For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

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.

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.

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.

Demonstration of Proficiency

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.

• 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 2020 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.

Preparation

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 2020.

Note: Remember that you can submit all, or a portion of, your 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 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 2020 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 2020 document.

• Use the literature on evaluation as guide to compare learning session content with best practices.
• Align teaching sessions to the Healthy People 2020 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.

Final Care Coordination Plan Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Design patient-centered health interventions and timelines for a selected health care problem.	Does not design patient-centered health interventions and timelines for a selected health care problem.	Designs patient-centered health intervention for a selected health care problem.	Designs patient-centered health interventions and timelines for a selected health care problem.	Designs patient-centered health interventions and timelines for a selected health care problem that includes community resources.
Consider ethical decisions in designing patient-centered health interventions.	Does not consider ethical decisions in designing health interventions.	Considers ill-defined or ambiguous ethical decisions in designing patient-centered health interventions.	Considers ethical decisions in designing patient-centered health interventions.	Considers insightful ethical decisions in designing patient-centered health interventions. These decisions are supported by the literature.
Identify relevant health policy implications for the coordination and continuum of care.	Does not identify relevant health policy implications for the coordination and continuum of care.	Identifies health policy implications that are inconsistent with the goals and objectives for the coordination and continuum of care.	Identifies relevant health policy implications for the coordination and continuum of care.	Identifies relevant health policy implications for the coordination and continuum of care, based on precise and accurate interpretations of relevant policy provisions. Makes valid, insightful inferences.
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.	Does not describe priorities that a care coordinator would establish when discussing the plan with a patient and family member.	Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member but does not use evidence-based practice to make changes to the plan.	Describes priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.	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 explains 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 2020 document.	Does not use the literature on evaluation as a guide to compare learning session content with best practices, and does not include how to align teaching sessions to the Healthy People 2020 document.	Discusses evaluation but does not use the literature as a guide to compare learning session content with best practices, or does not include how to align teaching sessions to the Healthy People 2020 document.	Uses 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 2020 document.	Uses 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 2020 document. Clearly explains the need for any revisions.
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.
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.