Coordination of Care

NUR 650 Milestone Two Guidelines and Rubric In this milestone, you will submit a draft of your coordination of care and conclusion for your final project. The clinical nurse leader (CNL) is a leader in all healthcare systems. CNLs collaborate with interdisciplinary teams that could consist of nurse practitioners, social workers, doctors, and pharmacists. CNLs are likely to encounter disparities in client care and treatment and will need to plan and implement care for improved client outcomes. Through the coordination of client care, CNLs assume accountability for client-centered outcomes. In this milestone, focus on the following:

 The use of evidence-based strategies to plan quality, cost-effective client care

 Performance improvement strategies for improving quality indicators in healthcare microsystems

 Health technology systems relevant to the management of the client's care and the promotion of effective intradisciplinary and interdisciplinary collaboration

 Strategies to promote the continuity of care for the client across settings and among providers

 Strategies to synchronize actions to meet the needs and preferences of care recipients and families from the point of admission through post-discharge Specifically, the following critical elements must be addressed:

III. Coordination of Care A. Plan: Develop a plan for coordination of care for the client using current, evidence-based best practice guidelines. In your plan, you should

address the following: i. Provide clinical guidelines necessary to move the client to the next level of care

ii. Address the client’s needs both as an inpatient and post-discharge iii. Provide detailed information explaining how treatment will be coordinated iv. Address the frequency of client encounters with clinicians

B. Facility: Is the current facility the appropriate setting for the client? Why or why not? Would it be cost-effective for this client be treated in an alternative care setting? Explain.

C. Interdisciplinary Relationships: Explain how interdisciplinary professional working relationships can facilitate ethical and strategic decision making. How can you encourage ethical and strategic decision making in your professional working relationships?

D. Services: What cost-effective solutions for services can be put in place to ensure that the client receives high-quality care? In other words, what provisions need to be made for durable medical equipment, home service, community health resources, and so on? Explain how these services can be cost-effective.

E. Discharge Checklist: Develop a discharge checklist or table using current, evidence-based best practice guidelines. Your discharge checklist should address the following items (however, you are not limited to only these items):

i. Have arrangements been made for client transportation?

ii. Has the client received discharge teaching specific to his or her condition? iii. Has medication reconciliation been completed? iv. Does the client have a follow-up appointment? v. Have the appropriate referrals for follow-up care been made?

IV. Conclusion

A. Technology: Can this client be managed through Telehealth or another remote health technological monitoring system? Why or why not? What are the benefits of using specific healthcare technologies or services, such as specialized applications for monitoring O2 saturation, blood pressure, and blood glucose?

B. Readmission: Do you think that this client will be readmitted within 30 days? Why or why not? What cost-effective solutions can you put in place to avoid readmission? Make sure to support your answer with evidence-based research and data.

C. Care Assessment: Assess the intradisciplinary and interdisciplinary care provided through your coordination of the client’s care. How can you use informatics systems to help you manage the client’s care?

Guidelines for Submission: Milestone Two should be 5 to 6 pages in length with double spacing, 12-point Times New Roman font, and one-inch margins. Use APA style to cite your sources.

Critical Elements Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value

Coordination of Care: Plan

Meets “Proficient” criteria and plan demonstrates in-depth scholarly insight into the delivery of coordinated care

Develops a comprehensive plan for client coordination of care based on evidence-based best practice guidelines

Develops plan for coordination of care but plan has gaps in clarity, continuity, or evidence- based best practice guidelines

Does not develop plan for coordination of care

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Coordination of Care: Facility

Meets “Proficient” criteria and assessment provides specific examples of cost-effective alternative care settings

Accurately assesses whether or not current facility is appropriate for client and if it would be cost-effective for client to be treated in alternative care setting

Assesses whether or not current facility is appropriate for client and if it would be cost-effective for client to be treated in alternative care setting but with gaps in accuracy or detail

Does not assess whether or not current facility is appropriate for client and if it would be cost- effective for client to be treated in alternative care setting

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Coordination of Care: Interdisciplinary

Relationships

Meets “Proficient” criteria and explanation demonstrates nuanced understanding of relationship among strategies, working relationships, and decision making

Clearly explains how interdisciplinary working relationships will facilitate and encourage ethical and strategic decision making

Explains how interdisciplinary working relationships will facilitate and encourage ethical and strategic decision making but with gaps in clarity or detail

Does not explain how interdisciplinary working relationships will facilitate and encourage ethical and strategic decision making

12

Coordination of Care: Services

Meets “Proficient” criteria and makes a direct correlation between services and financial impact on client or insurance company

Develops and explains cost- effective solutions for services to ensure that client receives high-quality care

Develops and explains solutions for services but solutions are not cost-effective or do not ensure high-quality care

Does not develop and explain solutions for services

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Coordination of Care: Discharge Checklist

Meets “Proficient” criteria and checklist demonstrates in- depth scholarly insight into the delivery of coordinated care

Develops a comprehensive discharge checklist based on evidence-based best practice guidelines

Develops discharge checklist but checklist has gaps in clarity, continuity, or best practice guidelines

Does not develop discharge checklist

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Conclusion: Technology

Meets “Proficient” criteria and assessment reflects scholarly synthesis of relationship between intradisciplinary and interdisciplinary care and informatics

Clearly explains whether or not client can be managed through remote health technological monitoring systems and addresses the benefits of using healthcare technologies or services

Explains whether or not client can be managed through remote health technological monitoring systems and addresses the benefits of using healthcare technologies or services but response lacks clarity or detail

Does not explain whether or not client can be managed through remote health technological monitoring systems and does not address the benefits of using healthcare technologies or services

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Conclusion: Readmission

Meets “Proficient” criteria and solutions demonstrate nuanced understanding of relationship between cost- effective, data-driven solutions and quality of care

Forms evidence-based conclusions regarding client readmission and provides cost- effective, evidence-based solutions to avoid client readmission

Forms conclusions regarding client readmission and provides solutions to avoid client readmission, but conclusions and solutions are not supported with evidence- based research or data or solutions are not cost-effective

Does not form conclusions regarding client readmission and does not provide solutions to avoid client readmission

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Conclusion: Care Assessment

Meets “Proficient” criteria and assessment reflects scholarly synthesis of relationship between intradisciplinary and interdisciplinary care and informatics

Accurately assesses the intradisciplinary and interdisciplinary care provided through client care coordination and explains how informatics systems can help manage client’s care

Assesses the intradisciplinary and interdisciplinary care provided through client care coordination and explains how informatics systems can help manage client’s care but with gaps in accuracy or detail

Does not assess the intradisciplinary and interdisciplinary care provided through client care coordination or does not explain how informatics systems can help manage client’s care

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Articulation of Response

Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to- read format

Submission has no major errors related to citations, grammar, spelling, syntax, or organization

Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas

Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas

4

Total 100%