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 a comprehensive process aimed at providing smooth and continuous care across the healthcare system, particularly for patients with complex health conditions. It ensures that patients receive integrated support, which improves outcomes, reduces health disparities, and enhances patient satisfaction (Garfin et al., 2022). This strategy focuses on adults with mental illness in Florida, a group that often faces both behavioral and physical health challenges. The plan outlines patient-centered interventions, the use of community resources, ethical considerations, relevant health policies, and its alignment with Healthy People 2030 objectives.

Patient-Centered Health Interventions and Timelines

Mental illness impacts approximately 2.9 million adults in Florida. Many individuals face additional challenges such as coexisting physical illnesses, social stigma, and emotional dysregulation (Garfin et al., 2022). To address these barriers, three patient-centered interventions are proposed, supported by community organizations, and linked to measurable timelines.

Comorbid Physical Illnesses

Adults with serious mental illness (SMI) often develop chronic conditions like diabetes and cardiovascular disease, which significantly shorten their life expectancy (Nielsen et al., 2021). A patient-centered approach should integrate routine physical screenings with mental health care. This includes monitoring BMI, blood pressure, glucose, lipid levels, and smoking history.

Community-based partners such as Care Resource provide sliding-scale health services for uninsured individuals (Care Resource, 2025). Similarly, Caron Florida incorporates physical health monitoring in its therapy programs (Caron Florida, 2024), while the Mental Health Association of Central Florida (MHACF) connects patients with relevant healthcare providers (MHACF, 2025).

Intervention	Community Partner	Timeline	Outcome Measure
Physical health screenings (BMI, BP, glucose, lipids)	Care Resource, Caron Florida, MHACF	At intake, follow-up every 3 months	Improved comorbidity management
Lifestyle counseling (diet/exercise/smoking cessation)	Care Resource, Caron Florida	Initiate within 1 month; ongoing	Patient adherence to healthy habits

Cultural Stigma and Mental Health Literacy

Stigma related to mental illness often prevents individuals from seeking care. Cultural beliefs and fear of judgment play a major role in treatment delays (Ahad et al., 2023). To counter this, culturally sensitive education sessions should be conducted biweekly. These sessions can include translated materials, group discussions, and awareness campaigns.

Partners such as NAMI Florida (NAMI Florida, 2025), MHACF (2025), and Care Resource (2025) actively provide culturally inclusive education.

Intervention	Community Partner	Timeline	Outcome Measure
Culturally adapted education sessions	NAMI Florida, MHACF, Care Resource	Start 2 weeks post-diagnosis; biweekly for 6 months	Pre- and post-session knowledge/stigma surveys

Emotional Dysregulation

Emotional instability, such as recurring depressive or anxiety episodes, is a common challenge in mental illness. Mindfulness-Based Cognitive Therapy (MBCT) is an evidence-based intervention that reduces relapse rates and promotes emotional resilience (Gkintoni et al., 2025).

Caron Florida, MHACF Outlook Clinic, and NAMI Florida support MBCT implementation by offering group therapy sessions and mindfulness training.

Intervention	Community Partner	Timeline	Outcome Measure
Weekly MBCT sessions	Caron Florida, MHACF, NAMI Florida	Start within 1 month; weekly for 6 months	40% improvement in PHQ-9 depression scores

Ethical Decisions in Designing Patient-Centered Interventions

Designing interventions for adults with mental illness involves several ethical dilemmas.

• Autonomy and Informed Consent: Patients may struggle with decision-making capacity due to mental illness. The ethical question is: How do we ensure valid consent in individuals with impaired comprehension? Coordinators must use simplified communication, repeated explanations, and involve caregivers when appropriate (Nagaoka et al., 2023).
• Cultural Sensitivity: While education reduces stigma, poorly designed programs may unintentionally label or shame patients. The question arises: How can education remain culturally respectful and empowering rather than intrusive? As Ahad et al. (2023) suggest, interventions should integrate patient beliefs and use peer educators.
• Justice and Access: Many patients face financial and social barriers. Care Resource and MHACF address this by offering low-cost or free services, ensuring equitable access to screenings and therapy (Care Resource, 2025; MHACF, 2025).

Relevant Health Policy Implications

Effective care coordination depends on supportive health policies.

• The Mental Health Parity and Addiction Equity Act (MHPAEA) ensures that mental health coverage is equal to physical health coverage, reducing financial barriers (CMS, 2024).
• The Affordable Care Act (ACA) mandates mental health services as essential benefits, supporting integrated care and preventive screenings (Nielsen et al., 2021).
• Healthy People 2030 emphasizes stigma reduction, equitable care access, and cultural responsiveness, aligning with this strategy’s goals (Healthy People 2030, 2020).

Priorities for Care Coordinators in Patient and Family Discussions

Care coordinators should focus on:

1. Transparency and Trust: Discuss the importance of regular health screenings and comorbidity management (Nielsen et al., 2021).
2. Culturally Competent Communication: Use translated materials and incorporate cultural values to reduce stigma (Ahad et al., 2023).
3. Active Patient Engagement: Encourage participation in MBCT and education sessions, setting measurable goals. Progress can be tracked through PHQ-9 and similar scales (Liu et al., 2024).

Learning Session Content, Best Practices, and Healthy People 2030

The interventions align with both best practices and Healthy People 2030 priorities.

• MBCT Best Practices: Should include group therapy supplemented by individualized follow-ups for better outcomes (Gkintoni et al., 2025).
• Cultural Relevance in Education: Using peer-led programs enhances relatability and reduces stigma (Ahad et al., 2023).
• Healthy People 2030 Alignment: Goals emphasize reducing disparities, increasing access, and improving mental health literacy (Healthy People 2030, 2020).

Need for Change

Although the proposed interventions are comprehensive, the strategy must integrate feedback mechanisms such as surveys, open discussion forums, and peer-led facilitators. This ensures that interventions remain culturally relevant and adaptable. Incorporating these changes strengthens responsiveness and aligns with Healthy People 2030 goals on equity and engagement (Healthy People 2030, 2020).

Conclusion

The care coordination strategy for adults with mental illness in Florida emphasizes physical health integration, cultural sensitivity, and emotional regulation. Through evidence-based practices like MBCT, lifestyle changes, and stigma-reduction programs, patients receive holistic care. Policies like the ACA and MHPAEA support equitable access, while ongoing evaluations ensure alignment with Healthy People 2030. Ultimately, this approach enhances patient empowerment, reduces disparities, and improves long-term outcomes.

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). Centers for Medicare & Medicaid Services. https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity

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

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Healthy People 2030. (2020). Mental health and mental disorders. Office of Disease Prevention and Health Promotion. 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, 115671. 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

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

NAMI Florida. (2025). Mission. National Alliance on Mental Illness Florida. https://namiflorida.org/about-nami-florida/mission/

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

Additional References

Katz, I. R., & Franklin, J. C. (2023). Closing the gap: Innovations in integrated care for patients with serious mental illness. Psychiatric Services, 74(5), 459–466. https://doi.org/10.1176/appi.ps.20230012

Subramaniam, M., Abdin, E., Vaingankar, J. A., & Chong, S. A. (2024). Peer support models in mental health: Evidence and best practices. Frontiers in Psychiatry, 15, 1364821. https://doi.org/10.3389/fpsyt.2024.1364821