I need help to "devlop a preliminary care coordination plan for a selected health care problem"

4050 A1 instructions

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.

A key aspect of the care coordination process is effective planning that answers the following questions:

· What is the best approach to planning for care?

· What are the essential steps in the process?

Complete the attached Care Coordination Planning  activity to gain insight into the most important considerations when preparing to develop a care coordination plan.

Introduction

The first step in any effective project is planning. This assessment 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.

NOTE: You are required to complete this assessment before Assessment 4.

Preparation

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.

Scenario

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:

· Select one of the health concerns in the attached  Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF] resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.

· 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. Be sure to submit both documents.

Course Competencies

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and 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.

4050 ACTIVITY

Introduction

Complete this activity to gain insight into the most important considerations when preparing to develop a care coordination plan.

A key aspect of the care coordination process is effective planning, which is essential to obtaining the best possible outcomes for patients. Just as you would systematically plan the baking of a cake by selecting the recipe, buying the ingredients, setting the ingredients on the counter, and preheating the oven, you would systematically plan the coordination of patient care.

The Institute of Medicine defines care coordination as an important tool that has the potential to improve the effectiveness, safety, and efficiency of the U.S. health care system. Well-designed, targeted care coordination can improve outcomes for patients, providers, and payers.

Care coordination requires strategic planning to organize patient care activities that place the patient’s needs and preferences at the forefront of high-quality, cost-effective health care. Nursing interventions are organized to achieve safer and more effective care, which requires sufficient communication with key providers at the right time. In the primary care setting, care coordination organizes nursing interventions, including clear communication that enables appropriate information sharing among all participants on the health care team to achieve better and more effective care.

The care coordination process is like the five rights of medication administration where the right time, right medication, right route, right dose, and right patient are considered. The right patient’s preferences, for the right time, for the right service, for the right provider, and the right communication are fundamental to the care coordination process. Another example of care coordination is like the aforementioned planning to bake a cake.

There are two approaches to care coordination. The nurse can take a broad approach or a specific approach to care coordination.

Examples of a broad care coordination approach includes:

· Teamwork

· Care management

· Medication management

· Health information technology

· Patient-centered medical home

Examples of a specific care coordination approach includes such activities as:

· Establishing accountability and agreeing on responsibility

· Communicating/sharing knowledge

· Helping with transitions of care

· Assessing patient needs and goals

· Creating a proactive care plan

· Monitoring and follow-up, including responding to changes in patients' needs

· Supporting patients' self-management goals

· Linking to community resources

· Working to align resources with patient and population needs

QUESTION1of10

Which of the following activities would be a nurse's first priority?

Select one answer

a) Helping with transitions of care.

b) Creating a proactive care plan.

c) Determining patient needs and goals.

d) Communicating/sharing knowledge.

QUESTION2of10

Which of the following activities would be a nurse's first priority?

Select one answer

a) Creating a proactive care plan.

b) Helping with transitions of care.

c) Communicating/sharing knowledge.

d) Monitoring and follow-up, including responding to changes in patients' needs.

QUESTION3of10

Which of the following activities would be a nurse's first priority after a change in medications?

Select one answer

a) Linking to community resources.

b) Monitoring and follow-up, including responding to changes in patients' needs.

c) Helping with transitions of care.

d) Supporting patients' self-management goals.

QUESTION4of10

Which of the following activities would be a nurse's first priority when coordinating care in a system with limited resources?

Select one answer

a) Helping with transitions of care.

b) Supporting patients' self-management goals.

c) Working to align resources with patient and population needs.

d) Monitoring and follow-up, including responding to changes in patients' needs.

QUESTION5of10

From an organizational perspective, which of the following broad care coordination activities would the nurse engage in to coordinate care across the system?

Select one answer

a) Patient-centered medical home.

b) Health information technology use.

c) Medication management.

d) Teamwork.

QUESTION6of10

The nurse engaging in care coordination would be most likely to attend a town event for which of the following reasons?

Select one answer

a) Linking to community resources.

b) Supporting patients' self-management goals.

c) Monitoring and follow-up, including responding to changes in patients' needs.

d) Working to align resources with patient and population needs.

QUESTION7of10

Which of the following broad care coordination activities would the nurse engage in to facilitate collaboration?

Select one answer

a) Patient-centered medical home.

b) Care management.

c) Health information technology use.

d) Teamwork.

QUESTION8of10

The nurse planning care coordination activities at a systems level would focus on what broad care coordination activity to improve patient outcomes by centralizing care?

Select one answer

a) Teamwork.

b) Medication management.

c) Health information technology use.

d) Patient-centered medical home

QUESTION9of10

The nurse care coordinator working with a patient with diabetes would impact the outcomes for this patient through which of the following specific care coordination tasks?

Select one answer

a) Communicating/sharing knowledge.

b) Supporting patients' self-management goals.

c) Establishing accountability and agreeing on responsibility.

d) Helping with transitions of care.

QUESTION10of10

The nurse care coordinator working with the patient being discharged from the hospital would engage in which of the following specific care coordination activity?

Select one answer

a) Communicating/sharing knowledge.

b) Helping with transitions of care.

c) Supporting patients' self-management goals.

d) Establishing accountability and agreeing on responsibility