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NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Student Name

Capella University

NURS4050 Coord Patient-Centered Care

Prof. Name


Preliminary Care Coordination Plan

Care coordination is described as a holistic approach, which includes interdisciplinary collaboration to provide patient and family-centric care within the healthcare and community settings. Taking the expanded role of case management staff in Lodi Community Care Center, the focus of this assessment is to address the mental health concerns in the community. World Health Organization (2022) describes mental health as psychological and emotional well-being that assists individuals in addressing life stresses, recognizing their potential, and contributing positively to the community.

Like physical health, mental well-being is also integral to human health. Communities must take appropriate actions to address such issues if observed. This assessment focuses on analyzing mental health concerns and best practices for improving community health, developing SMART goals, and identifying resources for care coordination.

Analysis of Health Concern and Best Practices for Improving Health

Mental health issues have extended significantly in recent years due to their persistent impact on individuals and communities. It is estimated that 57.8 million people in the United States have mental health problems (U.S. Department of Health and Human Services, 2023). Several communities often stigmatize mental health issues, leading to underreporting and inadequate support for concerned individuals.

Common mental health issues include stress and depression, anxiety disorders, schizophrenia, and substance abuse problems. These issues affect the individual’s emotional well-being, physical health, relations, productivity, and overall quality of life. Some evidence-based best practices for improving mental health are; mental health education, therapeutic care approaches, and community support programs. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

  1. Mental Health Education/Literacy: The increasing prevalence of mental health issues in the recent world has advocated raising awareness about mental health in the population, preventing stigmatization, and normalizing discussions about one’s mental health. Mental health literacy involves providing accurate information about well-being and available resources, which can help reduce stigma and encourage help-seeking behavior (Sampaio et al., 2022). 
  2. Therapeutic Care Approaches: Evidence-based psychotherapies such as mindfulness, cognitive-behavioral therapy, and dialectical behavior therapy have effectively managed various mental health concerns like depression and anxiety. Moreover, they have significantly improved patients’ quality of life and mental health conditions (Cuijpers, 2019; Garrote‐Caparrós et al., 2022). 
  3. Community Support Programs: Support programs within the communities provide safe spaces for community members to share their concerns without being stigmatized. Support groups and mental health organizations within the communities can offer various programs and foster peer support among individuals with mental health challenges. 

Assumptions and Uncertainties

The underlying assumption in this analysis is that mental health is equally important as physical health, which is why evidence-based best practices should be utilized to improve community health. The areas of uncertainty are; the community’s perception of discussing mental health concerns, commitment from community leadership in bringing reforms, and individuals’ cultural and social barriers to addressing the challenges. 

Specific Goals for Addressing Mental Health Issues

To effectively address the mental health challenges within the community setting, it is imperative to develop realistic, measurable, and attainable goals. The following goals are established for our community. 

Goal 1 – Increase mental health awareness and literacy

The goal is to implement educational campaigns about various mental health issues, alleviate stigma, and promote the culture of sharing and discussing mental well-being. The aim is to increase mental health literacy by 70% among the community members and increase their willingness to engage in open discussions about particular health aspects. Social media and various apps are considered effective in promoting and creating mental health awareness as the use is widespread and minor information can be disseminated in a shorter period (Latha et al., 2020). Furthermore, collaboration with mental health support groups, community care centers, and healthcare organizations can be another way to design awareness campaigns. 

Goal 2 – Implement school-based mental health programs

Since school-going children and adolescents are at high risk for developing mental health issues, the establishment of school-based mental support programs is significant to reduce the number of incidences, recognize the signs of distress among the concerned population, and improve mental health literacy from early ages of life (Richter et al., 2022). The goal is to observe a 40-50% reduction in the rate of mental health illnesses among children and adolescents. For this purpose, mental health curriculum and a partnership between local schools and healthcare providers will be established to deliver the curriculum effectively. Moreover, mental health counseling services and support groups will be provided to affected individuals. 

Goal 3 – Enhance community support networks

Establishing support groups within the community will ensure that individuals dealing with mental health issues have a safe space to discuss their concerns, implement coping interventions to alleviate challenges, and improve their well-being. This is only possible if community and faith-based leaders actively commit to implementing the change. The goal is to develop at least five support groups by the end of the year and ensure members’ participation through data monitoring. In this regard, collaboration with mental health institutions, community health centers, and religious organizations is essential to facilitate the setup. Moreover, support from healthcare providers and mental health specialists is fundamental for the successful operation of these support groups.

Community Resources for Care Coordination

A holistic care coordination plan for mental health issues in community settings must be developed utilizing community resources so that the continuum of care is established and individuals are aware of support sources in crises. One such resource for adequate management of mental health concerns is mental health organizations. According to CDC, various organizations provide mental health services to community individuals.

These organizations are the American Psychiatric Association Foundation, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatry. These organizations provide various mental health support programs, psychiatrists and psychologists’ services, and educational resources, which can be used for awareness, treatment, and management purposes (CDC, 2023). Another community-based resource is helplines/hotlines, which provide immediate assistance to individuals in mental health crises. They are offering emotional support and guidance on accessing appropriate care.

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

One of the national helplines is the Substance Abuse and Mental Health Services Administration (SAMHSA) (U.S. Department of Health and Human Services, 2022). Other than these, resources like faith-based support groups, online mental health platforms (BetterHelp, Talkspace), school-based counselors, and non-profitable organizations (NPOs) are some accessible resources for community individuals to utilize for mental health services. 


In conclusion, mental health issues are significant health challenges within community settings due to stigmatization and non-acceptance within society. For this purpose, preliminary care coordination plans are essential to improve the mental well-being of community members. A similar care plan has been developed for the Lodi community. The goals are to increase mental health literacy, implement school-based programs, and ensure accessible and adequate community resources available for the members.

Some U.S.-based community resources that can be utilized are national mental health organizations, helplines, online mental health platforms, faith-based groups, and NPOs working for similar purposes. Overall, the care coordination plan is significant for improving the quality of life of people within the community. 


Centers for Disease Control and Prevention. (2023, April 27). Tools and resources. Centers for Disease Control and Prevention. 

Cuijpers, P. (2019). Targets and outcomes of psychotherapies for mental disorders: An overview. World Psychiatry18(3), 276–285. 

Garrote‐Caparrós, E., Bellosta‐Batalla, M., Moya‐Albiol, L., & Cebolla, A. (2022). Effectiveness of mindfulness‐based interventions on psychotherapy processes: A systematic review. Clinical Psychology & Psychotherapy29(3), 783–798. 

Latha, K., Meena, K. S., Pravitha, M. R., Dasgupta, M., & Chaturvedi, S. K. (2020). Effective use of social media platforms for promotion of mental health awareness. Journal of Education and Health Promotion9, 124. 

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Richter, A., Sjunnestrand, M., Romare Strandh, M., & Hasson, H. (2022). Implementing school-based mental health services: A scoping review of the literature summarizing the factors that affect implementation. International Journal of Environmental Research and Public Health19(6), 3489. 

Sampaio, F., Gonçalves, P., & Sequeira, C. (2022). Mental health literacy: It is now time to put knowledge into practice. International Journal of Environmental Research and Public Health19(12), 7030. 

U.S. Department of Health and Human Services. (2023, March). Mental illness. National Institute of Mental Health. 

U.S. Department of Health and Human Services. (2022, November). Help for mental illnesses. National Institute of Mental Health. 

World Health Organization. (2022, June 17). Mental health. World Health Organization. 

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