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Care coordination plan

nursing care coordinator plan

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.

Chronic Disease Management
Physical considerations: Chronic diseases can cause physical limitations and
impairments that can affect an individual’s ability to perform daily activities.
o Psychosocial considerations: Chronic diseases can cause emotional distress,
anxiety, and depression.
Cultural considerations: Cultural beliefs and practices may influence an
individual’s willingness to manage their chronic disease.
o Community resources: Disease management programs, support groups, and
community health centers can provide resources and support for individuals with
chronic diseases.

·  In your plan, please include physical, psychosocial, and cultural needs.

· Identify available community resources for a safe and effective continuum of care.

· 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.

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and 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.

Grading Criterion

Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis.

Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable.

Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.

Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

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