The care plan to be implemented in this study mainly focused on the provision of proper interventions for a person with a mental health condition, using available resources. The plan is primarily based on the transfer of the patient from various health facilities to a local homecare facility that is dedicated to the provision of proper health services to chronic disease and mental health patients, as well as the elderly. Such a facility operates in the capacity of a healthcare facility as I have all the resources, including qualified personnel, to provide various services that can improve the recovery rate of the patients. Moreover, the facility’s services are more cost-effective as it mainly makes use of the readily available resources in the society such as the trained nursing professionals, pharmacists, and other professionals that can contribute to the active recovery of the patients (Daumit et al., 2019). Moreover, it significantly relies on care coordination, whereby different professionals, the patients, and their immediate family members are involved in the general service provider to improve the comfort and satisfaction of the patients. Ideally, contemporary research suggests that one in every four individuals in the U.S is likely to have mental disorders which show the magnitude of the health problem in the American community. In this regard, the coordination plan detailed in this study should be considered for adoption within the society to make care services more affordable and also to promote the achievement of desired patient outcomes.
Patient Issues
The
patient considered in this care coordination plan is Alvin, a 27-year-old
mental health patient. He had lived with psychological complications since 2012
when he was first diagnosed with the problem. Alvin was initially substance
depended which has been primarily considered as one of the fundamental elements
contributing to the development of his mental condition. He has been to various
healthcare facilities since 2012, with each trying its best to provide the most
appropriate interventions that would facilitate his healing. However, he is yet
to recover entirely, and an effective care plan is required to ensure that his
needs are adequately met. Besides, the patient requires extensive social and emotional
support from family members and close friends as that is essential or an
individual who is focusing on making a positive change in their lives. Some of
the problems noted with the patient include substance dependence, manic
episodes, and depression. Besides, they have been showing little progress after
the implementation of the recommended interventions in the previous mental
health facilities visited. This is an issue that indicates ineffectiveness and
inappropriateness of the interventions used. It is therefore essential that the
care coordination plan focuses on the application of revolutionary and
evidence-based interventions that will facilitate the acquisition of the
desired patient outcomes and his eventual full recovery.
Community Resources for Use in addressing client problems
The
healthcare coordination plan formulated for the patient requires resources that
can easily be attained from the immediate community. In this regard, it is
essential that we first focus on ensuring that there is a sufficient resource
that can be used to meet the needs of the patient, according to their problem.
One of the essential support required is the availability of a healthcare
facility that can provide a wide range of mental health services to the
patient, such as injections and close monitoring. This will be essential in the
addressing of the patient’s manic episodes which can get out of hand at times.
Ideally, the healthcare facilities available in the Bronx community can
perfectly provide such services and enable the patient to start experiencing
recovery. The other resource is the availability of substance abuse
rehabilitation specialists which are also available in the mental healthcare
facilities and rehabilitation centers in the Bronx. Ideally, the patient has a
substance dependency problem which should be addressed specialists who will
take him through the standard rehabilitation program. First, the program will
ensure that they get rid of the substance dependency problem and focus on
giving him a positive attitude towards drugs free life. The community based
mental health facilities also have professionals with extensive expertise in
areas such as psychiatry and counseling, among other specialities. The patient
requires comprehensive advice and psychological support to eradicate the
suicidal thoughts and make them see the positive side of life. It is through
counselling, and the application of various behavioral conditioning and
transformation approaches that the patient will be able to fully overcome the suicidal
behaviour and focus on building a positive lifestyle.
Ethical Considerations
Dealing
with mental health patients can be quite complicated as the nurses have to
ensure adherence to ethical policies and principles. The nurse practitioners
also face many dilemmas regarding the decisions they make, and this significant
impact on the quality of service provided. The care coordination plan has to
consider various ethical issues which might arise in the care provision process
regarding patient behavior. To begin with, the care services provided should
uphold respect for the client’s dignity, while at the same time prioritizing
his general wellbeing. In this regard, the care coordination plan should focus
on implementing the best interventions to facilitate healing, even when the
client is reluctant. Mental health patients are not fit to be involved in
making decisions regarding their care plan, and the immediate family should be
significantly involved in deciding the best approaches and setting the care goals
(Hannigan et al., 2018). This is explored in the beneficence ethical principle,
which suggests that all the actions should maximize the benefit for the
patient. In this case, the care coordination plan has to ensure that it
prioritizes the wellbeing of the patient.
Each
of the decisions made by the coordination should primarily consider the
standard ethical principles and policies that revolve around service provision.
For instance, the information of the patient should be handled with a high
degree of discretion. This is an ethical requirement that personal health
information of patients is protected and shared in a way that does not create a
risk for unauthorized access. In this regard, the teams involved in the care
coordination have to exercise a reasonable degree of discretion when sharing
information about the patient (Jones et al., 2018). Besides, it is essential
that the team considers the opinions of the family members and ensure their
involvement in the step by step processes that the patient will be taken
through. This will not only increase accountability but also ensure that the
patient receives constant social and psychological support which he needs
during this period.
Policy Implications
The
processes undertaken in the care coordination to facilitate continuum are
likely to be affected by a variety of federal policies. One of the strategies
that will affect the care coordination plan processes is the Medicare
Community-based Care Transitions Program (CCTP) which is a primary policy under
the Accountable Care Act. It was established to ensure evaluation of transition
models. Ideally, conducting the transition of the patient to the home care will
be guided by the application of this policy. The best transition model will be
used to ensure that he is successfully moved to the facility. Another strategy
that should be considered in the implementation of care coordination plan is
the Insurance Portability and Accountability Act (HIPAA). This policy aims at
enforcing patient information protection. In this regard, the transition and
care coordination processes will have to portray strict adherence to patient
information protection measures. Only involved healthcare practitioners will
have access to the information. Besides, every practitioner will only be
provided with information that is relevant to the service they provide. Lastly,
the affordable care act allows for the establishment of health homes to provide
healthcare services to people with chronic conditions (Rodriguez-Monguio,
Errea, & Volberg, 2017). The transfer of the patient will be following the
provisions of this policy as mental illness is in the list of vulnerable
individuals that can be admitted to the home care. Overall, the process will
ensure strict adherence to all governmental and healthcare policies to optimize
the service provision and facilitate the achievement of desired patient
outcomes.
Evaluation of Care
Several
approaches can be applied to evaluate the care provided to the patient. The
main reason for the assessment, in this case, will be to measure the
effectiveness of the care coordination plan in facilitating improved care
quality and achievement of improved patient outcomes. One of the evaluation
approaches is checking patient outcomes. Improvement in the rate of recovery of
the patient is a show of better service quality and effectiveness of the
interventions provided by the plan. Another approach that can be used is
patient satisfaction (Cordasco et al., 2019). The services provided through the
coordination should prioritize patient comfort, and it is for this reason that
increased levels of satisfaction in the patient should be considered an
indication of care effectiveness. The recovery of mental health patients is a
long term process that may take up to a few years, and the team involved in the
care coordination must exercise a reasonable degree of patience. However, any
interventions that seem not to be yielding results should be modified to
facilitate the achievement of the fundamental goals of the care plan.