Student Name
Capella University
NURS-FPX4065 Patient-Centered Care Coordination
Prof. Name
Date
Preliminary Care Coordination Plan
Wellness and Disease Prevention
During my practicum experience, I observed a range of health promotion and disease prevention strategies that were closely aligned with the social determinants of health affecting the local population. Key barriers included limited access to mental health services, stigma surrounding mental illness, unemployment, and financial instability. In response, the practicum site implemented several targeted interventions such as community outreach initiatives, mindfulness-based stress reduction programs, psychoeducational group sessions, and telehealth services to improve accessibility. Preventive screenings for depression and anxiety were routinely conducted during primary care visits, followed by referrals to behavioral health specialists and support groups when necessary. These strategies facilitated early identification of mental health concerns and contributed to reducing stigma by normalizing conversations around psychological well-being.
From a professional nursing perspective, this experience emphasized the importance of integrating mental health promotion into routine care. It reinforced the understanding that nursing responsibilities extend beyond clinical treatment to include addressing socioeconomic influences on health outcomes. Exposure to interprofessional collaboration further highlighted the value of culturally sensitive and team-based approaches in minimizing disparities. This practicum strengthened my commitment to holistic care models that prioritize prevention, education, and community support.
Key Observations and Professional Implications
| Observed Interventions | Purpose | Professional Insight |
|---|---|---|
| Mental health screenings | Early detection of depression/anxiety | Importance of preventive care |
| Telehealth services | Improved access for underserved populations | Role of technology in equity |
| Psychoeducation groups | Increase awareness and reduce stigma | Value of patient education |
| Community outreach | Address social determinants | Nurse as community advocate |
Chronic Disease Management
The practicum setting demonstrated effective integration of interprofessional, team-based care in managing chronic mental health conditions such as stress-related disorders and substance use disorders. The care team consisted of nurses, psychiatrists, psychologists, social workers, and case managers, all collaborating to develop individualized treatment plans. Nurses were primarily responsible for patient education and ongoing monitoring, while social workers addressed external barriers such as housing instability, unemployment, and transportation challenges. Psychiatrists and psychologists managed diagnosis and medication adjustments, and case managers ensured continuity of care through follow-ups and community referrals.
Additionally, preventive interventions such as routine screenings, counseling services, support groups, and telehealth platforms were integrated into chronic care management. These measures enhanced early identification of mental health concerns and improved patient adherence to treatment plans. They also fostered resilience by encouraging open discussions about mental health.
NURS FPX 4065 Assessment 2 Preliminary Care Coordination Plan
As a professional nurse, this experience reinforced the necessity of interdisciplinary collaboration and advocacy for equitable mental health care. It highlighted the importance of integrating prevention into chronic disease management and addressing broader social and economic determinants to ensure patient-centered care.
Interprofessional Roles in Chronic Disease Management
| Team Member | Primary Role | Impact on Patient Care |
|---|---|---|
| Nurses | Education and monitoring | Improved adherence and awareness |
| Psychiatrists/Psychologists | Diagnosis and treatment planning | Optimized clinical outcomes |
| Social Workers | Address social barriers | Reduced external stressors |
| Case Managers | Care coordination | Continuity and follow-up |
Regenerative and Restorative Care
During the practicum, I observed restorative care approaches in the acute management of severe mental health conditions, including major depression, acute psychosis, and suicidal ideation. Immediate priorities included ensuring patient safety, conducting comprehensive mental health assessments, and initiating crisis intervention strategies. Collaborative efforts among nurses, psychiatrists, and social workers enabled the rapid development of treatment plans, including medication management, counseling, and referrals to crisis services or inpatient care when necessary.
A key component of care was the use of therapeutic communication techniques to de-escalate patient distress and foster a sense of safety. Structured interventions such as group therapy sessions, psychoeducation, and daily care planning contributed to emotional stabilization and early recovery.
NURS FPX 4065 Assessment 2 Preliminary Care Coordination Plan
The practicum site also implemented the Illness Management and Recovery (IMR) model, which focused on empowering patients through education, coping strategy development, relapse prevention, and strengthening social support systems. Unlike traditional models that emphasize symptom control בלבד, IMR promotes a comprehensive, patient-centered approach that encourages autonomy and long-term recovery.
From a professional standpoint, this experience underscored the importance of timely, compassionate, and evidence-based care in acute mental health settings. It reinforced the nurse’s role in creating a safe therapeutic environment and supporting patient dignity. Furthermore, it highlighted how restorative care not only addresses immediate crises but also builds resilience and supports reintegration into daily life.
Hospice and Palliative Care
In the context of hospice and palliative care, I observed care strategies tailored to individuals with advanced mental illness, including severe dementia, treatment-resistant depression, and coexisting psychiatric and terminal medical conditions. The primary focus was on preserving patient dignity, ensuring comfort, and providing emotional support to both patients and their families.
Nurses played a central role in symptom management, addressing issues such as anxiety, agitation, and emotional distress while maintaining a calm and supportive environment. Therapeutic presence, active listening, and family counseling were essential components of care, helping families navigate the emotional complexities associated with end-of-life situations. Collaboration with an interprofessional team—including social workers, chaplains, psychiatrists, and palliative care physicians—ensured comprehensive support addressing physical, emotional, and spiritual needs.
This experience deepened my understanding of the nurse’s role in end-of-life care, particularly in prioritizing quality of life when curative treatment is no longer feasible. It reinforced the importance of compassion, dignity, and holistic care approaches. Additionally, it highlighted the need to address emotional suffering and reduce stigma associated with mental illness, even in palliative contexts. Ultimately, this practicum strengthened my commitment to providing empathetic, patient-centered care during the most vulnerable stages of life.
References
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). ANA Publishing.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Illness management and recovery: Evidence-based practices toolkit. U.S. Department of Health and Human Services.
NURS FPX 4065 Assessment 2 Preliminary Care Coordination Plan
World Health Organization. (2022). Mental health and social determinants of health. https://www.who.int
National Institute of Mental Health. (2023). Mental health information and resources. https://www.nimh.nih.gov