NURS FPX 4065 Assessment 5

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Name

Capella University

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Final Care Coordination Strategy

Care coordination is an essential framework that ensures continuous and seamless care across healthcare systems, particularly for individuals with complex health needs. Effective care coordination improves health outcomes, reduces disparities, and enhances patient satisfaction (Garfin et al., 2022). This paper outlines a final care coordination strategy for adults with mental illness in Florida, a population that experiences notable behavioral and physical health challenges. The strategy emphasizes patient-centered interventions, community partnerships, policy alignment, ethical considerations, and integration with Healthy People 2030 objectives.

Patient-Centered Health Interventions and Timelines

Mental illness significantly affects nearly 2.9 million adults in Florida, many of whom struggle with physical comorbidities, cultural stigma, and emotional dysregulation (Garfin et al., 2022). Effective interventions must be evidence-based, patient-centered, and culturally sensitive, leveraging community resources for comprehensive care. The following sections summarize key interventions targeting physical, cultural, and psychosocial barriers to mental health management.

Comorbid Physical Illnesses

Adults with serious mental illness (SMI) are prone to chronic diseases, such as cardiovascular disorders and diabetes, which reduce life expectancy by 15–20 years (Nielsen et al., 2021). A patient-centered approach integrates regular physical assessments—including BMI, blood pressure, glucose levels, lipid profiles, and smoking status—into routine mental health therapy.

Community Resources Supporting Physical Health

Timeline for Implementation:

• Intake: Initial assessment and baseline screenings
• Month 1: Begin lifestyle counseling
• Month 3: Conduct follow-up screenings

Cultural Stigma and Mental Health Literacy

Cultural stigma often delays treatment and reduces the effectiveness of mental health interventions (Ahad et al., 2023). To address this, biweekly culturally sensitive education sessions are recommended, using booklets, presentations, and face-to-face outreach.

Community Partners for Mental Health Education

Timeline for Implementation:

• Start: Two weeks post-diagnosis
• Frequency: Every two weeks for six months
• Evaluation: Pre- and post-session surveys to measure knowledge gains and stigma reduction

Emotional Dysregulation

Emotional dysregulation, including depressive or anxiety episodes, is prevalent in adults with mental illness. Weekly Mindfulness-Based Cognitive Therapy (MBCT) helps patients regulate emotions, prevent relapse, and enhance overall quality of life (Gkintoni et al., 2025).

Community Partners Providing MBCT

Timeline for Implementation:

• Start: Within first month of diagnosis
• Duration: Weekly sessions for six months
• Goal: Achieve 40% improvement in PHQ-9 depression scores

Ethical Decisions in Designing Patient-Centered Health Interventions

Patient-centered mental health interventions involve complex ethical considerations, balancing autonomy, cultural sensitivity, and equitable access:

1. Autonomy: Patients must provide informed consent for MBCT or lifestyle changes, despite possible cognitive or emotional impairments (Nagaoka et al., 2023).

   • Ethical Question: How do we ensure truly informed consent for individuals with compromised comprehension?

2. Cultural Sensitivity: Education programs must reduce stigma without making patients feel labeled or marginalized.

   • Ethical Question: How can interventions remain culturally competent and respectful?
   • Strategy: Engage patients in care planning to empower participation (Ahad et al., 2023).

3. Equitable Access: Sliding-scale and free services ensure that socioeconomic limitations do not prevent access to physical and mental health care (Care Resource, 2025; MHACF, 2025).

Relevant Health Policy Implications

Supportive policies increase access, integration, and continuity of mental health services:

These policies support holistic, ethical, and inclusive care for adults with mental illness in Florida.

Priorities for Care Coordinators in Patient and Family Discussions

Care coordinators should emphasize:

1. Transparent Communication: Explain diagnoses, treatment options, and the importance of routine physical assessments (Nielsen et al., 2021).
2. Cultural Competence: Engage families in culturally sensitive discussions to overcome stigma (Ahad et al., 2023).
3. Patient Engagement: Set measurable goals, such as weekly MBCT participation and biweekly educational sessions, monitored via tools like PHQ-9 (Liu et al., 2024).

These priorities foster trust, transparency, and sustainable care coordination.

Learning Session Content with Best Practices and Healthy People 2030

MBCT and Culturally Tailored Education align with best practices and Healthy People 2030 goals:

• MBCT: Reduces depressive symptoms and prevents relapse when combined with personalized follow-ups (Gkintoni et al., 2025).
• Culturally Adapted Education: Long-term effectiveness requires peer educators and real-life culturally accurate examples (Ahad et al., 2023).
• Alignment with Healthy People 2030: Reduces disparities, enhances health literacy, and increases access to mental health services.

Need for Change

The original strategy lacks feedback mechanisms and peer-led support, which are crucial for responsiveness and cultural engagement. Recommendations include:

• Regular evaluation surveys and feedback sessions
• Community-based peer facilitators
• Enhancements in cultural relevance and accessibility

These changes align with Healthy People 2030 objectives, promoting behavioral health equity and patient-centered interventions.

Conclusion

This care coordination strategy addresses the multifaceted needs of adults with mental illness in Florida through physical, cultural, and psychosocial interventions. Evidence-based practices like MBCT, lifestyle modification, and culturally adapted education support holistic patient care. Policies such as ACA and MHPAEA facilitate continuity and access to care, while evaluation and culturally sensitive improvements ensure alignment with Healthy People 2030. Overall, this strategy empowers patients, reduces stigma, and enhances health outcomes via coordinated, patient-centered care.

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/

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). Www.cms.gov. https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

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. Health.gov. 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. https://doi.org/10.1016/j.psychres.2023.115671

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

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/

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

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