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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.
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.
Final Care Coordination Plan Scoring Guide
NON-PERF
CRITERIA
PROFICIEN
DISTINGUIS
T
HED
BASIC
ORMANCE
Design
Does not
Designs
Designs
Designs
patient-centere
design
patient-cent
patient-cent
patient-cent
patient-cent
ered health
ered health
ered health
ered health
intervention
interventions
interventions
interventions
for a
and
and
and timelines
and
selected
timelines for
timelines for
for a selected
timelines for
health care
a selected
a selected
a selected
problem.
health care
health care
problem.
problem that
d health
interventions
health care
problem.
health care
problem.
includes
community
resources.
Consider
Does not
Considers
Considers
Considers
ethical
consider
ill-defined or
ethical
insightful
ethical
ambiguous
decisions in
ethical
decisions in
ethical
designing
decisions in
designing
decisions in
patient-cent
designing
health
designing
ered health
patient-cent
interventions
patient-cent
interventions
ered health
.
ered health
.
interventions
decisions in
designing
patient-centere
d health
interventions.
interventions
. These
.
decisions
are
supported
by the
literature.
Identify relevant
Does not
Identifies
Identifies
Identifies
health policy
identify
health policy
relevant
relevant
relevant
implications
health policy
health policy
health policy
that are
implications
implications
implications
inconsistent
for the
for the
coordination
for the
with the
coordination
coordination
and continuum
coordination
goals and
and
and
and
objectives
continuum of
continuum of
continuum of
for the
care.
care, based
care.
coordination
on precise
and
and
continuum of
accurate
care.
interpretatio
implications for
the
of care.
ns of
relevant
policy
provisions.
Makes valid,
insightful
inferences.
Describe
Does not
Describe
Describes
Describe
priorities that a
describe
priorities that
priorities that
priorities that
priorities that
a care
a care
a care
a care
coordinator
coordinator
coordinator
coordinator
would
would
would
would establish
would
establish
establish
establish
when
establish
when
when
when
when
discussing
discussing
discussing
discussing
the plan with
the plan with
the plan with
the plan with
a patient
a patient
a patient
a patient
and family
and family
and family
family member,
and family
member but
member,
member,
making
member.
does not use
making
making
evidence-ba
changes
changes
sed practice
based upon
based upon
to make
evidence-ba
evidence-ba
evidence-based
changes to
sed practice.
sed practice.
practice.
the plan.
care
coordinator
discussing the
plan with a
patient and
changes based
upon
Clearly
explains the
need for
changes to
the plan.
Use the
Does not
Discusses
Uses the
Uses the
literature on
use the
evaluation
literature on
literature on
literature on
but does not
evaluation
evaluation
evaluation
use the
as a guide to
as a guide to
as a guide to
literature as
compare
compare
compare
compare
a guide to
learning
learning
learning
learning
compare
session
session
session
learning
content with
content with
content with
session
best
best
best
content with
practices,
practices,
practices,
best
including
including
including how
and does
practices, or
how to align
how to align
to align
not include
does not
teaching
teaching
how to align
include how
sessions to
sessions to
teaching
to align
the Healthy
the Healthy
sessions to
teaching
People 2030
the Healthy
sessions to
document.
evaluation as a
guide to
session content
with best
practices,
teaching
sessions to the
Healthy People
2030
People 2030
the Healthy
People 2030
Clearly
document.
document.
People 2030
document.
explains the
document.
need for any
revisions.
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.
paraphrase
noticeably
Quotes and
correctly.
from the
paraphrases
content.
correctly.
in-text citations
and references,
exhibiting
nearly flawless
adherence to
APA format.
Inconsistentl
y uses
headings,
quotes
and/or
paraphrasin
g.
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
choice, and
grammar/pu
spelling.
nctuation,
word choice,
and free of
spelling
errors.
Managing Chronic Illnesses
Read through the resource on the following reading list to identify the role of care
coordination in managing chronic illnesses. Pay close attention to similarities between
your community and the patient population:
● Assessment 4: Managing Chronic Illnessesreading 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
Use the following resources to improve your writing skills and find answers to specific
questions.
● Academic Honesty & APA Style and Formatting.
● 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.
ePortfolio
Use the following resource to understand how to save your assessments to ePortfolio:
● Online ePortfolio Guidelines [PDF].
Additional Resources for Further Exploration
You may use the resource on the following reading list to further explore topics related
to the competencies. Consider how health care scientists assess and evaluate a diverse
cultural setting and the impact on needed health care.
● Assessment 4: Additional Resources for Further Exploration reading list.
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