Final Care Coordination Plan ( Revised)

For this assessment, you will evaluate the preliminary care

coordination plan you developed in Assessment 1 using best practices

found in the literature.

Introduction

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

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.

You are encouraged to complete the Vila Health: Cultural Competence
activity prior to completing this assessment. Completing course
activities before submitting your first attempt has been shown to make
the difference between basic and proficient assessment.

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

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

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.