For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.
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Introduction
This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
Preparation ”
You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.
In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.
To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify aimploolmilmilimi■ImpwEBP
Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Final 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.
• Design patient-centered health interventions and timelines for a selected health care problem. o Address three health care issues. o Design an intervention for each health issue. o Identify three community resources for each health intervention. • Consider ethical decisions in designing patient-centered health interventions. o Consider the practical effects of specific decisions. o Include the ethical questions that generate uncertainty about the decisions you have made. • Identify relevant health policy implications for the coordination and continuum of care. o Cite specific health policy provisions. • Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. o Clearly explain the need for changes to the plan. • Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document. o Use the literature on
Context
Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.
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. o Design patient-centered health interventions and timelines for a selected health
• Competency 5: Explain how health care policies affect patient-centered care. O Identify relevant health policy implications for the coordination and continuum of care. • Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care. o Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. o Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Communication and Teaching Priorities for Updating a Care Plan
When revising a patient’s care coordination plan, clear communication and ensuring patient understanding are top priorities for the care coordinator (Williamson & Perkins, 2014). Any changes to the plan should be explained simply to the patient and family members, allowing time for questions to facilitate comprehension. Teaching methods aligned with the patient’s health literacy and learning needs, such as using visual aids, repeating key points, and asking the patient to summarize in their own words, can help optimize learning (Samuels-Kalow et al., 2016).
Health Care Issues, Interventions, and Community Resources
For a patient with diabetes, effective interventions included in an updated care plan could be nutritional counseling, glucose monitoring education, and establishing an exercise routine (Powers et al., 2022). Referrals to a registered dietitian and certified diabetes educator can support lifestyle changes aimed at managing the condition. Community resources like the American Diabetes Association that offer diabetes self-management courses and support groups expand support options.
For a patient with hypertension, the revised care plan may incorporate medication management education, dietary sodium reduction recommendations, and stress coping techniques (Whelton et al., 2018). Nearby community centers that provide blood pressure monitoring and yoga or tai chi classes can complement medical treatment.
Ethical Considerations in Care Plan Decision-Making
When making decisions regarding a patient’s care plan, care coordinators must weigh considerations of patient autonomy, beneficence, and justice (Beauchamp & Childress, 2019). For instance, practically how certain treatment limitations due to cost may impact a patient. Ethical uncertainties should be discussed openly with the patient. Informed consent is essential to upholding patient rights and values in plan revisions.
Health Policy Implications
Policies like the Affordable Care Act, which expanded access to insurance coverage and preventive services, influence continuity of care for the uninsured population (Patient Protection and Affordable Care Act, 2010). Medicare and Medicaid eligibility criteria also impact referral options. Understanding applicable policies aids in navigating the complex healthcare system when coordinating care.
Evaluation Guidance from Literature
Comparing learning session content in the care plan to targets outlined by the Healthy People 2030 framework can help evaluate if the plan supports recommended clinical guidelines and population health goals (Office of Disease Prevention and Health Promotion, n.d.). Gathering post-session feedback and assessing knowledge retention over time further strengthens the evaluation process.
