Please see instructions, and refer to Care Coordination Plan.
Final Care Coordination Plan
For 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.
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 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.
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.
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.
- Document Format and Length
- Supporting Evidence
- Grading Requirements
