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 structured process that promotes continuous and integrated care across the health system, particularly for patients with complex medical and psychological conditions. It serves as a cornerstone in enhancing health outcomes, reducing healthcare disparities, and fostering patient satisfaction (Garfin et al., 2022). This strategy is designed for adults living with mental illness in Florida, a population that experiences overlapping behavioral and physical health challenges. The approach integrates patient-centered interventions, available community resources, policy frameworks, ethical concerns, and goals set by Healthy People 2030 to ensure sustainable and holistic outcomes.

Patient-Centered Health Interventions and Timelines

Adults with mental illness in Florida—estimated at 2.9 million—often experience comorbid conditions, cultural stigma, and psychosocial instability that make health management difficult (Garfin et al., 2022). Patient-centered interventions must therefore be individualized, evidence-based, and culturally sensitive. The strategy includes three core interventions targeting physical illnesses, stigma reduction, and emotional regulation.

Table 1

Patient-Centered Interventions, Timelines, and Community Partners

Intervention	Barrier Addressed	Timeline	Community Partners	Implementation Approach
Comorbid Physical Illnesses	Cardiovascular disease, diabetes, obesity	Screening at intake; follow-up every 3 months; lifestyle counseling initiated in 1st month	Care Resource, Caron Florida, MHACF	Physical exams (BMI, BP, glucose, lipid panel), lifestyle modification counseling, referrals
Cultural Stigma & Mental Health Literacy	Delayed treatment due to stigma and misinformation	Biweekly sessions for 6 months; pre- and post-surveys	NAMI Florida, MHACF, Care Resource	Educational workshops, bilingual materials, peer support groups
Emotional Dysregulation	Anxiety, depression, mood instability	Weekly MBCT sessions for 6 months; outcome measured via PHQ-9	Caron Florida, MHACF Outlook Clinic, NAMI Florida	Mindfulness-Based Cognitive Therapy, coping strategies, relapse prevention

Comorbid Physical Illnesses

Many adults with serious mental illness (SMI) also live with chronic diseases like cardiovascular disorders and diabetes, which shorten life expectancy by 15–20 years (Nielsen et al., 2021). To address this, routine physical health monitoring should be integrated into mental health care. Interventions include BMI checks, glucose and cholesterol monitoring, and lifestyle counseling. Care Resource provides affordable physical and behavioral health services (Care Resource, 2025), while Caron Florida integrates physical health screenings in its mental health programs (Caron Florida, 2024). MHACF facilitates referrals to primary care providers through its Mental Health Connections program (MHACF, 2025). This integration ensures that physical health does not remain neglected in mental health treatment plans.

Cultural Stigma and Mental Health Literacy

Cultural stigma remains a significant barrier to care. Individuals may avoid treatment due to fear of judgment, misconceptions, or cultural taboos surrounding mental illness (Ahad et al., 2023). To overcome this, culturally adapted educational programs should be held every two weeks, beginning two weeks post-diagnosis. NAMI Florida conducts statewide stigma-reduction campaigns (NAMI Florida, 2025), while MHACF hosts public outreach events to connect individuals with services (MHACF, 2025). Care Resource also offers mental health awareness sessions tailored for diverse communities (Care Resource, 2025). Educational sessions should include peer speakers, bilingual materials, and relatable case studies to maximize impact.

Emotional Dysregulation

Patients with mental illness often struggle with recurring depressive or anxious episodes. Mindfulness-Based Cognitive Therapy (MBCT) is an evidence-based method that blends cognitive therapy with mindfulness to enhance emotional resilience (Gkintoni et al., 2025). Weekly MBCT sessions beginning within the first month of diagnosis can reduce relapse rates and improve emotional regulation. Caron Florida and MHACF provide MBCT programs, while NAMI Florida partners with clinicians to expand access (Caron Florida, 2024; MHACF, 2025). The goal is a 40% reduction in PHQ-9 depression scores within six months.

Ethical Decisions in Designing Patient-Centered Health Interventions

Designing patient-centered care raises several ethical challenges. Patients with severe mental illness may struggle with comprehension or decision-making. Care coordinators must provide information in simple terms, use teach-back methods, and verify capacity for consent (Nagaoka et al., 2023). Educational programs should be respectful, patient-led, and culturally adapted. Engaging patients in program design and incorporating their cultural values reduces feelings of marginalization (Ahad et al., 2023). Justice demands equitable care. Many patients are uninsured or underinsured; community-based organizations like Care Resource and MHACF help bridge this gap through sliding-scale and free services (Care Resource, 2025; MHACF, 2025).

Relevant Health Policy Implications

Policies that enhance integration, affordability, and equity directly impact care coordination outcomes. The Mental Health Parity and Addiction Equity Act (MHPAEA) requires parity between mental and physical health insurance coverage, reducing financial barriers to psychotherapy, MBCT, and medication management (CMS, 2024). The Affordable Care Act (ACA) expands coverage of mental health services as essential benefits and supports preventive screenings for comorbid conditions (Nielsen et al., 2021). Healthy People 2030 prioritizes stigma reduction, health equity, and improved access to mental health care (Healthy People 2030, 2020). Together, these policies strengthen continuity of care and support the interventions proposed in this strategy.

Priorities for Care Coordinators in Patient and Family Discussions on Mental Illness

Care coordinators must adopt a three-tiered approach when engaging patients and families. First, they should promote transparency by explaining diagnoses, treatment options, and the need for routine physical screenings (Nielsen et al., 2021). Second, they should address cultural concerns by facilitating conversations that respect cultural values, using translation services when necessary, and incorporating community-based education (Ahad et al., 2023). Third, they should encourage active engagement by setting measurable goals, such as MBCT attendance and biweekly education participation, and track progress using tools like the PHQ-9 (Liu et al., 2024). This collaborative model ensures shared decision-making and sustainable care engagement.

Learning Session Content with Best Practices and Healthy People 2030

The interventions align with evidence-based best practices. MBCT has been demonstrated to reduce depression symptoms and prevent relapse. Follow-up check-ins are recommended to reinforce learning and individualize care (Gkintoni et al., 2025). Peer-led, culturally relevant sessions are effective in reducing stigma and promoting care-seeking behaviors among underserved populations (Ahad et al., 2023). These practices support Healthy People 2030 goals of improving mental health literacy, reducing disparities, and increasing equitable access to care.

Need for Change

While the current strategy is comprehensive, it requires stronger feedback mechanisms. The absence of peer-led programs and continuous evaluation may limit cultural engagement and long-term effectiveness. Implementing post-session surveys, peer-facilitated groups, and community feedback loops will enhance responsiveness and sustainability, supporting Healthy People 2030’s emphasis on behavioral health improvement (Healthy People 2030, 2020).

Conclusion

This coordinated care strategy integrates physical health monitoring, stigma-reduction education, and emotional regulation interventions for adults with mental illness in Florida. By aligning interventions with supportive policies and ethical considerations, the plan ensures inclusivity, accessibility, and patient empowerment. Regular evaluation and cultural adaptations will further align with Healthy People 2030 objectives, ultimately improving health outcomes, reducing disparities, and promoting holistic wellness.

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). www.cms.gov. 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. Journal of American Medical Association 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. Health.gov. 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. 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