For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. NOTE: You are required to complete this assessment after Assessment 1 is successfully completed. Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life. This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem. You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment. DEMONSTRATION OF PROFICIENCY By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: • • • • • • Competency 1: Adapt care based on patient-centered and person-focused factors. o Design patient-centered health interventions and timelines for a selected health care problem. Competency 2: Collaborate with patients and family to achieve desired outcomes. o Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. Competency 3: Create a satisfying patient experience. o Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document. Competency 4: Defend decisions based on the code of ethics for nursing. o Consider ethical decisions in designing patient-centered health interventions. Competency 5: Explain how health care policies affect patient-centered care. o Identify relevant health policy implications for the coordination and continuum of care. Competency 6: Apply professional, scholarly communication strategies to lead patientcentered care. o o Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. PREPARATION In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2020. Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback. INSTRUCTIONS Note: You are required to complete Assessment 1 before this assessment. For this assessment: • Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan. Document Format and Length Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA formatted paper, 5–7 pages in length, not including title page and reference list. Supporting Evidence Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources. Grading Requirements The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed. • Design patient-centered health interventions and timelines for a selected health care problem. o o o • • • • • • Address three health care issues. Design an intervention for each health issue. Identify three community resources for each health intervention. Consider ethical decisions in designing patient-centered health interventions. o Consider the practical effects of specific decisions. o Include the ethical questions that generate uncertainty about the decisions you have made. Identify relevant health policy implications for the coordination and continuum of care. o Cite specific health policy provisions. Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. o Clearly explain the need for changes to the plan. Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document. o Use the literature on evaluation as guide to compare learning session content with best practices. o Align teaching sessions to the Healthy People 2020 document. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Additional Requirements Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course. Running Head: COORDINATING CARE Coordination Preliminary Care Plan Erik Hovsepyan Capella University 1 COORDINATION CARE PLAN 2 Introduction Care coordination serves to ensure that there is service integration for the satisfaction of individuals' needs in the medical field. Services that are collaborative and those that are focused on recovery connecting people to health care opportunities and services are the main provision of the care coordination plan. Coordination care has a necessity that is primary of chronically ill patients' management. A preliminary coordination care plan creates an illness challenge to social relation alteration and to identity that is personal and uncertain creation. Since an effect on one life sphere may affect the other sphere of life, it's very much worrying (Jones, Coffey, Hannigan, & Simpson, 2018). Chronic diseases cause social problems, which cause a tremendous and complicated impact on the provision of service to the patient calling for friends, family, and approaches that are multidisciplinary in the provision of care in dealing with the chronic condition that mostly seems more complicated to the patient. Solely reason provides that the patient problems that are interconnected should, on rare occasions, fall in the hand of one professional (Jones, Coffey, Hannigan, & Simpson, 2018). This, therefore, resorts to the creation of coordination plans and approaches that are multidisciplinary to get a solution to chronic patient concerns. In my new role as a health care coordinator in our health facility, I identify an individual from the community, and my coordination care plan for the coordination process with the client is as presented below. Coordination Care Plan COORDINATION CARE PLAN 3 Patient’s Details Patient Name: Terry Johnson Date of birth: 08/10/1995 Address: tjohnson@gmail.com Payor Source: Medical Insurance Company Secondary Source: Journals on medicine Preliminary Care Coordination Plan Health Concern On focusing on my care coordination plan of a patient known as Laetitia (not her real name), I identified depression as her health concern. Generally, depression is a mental health problem identified with an obstinately depressed state or lack of interest in a person's usual activities that prompt consequential damage to a person's everyday activities. Its possible causes comprise social, psychological, and biological distress sources. These factors might also bring about massive changes in the brain's functioning, including the alteration of activities of some mind neural circuits. Laetitia is clinically depressed because of her persistent sadness and lack of interest in her usual activities, thus characterizing a significant depression that has prompted a range of physical and behavioral symptoms. Some other symptoms she displays include changes in sleeping patterns, decreased appetite, reduced concentration, and self-esteem. It was also previously reported that Laetitia had, in the past, tried to commit suicide. COORDINATION CARE PLAN 4 However, several best practices can be applied to improve her health. One of these best approaches includes prescribing depression drugs known as antidepressant drugs for her. These drugs include the SSRIs, an abbreviation for Selective Serotonin Reuptake inhibitors, which are the most known choice since they are practical and have lesser side effects than older antidepressants. Other than SSRIs, other antidepressants that can be prescribed include escitalopram, citalopram, fluoxetine, paroxetine, and sertraline. Another best approach is to talk about therapy or psychotherapy. This is particularly effective when merged with antidepressant treatment. Other treatments like E.C.T. (electroconvulsive therapy), V.N.S. (vagus nerve stimulation) will only be used if she does not respond to both the talk therapy the antidepressant therapy approach. Also, this calls even on the intervention of her friends and family. This is because the collaboration and coordination of health sector resources and services are solely needed for a proper solution that is not based on only one professional. This, in turn, makes it very important to have a coordinated care plan for an appropriate and well-managed service coordination process. Treatment Plan Laetitia's treatment plan involves setting a few short-term and long-term goals to help her live the life she desires and manage her mental heal. Thus, this section of the paper mainly focuses on identifying the treatment goals set for Laetitia, seeking outpatient depression treatment. Some of the short-term goals include walking up by a particular time, completing the available household tasks, calling for support groups, introducing herself to new members in her workplace, exercising, and sticking to her everyday schedule. Long-term treatment goals include building or improving how she relates with her friends or family members, finding or keeping the job she enjoys, organizing her home, incrementing positive health activities like eating a COORDINATION CARE PLAN 5 healthy diet, and involving herself in community or volunteering services. Another long-term goal to get herself an encouraging support network as she works towards accomplishing these goals. One way of making this possible by having a responsible partner. A person that holds her responsible for accomplishing her goals and holds him for accomplishing his. This will improve her health condition in all ways. Available Community Resources and Services/Referrals There is a number of available community services; these services include; hosting of fundraising and donating money, requesting for charitable donations, charity walk and run participation, local non-profitable activities volunteering, offering free tutoring services, and many others. The community resources available for safe and effective continuum care for Laetitia include WebMD, a depression and mental health online community where she can search out for any available depression specialist within her region and discover a lot of timely data on depression from hospitals recommended by the WebMD doctors. There also mental health organizations like NAMI (National Alliance on Mental Illness) and the National Suicide Prevention Lifeline (NSPL). Nami is a mental health firm devoted to enhancing the lives of a lot of depressed Americans. NSPL, on the other hand, is a toll-free and private hotline for preventing suicide for anybody experiencing emotional distress or suicidal crisis. This will be of great help to Laetitia due to previous failed suicidal attempts. Other community resources available include: • Hospitals COORDINATION CARE PLAN 6 ✓ The patient's Community treatment hospitals that are available are; Cleveland clinic, Hero's hospital, Rochester clinic, John-Hopkins general hospital, Cedars Sinai Medical center, UCLA Center, and New York Hospital. • Education Services ✓ Education services available in the community include centers for training and instructions such as colleges, schools, training centers, and universities. • Rehabilitation Services ✓ Rehabilitation services in the community include; cognitive therapy, mental health rehabilitation services, language and speech therapy, and physical and occupational therapy. • Pharmacies ✓ The community's available pharmacies include; Kroger Company, Omnicare, Safeway, Supervalu Inc., Walgreens, and Walmart stores. • D.M.E. Equipment Providers ✓ D.M.E. (Durable medical equipment) providers in the community include; A.R.C. Distributors, A+ Products Inc, A.A.P. Implantate AG, Abbott, and Abilitation Inc. • Incontinence Service Providers ✓ Service providers in the Incontinence field include; Jerusalem hospital, Rawls King, Einstein Hope, Safeway, and Clean-path. • Parenteral Service and Enteral Nutrition Providers COORDINATION CARE PLAN 7 ✓ The community parenteral service providers include; The Walkers, Chasers Hospital, John-Hopkins general hospital, Cedars Sinai Medical center, UCLA Center, and New York Hospital. • Social Services • Social services available in the community include; food subsidies, education, police services, lobbying, community management adoption, job training, and fire services. • Transition Services ✓ There are vocational training and post-secondary education transitional services available in the community. • Transportation Services ✓ The available modes of transport include; roadways, railways, waterways, pipelines, and airways • Skilled Nursing Services ✓ The skilled nursing services include nurse skills under professional supervision for management, evaluation, observation of health conditions, and therapy treatment. Cultural Needs Cultural needs involve individuals’ cultural norms and norms which need to be considered, for example; Religious beliefs, customs, traditions, laws, and architectural style that highly varies among communities. Hourly Nursing and Respite Care Services COORDINATION CARE PLAN 8 Care services include; talking at sitting with a disabled person, bathing, dressing, exercising, helping medication, helping the disabled get in and out of bed, assisting in travel lighting, housekeeping, and many others. Conclusion A preliminary coordination care plan is very important and more effective in managing chronic conditions. It provides a confident solution to the patient and also promotes teamwork. Patients should strictly follow the plan to manage their conditions. COORDINATION CARE PLAN 9 References Battle, C. L., Uebelacker, L., Friedman, M. A., Cardemil, E. V., Beevers, C. G., & Miller, I. W. (2010). Treatment goals of depressed outpatients: a qualitative investigation of goals identified by participants in a depression treatment trial. Journal of psychiatric practice, 16(6), 425. Cardoso, E. M., Reis, C., & Manzanares-Céspedes, M. C. (2018). Chronic periodontitis, inflammatory cytokines, and interrelationship with other chronic diseases. Postgraduate medicine, 130(1), 98-104. Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: findings from a cross-national mental health systems study—International Journal of Integrated Care, 18(3). Hannigan, B., & Simpson, A. ORCID: 0000-0003-3286-9846, Coffey, M., Barlow, S. ORCID: 0000-0002-2737-8287 and Jones, A.(2018). Care Coordination as Imagined, Care Coordination as Done: Findings from a Cross-national Mental Health Systems Study. International Journal of Integrated Care, 18(3), 12. Hallgren, M., Kraepelien, M., Lindefors, N., Zeebari, Z., Kaldo, V., & Forsell, Y. (2015). Physical exercise and internet-based cognitive–behavioral therapy in the treatment of depression: a randomized controlled trial. The British Journal of Psychiatry, 207(3), 227234. Jones, A., Hannigan, B., Coffey, M., & Simpson, A. (2018). Traditions of research in community mental health care planning and care coordination: A systematic meta-narrative review of the literature. PloS one, 13(6), e0198427. COORDINATION CARE PLAN 10 Nakimuli-Mpungu, E., Wamala, K., Okello, J., Alderman, S., Odokonyero, R., Mojtabai, R., ... & Musisi, S. (2015). Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-center randomized controlled trial. The Lancet H.I.V., 2(5), e190-e199. For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. NOTE: You are required to complete this assessment after Assessment 1 is successfully completed. Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life. This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem. You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment. DEMONSTRATION OF PROFICIENCY By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: • • • • • • Competency 1: Adapt care based on patient-centered and person-focused factors. o Design patient-centered health interventions and timelines for a selected health care problem. Competency 2: Collaborate with patients and family to achieve desired outcomes. o Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. Competency 3: Create a satisfying patient experience. o Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document. Competency 4: Defend decisions based on the code of ethics for nursing. o Consider ethical decisions in designing patient-centered health interventions. Competency 5: Explain how health care policies affect patient-centered care. o Identify relevant health policy implications for the coordination and continuum of care. Competency 6: Apply professional, scholarly communication strategies to lead patientcentered care. o o Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. PREPARATION In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature. To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2020. Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback. INSTRUCTIONS Note: You are required to complete Assessment 1 before this assessment. For this assessment: • Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan. Document Format and Length Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA formatted paper, 5–7 pages in length, not including title page and reference list. Supporting Evidence Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources. Grading Requirements The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed. • Design patient-centered health interventions and timelines for a selected health care problem. o o o • • • • • • Address three health care issues. Design an intervention for each health issue. Identify three community resources for each health intervention. Consider ethical decisions in designing patient-centered health interventions. o Consider the practical effects of specific decisions. o Include the ethical questions that generate uncertainty about the decisions you have made. Identify relevant health policy implications for the coordination and continuum of care. o Cite specific health policy provisions. Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. o Clearly explain the need for changes to the plan. Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document. o Use the literature on evaluation as guide to compare learning session content with best practices. o Align teaching sessions to the Healthy People 2020 document. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Additional Requirements Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course. Running Head: COORDINATING CARE Coordination Preliminary Care Plan Erik Hovsepyan Capella University 1 COORDINATION CARE PLAN 2 Introduction Care coordination serves to ensure that there is service integration for the satisfaction of individuals' needs in the medical field. Services that are collaborative and those that are focused on recovery connecting people to health care opportunities and services are the main provision of the care coordination plan. Coordination care has a necessity that is primary of chronically ill patients' management. A preliminary coordination care plan creates an illness challenge to social relation alteration and to identity that is personal and uncertain creation. Since an effect on one life sphere may affect the other sphere of life, it's very much worrying (Jones, Coffey, Hannigan, & Simpson, 2018). Chronic diseases cause social problems, which cause a tremendous and complicated impact on the provision of service to the patient calling for friends, family, and approaches that are multidisciplinary in the provision of care in dealing with the chronic condition that mostly seems more complicated to the patient. Solely reason provides that the patient problems that are interconnected should, on rare occasions, fall in the hand of one professional (Jones, Coffey, Hannigan, & Simpson, 2018). This, therefore, resorts to the creation of coordination plans and approaches that are multidisciplinary to get a solution to chronic patient concerns. In my new role as a health care coordinator in our health facility, I identify an individual from the community, and my coordination care plan for the coordination process with the client is as presented below. Coordination Care Plan COORDINATION CARE PLAN 3 Patient’s Details Patient Name: Terry Johnson Date of birth: 08/10/1995 Address: tjohnson@gmail.com Payor Source: Medical Insurance Company Secondary Source: Journals on medicine Preliminary Care Coordination Plan Health Concern On focusing on my care coordination plan of a patient known as Laetitia (not her real name), I identified depression as her health concern. Generally, depression is a mental health problem identified with an obstinately depressed state or lack of interest in a person's usual activities that prompt consequential damage to a person's everyday activities. Its possible causes comprise social, psychological, and biological distress sources. These factors might also bring about massive changes in the brain's functioning, including the alteration of activities of some mind neural circuits. Laetitia is clinically depressed because of her persistent sadness and lack of interest in her usual activities, thus characterizing a significant depression that has prompted a range of physical and behavioral symptoms. Some other symptoms she displays include changes in sleeping patterns, decreased appetite, reduced concentration, and self-esteem. It was also previously reported that Laetitia had, in the past, tried to commit suicide. COORDINATION CARE PLAN 4 However, several best practices can be applied to improve her health. One of these best approaches includes prescribing depression drugs known as antidepressant drugs for her. These drugs include the SSRIs, an abbreviation for Selective Serotonin Reuptake inhibitors, which are the most known choice since they are practical and have lesser side effects than older antidepressants. Other than SSRIs, other antidepressants that can be prescribed include escitalopram, citalopram, fluoxetine, paroxetine, and sertraline. Another best approach is to talk about therapy or psychotherapy. This is particularly effective when merged with antidepressant treatment. Other treatments like E.C.T. (electroconvulsive therapy), V.N.S. (vagus nerve stimulation) will only be used if she does not respond to both the talk therapy the antidepressant therapy approach. Also, this calls even on the intervention of her friends and family. This is because the collaboration and coordination of health sector resources and services are solely needed for a proper solution that is not based on only one professional. This, in turn, makes it very important to have a coordinated care plan for an appropriate and well-managed service coordination process. Treatment Plan Laetitia's treatment plan involves setting a few short-term and long-term goals to help her live the life she desires and manage her mental heal. Thus, this section of the paper mainly focuses on identifying the treatment goals set for Laetitia, seeking outpatient depression treatment. Some of the short-term goals include walking up by a particular time, completing the available household tasks, calling for support groups, introducing herself to new members in her workplace, exercising, and sticking to her everyday schedule. Long-term treatment goals include building or improving how she relates with her friends or family members, finding or keeping the job she enjoys, organizing her home, incrementing positive health activities like eating a COORDINATION CARE PLAN 5 healthy diet, and involving herself in community or volunteering services. Another long-term goal to get herself an encouraging support network as she works towards accomplishing these goals. One way of making this possible by having a responsible partner. A person that holds her responsible for accomplishing her goals and holds him for accomplishing his. This will improve her health condition in all ways. Available Community Resources and Services/Referrals There is a number of available community services; these services include; hosting of fundraising and donating money, requesting for charitable donations, charity walk and run participation, local non-profitable activities volunteering, offering free tutoring services, and many others. The community resources available for safe and effective continuum care for Laetitia include WebMD, a depression and mental health online community where she can search out for any available depression specialist within her region and discover a lot of timely data on depression from hospitals recommended by the WebMD doctors. There also mental health organizations like NAMI (National Alliance on Mental Illness) and the National Suicide Prevention Lifeline (NSPL). Nami is a mental health firm devoted to enhancing the lives of a lot of depressed Americans. NSPL, on the other hand, is a toll-free and private hotline for preventing suicide for anybody experiencing emotional distress or suicidal crisis. This will be of great help to Laetitia due to previous failed suicidal attempts. Other community resources available include: • Hospitals COORDINATION CARE PLAN 6 ✓ The patient's Community treatment hospitals that are available are; Cleveland clinic, Hero's hospital, Rochester clinic, John-Hopkins general hospital, Cedars Sinai Medical center, UCLA Center, and New York Hospital. • Education Services ✓ Education services available in the community include centers for training and instructions such as colleges, schools, training centers, and universities. • Rehabilitation Services ✓ Rehabilitation services in the community include; cognitive therapy, mental health rehabilitation services, language and speech therapy, and physical and occupational therapy. • Pharmacies ✓ The community's available pharmacies include; Kroger Company, Omnicare, Safeway, Supervalu Inc., Walgreens, and Walmart stores. • D.M.E. Equipment Providers ✓ D.M.E. (Durable medical equipment) providers in the community include; A.R.C. Distributors, A+ Products Inc, A.A.P. Implantate AG, Abbott, and Abilitation Inc. • Incontinence Service Providers ✓ Service providers in the Incontinence field include; Jerusalem hospital, Rawls King, Einstein Hope, Safeway, and Clean-path. • Parenteral Service and Enteral Nutrition Providers COORDINATION CARE PLAN 7 ✓ The community parenteral service providers include; The Walkers, Chasers Hospital, John-Hopkins general hospital, Cedars Sinai Medical center, UCLA Center, and New York Hospital. • Social Services • Social services available in the community include; food subsidies, education, police services, lobbying, community management adoption, job training, and fire services. • Transition Services ✓ There are vocational training and post-secondary education transitional services available in the community. • Transportation Services ✓ The available modes of transport include; roadways, railways, waterways, pipelines, and airways • Skilled Nursing Services ✓ The skilled nursing services include nurse skills under professional supervision for management, evaluation, observation of health conditions, and therapy treatment. Cultural Needs Cultural needs involve individuals’ cultural norms and norms which need to be considered, for example; Religious beliefs, customs, traditions, laws, and architectural style that highly varies among communities. Hourly Nursing and Respite Care Services COORDINATION CARE PLAN 8 Care services include; talking at sitting with a disabled person, bathing, dressing, exercising, helping medication, helping the disabled get in and out of bed, assisting in travel lighting, housekeeping, and many others. Conclusion A preliminary coordination care plan is very important and more effective in managing chronic conditions. It provides a confident solution to the patient and also promotes teamwork. Patients should strictly follow the plan to manage their conditions. COORDINATION CARE PLAN 9 References Battle, C. L., Uebelacker, L., Friedman, M. A., Cardemil, E. V., Beevers, C. G., & Miller, I. W. (2010). Treatment goals of depressed outpatients: a qualitative investigation of goals identified by participants in a depression treatment trial. Journal of psychiatric practice, 16(6), 425. Cardoso, E. M., Reis, C., & Manzanares-Céspedes, M. C. (2018). Chronic periodontitis, inflammatory cytokines, and interrelationship with other chronic diseases. Postgraduate medicine, 130(1), 98-104. Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: findings from a cross-national mental health systems study—International Journal of Integrated Care, 18(3). Hannigan, B., & Simpson, A. ORCID: 0000-0003-3286-9846, Coffey, M., Barlow, S. ORCID: 0000-0002-2737-8287 and Jones, A.(2018). Care Coordination as Imagined, Care Coordination as Done: Findings from a Cross-national Mental Health Systems Study. International Journal of Integrated Care, 18(3), 12. Hallgren, M., Kraepelien, M., Lindefors, N., Zeebari, Z., Kaldo, V., & Forsell, Y. (2015). Physical exercise and internet-based cognitive–behavioral therapy in the treatment of depression: a randomized controlled trial. The British Journal of Psychiatry, 207(3), 227234. Jones, A., Hannigan, B., Coffey, M., & Simpson, A. (2018). Traditions of research in community mental health care planning and care coordination: A systematic meta-narrative review of the literature. PloS one, 13(6), e0198427. COORDINATION CARE PLAN 10 Nakimuli-Mpungu, E., Wamala, K., Okello, J., Alderman, S., Odokonyero, R., Mojtabai, R., ... & Musisi, S. (2015). Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-center randomized controlled trial. The Lancet H.I.V., 2(5), e190-e199.
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