Final 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.