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Preliminary Care Coordination Plan Paper

 Preliminary Care Coordination Plan Paper

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All instructions attached , see proficiency details . See RUBRICS scoring guide., shooting for distinguished column please

Care Coordination Plan Template Name: DOB: Address: Payor Source: Secondary Source: 1. Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and the reason for care coordination planning.) 2. Routine Health Maintenance Physician: Physician’s Address: Physician’s Phone Number: Preferred Hospital: General Dentist: Dentist’s Address: Dentist’s Phone Number: Pharmacy: Pharmacy’s Address: Pharmacy’ Phone Number: 3. Specialty Care Specialist One: Discipline: Physician’s Address: Physician’s Phone Number: Treatment Goals: Specialist Two: Discipline: Physician’s Address: Physician’s Phone Number: 1 Treatment Goals: Specialist Three: Discipline: Physician’s Address: Physician’s Phone Number: Treatment Goals: Specialist Four: Discipline: Physician’s Address: Physician’s Phone Number: Treatment Goals: 4. Mental Health Provider Specialist One: Discipline: Provider’s Address: Provider’s Phone Number: Treatment Goals: 5. Hospital Care (List history of hospitalizations.) Date of Hospitalization: Hospital Name: Reason: Length of Stay: Discharged to Location: Date of Hospitalization: Hospital Name: Reason: Length of Stay: Discharged to Location: Date of Hospitalization: Hospital Name: 2 Reason: Length of Stay: Discharged to Location: 6. Patient Education (List any educational program or coordination that the patient has completed.) Name of Program: When: Where: Name of Program: When: Where: Name of Program: When: Where: Name of Program: When: Where: 7. Rehabilitation Services (List any rehabilitation stays, including in-patient, out-patient, Long Term Acute Care (LTAC), or Skilled Nursing Facility (SNF) stays.) Name of Rehabilitation Services: When: Where: Length of Stay: Name of Rehabilitation Services: When: Where: Length of Stay: Name of Rehabilitation Services: When: Where: 3 Length of Stay: Name of Rehabilitation Services: When: Where: Length of Stay: 8. Medication List (List all medications, dosage, and purpose.) Medication: Dosage: Purpose: Medication: Dosage: Purpose: Medication: Dosage: Purpose: Medication: Dosage: Purpose: Medication: Dosage: Purpose: 9. Durable Medical Equipment Equipment Owned: Provider: Equipment Rented: Provider: Equipment Ordered: Provider: 4 Equipment Needed: Provider: Incontinence Equipment: Provider: 10. Home Health Care Infusion Supplies Enteral Nutrition Provider: Phone Number: Parenteral Infusion Provider: Phone Number: 11. Other Services Social Services: Transition Services: Transportation Services: 12. Nursing Skilled Nursing Visits Name: Services: Indication Treatment Goals: Hourly Nursing Services Name: Services: Indication: Treatment Goals: Respite Care Name: Services: Indication: Treatment Goals: 5 Hospice Care Name: Services: Indication: Treatment Goals: 13. Community Services/Referrals 14. Cultural Needs 15. Signatures RN Care Coordinator Patient Patient Contact Information (e-mail or phone) 6 Care Coordination Plan Template Name: DOB: Address: Payor Source: Secondary Source: 1. Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and the reason for care coordination planning.) 2. Routine Health Maintenance Physician: Physician’s Address: Physician’s Phone Number: Preferred Hospital: General Dentist: Dentist’s Address: Dentist’s Phone Number: Pharmacy: Pharmacy’s Address: Pharmacy’ Phone Number: 3. Specialty Care Specialist One: Discipline: Physician’s Address: Physician’s Phone Number: Treatment Goals: Specialist Two: Discipline: Physician’s Address: Physician’s Phone Number: 1 Treatment Goals: Specialist Three: Discipline: Physician’s Address: Physician’s Phone Number: Treatment Goals: Specialist Four: Discipline: Physician’s Address: Physician’s Phone Number: Treatment Goals: 4. Mental Health Provider Specialist One: Discipline: Provider’s Address: Provider’s Phone Number: Treatment Goals: 5. Hospital Care (List history of hospitalizations.) Date of Hospitalization: Hospital Name: Reason: Length of Stay: Discharged to Location: Date of Hospitalization: Hospital Name: Reason: Length of Stay: Discharged to Location: Date of Hospitalization: Hospital Name: 2 Reason: Length of Stay: Discharged to Location: 6. Preliminary Care Coordination Plan Paper

Patient Education (List any educational program or coordination that the patient has completed.) Name of Program: When: Where: Name of Program: When: Where: Name of Program: When: Where: Name of Program: When: Where: 7. Rehabilitation Services (List any rehabilitation stays, including in-patient, out-patient, Long Term Acute Care (LTAC), or Skilled Nursing Facility (SNF) stays.) Name of Rehabilitation Services: When: Where: Length of Stay: Name of Rehabilitation Services: When: Where: Length of Stay: Name of Rehabilitation Services: When: Where: 3 Length of Stay: Name of Rehabilitation Services: When: Where: Length of Stay: 8. Medication List (List all medications, dosage, and purpose.) Medication: Dosage: Purpose: Medication: Dosage: Purpose: Medication: Dosage: Purpose: Medication: Dosage: Purpose: Medication: Dosage: Purpose: 9. Durable Medical Equipment Equipment Owned: Provider: Equipment Rented: Provider: Equipment Ordered: Provider: 4 Equipment Needed: Provider: Incontinence Equipment: Provider: 10. Home Health Care Infusion Supplies Enteral Nutrition Provider: Phone Number: Parenteral Infusion Provider: Phone

Number: 11. Other Services Social Services: Transition Services: Transportation Services: 12. Nursing Skilled Nursing Visits Name: Services: Indication Treatment Goals: Hourly Nursing Services Name: Services: Indication: Treatment Goals: Respite Care Name: Services: Indication: Treatment Goals: 5 Hospice Care Name: Services: Indication: Treatment Goals: 13. Community Services/Referrals 14. Cultural Needs 15. Signatures RN Care Coordinator Patient Patient Contact Information (e-mail or phone) 6 Community Resources Template Mental Health Providers Hospitals Education Services Rehabilitation Services Pharmacies DME Equipment Providers Incontinence Service Providers Parenteral Service Providers Enteral Nutrition Providers Social Services Transition Services 1 Transportation Services Skilled Nursing Services Hourly Nursing Services Respite Care Services Hospice Care Providers Community Services 2 3/26/2020 Preliminary Care Coordination Plan Scoring Guide Preliminary Care Coordination Plan Scoring Guide CRITERIA NONPERFORMANCE BASIC PROFICIENT DISTINGUISHED Analyze a health concern and the associated best practices for health improvement. Does not identify a health concern and the associated best practices for health improvement. Identifies 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. Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient. Does not establish health goals for a care coordination plan. Establishes health goals for a care coordination plan. Establishes mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.

Establishes mutually agreedupon health goals for a care coordination plan, in collaboration with the patient. Ensures 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. Identifies 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. Write clearly and concisely in a logically coherent and appropriate form and style. Does not write clearly and concisely in a logically coherent and appropriate form and style. Preliminary Care Coordination Plan Paper

Writes in a manner that lacks clarity or conciseness, is loosely structured, or includes errors in grammar, mechanics, or APA formatting that inhibit effective communication or detract from good scholarship. Writes clearly and concisely in a logically coherent and appropriate form and style. 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. https://courserooma.capella.edu/bbcswebdav/institution/NURS-FPX/NURS-FPX4050/200100/Scoring_Guides/a01_scoring_guide.html 1/1 …