Assignment: Care Coordination Plan
Assignment: Care Coordination Plan
Question Description
You will use the preliminary care coordination plan you created in Assessment 1 for this assessment. In a face-to-face clinical learning session, present the plan to the patient and collaborate with the patient in evaluating session outcomes and addressing potential plan revisions. NOTE: You must complete this assessment after you have successfully completed Assessment 1. The process of providing a smooth and seamless transition of care as part of the health continuum is known as care coordination. Nurses must be aware of community resources, ethical concerns, policy issues, cultural norms, patient safety, and physiological needs. Nurses play a critical role in providing the necessary knowledge and communication to ensure smooth care transitions. They use evidence-based practices to promote health and disease prevention in order to create a safe environment conducive to improving and maintaining the health of individuals, families, or communities. Patients benefit from a safe environment conducive to healing and a better quality of life when they are provided with a plan and the resources to achieve and maintain optimal health. This assessment allows you to apply best practices in communication, teaching, and learning to the presentation of a care coordination plan to the patient. Prior to taking this assessment, you should complete the Vila Health: Cultural Competence activity. Completing course activities prior to submitting your first attempt has been shown to differentiate between basic and proficient assessment. PROFICIENCY DEMONSTRATION
You will demonstrate your proficiency in the course competencies by successfully completing this assessment using the following assessment scoring guide criteria:
Competency 1: Tailor care to patient-centered and person-centered factors.
Create patient-centered health interventions and timelines for direct clinical interaction that is recorded in the CORE ELMS system.
Competency 2: Work with patients and families to achieve desired results.
In collaboration with a patient, evaluate learning session outcomes and achievement of mutually agreed-upon health goals.
Competency 3: Provide a positive patient experience.
Assess patient satisfaction with the care coordination plan, as well as progress toward Healthy People 2020 goals and leading health indicators.
Competency 4: Defend decisions based on the nursing code of ethics.
When designing patient-centered health interventions, make ethical decisions.
Explain how health-care policies affect patient-centered care in Competency 5.
Determine the health policy implications for coordination and the continuum of care.
Assignment: Care Coordination Plan
PREPARATION
In this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the patient in a professional, culturally sensitive, and ethical manner.To prepare for the assessment, consider the patient experience and how you will present the plan. Make sure you schedule time accordingly.Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.INSTRUCTIONS
Note: You are required to complete Assessment 1 before this assessment.For this assessment:Complete the preliminary care coordination plan you developed in Assessment 1.
Present the plan to the patient in a face-to-face clinical learning session. Communicate in a professional, culturally sensitive, and ethical manner.
Collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan.
Reminder: The time you spend presenting your final care coordination plan must be logged in the CORE ELMS system. The total time spent in securing individual participation in this activity in Assessment 1 and presenting your plan in this assessment must be at least three hours. The CORE ELMS link is located in the courseroom navigation menu.Please be advised that the Volunteer Experience form requires that you provide the name and contact information for at least one individual with whom you worked as part of your direct clinical activity. Your faculty may reach out to this individual to verify that you have accurately documented and completed your clinical hours.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 delivered through direct clinical interaction that is logged in the CORE ELMS system.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.
Make 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.
Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with the patient.What aspects of the session would you change?
How might revisions to the plan improve future outcomes?
Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators.What changes would you recommend to improve patient satisfaction and better align the session with Healthy People 2020 goals and leading health indicators?
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.You must submit your hours to the CORE ELMS system before you can complete this assessment and course.Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.