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Preliminary Care Coordination Plan

For this assessment, you will develop a 3–4-page preliminary care coordination plan for a
selected health care problem. Include physical, psychosocial, and cultural considerations for this
health care problem. Identify and list available community resources for a safe and effective
continuum of care.
Before you complete the instructions detailed in the course room, first select one of the following health care problems or issues:
 Health Literacy
• Physical considerations: Low health literacy can lead to poor health outcomes and difficulty managing chronic diseases.
• Psychosocial considerations: Low health literacy can cause emotional distress, anxiety, and depression.
• Cultural considerations: Cultural beliefs and practices may influence an individual.
• Community resources: Health literacy programs, patient education materials, and health navigators can provide resources and support for individuals with low health literacy.
 Environmental Health
• Physical considerations: Environmental hazards such as air pollution, lead exposure, and toxic waste can cause physical health problems.
• Psychosocial considerations: Environmental hazards can cause emotional distress, anxiety, and depression.
• Cultural considerations: Cultural beliefs and practices may influence an individual's exposure to environmental hazards.
• Community resources: Environmental health clinics, community clean-up programs, and advocacy groups can provide resources and support for individuals affected by environmental hazards.
After you have selected one of the problems/issues from the list above, return to the detailed instructions in the course room to complete your assessment.
Scenario
Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.
Instructions
Develop the Preliminary Care Coordination Plan

Full Answer Section

Environmental Health Concerns in the Community

Our community faces several environmental health concerns, including:

Air pollution: Our location near a major highway and industrial facilities exposes residents to high levels of air pollutants, leading to respiratory issues like asthma and chronic obstructive pulmonary disease (COPD).
Lead exposure: Older homes and buildings may contain lead paint or plumbing, posing a risk of lead poisoning, particularly for children. This can lead to developmental delays, learning difficulties, and behavioral problems.
Toxic waste: Improper disposal of hazardous waste from local industries or households can contaminate soil and water, causing various health problems like cancer, neurological disorders, and reproductive issues.

III. Physical, Psychosocial, and Cultural Considerations Physical:

Environmental hazards can exacerbate existing chronic conditions like asthma, heart disease, and diabetes.
Lead poisoning can cause physical damage to the nervous system, kidneys, and bones.
Exposure to toxic waste can lead to a wide range of physical health problems depending on the type of toxin and exposure level.

Psychosocial:

Concerns about environmental health can cause anxiety, stress, and depression.
Individuals may experience feelings of helplessness, powerlessness, and fear for their health and their families' health.
Social stigma and discrimination can further exacerbate mental health issues.

Cultural:

Cultural beliefs and practices may influence exposure to environmental hazards. For instance, some communities may rely on traditional cooking methods that expose them to indoor air pollution.
Culturally specific dietary habits may increase vulnerability to certain toxins.
Language barriers can hinder access to information and resources about environmental health risks.

Care Coordination Strategies
Patient Assessment and Education:

Conduct comprehensive patient assessments to identify environmental exposures and their potential health impacts.
Provide culturally sensitive education about specific environmental hazards, their health risks, and preventive measures.
Utilize translated materials and interpreters when necessary to ensure clear communication.

Referral and Collaboration:

Refer patients to appropriate specialists for diagnosis and treatment of health problems related to environmental exposure.
Collaborate with environmental health agencies to investigate pollution sources and advocate for mitigation efforts.
Partner with community organizations to provide support groups, educational workshops, and legal assistance.

Social Support and Advocacy:

Connect patients with social support services to address mental health concerns and manage stress.
Advocate for policies and regulations that protect the community from environmental hazards.
Empower residents to become advocates for their own health and the health of their community.

Community Resources

Environmental Health Agency: Provides information about environmental hazards, conducts investigations, and enforces regulations.
Local Clinics and Hospitals: Offer medical care and diagnostic services for health problems related to environmental exposure.
Community Health Centers: Provide culturally sensitive healthcare and educational resources.
Non-profit Organizations: Offer environmental education, advocacy support, and legal assistance.
Faith-based Organizations: Provide social support and community outreach programs.

Evaluation and Monitoring

Regularly monitor patients' health status and progress in managing their environmental exposures.
Track the effectiveness of care coordination interventions and identify areas for improvement.
Collaborate with community partners to evaluate the impact of environmental health initiatives on the community.

VII. Conclusion Effective care coordination is essential for addressing the complex health challenges posed by environmental hazards in our community. By considering physical, psychosocial, and cultural factors, and utilizing available community resources, we can empower individuals and families to manage their environmental exposure and improve their overall health and well-being. This preliminary plan provides a framework for implementing a comprehensive care coordination approach for environmental health issues in the community setting. It is important to continuously evaluate and adapt this plan based on the specific needs of our community and the evolving landscape of environmental risks.

Sample Answer

As a staff nurse at the community care center, I understand the importance of care coordination for effective patient management. With the recent relocation of the case management team, I am taking on the role of care coordinator for environmental health issues within the community. This preliminary plan outlines my approach to coordinating care for individuals affected by environmental hazards, considering physical, psychosocial, and cultural aspects, while also leveraging available community resources.