Assessment 1
Preliminary Care Coordination Plan
Instruction
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:
· 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:
· Stroke.
· 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.
· Trauma.
· 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
Preliminary Care Coordination Plan Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Analyze a health concern and the associated best practices for health improvement.
Describe specific goals that should be established to address a selected 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.
Preliminary Care Coordination Plan for Heart Disease
Heart disease, including conditions like heart attacks, heart failure, and stroke, is a leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2021). Coordinating care is essential to effectively managing heart disease and improving patient outcomes. This preliminary care coordination plan analyzes heart disease and associated best practices, establishes goals for treatment and recovery, and identifies available community resources.
Analysis of Heart Disease and Best Practices
Heart disease develops when the arteries become narrowed or blocked by fatty deposits called plaque (Mayo Clinic, 2022). Over time, this buildup restricts blood flow and oxygen to the heart, increasing risk of heart attack. High blood pressure, high cholesterol, obesity, diabetes, smoking, and lack of physical activity are major risk factors (American Heart Association [AHA], 2022). Best practices for prevention and management focus on modifying these risk factors through a heart-healthy diet, exercise, weight control, stress management, and medication adherence if needed (AHA, 2022; CDC, 2021). Regular checkups allow medical providers to monitor conditions and adjust treatment plans as needed.
Goals for Treatment and Recovery
Specific goals for the care coordination plan include stabilizing any acute cardiac events, controlling blood pressure and cholesterol levels, promoting lifestyle changes, and ensuring follow up care (AHA, 2022). In the first 30 days post-event or hospitalization, goals are to avoid additional cardiac incidents, manage symptoms and pain, adhere to medication and diet plans, and attend cardiac rehabilitation. Long term goals over 6-12 months focus on sustained lifestyle modifications, ongoing monitoring of cardiac health through routine doctor visits and testing, and management of any co-existing conditions like diabetes or obesity (CDC, 2021).
Available Community Resources
Several local resources can support this care coordination plan. The county health department offers low-cost blood pressure and cholesterol screenings, smoking cessation classes, and chronic disease management programs (County Health Department, 2022). The American Heart Association affiliates with the hospital to provide community education seminars on heart health topics and support groups for cardiac patients and families (AHA, 2022). The local YMCA offers exercise programs tailored for cardiac rehabilitation at a discounted rate for patients (YMCA, 2021). Meals on Wheels delivers heart-healthy meals to homebound residents (Meals on Wheels, 2022). The patient’s primary care physician and cardiologist will oversee medical treatment while these additional resources address lifestyle, psychosocial support, and access to care needs.
In conclusion, this preliminary care coordination plan analyzes heart disease and evidence-based best practices, establishes goals for treatment and recovery, and identifies local resources to support physical, psychosocial and cultural needs. Coordinating care through a multidisciplinary team approach can help patients successfully manage their condition in the community setting. Further refinement of this plan will occur as specific patient needs and preferences are determined.
References
American Heart Association. (2022). Heart disease and stroke statistics. https://www.heart.org/en/about-us/heart-disease-and-stroke-statistics
Centers for Disease Control and Prevention. (2021). Heart disease facts. https://www.cdc.gov/heartdisease/facts.htm
County Health Department. (2022). Chronic disease management programs. https://www.countyhealth.org/services/chronic-disease
Mayo Clinic. (2022). Heart disease. https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118
Meals on Wheels. (2022). Nutrition services. https://www.mowaa.org/services/nutrition-services/
YMCA. (2021). Cardiac rehabilitation. https://www.ymca.net/health-wellness-center/services/cardiac-rehab
