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Develop a preliminary care coordination plan for a selected health care problem.

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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
NOTE: You are required to complete this
assessment before Assessment 4.

The first step in any effective project is
planning. This assignment 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.

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.
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.
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.
Competencies Measured
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.
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.

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