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1
Develop a 3-4 page preliminary care coordination plan for a selected health care
problem. Include physical, psychosocial, and cultural considerations for this health care
problem. Identify and list available community resources for a safe and effective
continuum of care.
Expand All
Introduction
The first step in any effective project is planning. This assessment provides an
opportunity for you to strengthen your understanding of how to plan and negotiate the
coordination of care for a particular health care problem. Include physical, psychosocial,
and cultural considerations for this health care problem. Identify and list available
community resources for a safe and effective continuum of care.
NOTE: You are required to complete this assessment before Assessment 4.
Preparation
As you begin to prepare this assessment, you are encouraged to complete the Care
Coordination Planning activity. Completion of this will provide useful practice, particularly
for those of you who do not have care coordination experience in community settings.
The information gained from completing this activity will help you succeed with the
assessment. Completing formatives is also a way to demonstrate engagement.
Scenario
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
2
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.
To prepare for this assessment, you may wish to:
● Review the assessment instructions and scoring guide to ensure that you
understand the work you will be asked to complete.
● Allow plenty of time to plan your chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
● Select one of the health concerns in the Assessment 01 Supplement:
Preliminary Care Coordination Plan [PDF]
● Download Assessment 01 Supplement: Preliminary Care Coordination Plan
[PDF]
● resource as the focus of your care coordination plan. In your plan, please
include physical, psychosocial, and cultural needs.
● Identify available community resources for a safe and effective continuum of
care.
3
Document Format and Length
● 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.
● Be sure to review the scoring guide to make sure all criteria are addressed in
your paper.
○ Study the subtle differences between basic, proficient, and
distinguished.
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.
4
● Describe specific goals that should be established to address the health care
problem.
● Identify available community resources for a safe and effective continuum of
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.
○ 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.
Portfolio Prompt: Save your presentation to your ePortfolio.
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.
5
○ 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.
Preliminary Care Coordination Plan Scoring Guide
6
NON-PERF
CRITERIA
PROFICIEN
DISTINGUIS
T
HED
BASIC
ORMANCE
Analyze a
Does not
Attempts to
Analyzes a
Provides a
health concern
analyze a
analyze a
health
perceptive
health
health
concern and
analysis of a
concern and
concern and
the
health
the
the
associated
concern and
associated
associated
best
the
best
best
practices for
associated
practices for
practices for
health
best
health
health
improvemen
practices for
improvemen
improvemen
t.
health
t.
t.
and the
associated best
practices for
health
improvement.
improvemen
t. Provides
credible
evidence for
best
practices
and
7
articulates
underlying
assumptions
and points of
uncertainty
in the
analysis.
Describe
Does not
Attempts to
Describes
Describes
specific goals
describe
describe
specific
specific
specific
undefined
goals that
goals that
goals that
goals that
should be
should be
should be
should be
established
established
address a
established
established
to address a
to address a
selected health
to address a
to address a
selected
selected
selected
selected
health care
health care
health care
health care
problem.
problem.
problem.
problem.
that should be
established to
care problem.
Ensures that
the goals
are realistic,
8
measurable,
and
attainable.
Identify
Does not
Attempts to
Identifies
Identifies
available
identify
identify
available
significant
available
available
community
and
community
community
resources
available
resources.
resources.
for a safe
community
safe and
and effective
resources
effective
continuum of
for a safe
care.
and effective
community
resources for a
continuum of
care.
continuum of
care.
Provides a
comprehensi
ve list of
resources,
with credible
evidence of
9
their
contribution
toward
improving
community
health.
Organize
Does not
Organizes
Organizes
Organizes
content so
organize
content with
content so
content with
content for
some logical
ideas flow
a clear
ideas. Lacks
flow and
logically with
purpose.
logical flow
smooth
smooth
Content
smooth
and smooth
transitions.
transitions;
flows
transitions;
transitions.
Contains
contains few
logically with
errors in
errors in
smooth
grammar/pu
grammar/pu
transitions
nctuation,
nctuation,
using
word choice,
word choice,
coherent
and spelling.
and spelling.
paragraphs,
ideas flow
logically with
contains few
errors in
grammar/punct
uation, word
correct
10
choice, and
grammar/pu
spelling.
nctuation,
word choice,
and free of
spelling
errors.
Apply APA
Does not
Applies APA
Applies APA
Exhibits
formatting to
apply APA
formatting to
formatting to
strict and
formatting to
in-text
in-text
flawless
headings,
citations,
citations and
adherence
in-text
headings
references,
to APA
citations,
and
exhibiting
formatting of
and
references
nearly
headings,
references.
incorrectly
flawless
in-text
Does not
and/or
adherence
citations,
use quotes
inconsistentl
to APA
and
or
y, detracting
format.
references.
in-text citations
and references,
exhibiting
nearly flawless
adherence to
APA format.
noticeably
from the
Quotes and
11
paraphrase
content.
paraphrases
correctly.
Inconsistentl
correctly.
y uses
headings,
quotes
and/or
paraphrasin
g.
Use the resources linked below to help complete this assessment.
Expand All
Care Coordination Fundamentals
You may review the resources on the following reading list:
● Assessment 1: Care Coordination Fundamentalsreading list.
Academic Resources
A variety of writing resources are available in the NHS Learner Support Lab, linked in
the courseroom navigation menu.
Scholarly Writing and APA Style
12
Use the following resources to improve your writing skills and find answers to specific
questions.
● Academic Integrity and Honesty.
● APA Module.
Library Research
Use the following resources to help with any required or self-directed research you do to
support your coursework.
● BSN Program Library Research Guide.
● Capella University Library.
● Journal and Book Locator Library Guide.
● Library Research and Information Literacy Skills.
● NURS-FPX4050: Coordinating Patient-Centered Care Library Guide.
Writing SMART Goals for Care Coordination
During care coordination, nurses should ensure that they are creating patient-centered
goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable,
Relevant, Timely) goals. SMART goals provide direction for patient-centered care
coordination.
SMART goals must be effective, meaningful, achievable, and collaborative in nature.
Key stakeholders (such as the individual, group, or community; possibly significant
others; and you, the nurse) must be taken into account.
13
Often the best way to patient-centered functional goals is simply to ask the target group,
“What are your goals?” Doing this will help you to improve adherence, satisfaction, and
outcomes. Consider the following when developing SMART goals:
● Specific: Goals will specify who will be responsible, what is to be achieved,
where the activity is located, and why it is important or beneficial.
● Measurable: Goals must specify criteria for measuring progress against them.
This helps you to stay on track, reach milestones, and motivate the
stakeholders.
● Attainable: Setting attainable goals serves to motivate the individual or group.
● Relevant: Key stakeholders must see how a specific goal is relevant to them.
● Timely: To be most effective, goals must be structured around a specific time
frame to motivate individuals to begin working on their goals.
After developing a mutually agreed-upon goal, SMART objectives are developed to help
guide activities. Objectives help to determine whether the goals have been achieved
and if revisions need to be made for future educational sessions.
SMART objectives must be:
● Specific: Objectives need to be concrete, detailed, and well-defined so that
you know what exactly is going to occur and what to expect.
● Measurable: A way to determine how the goal was met or if it needs revision.
● Achievable: The objective must be appropriate and feasible for those
involved. Ask: What’s the patient’s learning style? For example, does the
14
patient prefer reading printed materials, viewing audiovisual materials, or
watching demonstrations?
● Realistic: It must take into consideration constraints such as resources,
personnel, cost, education level, learning style, reading level and
comprehension level. What language do they speak? How much does the
individual or group like to know? Ask: Can the patient read or comprehend
instructions or follow directions? Do they prefer reading printed materials,
viewing audiovisual materials, or demonstrations?
● Time-bound: A time frame helps set boundaries around the objective. Ask:
How long will it take to obtain the objective? Objectives may be process- or
outcome-oriented.
Outcome objectives can be short-term, intermediate, or long-term:
● Short-term objectives can be achieved after implementing certain activities or
interventions. Change may be in cognitive (knowledge), psychomotor
(demonstration), and values (attitude).
● Intermediate outcome objectives provide a sense of progress toward reaching
long-term objectives. This could be behavior and policy change.
● Long-term objectives occur after the program has been implemented. It may
take more than a month. These can be changes in mortality, moribundity, and
quality of life.
Example of a SMART goal:
● Walk for 30 minutes a day, seven days a week.
15
Example of a SMART objective:
● By the end of the week, patient will have walked 3.5 hours.
Example of an evaluation of a SMART objective:
● The patient will complete a daily log of miles each week.
Additional Resources
The additional resources on the following reading list will help you in establishing
SMART goals and objectives in collaboration with educational session participants:
● Assessment 1: Writing SMART Goals for Care Coordination reading list.
Additional Resources for Further Exploration
You may use the following resource to further explore topics related to the
competencies.
● Care Coordination: San Francisco General Hospital: Connectivity Through
Electronic Referral.
Assessment 01 – Preliminary Care Coordination Plan
For this assessment, you will develop a 3–4 page preliminary care coordination plan for a
selected health care problem. Include physical, psychosocial, and cultural considerations for this
health care problem. Identify and list available community resources for a safe and effective
continuum of care.
Before you complete the instructions detailed in the courseroom, first select one of the following
health care problems or issues:
•
Lack of Access to Healthcare Services
o Physical considerations: Limited transportation options, long wait times for
appointments, and lack of insurance coverage can prevent individuals from
accessing healthcare services.
o Psychosocial considerations: Fear of medical procedures, mistrust of
healthcare providers, and language barriers can also prevent individuals from
accessing healthcare services.
o Cultural considerations: Cultural beliefs and practices may influence an
individual’s willingness to seek medical care.
o Community resources: Community health clinics, mobile health clinics, and
telehealth services can provide accessible healthcare services to individuals who
may not have access to traditional healthcare settings.
•
Chronic Disease Management
o 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.
o 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.
After you have selected one of the problems/issues from the list above, return to the detailed
instructions in the courseroom to complete your assessment.
1
1
Develop a 3-4 page preliminary care coordination plan for a selected health care
problem. Include physical, psychosocial, and cultural considerations for this health care
problem. Identify and list available community resources for a safe and effective
continuum of care.
Expand All
Introduction
The first step in any effective project is planning. This assessment provides an
opportunity for you to strengthen your understanding of how to plan and negotiate the
coordination of care for a particular health care problem. Include physical, psychosocial,
and cultural considerations for this health care problem. Identify and list available
community resources for a safe and effective continuum of care.
NOTE: You are required to complete this assessment before Assessment 4.
Preparation
As you begin to prepare this assessment, you are encouraged to complete the Care
Coordination Planning activity. Completion of this will provide useful practice, particularly
for those of you who do not have care coordination experience in community settings.
The information gained from completing this activity will help you succeed with the
assessment. Completing formatives is also a way to demonstrate engagement.
Scenario
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
2
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.
To prepare for this assessment, you may wish to:
● Review the assessment instructions and scoring guide to ensure that you
understand the work you will be asked to complete.
● Allow plenty of time to plan your chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
● Select one of the health concerns in the Assessment 01 Supplement:
Preliminary Care Coordination Plan [PDF]
● Download Assessment 01 Supplement: Preliminary Care Coordination Plan
[PDF]
● resource as the focus of your care coordination plan. In your plan, please
include physical, psychosocial, and cultural needs.
● Identify available community resources for a safe and effective continuum of
care.
3
Document Format and Length
● 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.
● Be sure to review the scoring guide to make sure all criteria are addressed in
your paper.
○ Study the subtle differences between basic, proficient, and
distinguished.
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.
4
● Describe specific goals that should be established to address the health care
problem.
● Identify available community resources for a safe and effective continuum of
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.
○ 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.
Portfolio Prompt: Save your presentation to your ePortfolio.
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.
5
○ 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.
Preliminary Care Coordination Plan Scoring Guide
6
NON-PERF
CRITERIA
PROFICIEN
DISTINGUIS
T
HED
BASIC
ORMANCE
Analyze a
Does not
Attempts to
Analyzes a
Provides a
health concern
analyze a
analyze a
health
perceptive
health
health
concern and
analysis of a
concern and
concern and
the
health
the
the
associated
concern and
associated
associated
best
the
best
best
practices for
associated
practices for
practices for
health
best
health
health
improvemen
practices for
improvemen
improvemen
t.
health
t.
t.
and the
associated best
practices for
health
improvement.
improvemen
t. Provides
credible
evidence for
best
practices
and
7
articulates
underlying
assumptions
and points of
uncertainty
in the
analysis.
Describe
Does not
Attempts to
Describes
Describes
specific goals
describe
describe
specific
specific
specific
undefined
goals that
goals that
goals that
goals that
should be
should be
should be
should be
established
established
address a
established
established
to address a
to address a
selected health
to address a
to address a
selected
selected
selected
selected
health care
health care
health care
health care
problem.
problem.
problem.
problem.
that should be
established to
care problem.
Ensures that
the goals
are realistic,
8
measurable,
and
attainable.
Identify
Does not
Attempts to
Identifies
Identifies
available
identify
identify
available
significant
available
available
community
and
community
community
resources
available
resources.
resources.
for a safe
community
safe and
and effective
resources
effective
continuum of
for a safe
care.
and effective
community
resources for a
continuum of
care.
continuum of
care.
Provides a
comprehensi
ve list of
resources,
with credible
evidence of
9
their
contribution
toward
improving
community
health.
Organize
Does not
Organizes
Organizes
Organizes
content so
organize
content with
content so
content with
content for
some logical
ideas flow
a clear
ideas. Lacks
flow and
logically with
purpose.
logical flow
smooth
smooth
Content
smooth
and smooth
transitions.
transitions;
flows
transitions;
transitions.
Contains
contains few
logically with
errors in
errors in
smooth
grammar/pu
grammar/pu
transitions
nctuation,
nctuation,
using
word choice,
word choice,
coherent
and spelling.
and spelling.
paragraphs,
ideas flow
logically with
contains few
errors in
grammar/punct
uation, word
correct
10
choice, and
grammar/pu
spelling.
nctuation,
word choice,
and free of
spelling
errors.
Apply APA
Does not
Applies APA
Applies APA
Exhibits
formatting to
apply APA
formatting to
formatting to
strict and
formatting to
in-text
in-text
flawless
headings,
citations,
citations and
adherence
in-text
headings
references,
to APA
citations,
and
exhibiting
formatting of
and
references
nearly
headings,
references.
incorrectly
flawless
in-text
Does not
and/or
adherence
citations,
use quotes
inconsistentl
to APA
and
or
y, detracting
format.
references.
in-text citations
and references,
exhibiting
nearly flawless
adherence to
APA format.
noticeably
from the
Quotes and
11
paraphrase
content.
paraphrases
correctly.
Inconsistentl
correctly.
y uses
headings,
quotes
and/or
paraphrasin
g.
Use the resources linked below to help complete this assessment.
Expand All
Care Coordination Fundamentals
You may review the resources on the following reading list:
● Assessment 1: Care Coordination Fundamentalsreading list.
Academic Resources
A variety of writing resources are available in the NHS Learner Support Lab, linked in
the courseroom navigation menu.
Scholarly Writing and APA Style
12
Use the following resources to improve your writing skills and find answers to specific
questions.
● Academic Integrity and Honesty.
● APA Module.
Library Research
Use the following resources to help with any required or self-directed research you do to
support your coursework.
● BSN Program Library Research Guide.
● Capella University Library.
● Journal and Book Locator Library Guide.
● Library Research and Information Literacy Skills.
● NURS-FPX4050: Coordinating Patient-Centered Care Library Guide.
Writing SMART Goals for Care Coordination
During care coordination, nurses should ensure that they are creating patient-centered
goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable,
Relevant, Timely) goals. SMART goals provide direction for patient-centered care
coordination.
SMART goals must be effective, meaningful, achievable, and collaborative in nature.
Key stakeholders (such as the individual, group, or community; possibly significant
others; and you, the nurse) must be taken into account.
13
Often the best way to patient-centered functional goals is simply to ask the target group,
“What are your goals?” Doing this will help you to improve adherence, satisfaction, and
outcomes. Consider the following when developing SMART goals:
● Specific: Goals will specify who will be responsible, what is to be achieved,
where the activity is located, and why it is important or beneficial.
● Measurable: Goals must specify criteria for measuring progress against them.
This helps you to stay on track, reach milestones, and motivate the
stakeholders.
● Attainable: Setting attainable goals serves to motivate the individual or group.
● Relevant: Key stakeholders must see how a specific goal is relevant to them.
● Timely: To be most effective, goals must be structured around a specific time
frame to motivate individuals to begin working on their goals.
After developing a mutually agreed-upon goal, SMART objectives are developed to help
guide activities. Objectives help to determine whether the goals have been achieved
and if revisions need to be made for future educational sessions.
SMART objectives must be:
● Specific: Objectives need to be concrete, detailed, and well-defined so that
you know what exactly is going to occur and what to expect.
● Measurable: A way to determine how the goal was met or if it needs revision.
● Achievable: The objective must be appropriate and feasible for those
involved. Ask: What’s the patient’s learning style? For example, does the
14
patient prefer reading printed materials, viewing audiovisual materials, or
watching demonstrations?
● Realistic: It must take into consideration constraints such as resources,
personnel, cost, education level, learning style, reading level and
comprehension level. What language do they speak? How much does the
individual or group like to know? Ask: Can the patient read or comprehend
instructions or follow directions? Do they prefer reading printed materials,
viewing audiovisual materials, or demonstrations?
● Time-bound: A time frame helps set boundaries around the objective. Ask:
How long will it take to obtain the objective? Objectives may be process- or
outcome-oriented.
Outcome objectives can be short-term, intermediate, or long-term:
● Short-term objectives can be achieved after implementing certain activities or
interventions. Change may be in cognitive (knowledge), psychomotor
(demonstration), and values (attitude).
● Intermediate outcome objectives provide a sense of progress toward reaching
long-term objectives. This could be behavior and policy change.
● Long-term objectives occur after the program has been implemented. It may
take more than a month. These can be changes in mortality, moribundity, and
quality of life.
Example of a SMART goal:
● Walk for 30 minutes a day, seven days a week.
15
Example of a SMART objective:
● By the end of the week, patient will have walked 3.5 hours.
Example of an evaluation of a SMART objective:
● The patient will complete a daily log of miles each week.
Additional Resources
The additional resources on the following reading list will help you in establishing
SMART goals and objectives in collaboration with educational session participants:
● Assessment 1: Writing SMART Goals for Care Coordination reading list.
Additional Resources for Further Exploration
You may use the following resource to further explore topics related to the
competencies.
● Care Coordination: San Francisco General Hospital: Connectivity Through
Electronic Referral.
1
Develop a 3-4 page preliminary care coordination plan for a selected health care
problem. Include physical, psychosocial, and cultural considerations for this health care
problem. Identify and list available community resources for a safe and effective
continuum of care.
Expand All
Introduction
The first step in any effective project is planning. This assessment provides an
opportunity for you to strengthen your understanding of how to plan and negotiate the
coordination of care for a particular health care problem. Include physical, psychosocial,
and cultural considerations for this health care problem. Identify and list available
community resources for a safe and effective continuum of care.
NOTE: You are required to complete this assessment before Assessment 4.
Preparation
As you begin to prepare this assessment, you are encouraged to complete the Care
Coordination Planning activity. Completion of this will provide useful practice, particularly
for those of you who do not have care coordination experience in community settings.
The information gained from completing this activity will help you succeed with the
assessment. Completing formatives is also a way to demonstrate engagement.
Scenario
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
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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.
To prepare for this assessment, you may wish to:
● Review the assessment instructions and scoring guide to ensure that you
understand the work you will be asked to complete.
● Allow plenty of time to plan your chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
● Select one of the health concerns in the Assessment 01 Supplement:
Preliminary Care Coordination Plan [PDF]
● Download Assessment 01 Supplement: Preliminary Care Coordination Plan
[PDF]
● resource as the focus of your care coordination plan. In your plan, please
include physical, psychosocial, and cultural needs.
● Identify available community resources for a safe and effective continuum of
care.
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Document Format and Length
● Your preliminary plan should be an APA scholarly paper, 3–4 page
