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NURS-FPX4050 | Final Care Coordination Plan

Paper Details

School: Capella University
Subject: Nursing
Topic:Final Care Coordination Plan


Referencing: APA
Pages: 7





Final Care Coordination Plan









Patient Centered Health interventions for Mental Health

Interpersonal psychotherapy

Interpersonal psychotherapy (IPT) can be defined as a structured intervention that focuses on the interpersonal issues facing the patient suffering from mental illnesses (Johnson et al.2019). IPT is based on the close relationship between mental illnesses and interpersonal issues including unemployment, loss of a close relative and financial struggles. The health care provider should explore the patient’s perceptions, previous experiences and expectations to determine the interpersonal problems facing the patient. The health care provider should aim at enhancing communication with the patient and improving the patient’s interpersonal skills. There are various tools that can be used to conduct Interpersonal psychotherapy (IPT). The Worry Tree was developed by Butler & Hope (1995) to identify various challenges experienced by patients suffering from mental illnesses. The Worry Tree can be adopted to allow patients express their views and challenges hence enabling the health care professional to view the mental issue from the perspective of the patient. Additionally, the health care provider should interview the patient’s family members and close friends to further analyze the personal issue facing the patient. The Interpersonal psychotherapy can be carried out for a duration based on the extent of interpersonal issue under consideration. However, the therapy sessions should take at least three weeks for each patient. 

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Patient-Centered Medical Home (PCMH)

PCMH can be viewed as a care model where patient treatment is delivered by primary care physicians hence ensuring that patients receive care where they need it and in their unique way (Jolles, Lengnick-Hall and Mittman, 2019). The PCMH creates collaboration between health care providers, the patients’ families and the patient. Patients receive care in their preferred location including their homes hence the model crates a platform for personalized treatment. Treating mentally ill patients at their homes require the collaboration between health care providers and other stakeholders including the patients’ families and close friends. The family members are required to ensure that patients take their medication. Patient-Centered Medical Home has no specific time since care has to be provided until the patient has fully recovered. However, the process might take at least one month for every patient.

School-bases Interventions

The first two interventions are aimed at enhancing treatment for mental illnesses while the school-based interventions are aimed prevention and early detection of mental illnesses. The school-based interventions adopted for a particular school are determined by the school culture, school environment and policies. An example of a school-based program is the FRIENDS which is a manualized program that educate students on various aspects of mental health including anxiety management, emotional regulation and problem solving (Kozina, 2020). The FRIENDS program is coordinated by health care providers. The health care providers use the Revised Children’s Anxiety and Depression Scale to evaluate the health outcome of the programs and detect any mental illnesses at an early stage. The school-based program should take place annually and take at least two months. The program should allow children to ask questions and have private sessions with health care providers in case the child is exposed to a mental illness risk. 

Ethical decisions in designing patient centered health interventions

The school-based program requires the healthcare provider to educate students on preventing and detecting mental issues. Health care providers can select some children who are already experiencing mental illnesses and offer more specialized treatment. However, the school management should always protect the students’ education records as stipulated by the Family Educational Rights and Privacy Act (FERPA). The parties involved in the implementation of the educational programs should always strive to safeguard the privacy of the students. Health care professionals should also not disclose children’s medical assessment records to the school to prevent victimization and ensure student privacy. There are five main ethical principles which include truthfulness and confidentiality, autonomy and informed consent, beneficence, non-maleficence and justice. When designing healthcare professional-led school programs for mental health, health care professionals should ensure that health data and information related to the students are not assessed by unauthorized persons as stipulated by the confidentiality principle.

 Patient-Centered Medical Home is essential in ensuring the delivery of quality mental health treatment. However, there are various ethical issues associated with the process.  First, the healthcare provider and the patient might have divergent views on whether the patient should receive care at their home. Based on the autonomy principle, patients have total control over their bodies and the decision of the patient should be respected. Additionally, the beneficence principle demonstrate that health care providers should always do good. Health care providers should therefore demonstrate high level of skill and knowledge when providing home-based care. Home based care expose patients to risks including falls, failure to take medication and self-harm. Based on the non-maleficence ethical principle, health care providers should adopt risk management strategies and safety procedures to safeguard the patient from such risks. 

Interpersonal psychotherapy (IPT) requires each patient to be treated uniquely based on their personal behavior and stressors. One of the major ethical issues raised in healthcare is the privatization of healthcare delivery which has been found to raise injustice issues especially for disadvantaged groups. Critics against Interpersonal psychotherapy (IPT) claim that health care providers divert public resources into private hands. Health care provider should therefore ensure that they uphold the principle of justice and equality when providing IPT.

Relevant health policy implications

The school-based mental health programs are regulated under the Mental Health Services for Students Act of 2020. The Act was an amendment to the Public Health Service Act to provide access to school-based comprehensive mental health programs. According to the Act, the school-based programs should be developmentally, culturally and linguistically appropriate. The programs should also incorporate positive-behavioral interventions and support. The Overdose Prevention and Patient Safety Act 2018 protect the confidentiality and non-disclosure of records relating to substance use disorder. Therefore, when carrying out any of the proposed interventions, health care providers should ensure confidentiality of patients’ records. 

The Rise from Trauma Act 2019 stipulates the assessment and preventive assistance given to at risk populations with regards to trauma. People who have had traumatic experiences should be assessed for mental disorders and provided with the necessary assistance. The Act will be instrumental in delivering Interpersonal psychotherapy. The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) will be used to assess the patients for any mental illnesses.

The Lower Health Care Costs Act 2019 compels health care facilities to adopt technology and care processes that reduce the costs of treatment (Galvani et al. 2020). Health care providers should therefore ensure that the Patient-Centered Medical Home intervention is affordable to majority of mental health patients. 

Priorities that a care coordinator would establish when discussing the plan with a patient and family member

Developing Patients’ Strengths and Abilities

The healthcare provider should ensure that patients are empowered and involved in the care process. The family members will not only provide the necessary care but also empower the patients to care for themselves. 

Provide Personalized Care and Treatment

When implementing Patient-Centered Medical Home and Interpersonal psychotherapy the health care provider will learn the specific needs, cultural beliefs, personal circumstances and values to offer personalized care. The family members can provide vital information to further understand the needs of the patient. 

Coordinated Care

The healthcare provider should coordinate with other health and social care workers to ensure that the patients receive the most appropriate services. Coordination with other professionals will ensure the exchange of knowledge and skills for all the proposed interventions. 

Comparison between learning session content and best practices

Healthy People 2020 is a policy by the Federal Government to build a healthy nation. Healthy People 2020 has various goals that can be achieved by the implementation of the proposed mental health interventions. First, Healthy People 2020 seeks to identify nationwide health improvement priorities. The school-based mental health program creates a platform to understand mental issues that affect children. The program creates a platform for interaction between health care providers and children who are more vulnerable to mental illnesses. Healthy People 2020 also seek to increase public awareness and understanding of various determinants of health including diseases. The school-based program ensures children learn about mental illnesses at an early age hence increasing chances of early detection of mental-related illnesses. Additionally, the Patient-Centered Medical Home intervention ensures that family members are involved in the care process hence further increase public awareness and understanding. Healthy People 2020 also aim at providing measureable objectives and goals that can be adopted by various institutions. All the proposed interventions create an opportunity to measure various attributed of mental health. For example, Interpersonal psychotherapy can determine the most stressful event at a particular time. For example, if majority of the people experience stress due to the effects of Covid-19, then covid-19 can be viewed as a major stressor. The number of school programs in a state and their success in reducing the cases of mental-related illnesses can also be measured effectively hence enable a health care facility set realistic goals. 


  1. Galvani, A. P., Parpia, A. S., Foster, E. M., Singer, B. H., and Fitzpatrick, M. C. (2020). Improving the prognosis of health care in the USA. The Lancet, 395(10223), 524-533.
  2. Johnson, J. E., Stout, R. L., Miller, T. R., Zlotnick, C., Cerbo, L. A., Andrade, J. T., ... and Wiltsey-Stirman, S. (2019). Randomized cost-effectiveness trial of group interpersonal psychotherapy (IPT) for prisoners with major depression. Journal of consulting and clinical psychology, 87(4), 392.
  3. Jolles, M. P., Lengnick-Hall, R., and Mittman, B. S. (2019). Core functions and forms of complex health interventions: a patient-centered medical home illustration. Journal of general internal medicine, 34(6), 1032-1038.
  4. Kozina, A. (2020). School?based prevention of anxiety using the “My FRIENDS” emotional resilience program: Six?month follow?up. International Journal of Psychology, 55, 70-77.
  5. Kozina, A. (2020). School?based prevention of anxiety using the “My FRIENDS” emotional resilience program: Six?month follow?up. International Journal of Psychology, 55, 70-77.
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