Assessment 1 Instructions: Preliminary Care Coordination Plan
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- 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.
Introduction
NOTE: You are required to complete this assessment before Assessment 4.
The first step in any effective project is planning. This assignment 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.
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.
Preparation
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.
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:
- Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. 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.
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.
- 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.
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Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 1: Adapt care based on patient-centered and person-focused factors.
- 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
| CRITERIA | NON-PERFORMANCE | BASIC | PROFICIENT | DISTINGUISHED |
| Analyze a health concern and the associated best practices for health improvement. | Does not identify a health concern and the associated best practices for health improvement. | Identifies a health concern and the associated best practices for health improvement. | Analyzes a health concern and the associated best practices for health improvement. | Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis. |
| Describe specific goals that should be established to address a selected health care problem. | Does not describe specific goals that should be established to address a selected health care problem. | Identifies undefined goals that should be established to address a selected health care problem. | Describes specific goals that should be established to address a selected health care problem. | Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable. |
| Identify available community resources for a safe and effective continuum of care. | Does not identify available community resources. | Identifies available community resources. | Identifies available community resources for a safe and effective continuum of care. | Identifies significant and available community resources for a safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health. |
| Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. | Does not organize content for ideas. Lacks logical flow and smooth transitions. | Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling. | Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. | Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors. |
| Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. | Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly. | Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes and/or paraphrasing. | Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. | Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly. |