Preliminary Care Coordination Plan Discussion 2
Preliminary Care Coordination Plan Discussion 2
Develop a 3 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.
The first step in any effective project is planning. 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.
Demonstration of Proficiency
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.
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. Preliminary Care Coordination Plan Discussion 2
Instructions
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.
Grading Requirements 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.
You may review the following:
Improving Chronic Illness Care. (n.d.). Care coordination: Background. http://www.improvingchroniccare.org/index.php?p=Background&s=350This 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.htmlYou 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=344The 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=347The 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 Discussion 2