assessment 64

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

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Introduction

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Preparation

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of 

Healthy People 2030
.

Instructions

Note: You are required to complete Assessment 1 before this assessment.

(assessment 1 is down below)

For this assessment:

· Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 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 a selected health care problem.

· Address three health care issues.

· Design an intervention for each health issue.

· Identify three community resources for each health intervention.

· Consider 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.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

· Clearly explain the need for changes to the plan.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

· Use the literature on evaluation as guide to compare learning session content with best practices.

· Align teaching sessions to the Healthy People 2030 document.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

Portfolio Prompt: Save your presentation to your 
ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Context

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.

Course Competencies

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.

· Design patient-centered health interventions and timelines for a selected health care problem.

· Competency 2: Collaborate with patients and family to achieve desired outcomes.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

· Competency 3: Create a satisfying patient experience.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

· Competency 4: Defend decisions based on the code of ethics for nursing.

· Consider 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.

· Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Assessment 1

Preliminary Care Coordination Plan for Type 2 Diabetes Management

In the community care center environment, a coordinated pharmacological and non-pharmacological comprehensive focused care approach has to be targeted towards treating Type 2 Diabetes, considering the physical, psychosocial, and cultural aspects. The rate of Type 2 Diabetes increases with time and is a worthy concern that requires proper attention to best practices in CCM (Rajendran & Vijayashree, 2024). The American Diabetes Association has established in its Standards of Medical Care (2024) that diabetes management is comprehensive and involves wide-ranging aspects, including medication and patient education. Coordinated pharmacological and non-pharmacological comprehensive focused care approach has to be targeted towards treating Type 2 Diabetes, considering the physical, psychosocial, and cultural aspects.

The physically oriented aspects of diabetes care involve checking blood glucose levels, taking prescribed medications, and following prescribed changes in behavior. Some of the mentioned practices are keeping A1C below 7% for most adults, checking blood pressure often, and getting a comprehensive foot examination every year. Kaiser Permanente’s National Institute of Diabetes and Digestive and Kidney Diseases study has shown that when patients with T2DM are provided with coordinated, comprehensive physical care, they better manage their glycemic levels and complications. The nursing care plan must include exercise programs, diet, and weight management to maximize physical health.

Psychosocial factors remain central to practical diabetes care because diabetes affects mental health and well-being. Patients with diabetes have a high prevalence of depression and anxiety disorders; data show that 30% of type 2 diabetic patients meet the criteria for major depressive disorder. The care coordination plan should provide profound psychological aspects through routine triage and psychological testing, stress reduction activities, and counseling schedules (Khaledi et al., 2019). Also, families must be involved as they are relevant in progress assessment, medication compliance, and emotional encouragement.

Culture is essential in choosing an appropriate care plan that should respect a patient’s background. The patient’s culture may dictate what they take, the timing of the medication concerning their religion or cultural values, or other cultural practices of healing that practitioners have to respect and consider (Epstein & Timmermans, 2021). For example, suppose the need to take medicine is tightly connected with certain periods (religious fasts, for example). In that case, the regimen should be changed, whereas the diet should correspond to cultural aspects, but it must be as effective as possible.

Goals for handling Type 2 Diabetes should be SMART, which stands for Specific, Measurable, Achievable, Relevant, and Time-bound. They consist of stated or initial objectives, which embrace target blood glucose levels, exercising regime, appropriate diet plans, and drug adherence. Secondary objectives must be directed toward the prevention of weight gain, stress control, and the prevention of diabetes complications. These goals should be periodically revisited depending on the patient’s progress or the evolving requirement.

It cannot be emphasized enough that community resources are essential to developing a safe and effective model for continuity. Community-based diabetes professionals include certified diabetes educators in the community health centers, nutritionists in the local hospitals, and self-administered consumer groups such as the American Diabetes Association. There are programs, such as exercise, that are appropriate for diabetic clients, carried out by the local YMCA on diabetes prevention. Further, they offer other services such as medication management and diabetes suppliers. Specific contacts can ask for groceries and meals that are delivered for patients as they can request transport to medical appointments.

The following table presents the community resources available in the area for type 2 Diabetes management:

The overall outcome of this care coordination plan depends much on the efficient flow of information and integration between and within healthcare givers, patients, and their communities. Postoperative visits, phone calls, and referral sessions with primary care physicians are consistently implemented to maintain care continuities. Informed materials should be translated where needed, and cultural brokering is also vital in enhancing patients’ understanding of and compliance with the recommended treatment plan.

Mechanisms put in place to undertake the care coordination plan must undergo regular assessment to check efficiency and identify any changes that need to be implemented. This involves documenting the status of case findings, patients’ satisfaction and assessment, and the existing community resource use. This means that once again, assessing the barriers to care and addressing the challenges as they occur will keep the patient more involved in their care plan and the overall results.

By evaluating the aspects of the patient’s physical, psychosocial, and cultural characteristics and using the resources available in the community, the patient with Type 2 Diabetes could gain better quality of life and health outcomes. This plan has to be executed with a constant and immediate communication link, random checks to address individual patients’ conditions and circumstances, and frequent changes to fit individual patients’ needs and requirements.

References

American Diabetes Association. (2024). Standards of medical care in diabetes—2024. Diabetes Care, 47(Supplement 1), S1-S324.

Epstein, S., & Timmermans, S. (2021). From medicine to health: the proliferation and diversification of cultural authority. 
Journal of Health and Social Behavior, 
62(3), 240-254.

Khaledi, M., Haghighatdoost, F., Feizi, A., & Aminorroaya, A. (2019). The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on a huge number of observational studies. 
Acta diabetologica, 
56, 631-650.

Rajendran, A. J., & Vijayashree, N. (2024). Comprehensive Rehabilitation Program for Diabetes Management and Care. In 
Management of Diabetic Complications: Calling for a Team Approach (pp. 101-122). Singapore: Springer Nature Singapore.