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.

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.

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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 families 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.

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 provided care coordination template or 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 provided community resources template
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.

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