Preliminary Care Coordination Plan essay paper
Preliminary Care Coordination Plan
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Assessment 1 Instructions: Preliminary Care Coordination Plan
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- Develop a 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.Preliminary Care Coordination Plan
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.Preliminary Care Coordination Plan
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.Preliminary Care Coordination Plan
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.
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.
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:
- 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.
- Identify available community resources for a safe and effective continuum of care.Preliminary Care Coordination Plan
Document Format and Length
- Your preliminary plan should be an APA scholarly paper, 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.
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.
- SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.
Preliminary Care Coordination Plan Scoring Guide
| CRITERIA | NON-PERFORMANCE | BASIC | PROFICIENT | DISTINGUISHED |
| Analyze a health concern and the associated best practices for health improvement. | Does not analyze a health concern and the associated best practices for health improvement. | Attempts to analyze a health concern and the associated best practices for health improvement. | Analyzes a health concern and the associated best practices for health improvement. | 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. |
| Describe specific goals that should be established to address a selected health care problem. | Does not describe specific goals that should be established to address a selected health care problem. | Attempts to describe undefined goals that should be established to address a selected health care problem. | Describes specific goals that should be established to address a selected health care problem. | Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable. |
| Identify available community resources for a safe and effective continuum of care. | Does not identify available community resources. | Attempts to identify available community resources. | Identifies available community resources for a safe and effective continuum of care. | 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. |
| Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. | Does not organize content for ideas. Lacks logical flow and smooth transitions. | Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling. | Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. | 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. |
| Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. | Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly. | 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. | Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. | Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly. |
Resources: Care Coordination Fundamentals
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- You may review the following:
- Improving Chronic Illness Care. (n.d.). Care coordination: Background. http://www.improvingchroniccare.org/index.php?p=Background&s=350
- This resource provides background information of care coordination. Think about how this information applies to your community and patients as you read the case study of Ms. G., which highlights the importance of care coordination.
- McGee, B. T., & Breslin, S. E. (2020, May). The Affordable Care Act 10 years in: What nursing leaders should know.Nurse Leader.
- Cleveland, K. A., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses.The Online Journal of Issues in Nursing, 24(19). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-24-2019/No2-May-2019/Affordable-Care.html
- Improving Chronic Illness Care. (n.d.). Care coordination: Background. http://www.improvingchroniccare.org/index.php?p=Background&s=350
Resources: Academic Resources
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- A variety of writing resources are available in the NHS Learner Support Lab, linked in the courseroom navigation menu.
Scholarly Writing and APA Style
Use the following resources to improve your writing skills and find answers to specific questions.
Library Research
Use the following resources to help with any required or self-directed research you do to support your coursework.
- BSN Program Library Research Guide.
- Capella University Library.
- Journal and Book Locator Library Guide.
- Library Research and Information Literacy Skills.
Resources: Writing SMART Goals for Care Coordination
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- During care coordination, nurses should ensure that they are creating patient-centered goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable, Relevant, Timely) goals. SMART goals provide direction for patient-centered care coordination.
SMART goals must be effective, meaningful, achievable, and collaborative in nature. Key stakeholders (such as the individual, group, or community; possibly significant others; and you, the nurse) must be taken into account.
Often the best way to patient-centered functional goals is simply to ask the target group, “What are your goals?” Doing this will help you to improve adherence, satisfaction, and outcomes. Consider the following when developing SMART goals:
- Specific: Goals will specify who will be responsible, what is to be achieved, where the activity is located, and why it is important or beneficial.
- Measurable: Goals must specify criteria for measuring progress against them. This helps you to stay on track, reach milestones, and motivate the stakeholders.
- Attainable: Setting attainable goals serves to motivate the individual or group.
- Relevant: Key stakeholders must see how a specific goal is relevant to them.
- Timely: To be most effective, goals must be structured around a specific time frame to motivate individuals to begin working on their goals.
After developing a mutually agreed-upon goal, SMART objectives are developed to help guide activities. Objectives help to determine whether the goals have been achieved and if revisions need to be made for future educational sessions.
SMART objectives must be:
- Specific: Objectives need to be concrete, detailed, and well-defined so that you know what exactly is going to occur and what to expect.
- Measurable: A way to determine how the goal was met or if it needs revision.
- Achievable: The objective must be appropriate and feasible for those involved. Ask: What’s the patient’s learning style? For example, does the patient prefer reading printed materials, viewing audiovisual materials, or watching demonstrations?
- Realistic: It must take into consideration constraints such as resources, personnel, cost, education level, learning style, reading level and comprehension level. What language do they speak? How much does the individual or group like to know? Ask: Can the patient read or comprehend instructions or follow directions? Do they prefer reading printed materials, viewing audiovisual materials, or demonstrations?
- Time-bound: A time frame helps set boundaries around the objective. Ask: How long will it take to obtain the objective? Objectives may be process- or outcome-oriented.
Outcome objectives can be short-term, intermediate, or long-term:
- Short-term objectives can be achieved after implementing certain activities or interventions. Change may be in cognitive (knowledge), psychomotor (demonstration), and values (attitude).
- Intermediate outcome objectives provide a sense of progress toward reaching long-term objectives. This could be behavior and policy change.
- Long-term objectives occur after the program has been implemented. It may take more than a month. These can be changes in mortality, moribundity, and quality of life.
Example of a SMART goal:
- Walk for 30 minutes a day, seven days a week.
Example of a SMART objective:
- By the end of the week, patient will have walked 3.5 hours.
Example of an evaluation of a SMART objective:
- The patient will complete a daily log of miles each week.
Additional Resources
The following additional resources will help you in establishing SMART goals and objectives in collaboration with educational session participants:
- Centers for Disease Control and Prevention. (n.d.) Develop SMART objectives. https://www.cdc.gov/phcommunities/resourcekit/evaluate/smart_objectives.html
- Centers for Disease Control and Prevention. (n.d.) Resources. https://www.cdc.gov/phcommunities/resourcekit/resources.html
- This site has a template for you to use as a guide.
- L. (2012). Making SMART goals smarter. Physician Executive, 38(2), 68-70.
Resources: Additional Resources for Further Exploration
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- You may use the following optional resources to further explore topics related to the competencies.
- Improving Chronic Illness Care. (n.d.). Care coordination: Family Care Network: Developing agreements between primary care and specialty groups. http://www.improvingchroniccare.org/index.php?p=Family_Care_Network&s=344
- The Family Care Network case study highlights the importance of care coordination. Look for similarities with your own practice and community.
- Improving Chronic Illness Care. (n.d.). Care coordination: San Francisco General Hospital: Connectivity through electronic referral. http://www.improvingchroniccare.org/index.php?p=San_Francisco_General_Hospital&s=347
- The San Francisco General Hospital case study addresses how care coordination can change patient outcomes. This is a great resource as you think about care coordination in your community.Preliminary Care Coordination Plan
- Improving Chronic Illness Care. (n.d.). Care coordination: Family Care Network: Developing agreements between primary care and specialty groups. http://www.improvingchroniccare.org/index.php?p=Family_Care_Network&s=344
