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.
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
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.
As you assume your expanded care coordination role, you have been tasked with addressing the specific health concerns of a particular individual within the community. You decide to prepare a preliminary care coordination plan and proceed by identifying the patient’s three priorities for health and by investigating the resources available in your community for a safe and effective continuum of care.
To prepare for this assessment, you may wish to:
Note: Remember that you can submit all, or a portion of, your draft 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.
Note: You are required to complete this assessment before Assessment 4.
This assessment has two parts.
Complete the following:
Complete the following:
For your care coordination plan, you may use the Care Coordination Plan Template [DOCX], choose a format used in your own organization, or choose a format you are familiar with that adequately serves your needs for this assessment.
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.
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.
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. Be sure to submit both documents.
Important note: The time you spend securing individual participation in this activity and the time you spend presenting your final care coordination plan to the patient in Assessment 4 must total at least three hours. Be sure to log your time in the CORE ELMS system. The CORE ELMS link is located in the courseroom navigation menu.
1. Analyze a health concern and the associated best practices for health improvement.
Passing Grade: Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis.
2. Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.
Passing Grade: Establishes mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient. Ensures the goals are realistic, measurable, and attainable.
3. Identify available community resources for a safe and effective continuum of care.
Passing Grade: Identifies significant and available community resources for a safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health.
4. Write clearly and concisely in a logically coherent and appropriate form and style.
Passing Grade: Writes clearly and concisely in a logically coherent and appropriate form and style. Main points, ideas, arguments, or propositions are well-developed and engaging. Adheres to all applicable disciplinary and scholarly writing standards.