Preliminary Care Coordination Plan Essay

Preliminary Care Coordination Plan Essay


Preliminary care Coordination Plan: Mental Health

Care coordination involves more activity than mere service. The Care Coordination for Certified Community Behavioral Health Clinics (CCBHCs) organizes care activities linked to several providers and services traversing multiple facilities. Care coordination, by definition, entails “deliberately organizing consumer care activities and sharing information among all of the participants concerned with a consumer’s care to achieve safer and more effective care” (Karam et al., 2021). The role of the mental health nurse entails identifying the patient’s needs and preferences early enough and communicating them to the right persons at the right time. Also, the nurse should apply the right information to offer safe, appropriate and effective care to the patient.

Community Resources

The nurse has to incorporate the following facilities and services in achieving care coordination: federally qualified health centers and rural health clinics offering services not provided directly via CCBHC; inpatient psychiatric facilities, substance use detoxification services, post-detoxification step-down services, and residential programs; and schools, child welfare agencies, juvenile and criminal justice agencies and facilities, Indian Health Service (HIS) youth regional treatment centers, state-licensed and nationally accredited child-placing agencies for therapeutic foster care service, and other social and human services (Karam et al., 2021). Other parties involved in care coordination are the Department of Veteran Affairs medical centers, independent outpatient clinics, drop-in centers, other Veteran Affairs facilities, and inpatient acute care hospitals and hospital outpatient clinics.

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Goals of Care Coordination in Mental Health

The primary goal of care coordination for mental health is to ameliorate the health and functioning of people with mental illness. The nurse achieves this goal by alleviating patient suffering through pharmacologic and non-pharmacologic interventions and improving the quality of life (Jones et al., 2018; Karam et al., 2021). Since persons with mental health complications have unique physical and mental health needs, the nurse often works with multidisciplinary teams, psychosocial support providers, and self-management as an adjunct to clinical treatment with medication.

In addition, the nurse should aim at integrating health promotion into community environments of persons with mental retardation. Patients with mental retardation require empowerment with appropriate and sufficient information, besides reinforcements that minimize risks to health (Falconer et al., 2018). Proper education assists them in maintaining healthy individual habits. The healthcare provider should educate each patient, family, and caregivers concerning wellness and proper self-care.

Moreover, the nurse should enhance the understanding and knowledge of mental health and mental retardation, ascertaining the information is applicable, practical, and straightforward. The nurse could achieve this goal by providing scientific knowledge to stakeholders, ensuring optimum healthcare standards (Falconer et al., 2018). Scientific information is vital in improving the capacity of patients and families to maintain and protect their well-being. Recent findings from studies in genetics, neuroscience, psychopharmacology, and other research disciplines are instrumental in improving the understanding of mental illness.

Of note, improving healthcare quality for persons with mental illness is vital. This goal is achievable by enrolling adequately skilled members of the care team, such as nurses, physicians, medical officers, counselors, psychologists, and pharmacists (Iorfino et al., 2021). Improving healthcare quality also entails monitoring the use of available services vis-à-vis the treatment outcomes. The health workers should correct deficiencies in the quality of care such as medication errors, underutilization of facilities/services, and ineffective interactions with mental health patients and their families.

Care coordination also involves training health care providers in caring for children and adults with mental illnesses. The nurse should aim to train self, and other members of the care team approaches to support healthy lifestyles for mentally ill persons (Iorfino et al., 2021). Also, the nurse could advocate for policy change to include early exposure to people with a mental health condition during medical training and other health professional training. Early clinical experience increases the capacity of providers to handle the patients appropriately in practice.

Moreover, the health worker should ensure adequate healthcare financing to promote a good prognosis in mentally ill children and adults. The nurse could achieve this goal by championing the reimbursement system that respects the diverse needs of mental health patients and their families (Iorfino et al., 2021). Since mental illness is a form of disability, special policies are needed to cover more persons with higher flexibility and provide more than basic care. The reimbursement should be considerate of the outcomes patients and families value.


In a nutshell, the nurse plays a significant role in forming, implementing, and evaluating a preliminary care coordination plan. In the case of mental health, the nurse ought to set appropriate goals and engage the necessary stakeholders to provide optimum quality healthcare. Also, the utility of community resources cannot be ignored.



Falconer, E., Kho, D., & Docherty, J. P. (2018). Use of technology for care coordination initiatives for patients with mental health issues: a systematic literature review. Neuropsychiatric Disease and Treatment14, 2337.

Iorfino, F., Occhipinti, J. A., Skinner, A., Davenport, T., Rowe, S., Prodan, A., Sturgess, J. & Hickie, I. B. (2021). The impact of technology-enabled care coordination in a complex mental health system: a local system dynamics model. Journal of Medical Internet Research23(6), e25331.

Jones, A., Hannigan, B., Coffey, M., & Simpson, A. (2018). Traditions of research in community mental health care planning and care coordination: A systematic meta-narrative review of the literature. PLoS One13(6), e0198427.

Karam, M., Chouinard, M. C., Poitras, M. E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care21(1).


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.


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.

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 health care 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:
    • Stroke.
    • 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.
    • Trauma.
  • 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, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
  • In your paper include 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 health care problem.
  • Identify available community resources for a safe and effective continuum of care.
  • Organize content so ideas flow logically with smooth transitions; contains 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.


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