Preliminary Care Coordination Plan Paper

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Develop a 3-4-page preliminary care coordination plan for an individual in your community with whom you choose to work. 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. The first step in any effective project or clinical patient encounter is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for an individual in your community as you consider the patient’s unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the continuum of care. 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.

DEMONSTRATION OF PROFICIENCY

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.
- Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.
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.
- Write clearly and concisely in a logically coherent and appropriate form and style.

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. As you assume your expanded care coordination role, you have been tasked with addressing the specific health concerns of a particular individual within the community. You decide to prepare a preliminary care coordination plan and proceed by identifying the patient’s three priorities for health and by investigating the resources available in your community for a safe and effective continuum of care. 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 patient clinical encounter.
Be sure that you have a patient in mind that you can work with throughout the course.

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.This assessment has two parts.

Part 1: Develop the Preliminary Care Coordination Plan

Complete the following:

Identify a health concern as the focus of your care coordination plan. Possible health concerns may include, but are not limited to:
- Stroke.
- Heart disease (high blood pressure, stroke, or heart failure). Preliminary Care Coordination Plan Paper
- 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.
- Trauma.
Identify available community resources for a safe and effective continuum of care.

Part 2: Secure Individual Participation in the Activity

Complete the following:

Contact local individuals who may be open to an interview and a care coordination plan addressing their health concerns. The person you choose to work with may be a colleague, community member, friend, or family member.
Meet with the individual to describe the care coordination plan session that you intend to provide. Collaborate with the participant in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to the plan.
Establish a tentative date and time for the care coordination plan session. Document the name of the individual and a single point of contact, either an e-mail address or a phone number.

Document Format and Length

For your care coordination plan, you may use the Care Coordination Plan Template [DOCX], choose a format used in your own organization, or choose a format you are familiar with that adequately serves your needs for this assessment.

Your preliminary plan should be 3–4 pages in length. In a separate section of the plan, identify the person you have chosen to work with, and be sure to include his or her contact information.
Document the community resources you have identified using the Community Resources Template [DOCX].

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.
Establish mutually agreed-upon health goals for the care coordination plan, in collaboration with the selected individual.
Identify available community resources for a safe and effective continuum of care.
Write clearly and concisely in a logically coherent and appropriate form and style.
- 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.

CORE ELMS

Important note: The time you spend securing individual participation in this activity and the time you spend presenting your final care coordination plan to the patient in Assessment 4 must total at least three hours. Be sure to log your time in the CORE ELMS system. The CORE ELMS link is located in the courseroom navigation menu.Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

SCORING GUIDE

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

scoring_guide_and_resources_1.docx

cf_care_coordination_plan_template.docx

cf_community_resources_template.docx

Unformatted Attachment Preview

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 Does not identify available community resources. Identifies available community resources.Preliminary Care Coordination Plan Paper

Identifies available community resources for a safe and Identifies significant and available community resources for a CRITERIA NONPERFORMANCE BASIC a safe and effective continuum of care. 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. Writes in a manner that lacks clarity or conciseness, is loosely structured, or includes errors in grammar, mechanics, or APA formatting that inhibit effective communicatio n or detract from good scholarship. PROFICIENT DISTINGUISHED effective continuum of care. safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health. 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. I’ve notice that many new folks in the course are struggling a bit with this first assessment and leaving out parts, thusly requiring a second submission. Perhaps this can help: Use the first template to gather data when you interview your client/family. Then once you have a sense of the client’s priority problem(s), then you can make some informed choices about the types of community resources they’ll need, and use the second template. Some sections won’t apply, you can either delete that category, or you can insert NA. Don’t be to hasty to delete things you don’t think they need right now. So, that’s the first two parts of the assignment.

The third part is the 3-5 page paper where you analyze the problem (define, describe, etc) and include evidenced based interventions. These interventions should be both nursing and from some of the other health care disciplines, that you believe are appropriate. You then develop SMART goals in collaboration with the client/family. Don’t forget about a title page and a reference page to begin and end the paper. Dr. Diesel Resources: Care Coordination Fundamentals: • You may review the following: • McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., . . . Davies, S. (2014). Care coordination measures Atlas update. Retrieved from Preliminary Care Coordination Plan Paperhttps://www.ahrq.gov/professionals/preventionchroniccare/improve/coordination/atlas2014/index.htm l This resource will help you understand the basics of care coordination and how it is measured. Play close attention to the patientcentric language used in Chapters 2 and 3. Chapter 2, “What Is Care Coordination.” Chapter 3, “Care Coordination Measurement Framework.” Improving Chronic Illness Care. (n.d.). Care coordination: Background. Retrieved from http://www.improvingchroniccare.org/index.ph p?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., o o o • o which highlights the importance of care coordination. Academic Resources: • 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. • • Academic Honesty & APA Style and Formatting. APA Module. 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. Additional Resources for Further Exploration: • 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. o

• oPreliminary Care Coordination Plan Paper

http://www.improvingchroniccare.org/index.ph p?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. Retrieved from http://www.improvingchroniccare.org/index.ph p?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. 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.)Preliminary Care Coordination Plan Paper

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.Preliminary Care Coordination Plan Pap

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 …Preliminary Care Coordination Plan Paper