Final Care Coordination Plan

Final Care Coordination Plan

Patient health outcomes primarily depend on the interventions health care providers use to address a health care problem. Care coordination is paramount, as healthcare providers look forward to safer and more effective care. Interventions based on care coordination seek to empower and engage patients while sharing information with patients and those close to them to provide the best care possible. As discussed in assessment 1, the focus of the care coordination plan is trauma, with particular attention to trauma-informed care. The goal is to provide care that meets patients’ needs and ensure that patient’s values and preferences are integrated into the care plan. The purpose of this paper is to build on the preliminary plan to develop a more comprehensive care coordinated plan. Focus areas include patient-centered health interventions, ethical decisions, policy implications, and care coordination priorities.

Patient-Centered Health Interventions and Timelines

Trauma is characterized by disturbing and stressful emotions after a terrible event. Most events triggering trauma are unexpected, such as rape and accidents. Often, they change a person’s perception of issues and how they cope with challenges. Matheson et al. (2019) conjectured that shock and denial often precede other long-term emotional and psychological responses like flashbacks and relationship problems. Health care providers must be conversant with trauma manifestations, challenges, and strategies to provide patient-centered care.

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Patient-centered interventions respond to specific health care issues characterizing a health care problem. One of the major issues with individuals with trauma is a distorted psychological state. Ranjbar et al. (2020) explained that individuals with trauma are likely to re-experience the terrible event through nightmares and flashbacks, prompting them to avoid places associated with the terrible event. The second issue is vulnerability to other health care problems with lasting effects. Gerber (2019) noted that persistent trauma develops into post-traumatic stress disorder (PTSD). Depression is also typical in people with trauma. The third issue is the lack of immediate support. People with trauma are segregated, increasing their mental distress (Matheson et al., 2019). Segregation also makes it difficult for individuals with trauma to access resources when needed.

Background reflection of the typical health care issues for individuals with trauma helps develop interventions that address specific needs with definite timelines. The most effective intervention to deal with the distorted psychological state is improved knowledge about triggers and therapy. Through information, individuals with trauma understand their problem in more detail and how to cope with it. Therapy, particularly cognitive-behavioral therapy (CBT), helps patients change their thought patterns to positively influence their behaviors and emotions (Possemato et al., 2019). CBT is the highly recommended non-pharmacological intervention to help people cope with trauma. In a coordinated practice, knowledge building through information can take three months. CBT can take the same period or more depending on symptoms and comorbidities.

Vulnerability to other health care problems impeded recovery. An effective intervention is self-care and support to ensure that individuals live in a safe and comfortable environment. Self-care includes eating healthily and exercising while avoiding activities and places that can trigger trauma. Individuals with trauma can learn self-care tips in four one-hour sessions. It should take approximately two weeks to increase the recovery period as much as possible. Lack of immediate support can be distressing, particularly when associated with segregation. Self-care tips can help a patient to live under such conditions. They can also be educated about available resources such as peer support and how to connect in a broader community. Knowledge and skills-building can take approximately one month.

Community resources for trauma and trauma-related care are widespread. They vary depending on the locality, types of problems handled, and objectives. In most cases, community resources can be used interchangeably to support the patient and promote comprehensive recovery. The same case applies to trauma care. Peer support groups are a reliable community resource for improving knowledge about triggers and productive living. Health care providers can help individuals with trauma connect with peers facing similar challenges in their respective communities. In peer support groups, individuals share experiences and give each other hope (Possemato et al., 2019). Family members and friends are a reliable resource for ensuring that individuals with trauma live in safe and comfortable environments. As a result, trusted family members should be included in the coordinated care plan. The other important resource is helplines and information apps. Most are nationally-based, but a significant number addresses a specific population’s needs. Patients should use such resources for everyday support and tips to avoid health complications.

Ethical Decisions in Designing Patient-Centered Health Interventions

The coordinated care plan for trauma-informed care comprises four main areas/goals. The first area is enhancing knowledge about trauma to enable the traumatized individual to understand why some reactions occur. The second priority area is reestablishing safety, where the individual with trauma gets assistance to restore their sense of safety. The third area is enabling traumatized individuals to develop healthy coping skills to respond to feelings, thoughts, and triggers more effectively. The fourth area is decreased traumatic stress symptoms after empowering the patient with knowledge, skills, and resources to cope with the problem. However, no intervention or decision can be made without involving patients and understanding how they perceive the problem and barriers that impede recovery.

To achieve the desired outcomes, health care providers must understand the importance of culturally-sensitive care and why it should dominate trauma care. For instance, religious and cultural beliefs affect how patients perceive trauma and are significant barriers to mental health care (Ranjbar et al., 2020). Health care professionals should ensure that assessment, treatment methods, and resources are culturally-sensitive. Patients’ values and preferences should also be examined and integrated into the care plan. The other ethical consideration is respect for individuals. DeCamp et al. (2018) advised health care providers to respect a patient’s ability to make free and informed choices about care. The same approach should be used to ensure that traumatic patients adhere to all interventions and recommendations.

Health care providers make decisions based on the patient’s needs. However, uncertainty is typical since it is challenging to establish whether the patient can follow all the recommendations as advised. The other ethical question is whether the treatment plan adheres to the patient’s values, preferences, and unique needs. Another question that can generate uncertainty is whether the health care problem was examined from all dimensions to prevent the development of other conditions that can complicate the patient’s health.

Policy Implications for the Coordination and Continuum of Care

Many factors influence patient care delivery, including the type of care that patients should receive, patient-provider relationships, and support beyond the organizational settings. Health policies imply that there are goals, actions, and decisions that determine patient care administration and access (Edemekong et al., 2018). Regarding coordination and continuum of care, health policies provide guidelines to ensure that patient care benefits patients and the health care system. Relevant health care providers should also collaborate to optimize coordination, enhance communication, and reduce human error.

Specific healthy provisions for trauma care coordination include patient care policies and security and privacy policies. Patient care policies outline how health care professionals should respond to a specific health care problem. A suitable example is an organization-based policy emphasizing a trauma-informed approach, which ensures the patient is more involved in health care to improve the patient-provider trust (Gerber, 2019). Security and privacy policies guide health care providers in handling situations that pose security threats. For instance, the HIPAA privacy rule protects patient information access by unauthorized users (Edemekong et al., 2018). Care for traumatized patients should follow such policy recommendations.


Priorities When Discussing the Plan

In trauma-informed care and other comprehensive care plans that engage a patient and family, a care coordinator must prioritize some elements when discussing the plan. One of the priority areas is the patient’s knowledge to adhere to the care plan. The second priority is the availability of support and resources at home. Since family members determine the safety and comfort of a patient at home, care coordinators must ensure that the home environment is as supportive as possible. Barriers to effective care should be identified as the care coordinator, family, and patient outline strategies to address such barriers. The other priority area is the severity of the condition. The patient and family members need to understand symptoms and triggers and appropriate responses.

Changes to the coordination plan would be necessary when the plan does not promote patient-centered care. For individuals with trauma, patient-centered care respects the patients’ view of the trauma, cultural values, and expressed needs (Godat et al., 2020). The patient should also get maximum emotional support to alleviate fear and anxiety. The other consideration for patient-centered care is the involvement of the family and friends. As a result, changes in the plan would be inevitable if the patient does not get support, information, and education.

Learning Session Content with Best Practices

The primary objective of a learning session is to empower individuals with trauma to cope effectively and prevent re-traumatization. Accordingly, the first content area should be triggers and how to live in environments that suppress the triggers. The second content area is coping strategies. Amnie (2018) recommended healthy eating, exercises, and meditation as effective coping strategies. Individuals with trauma should be educated on using such strategies as situations necessitate. The third content area is resources and support. Martinez et al. (2020) argued that education and counseling on trauma should allow patients to express themselves as much as possible. It should be among best practices besides others, such as relationship building and a time for questions and answers.

The Healthy People 2030 document looks forward to a healthy populace. Overarching goals include enabling people to attain healthy lives and well-being and health literacy to improve people’s well-being (Healthy People 2030, n.d.). Aligning teaching sessions to the Healthy People 2030 goals would require a care coordinator to prioritize content that enables patients to live healthy lives. Improving literacy would be achieved by ensuring that patients have adequate educational materials and information on where to access information and tips regarding their health. Overall, Healthy People 2030 has elaborate objectives to improve health and well-being over the next decade. Revisions will only be needed if new health care challenges emerge and require data-driven national objectives not included in the document.



Care coordination seeks to meet patient needs and deliver high-quality care. Regarding trauma and trauma-related care, care coordinators should understand patients’ needs comprehensively and ensure that the care plan responds effectively. As discussed in this paper, care coordination should consider patient-centered health interventions with measurable and attainable goals. Health care coordinators must also ensure that decisions made in designing patient-centered health interventions are ethical. Priorities when discussing the plan with a patient and family member include the patient’s knowledge, support and conditions of the home environment, and severity of the health problem.




Amnie, A. G. (2018). Emerging themes in coping with lifetime stress and implication for stress management education. SAGE open medicine6, 2050312118782545.

DeCamp, M., Pomerantz, D., Cotts, K., Dzeng, E., Farber, N., Lehmann, L., Reynolds, P. P., Sulmasy, L. S., &Tilburt, J. (2018). Ethical Issues in the design and implementation of population health programs. Journal of General Internal Medicine33(3), 370–375.

Edemekong, P. F., Annamaraju, P., &Haydel, M. J. (2018).Health insurance portability and accountability act. StartPearls [Internet].

Gerber, M. R. (Ed.). (2019). Trauma-informed healthcare approaches: A guide for primary care. Springer.

Godat, L. N., Jensen, A. R., & Stein, D. M. (2020). Patient-centered outcomes research and the injured patient: A summary of application. Trauma Surgery & Acute Care Open5(1), e000422.

Healthy People 2030.(n.d.).Healthy People 2030 framework.’s%20overarching%20goals,and%20well%2Dbeing%20of%20all.

Martinez, Jr, R. R., Gavin Williams, R., & Green, J. (2020).The role of school counselors delivering a trauma-informed care approach to supporting youth in foster care. Professional School Counseling23(1), 2156759X20947747.

Matheson, K., Foster, M. D., Bombay, A., McQuaid, R. J., &Anisman, H. (2019). Traumatic experiences, perceived discrimination, and psychological distress among members of various socially marginalized groups. Frontiers in Psychology10, 416.

Possemato, K., Johnson, E. M., Emery, J. B., Wade, M., Acosta, M. C., Marsch, L. A., Rosenblum, A., &Maisto, S. A. (2019). A pilot study comparing peer supported web-based CBT to self-managed web CBT for primary care veterans with PTSD and hazardous alcohol use. Psychiatric Rehabilitation Journal42(3), 305–313.

Ranjbar, N., Erb, M., Mohammad, O., & Moreno, F. A. (2020). Trauma-informed care and cultural humility in the mental health care of people from minoritized communities. Focus18(1), 8-15.

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.


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 2030 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 Address three health care issues.
o Design an intervention for each health issue.
o 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 2030 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 2030 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

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