Preliminary Care Coordination Plan

1 Assessment 01 – Preliminary Care Coordination Plan

For this assessment, you will 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. Before you complete the instructions detailed in the courseroom, first select one of the following health care problems or issues:

• Health Literacy • Physical considerations: Low health literacy can lead to poor health outcomes and

difficulty managing chronic diseases. • Psychosocial considerations: Low health literacy can cause emotional distress,

anxiety, and depression. • Cultural considerations: Cultural beliefs and practices may influence an individual’s

health literacy. • Community resources: Health literacy programs, patient education materials, and

health navigators can provide resources and support for individuals with low health literacy.

• Environmental Health • Physical considerations: Environmental hazards such as air pollution, lead

exposure, and toxic waste can cause physical health problems. • Psychosocial considerations: Environmental hazards can cause emotional

distress, anxiety, and depression. • Cultural considerations: Cultural beliefs and practices may influence an individual’s

exposure to environmental hazards. • Community resources: Environmental health clinics, community clean-up

programs, and advocacy groups can provide resources and support for individuals affected by environmental hazards.

After you have selected one of the problems/issues from the list above, return to the detailed instructions in the courseroom to complete your assessment.

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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

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  Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]  Download 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.

Portfolio Prompt: Save your presentation to your  ePortfolio.

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.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

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Criterion 1

Analyze a health concern and the associated best practices for health improvement.

Distinguished

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.

Proficient

Analyzes a health concern and the associated best practices for health improvement.

Basic

Attempts to analyze a health concern and the associated best practices for health improvement.

Non Performance

Does not analyze a health concern and the associated best practices for health improvement.

Criterion 2

Describe specific goals that should be established to address a selected health care problem.

Distinguished

Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable.

Proficient

Describes specific goals that should be established to address a selected health care problem.

Basic

Attempts to describe undefined goals that should be established to address a selected health care problem.

Non Performance

Does not describe specific goals that should be established to address a selected health care problem.

Criterion 3

Identify available community resources for a safe and effective continuum of care.

Distinguished

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.

Proficient

Identifies available community resources for a safe and effective continuum of care.

Basic

Attempts to identify available community resources.

Non Performance

Does not identify available community resources.

Criterion 4

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Distinguished

Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.

Proficient

Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Basic

Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.

Non Performance

Does not organize content for ideas. Lacks logical flow and smooth transitions.

Criterion 5

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Distinguished

Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

Proficient

Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Basic

Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes and/or paraphrasing.

Non Performance

Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.