Preliminary Care Coordination Plan
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 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.
Instructions
Develop the Preliminary Care Coordination Plan
Complete the following:
1. 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.
2. 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 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.