NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

Student Name

Capella University

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Final Care Coordination Strategy

Care coordination is a structured approach that ensures continuous, integrated care across multiple healthcare settings, particularly for patients with complex needs. It is instrumental in reducing health disparities, improving outcomes, and fostering patient satisfaction (Garfin et al., 2022). This strategy focuses on adults living with mental illness in Florida, a group that faces significant barriers in accessing behavioral and physical healthcare. The discussion explores patient-centered health interventions, timelines, ethical issues, health policy implications, and alignment with Healthy People 2030 goals.

Patient-Centered Health Interventions and Timelines

Florida is home to more than 2.9 million adults living with mental illness, many of whom also struggle with physical illnesses, cultural stigma, and psychosocial challenges (Garfin et al., 2022). To address these barriers, three primary interventions are outlined.

Comorbid Physical Illnesses

Adults with serious mental illness (SMI) often face comorbidities like cardiovascular disease and diabetes, conditions that shorten life expectancy by nearly 20 years (Nielsen et al., 2021). Routine screenings such as BMI, blood pressure, lipid profiles, and glucose levels should be embedded in their mental health care plan.

Community Partners and Resources: Care Resource provides both primary and behavioral health care on a sliding fee scale. Caron Florida integrates physical assessments into mental health programs. The Mental Health Association of Central Florida (MHACF) connects clients to medical providers via its Mental Health Connections program.

Timeline: Initial screenings at intake, follow-up every three months, and lifestyle counseling beginning in the first month and continuing throughout treatment.

Intervention	Community Partner	Timeline	Outcome Goal
Routine physical health screenings	Care Resource, Caron Florida, MHACF	Intake, 3 months, ongoing	Early detection and management of comorbidities

Cultural Stigma and Mental Health Literacy

Stigma in culturally diverse populations often delays treatment and worsens outcomes (Ahad et al., 2023). Biweekly culturally tailored mental health education sessions—using translated materials, community speakers, and peer educators—are effective in reducing stigma.

Community Partners and Resources: NAMI Florida conducts culturally relevant awareness campaigns. MHACF provides community outreach and support groups. Care Resource offers educational programs for underserved populations.

Timeline: Education begins two weeks post-diagnosis, with sessions every two weeks for six months. Evaluation is conducted using pre- and post-session surveys.

Intervention	Community Partner	Timeline	Evaluation Method
Culturally tailored education	NAMI Florida, MHACF, Care Resource	Biweekly, 6 months	Surveys measuring stigma reduction and awareness

Emotional Dysregulation

Emotional dysregulation, such as recurring depressive or anxiety episodes, is common among adults with SMI. Mindfulness-Based Cognitive Therapy (MBCT) combines mindfulness with cognitive strategies to reduce relapse and improve emotional regulation (Gkintoni et al., 2025).

Community Partners and Resources: Caron Florida provides MBCT as part of treatment programs. The Outlook Clinic (MHACF) offers free MBCT sessions. NAMI Florida collaborates with providers for mindfulness programs.

Timeline: MBCT begins within the first month of diagnosis and continues weekly for six months, with a goal of 40% improvement in PHQ-9 depression scores.

Intervention	Community Partner	Timeline	Outcome Goal
Weekly MBCT therapy	Caron Florida, MHACF, NAMI Florida	Weekly, 6 months	40% improvement in PHQ-9 scores

Ethical Decisions in Designing Patient-Centered Health Interventions

Question: How do we ensure truly informed consent in individuals who may struggle with comprehension due to their mental state?
Patients with impaired judgment may struggle to process treatment details. Ethical care requires simplified explanations, use of interpreters, and teach-back methods to confirm understanding (Nagaoka et al., 2023).

Question: How do we make interventions culturally competent and respectful in a way that does not make patients feel labeled or marginalized?
Programs must avoid stereotyping and instead integrate patient voices into planning. Peer educators and culturally adapted examples help reduce stigma (Ahad et al., 2023).

Question: How do we ensure equal access to healthcare services for uninsured or low-income individuals?
Justice in care requires affordable services. Programs such as Care Resource and MHACF offer free or sliding-scale services to ensure equity (Care Resource, 2025; MHACF, 2025).

Relevant Health Policy Implications

The Mental Health Parity and Addiction Equity Act (MHPAEA) ensures insurance coverage for mental health matches physical health (CMS, 2024). The Affordable Care Act (ACA) mandates coverage for mental health and substance use services, enabling routine screenings and preventive care (Nielsen et al., 2021). Healthy People 2030 provides a framework for reducing stigma, improving access, and advancing equity (Healthy People 2030, 2020). Together, these policies reinforce patient access, affordability, and holistic integration of care.

Priorities for Care Coordinators in Patient and Family Discussions

Care coordinators should emphasize transparency and trust by explaining diagnoses and comorbid risks clearly. They should engage families through culturally sensitive communication and translated resources, while also encouraging patients to set measurable goals such as attending MBCT sessions or education workshops. Progress tracking with tools like PHQ-9 ensures accountability and sustained engagement (Liu et al., 2024).

Learning Session Content with Best Practices and Healthy People 2030

Best practices in MBCT recommend supplementing group therapy with individual follow-ups to reinforce skills (Gkintoni et al., 2025). In mental health education, peer-led, culturally relevant sessions with real-world examples have been shown to be especially effective in underserved groups (Ahad et al., 2023). Both approaches align with Healthy People 2030 objectives of reducing disparities, improving literacy, and enhancing equitable access.

Need for Change

The strategy should incorporate feedback mechanisms such as surveys, peer facilitators, and open community forums. Without these elements, interventions risk losing cultural relevance and effectiveness. Integrating feedback supports Healthy People 2030 objectives by improving behavioral health and reducing inequities (Healthy People 2030, 2020).

Conclusion

This care coordination strategy integrates physical, cultural, and psychosocial interventions for adults with mental illness in Florida. Evidence-based practices such as MBCT, routine screenings, and culturally tailored education foster holistic wellness, reduce stigma, and promote engagement. Supported by MHPAEA, ACA, and Healthy People 2030, the plan ensures equitable access and sustainable care, empowering patients and improving 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/

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

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

Healthy People 2030. (2020). Mental health and mental disorders. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/mental-health-and-mental-disorders

NURS FPX 4065 Assessment 5 Final Care Coordination Strategy

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

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