Assessment 1 Instructions: Preliminary Care Coordination Plan

Develop a 3-4 page preliminary care coordination plan for a hypothetical individual in your community. 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 hypothetical patient in mind.
• 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.
  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).
  • 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
  You can use the linked templates as a guide for the needs of your hypothetical patient who has a selected health care problem.
  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 hypothetical person you have chosen to work with.
• Document the community resources you have identified using the Community Resources Template [DOCX].
• You can use real or fictitious names/addresses for the community resources you identify
  • The type of resource, not the name, is what you need to pay attention to for this assessment.
• 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.
• Identify a hypothetical individual who would benefit from a care coordination plan.
• Document goals for the care coordination plan.
• 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.
  Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Care Coordination Plan Template

Name:

DOB:

Address:

Payor Source:

Secondary Source:

Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and the reason for care coordination planning.)

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:

Specialty Care

Specialist One:

Discipline:

Physician’s Address:

Physician’s Phone Number:

Treatment Goals:

Specialist Two:

Discipline:

Physician’s Address:

Physician’s Phone Number:

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:

Mental Health Provider

Specialist One:

Discipline:

Provider’s Address:

Provider’s Phone Number:

Treatment Goals:

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:

Reason:

Length of Stay:

Discharged to Location:

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:

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:

Length of Stay:

Name of Rehabilitation Services:

When:

Where:

Length of Stay:

Medication List (List all medications, dosage, and purpose.)

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Durable Medical Equipment

Equipment Owned:

Provider:

Equipment Rented:

Provider:

Equipment Ordered:

Provider:

Equipment Needed:

Provider:

Incontinence Equipment:

Provider:

Home Health Care Infusion Supplies

Enteral Nutrition Provider:

Phone Number:

Parenteral Infusion Provider:

Phone Number:

Other Services

Social Services:

Transition Services:

Transportation Services:

Nursing

Skilled Nursing Visits

Name:

Services:

Indication

Treatment Goals:

Hourly Nursing Services

Name:

Services:

Indication:

Treatment Goals:

Respite Care

Name:

Services:

Indication:

Treatment Goals:

Hospice Care

Name:

Services:

Indication:

Treatment Goals:

Community Services/Referrals

Cultural Needs

Signatures

RN Care Coordinator

Patient

Patient Contact Information (e-mail or phone)

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