Preliminary Care Coordinated Plan assessment
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 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.
As you assume your expanded care coordination role, you have been tasked with addressing the specific health concerns of a particular individual within the community. You decide to prepare a preliminary care coordination plan and proceed by identifying the patient’s three priorities for health and by investigating the resources available in your community for a safe and effective continuum of care.
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 patient clinical encounter.
- Be sure that you have a patient in mind that you can work with throughout the course.
Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
INSTRUCTIONS
Note: You are required to complete this assessment before Assessment 4.
This assessment has two parts.
Part 1: Develop the Preliminary Care Coordination Plan
Complete the following:
- Identify a health concern as the focus of your care coordination plan. Possible health concerns may include, but are not limited to:
- Stroke.
- Heart disease (high blood pressure, stroke, or heart failure).
- Home safety.
- Pulmonary disease (COPD or fibrotic lung disease).
- Orthopedic concerns (hip replacement or knee replacement).
- Cognitive impairment (Alzheimer’s disease or dementia).
- Pain management.
- Mental health.
- Trauma.
- Identify available community resources for a safe and effective continuum of care.
**Part 1: Preliminary Care Coordination Plan**
**Health Concern:** Stroke
**Available Community Resources for a Safe and Effective Continuum of Care:**
- **Stroke Support Groups:** These groups provide emotional support, education, and resources for stroke survivors and their caregivers. They often organize meetings, events, and activities to promote socialization and recovery.
- **Home Health Care Services:** Home health care agencies offer skilled nursing, therapy services, and personal care assistance in the comfort of the patient’s home. They can assist with medication management, rehabilitation exercises, and activities of daily living.
- **Rehabilitation Centers:** Specialized rehabilitation centers offer comprehensive stroke rehabilitation programs, including physical therapy, occupational therapy, speech therapy, and cognitive therapy. These programs aim to maximize functional independence and improve quality of life for stroke survivors.
- **Community Centers:** Community centers often host wellness programs, exercise classes, and recreational activities tailored to individuals recovering from stroke. These programs promote physical activity, social engagement, and overall well-being.
- **Transportation Services:** Transportation services for individuals with disabilities or mobility limitations can facilitate access to medical appointments, therapy sessions, and community resources. These services may include accessible vans, medical transport, and volunteer driver programs.
- **Nutrition Services:** Registered dietitians and nutritionists can provide personalized dietary recommendations to optimize recovery and prevent complications after a stroke. They can address dietary restrictions, meal planning, and healthy eating habits tailored to individual needs.
- **Home Modification Programs:** These programs offer assistance with home modifications to enhance safety and accessibility for stroke survivors. Modifications may include installing grab bars, ramps, handrails, and other adaptive equipment to prevent falls and promote independence.
- **Caregiver Support Services:** Caregiver support services provide education, training, and respite care for family caregivers of stroke survivors. These services help caregivers cope with the challenges of caregiving, prevent burnout, and maintain their own health and well-being.
Part 2: Secure Individual Participation in the Activity
Complete the following:
- Contact local individuals who may be open to an interview and a care coordination plan addressing their health concerns. The person you choose to work with may be a colleague, community member, friend, or family member.
- Meet with the individual to describe the care coordination plan session that you intend to provide. Collaborate with the participant in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to the plan.
- Establish a tentative date and time for the care coordination plan session. Document the name of the individual and a single point of contact, either an e-mail address or a phone number.
Document Format and Length
For your care coordination plan, you may use the Care Coordination Plan Template [DOCX], choose a format used in your own organization, or choose a format you are familiar with that adequately serves your needs for this assessment.
- Your preliminary plan should be 3–4 pages in length. In a separate section of the plan, identify the person you have chosen to work with, and be sure to include his or her contact information.
- Document the community resources you have identified using the Community Resources Template [DOCX].
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.
- Establish mutually agreed-upon health goals for the care coordination plan, in collaboration with the selected individual.
- Identify available community resources for a safe and effective continuum of care.
- Write clearly and concisely in a logically coherent and appropriate form and style.
- 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.
Imagine that you are a staff nurse in a community care center
Preliminary Care Coordinated Plan assessment
**Part 2: Secure Individual Participation in the Activity**
**Individual:** Ms. Smith (pseudonym)
**Contact Information:**
– Name: Ms. Smith
– Email: ms.smith@example.com
– Phone: (555) 123-4567
**Meeting Description:**
I will meet with Ms. Smith to describe the care coordination plan session and discuss her health concerns related to stroke. During the meeting, I will collaborate with Ms. Smith to set goals for the session, evaluate outcomes, and suggest possible revisions to the plan based on her needs and preferences.
**Tentative Date and Time:**
– Date: [Insert Date]
– Time: [Insert Time]
**Agenda:**
- Introduction and Overview of Care Coordination Plan Session
- Discussion of Ms. Smith’s Health Concerns and Goals
- Collaborative Goal Setting
- Review of Available Community Resources
- Evaluation of Session Outcomes
- Revision of Care Coordination Plan, if necessary
- Closing Remarks and Next Steps
**Note:** The date and time of the care coordination plan session are subject to change based on Ms. Smith’s availability.
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