For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

 

Introduction

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

 

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

 

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

 

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Instructions

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, 6–7 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.

Address three health care issues.

Design an intervention for each health issue.

Identify three community resources for each health intervention.

Consider ethical decisions in designing patient-centered health interventions.

Consider the practical effects of specific decisions.

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.

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.

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. https://health.gov/healthypeople

Use the literature on evaluation as guide to compare learning session content with best practices.

Align teaching sessions to the Healthy People 2030 document. https://health.gov/healthypeople

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

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

 

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

 

Competency 1: Adapt care based on patient-centered and person-focused factors.

Design patient-centered health interventions and timelines for a selected health care problem.

Competency 2: Collaborate with patients and family to achieve desired outcomes.

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.

Competency 3: Create a satisfying patient experience.

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.

Competency 4: Defend decisions based on the code of ethics for nursing.

Consider ethical decisions in designing patient-centered health interventions.

Competency 5: Explain how health care policies affect patient-centered care.

Identify relevant health policy implications for the coordination and continuum of care.

Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

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.

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For this assessment, you will simulate implementation of the preliminary care coordination plan you developed in Assessment 1. The presentation would be structured for the hypothetical patient.

 

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

 

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 1: Adapt care based on patient-centered and person-focused factors.
    • Design patient-centered health interventions and timelines for care delivered through direct clinical interaction that is logged in the CORE ELMS system.
  • Competency 2: Collaborate with patients and family to achieve desired outcomes.
    • Use the literature on evaluation as a guide to compare learning session content with best practices.
  • Competency 3: Create a satisfying patient experience.
    • Describe what the literature says about effective care coordination and patient satisfaction verses experience, including how to align teaching sessions to the Healthy people 2020 document..
  • Competency 4: Defend decisions based on the code of ethics for nursing.
    • Make ethical decisions in designing patient-centered health interventions.
  • Competency 5: Explain how health care policies affect patient-centered care.
    • Identify relevant health policy implications for the coordination and continuum of care.

 

Preparation

In this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the hypothetical patient in a professional, culturally sensitive, and ethical manner.

To prepare for the assessment, consider the patient experience and how you would present the plan.

 

Instructions

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 5–7 pages in length.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 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 care.
    •  
    • -Address three patient health issues.
    •  
    • -Design an intervention for each health issue.
    •  
    • -Identify three community resources for each health intervention, so the patient may make an informed decision about what resources to use.
  •  
  • -Consider ethical decisions in designing patient-centered health interventions.
    •  
    • -Consider the practical effects of specific decisions.
    •  
    • -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.
    •  
    • -Cite specific health policy provisions.
  •  
  • -What does the literature say about evaluation in care coordination?
    •  
    • -How might revisions to the plan improve future outcomes?
  •  
  • -What does literature say about:
    • Effective care coordination and patient satisfaction verses experience?
    • How to align teaching sessions to the Healthy People 2020 document?

 

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

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