Mental health disorders such as depression, anxiety, schizophrenia, and bipolar disorder are increasingly prevalent and constitute immense public health concerns. These conditions substantially impair the quality of life across physical, psychosocial, occupational, and functional domains (Walker et al., 2015). Mortality rates are also significantly higher among those with mental illness compared to the general population (Hjorthøj et al., 2015). Careful coordination across specialities is imperative for improving outcomes and continuity of care.
This final care plan expands upon the preliminary coordination plan to fully address key health issues and evidence-based interventions for adults with mental health disorders. Details on associated ethical considerations, health policies, patient/family communication priorities, community resources, timeline/evaluation specifics, and connections to Healthy People 2030 goals are also provided. The overarching focus is crafting integrated, holistic care centred on individual patient needs, preferences, safety, and shared decision-making.
Health Care Issues and Interventions
Poor Physical Health & Increased Mortality
As outlined in Assessment 1, mental health conditions are tied to higher risks of preventable mortality and comorbid physical illnesses like cardiovascular disease, respiratory disease, diabetes, and hypertension (Druss et al., 2011). The life expectancy gap for those with serious mental illness spans 10-32 years lower than the general population (Walker et al., 2015). Reasons include higher smoking rates, obesity, inactivity, substance abuse, and inadequate access to medical services. Successfully addressing this mortality/morbidity disparity requires focused coordination between mental, physical, and social services.
Interventions:
- Depression/health screenings every visit
- Smoking cessation counselling/meds if needed
- education on heart health, diet, exercise, medication adherence
- Active collaboration with PCPs to coordinate medications and diagnose/treat any emerging conditions early
- Home health referrals for personal care assistance if needed
- Encourage engagement with meaningful activities and social ties
Community Resources:
- Outpatient clinics with integrated mental/physical health services
- Wellness/fitness centers with behavioural health supports
- Home health/public health nursing agencies
- Smoking cessation programs (1-800-QUIT-NOW helpline)
- Meals on Wheels assistance with nutrition
Poor Medication & Treatment Adherence
Medication non-adherence rates in mental health range from 50-80% (Gadkari & McHorney, 2012). Reasons include forgetfulness, complex regimens, intolerable side effects, lack of perceived benefit, stigma concerns, cost issues, ambivalence towards diagnosis, and distrust in treatment. Unfortunately, poor adherence leads to worse symptoms, lower functioning, more hospitalizations, and higher mortality in this population. Care coordination plays a vital role in sustaining engagement.
Interventions:
- Incorporate patient preferences/goals into medication decisions
- Provide education on purpose and expectations for medications
- Evaluate barriers to adherence at each encounter
- Utilize adherence aids like pillboxes, alarms, or phone apps as needed
- Schedule frequent follow-ups after medication changes
- Develop plans managing side effects
- Connect patients to peer support services
- Discuss lower-cost medication options if cost is an issue
Community Resources:
- Behavioral health case managers to coordinate care goals
- Peer support groups to discuss medication experiences
- Pharmaceutical patient assistance programs
- GoodRx and SingleCare prescription discounts
- Medicaid health insurance options
Recurring Crisis Episodes/Hospitalizations
Frequent psychiatric crisis episodes requiring ER visits or hospitalization are common for some patients and massively disrupt functioning and recovery. Contributing factors range from medication non-adherence and dual diagnoses to loss of housing, lack of crisis planning by outpatient providers, and gaps bridging community services (Chun Tie et al., 2019). Care coordination should aim to prevent cyclical acute flare-ups.
Interventions:
- Ensure psychiatrist follow-up after hospital discharge.
- Develop WRAP crisis prevention plans outlining triggers and coping strategies
- Have crisis hotline numbers and urgent care options readily available
- Connect patient to ACT or intensive community resources if needed
- Screen frequently for risks like substance use disorder or suicidal thinking
- Provide education on early warning signs of instability
- Update the case manager with any adherence issues or emerging problems
Community Resources:
- Crisis stabilization units, psychiatric urgent care centers
- WARM peer support lines
- Alcoholics Anonymous or Narcotics Anonymous meetings
- Assertive community treatment (ACT) teams
- Bridge housing for post-discharge transitions
Ethical Considerations
Providing patient-centered care coordination that respects autonomy and builds therapeutic partnerships supports core ethical principles of beneficence, nonmaleficence, and justice (Ganzini et al., 2013). However, difficulties balancing different stakeholder priorities create uncertainties. For instance, family members may request more disclosure of health details than patients are comfortable sharing, given privacy laws. Hospitals may discharge unstable patients prematurely due to cost pressures before optimal community supports are secured. Rigid case manager caseloads could limit time addressing individual priorities.
Care coordinators also face challenges getting patients needed mental health services due to state budget cuts or poor coverage for non-medical therapies through some insurance plans. Such barriers that perpetuate disparities generate moral distress about the ability to advocate effectively within broken systems. Careful reflection about whose interests are being served and open communication with patients about constraints can help mitigate integrity concerns. The tension between paternalistic attitudes and respect for autonomy is another recurring tension requiring dialogue and shared decision-making.
Health Policy Considerations
Several health policies shape care coordination processes for mental health patients. The Affordable Care Act expanded access to insurance coverage through Medicaid expansion and essential benefit inclusion of mental health services (Creedon et al., 2022). Requirements to integrate physical and behavioural care also prompted a collaboration between previously siloed providers. HIPAA and 42 CFR Part 2 regulations govern patient privacy and record-sharing permissions between entities.
The Excellence in Mental Health Act increased Medicaid reimbursements for community behavioural health clinics to expand access. State policies on involuntary treatment, scope of practice for coordinators, and reentry linkages after incarceration likewise influence care realities. Understanding this landscape helps navigate policy barriers impeding care.
Communication Priorities with Patients/Families
Talking openly with patients and family members is key to good care coordination. When first meeting patients, coordinators should focus on building trust by actively listening to understand their situation, needs, values and views of their health issues (Kraszewski & Mcewen, 2013); as trust grows over time, coordinators can act as interpreters, understandably explaining complicated health system processes and providing informational and emotional support.
It is important to regularly update patients and families on things like:
- Progress with connecting to local health services
- Benefits and risks of different treatment options
- Changes in medications
Coordinators should find out caregivers’ abilities and clarify expectations around roles. Building these partnerships is linked to better medication adherence and the use of preventive health services. Conversations should focus on setting goals that align with what matters most to the patient rather than just telling them what to do. Being adaptable to life changes or differences in willingness to engage in care over time is essential, too.
Evaluation & Learning Best Practices
Comparing care coordination interventions to best practices established in the literature is key for quality appraisal. Benchmarking tools like Care Coordination Quality Indicators, including components for proactive planning, clear communication, community linkages, family support, cultural competence, and EHR coordination, help structure evaluation (McDonald et al., 2007). Patient satisfaction surveys and coordination competency self-assessments also give useful insight.
Aligning learning principles with evidence on adult education best practices enhances outcomes as well. Andragogy frameworks emphasize the need for patient health education curriculums covering mental illness itself, treatment options, crisis planning, lifestyle factors, and navigating systems issues to be highly interactive, build on prior experience, provide just-in-time resources, identify learner-defined problems, and promote self-directedness. Teaching sessions around medication specifics, warning signs identification, WRAP tools, or nutrition can all help strengthen maintenance functioning.
Tying this patient and caregiver education ethos to wider public health promotion priorities per Healthy People 2030 supports population orientation for supporting community-living challenges to reduce risk factors and improve quality of life across ability, age, socioeconomic, racial and geographic groups. Goals spanning mental health stigma reduction, community integration, homelessness alleviation, criminal justice diversion, health literacy advancement, health technology expansion and building resilience all reinforce a systemic lens integrating individual and social determinants of recovery (Healthy People, 2030). Evaluating the impact of care coordination demands considering both micro- and macro-level contributors.
Conclusion
Adults with mental illness face disproportionate risks for mortality, co-occurring conditions, crisis episodes, and inadequate quality of life. These health issues often arise from fragmented systems lacking integrated services centered on holistic needs. Effective care coordination can help remedy such gaps by establishing meaningful partnerships, prioritizing individual preferences and dignity, leveraging community resources, evaluating processes against evidence-based practices, and aligning services with broader health equity promotion efforts per Healthy People 2030. As key advocates bridging medical and social service divides, care coordinators play instrumental roles in transforming lives by fostering empowerment, functioning, and longevity in one of society’s most stigmatized and underserved populations.
References
Chun Tie, Y. L., Birks, M., & Francis, K. (2019). Grounded theory research: A design framework for novice researchers. SAGE open medicine. https://doi.org/10.1177/2050312118822927
Creedon, T. B., Zuvekas, S. H., Hill, S. C., Ali, M. M., McClellan, C., & Dey, J. G. (2022). Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid. Health Services Research. https://doi.org/10.1111/1475-6773.14034
Druss, B. G., Zhao, L., Von Esenwein, S., Morrato, E. H., & Marcus, S. C. (2011). Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical care, 599-604. https://pubmed.ncbi.nlm.nih.gov/21577183/
Gadkari, A. S., & McHorney, C. A. (2012). Unintentional non-adherence to chronic prescription medications: How unintentional is it really? BMC Health Services Research, 12(1), 1-10. https://pubmed.ncbi.nlm.nih.gov/22510235/
Ganzini, L., Dennison, L. M., Press, N., Bair, M. J., Helmer, D. A., Poat, J., & Dobscha, S. K. (2013). Trust is the basis for effective suicide risk screening and assessment in veterans. Journal of General Internal Medicine, 28(9), 1215–1221. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3744302/
Healthy People 2030. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.). https://health.gov/healthypeople
Hjorthøj, C., Østergaard, M. L., Benros, M. E., Toftdahl, N. G., Erlangsen, A., Andersen, J. T., & Nordentoft, M. (2015). Association between alcohol and substance use disorders and all-cause and cause-specific mortality in schizophrenia, bipolar disorder, and unipolar depression: a nationwide, prospective, register-based study. The Lancet Psychiatry, 4(9), 801-808.
Kraszewski, S., & Mcewen, A. (2013). Communication skills for adult nurses. New York McGraw Hill Professional.
Walker, E. R., McGee, R. E., & Druss, B. G. (2015). Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA psychiatry, 72(4), 334-341. https://pubmed.ncbi.nlm.nih.gov/25671328/
write