PSYC 5304 Design a Collaborative Care Model for a Community Health Center

PSYC 5304 Design a Collaborative Care Model for a Community Health Center

PSYC 5304 Design a Collaborative Care Model for a Community Health Center

The need for improved patient outcomes in patient care settings and populations in communities has led to the establishment of various approaches aimed at achieving such goals (Lazarus et al.,2022). One approach which has gained considerable attention in recent times is the use of a collaborative care model, which entails an integration where consultants, care managers, and primary care providers operate together with the major focus on monitoring and providing care to patients (Shaw et al.,2019). Such an approach can be useful, especially in cases where there is a disconnect between the providers and the healthcare professionals regarding care provision. In recent years, programs that apply the collaborative care model have been shown to achieve improved patient and community outcomes and reduced costs in various aspects of care. As such, the purpose of this assignment is to formulate a collaborative care model within a local community health center in an at-risk neighborhood. Various aspects will be discussed, including a description of the current population, an interpretation of the current operations, the proposed collaborative model and implementation plan, and the relevant policies.

The Current Population

The local health community is located in a rural area, with the healthcare facility serving mainly the local community. The current population living in the community is predominantly people of color, even though there are also a considerable number of Hispanic whites. The economic status of the current population can be described as below average, as the majority barely live above the poverty line. The implication is that a considerable number of the people in this community are semi-educated, with a few having managed past secondary education hence poor health (Donkin et al.,2018). The community also has a substantial number of immigrants who have their native languages as their native language. Therefore, many of them are in the process of learning to speak fluent English. They are focused on taking their children to school with the major aim of improving their living conditions.

The low economic and social status of the individuals living in this community means that the majority of them do not have medical insurance which is a major hindrance to their accessing healthcare and treatment (Artiga & Hinton, 2019). Therefore, there have been several initiatives in the local community to raise awareness of the importance of having medical insurance coverage. However, their economic disadvantage is still holding several of them back, and they are incapable of obtaining appropriate medical or insurance coverage. Consequently, the community members have been facing various chronic conditions.

One of the predominant chronic conditions experienced by the current population is obesity. A close assessment of the community members revealed that these individuals have various factors which increase their chances of acquiring obesity as a condition. In deeds, a considerable percentage of children and adults are currently obese. Among the factors that have contributed to the condition are their cultural beliefs, customs, and behaviors (Chatham & Mixer, 2018). For example, the members of the community use carbohydrates as their major source of food and consume carbohydrate-rich food at least twice a day, and almost always, carbohydrates form part of their meals. The children also tend to value a sedentary lifestyle and spend most of their non-school days indoors, either watching television or playing computer games. One of the major contributing factors to such a behavior is that the children lack any fields which they can use to run and play as the fields have been occupied mostly by surrounding industries.

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An assessment of the current state of the community members revealed that the adult population is concerned

PSYC 5304 Design a Collaborative Care Model for a Community Health Center
PSYC 5304 Design a Collaborative Care Model for a Community Health Center

with their general way of life, and some express fears that there is a big difference between the foods they have found in the US and what they used to eat in their native land. Therefore, they feel that it would be better if they could seek better medical access and attention to help them better improve their overall health. The community members also expressed fears and concerns that they have been experiencing difficulty in getting appropriate care to help them with their chronic conditions, such as obesity. Quizzed further on why such is happening, the community leaders indicated that there is a lack of communication between the current health professionals. A lack of communication between professionals can impact patient outcomes negatively (Gittell et al.,2020). One of the residents gave an example of a case when a group of healthcare professionals visited them to look into their chronic condition cases. While they were willing to help, especially two of his children who were obese, they never bothered to ask if there was any group currently attending to them. In reality, there is a group who had visited them some two weeks earlier and had taken up their case and given them the first round of education tips on the best way to manage obesity.

The Current Operations of the Community Health Centers

The community health centers have various operations which can support at-risk individuals and the vulnerable population. The centers have general and primary care teams. These teams are composed of nurse practitioners and general practitioners, as well as other multidisciplinary primary care team members who undertake important functions in this setting. As far as obesity is concerned, they are expected to lead in the timeous identification of obesity and overweight complication, offer advice to the patient, and give initial management. They are also expected to give referrals to specialists and arrange for follow-ups and offer ongoing support.

Even though there are specialists who can collaborate to ensure that chronic conditions such as diabetes among the members of the community are well managed, there is a lack of sufficient gap or needs assessment regarding the resources or programs which can be beneficial to the members of the community. Such gaps can negatively impact care coordination (Swan et al.,2019). There is also no clear framework for identifying the professionals who are willing to collaborate and participate in obesity management programs. It is also important to note that obesity care is not the major focus of these healthcare facilities, which can partially explain the disconnect between the healthcare professionals who are willing to participate in obesity management. The community health centers also have qualified healthcare professionals, as has been highlighted earlier; however, there is a glaring lack of training and education of the care team regarding obesity management, which raises ethical concerns.

Currently, when a patient reports to the community health center with health complications related to obesity or overweight, necessary examinations are performed by a general practitioner physician who then decides the next course of action to take. This is where the first problem appears as these healthcare professionals make such decisions alone without consulting. The result is that, at times, local management is indicated when a referral could have been a better option. This, in turn, leads to poor outcomes (Vimalananda et al.,2018). Besides, in the process of formulating the management plan, the patients and their families are rarely involved. Hence patients find it difficult to participate in such treatment and management plans. As earlier indicated, there is little communication between the healthcare professionals who handle the patients with obesity, as obesity is not a major focus of the facility.

The complaints from the community members have been that they don’t get as appropriate care as they should. It is important to note that this complaint has mainly been among patients with obesity and those who are overweight. Indeed, they have reported stigma, and they feel vulnerable since there is no single day set for an obesity clinic as in other chronic conditions such as diabetes. As part of the facility’s policies, patients with obesity and in need of intensive care are usually referred to other facilities located out of the community without any transportation or care coordination help. The result is that most of these community members prefer remaining in the community and suffering the consequences. This has also led to ethical violations, violating the patients’ rights to appropriate care access, beneficence, and nonmaleficence.

The Proposed Collaborative Model

A collaborative care model can be key in improving patient outcomes when patients are not getting appropriate care from the concerned individuals or professionals. Therefore, it is important to come up with a proposed collaborative care model which can be used to improve patient outcomes among the described populations.  The proposed collaborative care model targets an integration where consultants, care managers, and primary care providers operate together with a major focus on monitoring and providing care to patients (Danielle et al.,2021). As part of the model, the population will actively be engaged in self-management support, health behavior improvement, and prevention of obesity to ensure that the population gets appropriate care as needed. The major focus of the model will entail the prevention of future weight gain and supporting the already obese individuals to prevent them from developing obesity or overweight complications. However, the primary aim of the model is to offer timely identification and intervention before the problem of obesity progresses. Therefore, through a collaboration between the healthcare professionals in the community healthcare centers, the population will be stratified into groups that reflect their levels of risk. In addition, depending on the levels of risk, a different kind of intervention will be used. Such an approach will require a high level of engagement between the professionals as well as proactive efforts to improve patient outcomes related to obesity.

As part of the model, there will be various tiers of management of the condition. For example, there will be a primary level tier which is the first level of contact for the population with the proposed plan of care. Professionals who will be involved in this tier are the community health workers, nurses, and general practice teams. At the primary level, the model will focus on offering accessible, integrated, and high-quality obesity care and management services while focusing on the needs of the local population. The next level will be the secondary level which will only entail referrals. As part of the proposal, it is envisioned that primary care will be offered by highly qualified personnel; hence there will be little need for referrals.

From the population health perspective, it is expected that children, adolescents, and adults will have various levels of obesity complexity as well as risk, hence needing various healthcare services, which will majorly be provided within primary care. As part of the model, the care to be offered will be individual-centered. The implication is that the professionals will collaborate to offer appropriate care at the right time and place while building such care services around the individual’s needs. The application of various evidence-based tools, such as the Edmonton Obesity Staging Systems for adults and children, will be key in classifying individuals for better services (Hadjiyannakis et al.,2019). To make the care more appealing and effective, the collaborating healthcare professionals will be expected to engage in non-stigmatizing, non-judgemental, and respectful conversations and actions. In addition, they are not to discriminate against individuals of their body size.

Central to this model is the coordination of care. All the healthcare professionals across all the social and healthcare settings will be encouraged to actively participate in the care and management of obesity among this population. For example, they will be expected to fulfill various obligations key to early identification of obesity and overweight. As part of the model, they will also be required to participate in the life-long support of these patients by offering a spectrum of services that support continuity of care throughout the whole program. Equity will also be a guiding principle in this model as the collaborating professionals will be expected to apply the principle of equity when offering services to this population (Gunderson et al.,2018). They will be expected to be careful with aspects such as possible waiting lists for individuals who need specialist care and services and individuals who need additional support and interventions due to factors such as age and other comorbidities.

The Implementation Plan

Implementation is arguably the most important phase of any project, and therefore, it is no different in the case of the collaborative care model (Kokorelias et al.,2019). As earlier indicated, the major focus of this model is to ensure that the described population gets adequate services, especially in relation to chronic conditions can improve the levels of communication and collaboration between healthcare professionals. Therefore, as part of the implementation plan, the required resources will have to be procured and made available for implementation. For example, a document detailing a need assessment of the community and the identified gap. Another aspect is finding out if all the personnel required as per the model are available, and if some are unavailable, what are the steps to follow to fulfill such gaps. An implementation timeline has been subjected to six months. Such a duration will be sufficient to bring the needed resources together and ensure that the care model is applied as appropriate.

The collaborative care model for managing obesity in this population will require the collaboration of various healthcare professionals. The professionals required include nurse practitioners, general practitioner physicians, occupational therapists, psychologists, physiotherapists, and dieticians. All these professionals have a vital role to play in the model. The nurse practitioners and the general practitioner physicians are tasked with early identification and diagnosis of overweight and obesity.  They then collaborate with the dieticians to decide on the next course of action, for example, if a referral to a specialist is indicated or not. Psychologists will play a key role in counseling the patients so that they have the right frame of mind when fighting the condition (Kokorelias et al.,2019). The physiotherapists will help formulate patient-specific or patient-centered individual plans of weight reduction, for example, coming up with the necessary weight loss programs.

Potential Limitations and Barriers to Implementation

It is no secret that implementing an appropriate care model such as a collaborative care model can lead to an immediate improvement in patient outcomes and the health of the community. However, the implementation of such care models may have potential limitations and face various barriers which may hinder successful implementation. One of the potential limitations is a lack of enough resources. Resources can take the form of both financial and material needs. The implementation of this model needs considerable financial backing (Danielle et al.,2021). However, in the face of insufficient finances, there are higher chances that the implementation can fail. The other major barrier, as mentioned earlier, is that the current community health centers do not focus on obesity management, implying that the leaders are likely to resist the proposal. They may view the proposal as a burden that is likely to stretch both the finances and time.

The model is majorly based on the collaboration between various healthcare professionals. Collaboration requires that individuals excellently perform their roles. However, in a collaborative environment, there is a danger of conflict due to overlapping roles. Such conflicts can threaten the successful implementation of the model since there will be some disconnection along the way. Another danger in collaboration is that some of the collaborating professionals may fail to fulfill their duties as assigned. The results could be errors in the coordination of care and inadequate collaboration. The next limitation is the potential lack of adequate training among healthcare professionals regarding the need to collaborate in the care environment for better patient outcomes (Danielle et al.,2021). Even though professionals are generally trained on aspects of collaboration, it can be challenging to seamlessly participate in the collaborative care model if the specific aspects of collaboration within the model are not explored, as each collaboration may be different, depending on the collaboration environment.

The Internal Policies and External Policies Needed

The successful implementation of the proposed collaborative care model may be supported by various internal and external policies. Therefore, it is important to explore such policies and how useful they can be in supporting the implementation. One of the internal policies in the community health centers is the requirement that healthcare professionals collaborate whenever an opportunity to do so arises with the major focus of improving patient care outcomes. As earlier indicated, the major pillar of this model is collaboration. The implication is that the implementation of the model can be highly successful in environments where collaboration is encouraged (Danielle et al.,2021). Therefore, using this policy, the project leaders can encourage every participating healthcare professional, be it internal or external, to embrace collaboration for the sake of the successful implementation of the collaborative care model.

The other internal policy indicates that healthcare professionals should undertake healthcare promotion and patient education duties to improve patient outcomes. As such, the organization expects healthcare professionals to be proactive and innovative in using resources and expertise to promote patient health through health promotion and patient education (Danielle et al.,2021). This internal policy is also vital as it can help in the implementation of the collaborative care model. As earlier stated, part of the model entails early identification of obese or overweight patients and engaging the services of physiotherapists to formulate appropriate exercise programs that can help in reducing weight. Such actions align with this internal policy hence supporting its implementation.

One of the external policies that can help in the implementation of the collaborative care model is the requirement that individuals should be offered equitable access to primary care to improve their outcomes and well-being. This policy seeks to support vulnerable populations as well as underserved communities. The population described here is both underserved and vulnerable. Therefore, by following this policy, it is evident that the policy supports initiatives that focus on providing access to primary care to various populations. As part of the proposed collaborative care model, the targeted population will be offered primary obesity care by the identified healthcare professionals hence supporting its implementation.


The collaborative care model is important in improving patient care outcomes since it seeks to integrate the services of various professionals. They are key for underserved, at-risk, and vulnerable populations. Therefore, a collaborative care model has been proposed that will help in solving the care problems faced by the described population. The implementation of the care model is expected to improve the quality of services offered to this population, especially those living with obesity.



Artiga, S., & Hinton, E. (2019). Beyond health care: the role of social determinants in promoting health and health equity. Health20(10), 1-13.

Chatham, R. E., & Mixer, S. J. (2020). Cultural influences on childhood obesity in ethnic minorities: a qualitative systematic review. Journal of Transcultural Nursing31(1), 87–99.

Danielle Casanova, M. B. A., Kushner, R. F., & Ciemins, E. L (2021). Building Successful Models in Primary Care to Improve the Management of Adult Patients with Obesity.

Donkin, A., Goldblatt, P., Allen, J., Nathanson, V., & Marmot, M. (2018). Global action on the social determinants of health. BMJ Global Health3(Suppl 1), e000603.

Gittell, J. H., Logan, C., Cronenwett, J., Foster, T. C., Freeman, R., Godfrey, M., & Vidal, D. C. (2020). Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics. Health Care Management Review45(1), 12-20.

Gunderson, J. M., Wieland, M. L., Quirindongo-Cedeno, O., Asiedu, G. B., Ridgeway, J. L., O’Brien, M. W., … & Njeru, J. W. (2018). Community health workers as an extension of care coordination in primary care: a community-based cosupervisory model. The Journal of Ambulatory Care Management41(4), 333.

Hadjiyannakis, S., Ibrahim, Q., Li, J., Ball, G. D., Buchholz, A., Hamilton, J. K., … & Morrison, K. M. (2019). Obesity class versus the Edmonton Obesity Staging System for Pediatrics to define health risk in childhood obesity: results from the CANPWR cross-sectional study. The Lancet Child & Adolescent Health3(6), 398-407.

Kokorelias, K. M., Gignac, M. A., Naglie, G., & Cameron, J. I. (2019). Towards a universal model of family-centered care: a scoping review. BMC Health Services Research19, 1-11.

Lazarus, J. V., Mark, H. E., Anstee, Q. M., Arab, J. P., Batterham, R. L., Castera, L., … & Zelber-Sagi, S. (2022). Advancing the global public health agenda for NAFLD: a consensus statement. Nature Reviews Gastroenterology & Hepatology19(1), 60–78.

Shaw, J., Sethi, S., Vaccaro, L., Beatty, L., Kirsten, L., Kissane, D., … & Turner, J. (2019). Is care really shared? A systematic review of collaborative care (shared care) interventions for adult cancer patients with depression. BMC health services research19(1), 1–18.

Swan, B. A., Haas, S., & Jessie, A. T. (2019). Care coordination: roles of registered nurses across the care continuum. Nursing Economics37(6), 317-323.

Vimalananda, V., Dvorin, K., Fincke, B. G., Tardiff, N., & Bokhour, B. G. (2018). Patient, PCP, and specialist perspectives on specialty care coordination in an integrated health care system. The Journal of Ambulatory Care Management41(1), 15.