Preliminary Care Coordination Plan
- Develop a 3-4-page preliminary care coordination plan for an individual in your community with whom you choose to work. Identify and list available community resources for a safe and effective continuum of care.NOTE: You are required to complete this assessment before Assessment 4.The first step in any effective project or clinical patient encounter is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for an individual in your community as you consider the patient’s unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the continuum of care.As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.Demonstration of ProficiencyBy 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.
- Analyze a health concern and the associated best practices for health improvement.
- Competency 2: Collaborate with patients and family to achieve desired outcomes.
- Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.
- Competency 3: Create a satisfying patient experience.
- Identify available community resources for a safe and effective continuum of care.
- Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
- Write clearly and concisely in a logically coherent and appropriate form and style.
- Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
- Allow plenty of time to plan your patient clinical encounter.
- Be sure that you have a patient in mind that you can work with throughout the course.
- Identify a health concern as the focus of your care coordination plan. Possible health concerns may include, but are not limited to:
- Stroke.
- Heart disease (high blood pressure, stroke, or heart failure).
- Home safety.
- Pulmonary disease (COPD or fibrotic lung disease).
- Orthopedic concerns (hip replacement or knee replacement).
- Cognitive impairment (Alzheimer’s disease or dementia).
- Pain management.
- Mental health.
- Trauma.
- Identify available community resources for a safe and effective continuum of care.
- Contact local individuals who may be open to an interview and a care coordination plan addressing their health concerns. The person you choose to work with may be a colleague, community member, friend, or family member.
- Meet with the individual to describe the care coordination plan session that you intend to provide. Collaborate with the participant in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to the plan.
- Establish a tentative date and time for the care coordination plan session. Document the name of the individual and a single point of contact, either an e-mail address or a phone number.
- Your preliminary plan should be 3–4 pages in length. In a separate section of the plan, identify the person you have chosen to work with, and be sure to include his or her contact information.
- Document the community resources you have identified using the Community Resources Template [DOCX].
- Analyze your selected health concern and the associated best practices for health improvement.
- Cite supporting evidence for best practices.
- Consider underlying assumptions and points of uncertainty in your analysis.
- Establish mutually agreed-upon health goals for the care coordination plan, in collaboration with the selected individual.
- Identify available community resources for a safe and effective continuum of care.
- Write clearly and concisely in a logically coherent and appropriate form and style.
- Write with a specific purpose with your patient in mind.
- Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
- Competency 1: Adapt care based on patient-centered and person-focused factors.