to accommodate emerging needs or preferences would be communicated clearly. This could involve adjustments in accessing food assistance programs or incorporating new strategies for improving food security tailored to the patient’s circumstances. By fostering open communication and collaboration with patients and families, the care coordinator ensures that changes to the plan align with their specific needs and preferences. This ultimately promotes patient-centered care and better outcomes in addressing food insecurity (Bernhardt et al., 2021).

Healthy People 2030 and Evaluation Learning Session with Best Practices

Utilizing evaluation literature as a guide, educators meticulously compare learning session content with best practices, drawing insights from specific interventions proven effective in addressing food insecurity. This involves critically assessing the effectiveness of teaching methods and materials in alignment with evidence-based strategies. The data highlights interventions such as SNAP enrollment assistance and community gardens as practical approaches. By referencing these specific interventions, educators can identify strategies that have been proven to be successful. Incorporating interactive activities, culturally sensitive materials, and community engagement initiatives ensures participant engagement and knowledge retention, aligning with established best practices (McKay et al., 2022). Aligning teaching sessions with the Healthy People 2030 document involves integrating its objectives into the curriculum. Healthy People 2030 objectives related to food security and nutrition, such as reducing food insecurity and promoting healthy eating behaviors, serve as guiding principles for educators. By incorporating these objectives into the curriculum, educators ensure that their teaching sessions contribute to overarching public health goals and address specific needs identified in the community (Guzman & Hatton, 2024).

When explaining the need for revisions to the plan, educators rely on evidence from evaluations and data collected. Transparent communication with stakeholders is essential in this process, as it fosters collaboration and ensures that the revised plan effectively meets the needs of the target audience. By soliciting input from participants and stakeholders, educators can make informed decisions and tailor their teaching sessions to address specific challenges related to food insecurity identified in the community (Nur et al., 2021). By utilizing evaluation literature, aligning with evidence-based strategies, and integrating data and Healthy People 2030 objectives, educators can create impactful learning sessions that address food insecurity comprehensively. This approach promotes participant engagement, fosters knowledge acquisition, and contributes to advancing public health goals in the community.

Conclusion

In conclusion, the multifaceted approach presented addresses food insecurity through community-driven interventions targeting access to nutritious food, psychosocial support, and SNAP enrollment. Each intervention integrates ethical considerations, aligning with principles of equity, confidentiality, and empowerment. Health policies like HFFI and SNAP bolster the continuum of care by addressing social determinants of health. The care coordinator prioritizes discussions on access to nutritious food, transparently incorporating evidence-based practices into care plans. Education sessions align with Healthy People 2030 objectives, utilizing evaluation data to refine interventions and promote community engagement.

References

Arensberg, M. B., Ridpath, K. S., Kerr, K., & Phillips, W. (2022). Opportunities to improve quality outcomes: Integrating nutrition care into medicare advantage to address malnutrition and support social determinants of health. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 59, 004695802210814. https://doi.org/10.1177/00469580221081431 

Bahn, R. A., Hwalla, N., & Labban, S. E. (2021). Chapter 1 – Leveraging nutrition for food security: The integration of nutrition in the four pillars of food security (C. M. Galanakis, Ed.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128205211000010 

Bernhardt, C., Hou, S.-I., King, C., & Miller, A. (2021). Identifying barriers to effective patient-provider communication about food insecurity screenings in outpatient clinical settings in central Florida. Journal of Public Health Management and Practice, Publish Ahead of Print. https://doi.org/10.1097/phh.0000000000001449 

Bleich, S. N., Moran, A. J., Vercammen, K. A., Frelier, J. M., Dunn, C. G., Zhong, A., & Fleischhacker, S. E. (2020). Strengthening the public health impacts of the supplemental nutrition assistance program through policy. Annual Review of Public Health, 41(1), 453–480. https://doi.org/10.1146/annurev-publhealth-040119-094143 

Burt, K. G., Mayer, G., & Paul, R. (2020). A systematic, mixed studies review of the outcomes of community garden participation related to food justice. Local Environment, 26(1), 17–42. https://doi.org/10.1080/13549839.2020.1861589 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Foster, N. H. (2022). Food systems financing action plan. Master of Urban and Regional Planning Capstone Projects. https://scholarscompass.vcu.edu/murp_capstone/62/ 

Guzman, M. R. T. de, & Hatton, H. (2024). Extension education and the social sciences: Uplifting children, youth, families, and communities. In Google Books. Cambridge University Press. https://books.google.com/books?hl=en&lr=&id=Wv_5EAAAQBAJ&oi=fnd&pg=PA166&dq=+Healthy+People+2030+objectives+related+to+food+security+and+nutrition 

Henderson, C. G., Hiestand, E., Schluter, E., Olson, E., Tacheny, J., Crusan, A., & Hearst, M. O. (2023). A campus-based community clinic and food-shelf join efforts to reduce food insecurity using a one health approach toward building a vibrant living system. Journal of American College Health, 1–5. https://doi.org/10.1080/07448481.2023.2232461 

Higashi, R. T., Sood, A., Conrado, A. B., Shahan, K. L., Leonard, T., & Pruitt, S. L. (2021). Experiences of increased food insecurity, economic and psychological distress during the COVID-19 pandemic among supplemental nutrition assistance program-enrolled food pantry clients. Public Health Nutrition, 1–11. https://doi.org/10.1017/s1368980021004717 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

McKay, F. H., Spiteri, S., Zinga, J., Sulemani, K., Jacobs, S. E., Ranjan, N., Ralph, L., Raeburn, E., Threlfall, S., Bergmeier, M. L., & Pligt, P. van der . (2022). Systematic review of interventions addressing food insecurity in pregnant women and new mothers. Current Nutrition Reports. https://doi.org/10.1007/s13668-022-00418-z 

Nur, H. A., Atoloye, A. T., Wengreen, H., Archuleta, M., Roskos, M. R. S., Wille, C., & Jewkes, M. (2021). A scoping review and assessing the evidence for nutrition education delivery strategies for refugees in high-income countries. Advances in Nutrition, 12(6), 2508–2524. https://doi.org/10.1093/advances/nmab080 

Schanzenbach, D. W. (2023). Understanding SNAP: An overview of recent research. Food Policy, 114, 102397. https://doi.org/10.1016/j.foodpol.2022.102397 

Whitmire, M., Arensberg, M. B., Ashbrook, A., & Blancato, R. (2021). Nutrition-related policy fundamentals for supporting older adults in the community during a pandemic: Lessons from COVID-19. Journal of Elder Policy, 1(3). https://doi.org/10.18278/jep.1.3.9