role of the nurse in health care coordination.

Description

Complete an interactive simulation of the role of the nurse in health care coordination. Then, create a comprehensive patient needs assessment of 4-5 pages based on that simulation.

Note: Each assessment in this course builds on your work from preceding assessments; therefore, complete the assessments in the order in which they are presented.

Care coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment.

In the 2000 report To Err Is Human: Building a Safer Health System, the Institute of Medicine identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery.

Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice settings. Whether educating a patient about his or her medication and plan of care or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination.

REFERENCE

Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press.

Note: Complete the assessments in this course in the order in which they are presented.

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

What are the key reasons for completing a patient needs assessment?
Which types of information are likely to be most valuable for improving patient outcomes?
What are the benefits of a multidisciplinary approach to coordinated care?

To prepare for this assessment, complete the following simulation:

Vila Health: The Nurse’s Role in Care Coordination.

This simulation explores the roles that case managers and other team members play in care coordination. Upon completion of the exercise, you should have a better understanding of care coordination trends and their historical contexts. Use the information available in this simulation to begin your assessment of the patient, Mr. Decker.

Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.

Complete a comprehensive needs assessment for Mr. Decker, based on the information provided in the Vila Health simulation and your own research.

Comprehensive Needs Assessment Format and Length

Format your comprehensive needs assessment using APA style:

Use the APA Style Paper Tutorial [DOCX] provided. Be sure to include:
A title page and references page. An abstract is not required.
A running head on all pages.
Appropriate section headings.
Your needs assessment should be 4–5 pages in length, not including the title page and references page.
Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your assessment.

Conducting the Assessment

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your needs assessment addresses each point, at a minimum. Read the Comprehensive Needs Assessment Scoring Guide to better understand how each criterion will be assessed.

Identify current gaps in a patient’s care.
Use an appropriate needs assessment tool to identify gaps. This tool may be one in use at your place of employment, one you locate for yourself, or one provided by faculty.
Consider the types of patient information that will be most useful in assessing the current level of care.
Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.
Consider the full range of interrelated needs that affect the patient’s health.
Discuss 3–5 societal, economic, and interprofessional factors most likely to affect patient outcomes.
Consider the potential effects of these factors on outcomes.
Support your conclusions with evidence.
Relate specific patient and care coordination outcome measures to professional standards.
Provide the rationale for measuring outcomes based on established agencies and organizations.
Describe the relationship between specific outcomes and the identified standards.
Identify evidence-based practices for successful implementation of care coordination.
Use relevant and credible sources from the research literature.
Consider best practices for a population-health focus on patient outcomes.
Advocate for the benefits of a multidisciplinary approach to patient care.
Provide the key points in your argument.
Support your assertions with evidence.
Write clearly and concisely, using correct grammar and mechanics.
Express your main points and conclusions coherently.
Proofread your writing to minimize errors that could distract readers and make it more difficult to focus on the substance of your needs assessment.
Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Develop patient assessments.
Identify current gaps in a patient’s care.
Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.
Competency 2: Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role.
Discuss societal, economic, and interprofessional factors most likely to affect patient outcomes.
Advocate for the benefits of a multidisciplinary approach to patient care.
Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.
Relate specific patient and care coordination outcome measures to professional standards.
Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.
Identify evidence-based practices for successful implementation of care coordination.
Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Write clearly and concisely, using correct grammar and mechanics.
Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style

Unformatted Attachment Preview

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Document Format: Margins are 1 in. (2.54 cm) on all sides.
All text in the document should be double-spaced.
The font is 12-point Times New Roman. Other choices are 11-point Arial and 11-point Calibri.
The title page is page 1.
There is no running head for learner assignments. (See Academic Writer: Publication Manual §§ 2.1–2.24
for paper requirements.)
Full Title of Your Paper
Learner’s Full Name (no credentials)
School of Nursing and Health Sciences, Capella University
Course Number: Course Name
Instructor’s Name
Month, Year
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Abstract
An abstract is useful in professional papers, but not always in learner assignments. In fact,
unless you are instructed by your faculty or in the course syllabus, do not expect to use
abstracts very often at Capella. If you are submitting for publication, remember to check
with the journal or professional organization about their criteria for an abstract. The
abstract tells your reader about the article, is brief, and stands alone, so no citations are included.
The format for an abstract is a single paragraph (not indented on the first line) that follows the
title page and is less than 250 words in length. A structured abstract will have a single paragraph
without indentation but having labels (e.g., Objective, Method, Results, and Conclusions) on the
same line as the text and bold. For published works, the publishing organization will give you
guidance on these. However, for student papers, no abstract is needed unless the faculty request
one or the assignment requires it. Remember, no citations.
Keywords: include keywords in the abstract—they should be labeled like this, with the
words all in lowercase and separated by commas. Only the first line is indented, like a regular
paragraph. No period at the end.
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APA Style Seventh Edition Paper Template: A Resource for Academic Writing
American Psychological Association (APA) style is one of the most popular methods
used to cite sources in the social sciences, but it is not the only one. When writing papers in the
programs offered at Capella University, you will likely use APA style. This document serves as
an APA style resource for the seventh edition guidelines, containing valuable information that
you can use when writing academic papers. For more information on APA style, refer to the
Publication Manual of the American Psychological Association, also referred to as the APA
manual (American Psychological Association, 2020b).
The first section of this paper shows how an introduction effectively introduces the reader
to the topic of the paper. In APA style, an introduction never gets a heading. For example, this
section did not begin with a heading titled “Introduction,” unlike the following section, which is
titled “Writing an Effective Introduction.” The following section will explain in greater detail a
model that can be used to effectively write an introduction in an academic paper. The remaining
sections of the paper will continue to address APA style and effective writing concepts,
including section headings, organizing information, the conclusion, and the reference list.
Writing an Effective Introduction
An effective introduction often consists of four main components, including (a) the
position statement, thesis, or hypothesis, which describes the author’s main position; (b) the
purpose, which outlines the objective of the paper; (c) the background, which is general
information needed to understand the content of the paper; and (d) the approach, which is the
process or methodology the author uses to achieve the purpose of the paper. This information
will help readers understand what will be discussed in the paper. It can also serve as a tool to
grab the reader’s attention. Authors may choose to briefly reference sources that will be
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identified later in the paper as in this example (American Psychological Association, 2020a;
American Psychological Association, 2020b). The Writing Center has developed the acronym
POETS to help describe the proper writing style for submissions. POETS is the acronym for
purpose, organization, evidence, tone, and sentence structure (Capella Writing Center, n.d.).
There will be more on this later.
In an introduction, the writer will often present something of interest to capture the
reader’s attention and introduce the issue. Adding an obvious statement of purpose helps the
reader know what to expect, while helping the writer to focus and stay on task. For example, this
paper will address several components necessary to effectively write an academic paper,
including how to write an introduction, how to write effective paragraphs, and how to effectively
use APA style.
Level 1 Section Heading Is Centered, Bold, and Title Case
Using section headings can be an effective method of organizing an academic paper.
Section headings are not required according to APA style; however, they can significantly
improve the quality of a paper by helping both the reader and the author, as will soon be
discussed.
Level 2 Section Heading Is Aligned Left, Bold, and Title Case
The heading style recommended by APA consists of five levels (APA, 2020b, pp. 47–
48). This document contains multiple levels to demonstrate how headings are structured
according to APA style. Immediately before the previous paragraph, a Level 1 section heading
was used. That section heading describes how a Level 1 heading should be written, which is
centered, bold, and using uppercase and lowercase letters (also referred to as title case). For
another example, see the section heading “Writing an Effective Introduction” on page 3 of this
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document. The heading is centered and bold and uses uppercase and lowercase letters. If used
properly, section headings can significantly contribute to the quality of a paper by helping the
reader, who wants to understand the information in the document, and the author, who desires to
effectively describe it.
Section Heading Purposes
Section Headings Help the Reader. Section headings serve multiple purposes, including
helping the reader understand what is being addressed in each section, maintain an interest in the
paper, and choose what they want to read. For example, if the reader of this document wants to
learn more about writing an effective introduction, the previous section heading clearly states
that is where information can be found. When subtopics are needed to explain concepts in greater
detail, different levels of headings are used according to APA style.
Section Headings Help the Author. Section headings not only help the reader; they also
help the author organize the document during the writing process. Section headings can be used
to arrange topics in a logical order, and they can help an author manage the length of the paper.
In addition to an effective introduction and the use of section headings, each paragraph of an
academic paper can be written in a manner that helps the reader stay engaged.
Section Headings Can Demonstrate Fine Detail. Short papers and assignments may not
require or need a Level 5 heading, but these will be indented, bold, italic, and title case and end
with a period. Note the text starts on the line at the end of the heading following the period.
How to Write Effective Paragraphs
Capella University’s Writing Center (n.d.) has adopted a new set of writing standards to
assist learners in their goals to improve their scholarly writing. It is based on five skills known by
the mnemonic POETS. In other words, a well-developed Capella paper will demonstrate the
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following standards. The paper will have a clear purpose statement, be logically organized,
utilize current and appropriate evidence that is properly cited, maintain a scholarly tone, and
demonstrate proper grammar and writing mechanics in the sentence structure (Capella Writing
Center, n.d.). Academic writing is sometimes considered dry and boring. A learning experience
may need that formula to encourage learning in different ways as the learner moves from passive
learner to active scholar. This growth, according to Gilmore et al. (2019), requires the writer to
not only think but also to write differently.
Bias-Free Language
In the seventh edition of the APA manual, another focus is on eliminating bias in
language in order to provide a more inclusive tone in scholarly writing. While long considered a
grammar issue, it is acceptable in APA to utilize they as a singular pronoun (APA, 2020b). In
fact, there is an entire chapter of the manual dedicated to ways to reduce bias in scholarly
writing. It is important to use an appropriate level of specificity in descriptions and use
sensitivity with the use of labels. Other sections include guidelines on age, disability, gender,
race and ethnicity, sexual orientation, socioeconomic status, and participation in research. Be
aware of intersectionality, a term used to describe a person based on their identified multiple
identities, interconnectivity, social context, power relations, complexity, social justice, and
inequalities that can result in oppression (Cole, 2019; Hopkins, 2017).
Considering Direct Quotations
Another important point to consider is the use of direct quotations in papers. While
plagiarism is considered an academic integrity issue, many learners are concerned with issues
such as self-plagiarism and unintentional plagiarism, and there are others who may go as far as
purchasing papers for submission (Colella & Alahmadi, 2019). As a learner travels along their
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chosen academic pathway, their writing skills and mechanics are expected to improve. It is
imperative that the learner transition from finding information and quoting the author word for
word to using the information to support an idea, paraphrase, and then synthesize and express the
findings in one’s own words. Having said that, there are situations in which quotations may be
appropriate, so it is important to cite them properly. According to the seventh edition of the APA
manual, “When quoting directly, always provide the author, year, and page number of the
quotation in the in-text citation in either parenthetical or narrative format” (APA, 2020b, p. 270).
If there are not page numbers, identify the location in another manner (such as a paragraph
number).
Notice that the above quote contains fewer than 40 words. There is a different style for
quotes containing 40 words or more. These longer quotes use a block quotation format:
Do not use quotation marks to enclose a block quotation. Start a block quotation on a new
line and indent the whole block 0.5 in. from the left margin. If there are additional
paragraphs within the quotation, indent the first line of each subsequent paragraph an
additional 0.5 in. Double-space the entire block quotation; do not add extra space before
or after it. Either (a) cite the source in parentheses after the quotation’s final punctuation
or (b) cite the author and year in the narrative before the quotation and place only the
page number in parentheses after the quotation’s final punctuation. Do not add a period
after the closing parenthesis in either case. (APA, 2020b, p. 272)
Conclusion
A summary and conclusion section, which can also be the discussion section of an APA
style paper, is the final opportunity for the author to make a lasting impression on the reader. The
author can begin by restating opinions or positions and summarizing the most important points
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that have been presented in the paper. For example, this paper was written to demonstrate to
readers how to effectively use APA style when writing academic papers. Various components of
an APA style paper that were discussed or displayed in the form of examples include a title page,
introduction section, levels of section headings and their use, the POETS format, bias-free
language, in-text citations, a conclusion, and the reference list.
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References
American Psychological Association. (2020a). Ethical principles of psychologists and code of
conduct (2002, amended effective June 1, 2010, and January 1, 2017).
https://doi.org.apa.org/ethics/code/index.aspx
American Psychological Association. (2020b). Publication manual of the American
Psychological Association (7th ed.).
Capella University. (n.d.). Writing Center. https://campus.capella.edu/writing-center/home
Cole, N. L. (2019, October 13). Definition of intersectionality: On the intersecting nature of
privileges and oppression. ThoughtCo. https://www.thoughtco.com/intersectionalitydefinition-3026353
Colella, J., & Alahmadi, H. (2019). Combating plagiarism from a transformation viewpoint.
Journal of Transformative Learning, 6(1), 59–67.
https://jotl.uco.edu/index.php/jotl/article/view/184
Gilmore, S., Harding, N., Helin, J., & Pullen, A. (2019). Writing differently. Management
Learning, 50(1), 3–10. https://doi.org/10.1177/1350507618811027
Hopkins, P. (2017). Social geography I: Intersectionality. Progress in Human Geography, 43(5),
937–947. https://doi.org/10.1177/0309132517743677
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Appendix
Tips for the Reference List
•
Always begin a reference list on a new page. It should be placed before any appendices, figures,
or tables and titled References.
•
Set a hanging indent that starts with the second line and is double-spaced. You can look in the
Paragraph menu of Microsoft Word for formatting the hanging indent so that you will not have to
tab the indent. It gives the text a smoother look that remains consistent, even if you make edits.
•
The reference list is in alphabetical order by the first author’s last name. A reference list only
contains sources that are cited in the body of the paper, and all sources cited in the body of the
paper must be included in the reference list. If you did not cite it, do not list it.
•
The reference list above contains an example of how to cite a source when two documents are
written in the same year by the same author.
•
•
o
The lowercase letters are used after the date to differentiate the sources. The “a” reflects
the alphabetical order in the reference list—not whether it appeared first in the text.
o
The year is also displayed using this method for the corresponding in-text citations, as in
the following sentence: The author of the first citation (American Psychological
Association, 2020b) is also the publisher; therefore, the word Author is no longer used in
the seventh edition.
DOI is the digital object identifier.
o
It can be found on the first page of an article, on the copyright page of a book, in the
database record of a work, or by searching Crossref.
o
Even if the book is in print, if there is a DOI, use it.
o
Always use the hyperlink format for a DOI—it will always start with https://doi.org/ and will
be followed by a number. If the DOI is not in this format, convert it. Do not alter this
format, and do not add a final period.
o
There is a short DOI service at http://shortdoi.org/.
URL is the uniform resource locator.
o
If there is no DOI, the URL should be used in the reference.
o
Copy and paste the URL directly into your list.
o
Do not add a period at the end.
o
Do use “Retrieved from” before a URL.
•
The Colella and Alahmadi reference is an example of how to cite a source using a URL. Please
note that you will not use the Capella link that is often provided in the courseroom. If the URL
contains a database title, such as EBSCO or ProQuest, or the name Capella, do not use that in
your citation as it will only work for Capella learners and faculty.
•
For examples and further information on references go to:
o
Academic Writer: Sample References.
o
Academic Writer: Reference List.
12/20/23, 12:13 AM
Comprehensive Needs Assessment Scoring Guide
Comprehensive Needs Assessment Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Identify current gaps Does not identify gaps Identifies gaps in a
in a patient’s care.
in a patient’s care.
patient’s care, but is
incomplete or
unsupported by the
available data.
Identifies current
gaps in a patient’s
care.
Identifies current gaps in
a patient’s care, based
on a comprehensive,
patient-centered needs
assessment that
includes patient-reported
data.
Develop a strategy
for gathering
additional necessary
assessment data not
readily available
from an initial
patient interview.
Does not suggest any
approach for
gathering additional
necessary
assessment data not
readily available from
an initial patient
interview.
Suggests a general
approach for
gathering needs
assessment data
from an initial patient
interview.
Develops a strategy
for gathering
additional necessary
assessment data not
readily available from
an initial patient
interview.
Develops a strategy for
gathering additional
necessary assessment
data not readily
available from an initial
patient interview. The
strategy reflects a
holistic, coordinated
care perspective.
Discuss societal,
economic, and
interprofessional
factors most likely
to affect patient
outcomes.
Does not identify
factors having some
effect on patient
outcomes.
Identifies factors
having some effect
on patient
outcomes, including
those that are
substantially
unrelated to patient
outcomes.
Discusses societal,
economic, and
interprofessional
factors most likely to
affect patient
outcomes.
Discusses factors most
likely to affect patient
outcomes. Describes
clear cause-and-effect
relationships supported
by credible evidence.
Relate specific
patient and care
coordination
outcome measures
to professional
standards.
Does not identify
patient and care
coordination outcome
measures.
Identifies patient and
care coordination
outcome measures,
but does not relate
to standards.
Relates specific
patient and care
coordination outcome
measures to
professional
standards.
Relates specific patient
and care coordination
outcome measures to
specific professional
standards. Provides
justification for following
guidelines and
articulates clear
relationships among
outcomes and
standards.
Identify evidencebased practices for
successful
implementation of
care coordination.
Does not identify
evidence-based
practices that support
a plan of care.
Identifies evidencebased practices, but
support for a plan of
care is insufficient.
Identifies evidencebased practices for
successful
implementation of
care coordination.
Identifies evidencebased practices from
current and credible
sources that are
necessary to
successfully implement
a plan of care from a
population-health
perspective.
Advocate for the
benefits of a
multidisciplinary
approach to patient
care.
Does not identify
benefits of a
multidisciplinary
approach to patient
care.
Identifies benefits of
a multidisciplinary
approach to patient
care.
Advocates for the
benefits of a
multidisciplinary
approach to patient
care.
Advocates for the
benefits of a
multidisciplinary
approach to patient care
that a care coordination
plan would foster.
Presents an astute, wellreasoned argument
supported by credible
evidence.
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12/20/23, 12:13 AM
Comprehensive Needs Assessment Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Write clearly and
concisely, using
correct grammar
and mechanics.
Does not write clearly
and concisely; does
not use correct
grammar and
mechanics.
Writing is not
consistently clear or
concise, or errors in
grammar and
mechanics inhibit
effective
communication.
Writes clearly and
concisely, using
correct grammar and
mechanics.
Writes clearly and
concisely. Grammar and
mechanics are errorfree.
Support main
points, claims, and
conclusions with
credible evidence,
correctly formatting
citations and
references using
APA style.
Does not support
main points, claims,
and conclusions with
relevant and credible
evidence; does not
correctly format
citations and
references using APA
style.
Main points, claims,
and conclusions are
not well supported.
Sources lack
relevance or
credibility or are
incorrectly
formatted.
Supports main
points, claims, and
conclusions with
credible evidence,
correctly formatting
citations and
references using APA
style.
Supports main points,
claims, and conclusions
with relevant, credible,
and convincing
evidence. Source
citations and references
are error-free.
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