Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.
Introduction
NOTE: You are required to complete this assessment before Assessment 4.
The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem.
Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective 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.
Preparation
Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.
To prepare for this assessment, you may wish to:
- 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 chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
- Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. 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.
Document Format and Length
- Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
- Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
- In your paper include possible community resources that can be used.
- Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
- Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.
Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.
- 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.
- Describe specific goals that should be established to address the health care problem.
- Identify available community resources for a safe and effective continuum of care.
- Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
- Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
- Write with a specific purpose with your patient in mind.
- Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.
Portfolio Prompt: Save your presentation to your ePortfolio.
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.
- Analyze a health concern and the associated best practices for health improvement.
- Competency 2: Collaborate with patients and family to achieve desired outcomes.
- Describe specific goals that should be established to address a selected health care problem.
- 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.
- Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
- Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Solution
Preliminary Care Coordination Plan
Student’s Name
Institutional Affiliation
Department
Course Name
Professor’s Name
Date
Preliminary Care Coordination Plan
Care coordination is essential in healthcare due to its ability to help integrate several services and the roles of key stakeholders in meeting patient needs. According to Hannigan et al. (2018), care coordination focuses on recovery and connecting patients to healthcare services. Patients with chronic illness often require care coordination because of the multifaceted impact of their diseases. Therefore, care coordination becomes significant as it incorporates several people, such as patients and their families and adopts an interdisciplinary approach to managing the underlying illness. This assessment develops an effective care coordination plan at an acute care healthcare facility based on the significant health concern affecting many patients. The suggested intervention by the care coordination plan develops goals of managing the identified condition while utilizing underlying resources.
Selected Healthcare Concern
The selected healthcare concern at the acute care hospital is stroke. Despite experiencing many patient issues such as heart disease, chronic obstructive pulmonary diseases, trauma, and cognitive impairment, stroke has affected many patients and requires continued care even in out-of-hospital settings. Moreover, the impacts of the condition are severe as they expedite functional decline for victims. In addition, stroke is selected because it contributes significantly to adverse outcomes in public health. For instance, Donkor (2018) explains that stroke is among chronic illnesses associated with a high mortality rate, as about
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