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Complete the preliminary care coordination plan you developed
in Assessment 1. Present the plan to the patient in a face-to-face
clinical learning session and collaborate with the patient in
evaluating session outcomes and addressing possible revisions
to the plan
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.
This assessment provides an opportunity for you to apply
communication, teaching, and learning best practices to the
presentation of a care coordination plan to the patient.
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.
Design patient-centered health interventions and timelines for
care.
Competency 2: Collaborate with patients and family to achieve
desired outcomes.
Evaluate learning session outcomes and the attainment of
mutually agreed-upon health goals, in collaboration with a
patient.
Competency 3: Create a satisfying patient experience.
Evaluate patient satisfaction with the care coordination plan and
progress made toward Healthy People 2020 goals and leading
health indicators.
Competency 4: Defend decisions based on the code of ethics for
nursing.
Make ethical decisions in designing patient-centered health
interventions.
Competency 5: Explain how health care policies affect patient-
centered care.
Identify relevant health policy implications for the coordination
and continuum of care.
Preparation
In this assessment, you will complete the preliminary care
coordination plan you developed in Assessment 1 and
communicate the plan to the patient in a professional, culturally
sensitive, and ethical manner.
To prepare for the assessment, consider the patient experience
and how you will present the plan. Make sure you schedule time
accordingly.
Note
: Remember that you can submit all, or a portion of, your 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 Assessment 1 before this
assessment.
For this assessment:
Complete the preliminary care coordination plan you developed
in Assessment 1.
Present the plan to the patient in a face-to-face clinical learning
session. Communicate in a professional, culturally sensitive,
and ethical manner.
Collaborate with the patient in evaluating session outcomes and
addressing possible revisions to the plan.
Reminder
: The time you spend presenting your final care coordination
plan must be logged in the CORE ELMS system. The total time
spent in securing individual participation in this activity in
Assessment 1 and presenting your plan in this assessment must
be at least three hours. The CORE ELMS link is located in the
courseroom navigation menu.
Document Format and Length
Build on the preliminary plan document you created in
Assessment 1. Your final plan should be 5–7 pages in length.
Supporting Evidence
Support your care coordination plan with peer-reviewed
articles, course study resources, and Healthy People 2020
resources. Cite at least three credible sources.
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
care.
Address three patient health issues.
Design an intervention for each health issue.
Identify three community resources for each health intervention,
so the patient may make an informed decision about what
resources to use.
Make ethical decisions in designing patient-centered health
interventions.
Consider the practical effects of specific decisions.
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.
Cite specific health policy provisions.
Evaluate learning session outcomes and the attainment of
mutually agreed-upon health goals, in collaboration with the
patient.
What aspects of the session would you change?
How might revisions to the plan improve future outcomes?
Evaluate patient satisfaction with the care coordination plan and
progress made toward Healthy People 2020 goals and leading
health indicators.
What changes would you recommend to improve patient
satisfaction and better align the session with Healthy People
2020 goals and leading health indicators?

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Complete the preliminary care coordination plan you developed in Ass.docx

  • 1. Complete the preliminary care coordination plan you developed in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session and collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan 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. This assessment provides an opportunity for you to apply communication, teaching, and learning best practices to the presentation of a care coordination plan to the patient. 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.
  • 2. Design patient-centered health interventions and timelines for care. Competency 2: Collaborate with patients and family to achieve desired outcomes. Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with a patient. Competency 3: Create a satisfying patient experience. Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators. Competency 4: Defend decisions based on the code of ethics for nursing. Make ethical decisions in designing patient-centered health interventions. Competency 5: Explain how health care policies affect patient- centered care.
  • 3. Identify relevant health policy implications for the coordination and continuum of care. Preparation In this assessment, you will complete the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the patient in a professional, culturally sensitive, and ethical manner. To prepare for the assessment, consider the patient experience and how you will present the plan. Make sure you schedule time accordingly. Note : Remember that you can submit all, or a portion of, your 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 Assessment 1 before this assessment. For this assessment: Complete the preliminary care coordination plan you developed
  • 4. in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session. Communicate in a professional, culturally sensitive, and ethical manner. Collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan. Reminder : The time you spend presenting your final care coordination plan must be logged in the CORE ELMS system. The total time spent in securing individual participation in this activity in Assessment 1 and presenting your plan in this assessment must be at least three hours. The CORE ELMS link is located in the courseroom navigation menu. Document Format and Length Build on the preliminary plan document you created in Assessment 1. Your final plan should be 5–7 pages in length. Supporting Evidence Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources. 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.
  • 5. Design patient-centered health interventions and timelines for care. Address three patient health issues. Design an intervention for each health issue. Identify three community resources for each health intervention, so the patient may make an informed decision about what resources to use. Make ethical decisions in designing patient-centered health interventions. Consider the practical effects of specific decisions. 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. Cite specific health policy provisions. Evaluate learning session outcomes and the attainment of
  • 6. mutually agreed-upon health goals, in collaboration with the patient. What aspects of the session would you change? How might revisions to the plan improve future outcomes? Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators. What changes would you recommend to improve patient satisfaction and better align the session with Healthy People 2020 goals and leading health indicators?