Discussion: Coordination Care Plan in Medical Fields

Running head: COORDINATING CARE 1 Coordination Care Plan Erik Hovsepyan Capella University COORDINATING CARE 2 Coordination Care plan Introduction Care coordination serves to ensure that there is service integration for the satisfaction of individuals’ needs in the medical field. Services that are collaborative and those that are focused on recovery connecting people to health care opportunities and services are the main provision of the care coordination plan. Coordination care has a necessity that is primary of chronically ill patients’ management. A preliminary coordination care plan creates an illness challenge to social relation alteration and to identity that is personal and uncertain creation. Since an effect on one life sphere may affect the other sphere of life, it’s very much worrying (Jones et al, 2018). Chronic diseases cause social problems, which cause a tremendous and complicated impact on the provision of service to the patient calling for friends, family, and approaches that are multidisciplinary in the provision of care in dealing with the chronic condition that mostly seems more complicated to the patient. Solely reason provides that the patient problems that are interconnected should, on rare occasions, fall in the hand of one professional (Jones et al., 2018). This, therefore, resorts to the creation of coordination plans and approaches that are multidisciplinary to get a solution to chronic patient concerns. In my new role as a health care coordinator in our health facility, I identify an individual from the community, and my coordination care plan for the coordination process with the client is as presented below. Coordination Care Plan Depression Patient’s Details Patient Name: Terry Johnson COORDINATING CARE 3 Date of birth: 08/10/1995 Address: tjohnson@gmail.com Payer Source: Medical Insurance Company Secondary Source: Journals on medicine Preliminary Care Coordination Plan Health Concern On focusing on my care coordination plan of a patient known as Laetitia (not her real name), I identified depression as her health concern. Generally, depression is a mental health problem identified with an obstinately depressed state or lack of interest in a person’s usual activities that prompt consequential damage to a person’s everyday activities. Its possible causes comprise social, psychological, and biological distress sources (Battle et al, 2010). These factors might also bring about massive changes in the brain’s functioning, including the alteration of activities of some mind neural circuits. Laetitia is clinically depressed because of her persistent sadness and lack of interest in her usual activities, thus characterizing a significant depression that has prompted a range of physical and behavioral symptoms. Some other symptoms she displays include changes in sleeping patterns, decreased appetite, reduced concentration, and self-esteem. It was also previously reported that Laetitia had, in the past, tried to commit suicide. Several best practices can be applied to improve her health. One of these best approaches includes prescribing depression drugs known as antidepressant drugs for her. These drugs include the SSRIs, an abbreviation for Selective Serotonin Reuptake inhibitors, which are the most known choice since they are practical and have lesser side effects than older antidepressants. Other than COORDINATING CARE 4 SSRIs, other antidepressants that can be prescribed include escitalopram, citalopram, fluoxetine, paroxetine, and sertraline. Another best approach is to talk about therapy or psychotherapy. This is particularly effective when merged with antidepressant treatment. Other treatments like E.C.T. (electroconvulsive therapy), V.N.S. (vagus nerve stimulation) will only be used if she does not respond to both the talk therapy the antidepressant therapy approach (Hallgren et al., 2010). Also, this calls even on the intervention of her friends and family. This is because the collaboration and coordination of health sector resources and services are solely needed for a proper solution that is not based on only one professional. This, in turn, makes it very important to have a coordinated care plan for an appropriate and well-managed service coordination process. Treatment Plan Laetitia’s treatment plan involves setting a few short-term and long-term goals to help her live the life she desires and manage her mental heal. Thus, this section of the paper mainly focuses on identifying the treatment goals set for Laetitia, seeking outpatient depression treatment. Some of the short-term goals include walking up by a particular time, completing the available household tasks, calling for support groups, introducing herself to new members in her workplace, exercising, and sticking to her everyday schedule (Hannigan et al., 2018). Long-term treatment goals include building or improving how she relates with her friends or family members, finding or keeping the job she enjoys, organizing her home, incrementing positive health activities like eating a healthy diet, and involving herself in community or volunteering services. Another long-term goal to get herself an encouraging support network as she works towards accomplishing these goals. One way of making this possible by having a responsible partner. A person that holds her responsible for COORDINATING CARE 5 accomplishing her goals and holds him for accomplishing his. This will improve her health condition in all ways. Available Community Resources and Services/Referrals There is a number of available community services; these services include; hosting of fundraising and donating money, requesting for charitable donations, charity walk and run participation, local non-profitable activities volunteering, offering free tutoring services, and many others. The community resources available for safe and effective continuum care for Laetitia include WebMD, a depression and mental health online community where she can search out for any available depression specialist within her region and discover a lot of timely data on depression from hospitals recommended by the WebMD doctors. There also mental health organizations like NAMI (National Alliance on Mental Illness) and the National Suicide Prevention Lifeline (NSPL). Nami is a mental health firm devoted to enhancing the lives of a lot of depressed Americans. NSPL, on the other hand, is a toll-free and private hotline for preventing suicide for anybody experiencing emotional distress or suicidal crisis. This will be of great help to Laetitia due to previous failed suicidal attempts. Other community resources available include: • Hospitals ✓ The patient’s Community treatment hospitals that are available are; Cleveland clinic, Hero’s hospital, Rochester clinic, John-Hopkins general hospital, Cedars Sinai Medical center, UCLA Center, and New York Hospital. Discussion: Coordination Care Plan in Medical Fields

• Education Services COORDINATING CARE 6 ✓ Education services available in the community include centers for training and instructions such as colleges, schools, training centers, and universities. • Rehabilitation Services ✓ Rehabilitation services in the community include; cognitive therapy, mental health rehabilitation services, language and speech therapy, and physical and occupational therapy. • Pharmacies ✓ The community’s available pharmacies include; Kroger Company, Omnicare, Safeway, Supervalu Inc., Walgreens, and Walmart stores. • D.M.E. Equipment Providers ✓ D.M.E. (Durable medical equipment) providers in the community include; A.R.C. Distributors, A+ Products Inc, A.A.P. Implantate AG, Abbott, and Abilitation Inc. • Incontinence Service Providers ✓ Service providers in the Incontinence field include; Jerusalem hospital, Rawls King, Einstein Hope, Safeway, and Clean-path. • Parenteral Service and Enteral Nutrition Providers ✓ The community parenteral service providers include; The Walkers, Chasers Hospital, John-Hopkins general hospital, Cedars Sinai Medical center, UCLA Center, and New York Hospital. • Social Services COORDINATING CARE • 7 Social services available in the community include; food subsidies, education, police services, lobbying, community management adoption, job training, and fire services. • Transition Services ✓ There are vocational training and post-secondary education transitional services available in the community. • Transportation Services ✓ The available modes of transport include; roadways, railways, waterways, pipelines, and airways • Skilled Nursing Services ✓ The skilled nursing services include nurse skills under professional supervision for management, evaluation, observation of health conditions, and therapy treatment. Cultural Needs Cultural needs involve individuals’ cultural norms and norms which need to be considered, for example; Religious beliefs, customs, traditions, laws, and architectural style that highly varies among communities. Schizophrenia Patient’s Details Patient Name: Mia Malik Date of birth: 16/11/1987 Address: malikm@gmail.com COORDINATING CARE Payer Source: Medical Insurance Company Secondary Source: Journals on medicine 8 Preliminary Care Coordination Plan Health concerns During the care plan identified, the patient had schizophrenia, a mental disorder that causes the affected patients to have an abnormal interpretation of reality. Some of the symptoms include delusions and hallucinations. Also, the patients experience behavior and thinking disorder that disrupts their daily activities. Mia was suffered from schizophrenia since she could not coordinate speech and could have episodes of hallucination and delusions because he claimed to experience scenarios that were not present at the moment (Conley, 2016). The exact causes of the condition are unknown, but the researchers suggest that some environmental factors, including stress, can contribute to schizophrenia disorder. Discussion: Coordination Care Plan in Medical Fields

The patients’ health condition can be improved by combining some approaches, including antipsychotic medication, which manipulates the patients’ serotonin and dopamine hormones to manage delusions and hallucinations. Also, physiological therapy, including psych educations and cognitive behavioral therapy. The management must incorporate the family from training skills on schizophrenia management. Treatment plan Mia’s treatment plan involves both the long-term and short-term goals for the patient’s medications and treatments to realize reality-based thought and execute verbal communication. Also, for the patient to conduct neural activity topics and share the environmental observation, COORDINATING CARE 9 which represents the treatment’s short-term results. In the long term, the patient is expected to communicate in an understandable manner to her friends and family members. Interventions Establishing a baseline that will ensure realistic goals for the effective care plan identifies the psychotic medication plan. Also, ensure when talking to the patients, the voice is low and in a calm environment. Short, frequent sessions should be planned with the patients by using simple words and gentle directions. Focus on meaningful activities should be maintained, and replace negative perception with a constructive and positive thought. Community resources The community support groups of schizophrenia involve health care facilities, national alliances on mental health, and mental health facilities that ensure robust support for the affected patients. The pharmacies offering emergency medications are also viable community resources. Anxiety disorder Patient’s Details Patient Name: John White Date of birth: 14/12/1995 Address: malikm@gmail.com Payer Source: Medical Insurance Company Secondary Source: Journals on medicine COORDINATING CARE 10 Preliminary Care Coordination Plan Health concerns After interaction with the patient, I discovered the patient was suffering from an anxiety disorder, which manifested in depicting unusual panic disorders without significant reasons and exhibiting unwavering worries and unwarranted fear of various objects. The anxiety causes the affected patient to have distress, which impairs their daily expressions. Jacob presented with episodes of panic attacks, which were sufficient markers to suffer from anxiety disorders. Interventions Some of the interventions to realize resilience include recognizing a patient’s anxiety and ensuring presence and touch to remind patients they are not alone. Also, familiarize patients with new individuals and environment and ensure peaceful interaction with the patients. Another crucial measure is communicating using simple language and reinforcing the patient’s expressions of discomfort and pain (Craske, 2015). Also, the patients should be assisted in identifying anxiety triggers to have a situational response and encouraging them to maintain a positive perception that anxiety is not lethal. Community resources The community resources that exist to reinforce anxiety disorders management include mental health facilities that offer medication services and follow up. Support groups that ensure there are psychosocial assistances, including anxiety disorder associations. Mental institutes and health facilities. The community resources offer both management and treatment services to the affected individuals. COORDINATING CARE 11 Hourly Nursing and Respite Care Services Care services include; talking at sitting with a disabled person, bathing, dressing, and exercising, helping medication, helping the disabled get in and out of bed, assisting in travel lighting, housekeeping, and many others. Conclusion A preliminary coordination care plan is very important and more effective in managing chronic conditions. It provides a confident solution to the patient and also promotes teamwork. Patients should strictly follow the plan to manage their conditions. A preliminary coordination care plan creates an illness challenge to social relation alteration and to identity that is personal and uncertain creation. Since an effect on one life sphere may affect the other sphere of life, it’s very much worrying. COORDINATING CARE 12 References Battle, C. L., Uebelacker, L., Friedman, M. A., Cardemil, E. V., Beevers, C. G., & Miller, I. W. (2010). Treatment goals of depressed outpatients: a qualitative investigation of goals identified by participants in a depression treatment trial. Journal of psychiatric practice, 16(6), 425. Cardoso, E. M., Reis, C., & Manzanares-Céspedes, M. C. (2018). Discussion: Coordination Care Plan in Medical Fields

Chronic periodontitis, inflammatory cytokines, and interrelationship with other chronic diseases. Postgraduate medicine, 130(1), 98-104. Conley, R. R., & Kelly, D. L. (2016). Management of treatment resistance in schizophrenia. Biological psychiatry, 50(11), 898-911. Craske, M. G., Stein, M. B., Sullivan, G., Sherbourne, C., Bystritsky, A., Rose, R. D., & RoyByrne, P. (2015). Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care. Archives of General Psychiatry, 68(4), 378-388. Hallgren, M., Kraepelien, M., Lindefors, N., Zeebari, Z., Kaldo, V., & Forsell, Y. (2015). Physical exercise and internet-based cognitive–behavioral therapy in the treatment of depression: a randomized controlled trial. The British Journal of Psychiatry, 207(3), 227-234. Hannigan, B., & Simpson, A. ORCID: 0000-0003-3286-9846, Coffey, M., Barlow, S. ORCID: 0000-0002-2737-8287 and Jones, A.(2018). Care Coordination as Imagined, Care Coordination as Done: Findings from a Cross-national Mental Health Systems Study. International Journal of Integrated Care, 18(3), 12. COORDINATING CARE 13 Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: findings from a cross-national mental health systems study—International Journal of Integrated Care, 18(3). 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 one, 13(6), e0198427. Nakimuli-Mpungu, E., Wamala, K., Okello, J., Alderman, S., Odokonyero, R., Mojtabai, R., & Musisi, S. (2015). Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-center randomized controlled trial. The Lancet H.I.V., 2(5), e190-e199. 12/8/2020 Capella University Scoring Guide Tool NURS-FPX4050 u04a1 – Final Care Coordination Plan Learner: Erik , Hovsepyan OVERALL COMMENTS Hi Erik Thank you for your work on this final assessment. I think you did a very nice job of presenting a final care coordination plan for your selected patient. I like that you included specific health interventions and timelines grounded in evidence-based practice. This is so important and is often overlooked, especially considering the different ethical issues and policies that guide the care of your unique patient population. Overall, this is a very good effort on this final care coordination plan, and I value your time and professionalism and creativity in preparing this. I hope you will take the information you learned on creating this final care coordination plan back to your facility to identify opportunities to improve health outcomes. This would be a great way to share nursing knowledge. I look forward to seeing what you do in your future educational endeavors. **Please fill out the end of course survey when you receive it. Thanks Dr. Hooven RUBRICS https://scoringguide.capella.edu/grading-web/gradingdetails 1/13 12/8/2020 Capella University Scoring Guide Tool CRITERIA 1 Design patient-centered health interventions and timelines for a selected health care problem. COMPETENCY Adapt care based on patient-centered and person-focused factors. NON_PERFORMANCE: Does not design patient-centered health interventions and timelines for a selected health care problem. BASIC: Designs patient-centered health intervention for a selected health care problem. PROFICIENT: Designs patient-centered health interventions and timelines for a selected health care problem. DISTINGUISHED: Designs patient-centered health interventions and timelines for a selected health care problem that includes community resources. Comments: I like that you designed a care plan for depression/anxiety/schizophrenia that provides a comprehensive and patient-centered plan that provides health interventions and timelines for care that reflect patient needs and preferences based on the availability of essential resources available in your community. https://scoringguide.capella.edu/grading-web/gradingdetails 2/13 12/8/2020 Capella University Scoring Guide Tool CRITERIA 2 Consider ethical decisions in designing patient-centered health interventions. COMPETENCY Defend decisions based on the code of ethics for nursing. NON_PERFORMANCE: Does not consider ethical decisions in designing health interventions. BASIC: Considers ill-defined or ambiguous ethical decisions in designing patient-centered health interventions. PROFICIENT: Considers ethical decisions in designing patient-centered health interventions. DISTINGUISHED: Considers insightful ethical decisions in designing patient-centered health interventions. These decisions are supported by the literature. Comments: I see that you made ethical decisions in designing patient-centered health interventions. Discussion: Coordination Care Plan in Medical Fields

To earn distinguished in this criterion, I recommend you address insight ethical decisions informed by relevant ethical considerations, the practical effects of specific actions, and the significance of key uncertainties. Can you discuss the code of ethics for nurses in here? https://scoringguide.capella.edu/grading-web/gradingdetails 3/13 12/8/2020 Capella University Scoring Guide Tool CRITERIA 3 Identify relevant health policy implications for th .. Discussion: Coordination Care Plan in Medical Fields