Homework: Preliminary Care Coordination Plan
Develop a 3 to 4 pages preliminary care coordination plan for a hypothetical individual in your community. Identify and list available community resources for a safe and effective continuum of care.
The first step in any effective project or clinical patient encounter is planning. This homework provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for an individual in your community as you consider the patient's unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the continuum of care.
As you begin to prepare this homework, 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 homework. Completing formatives is also a way to demonstrate engagement.
Demonstration of Proficiency
By successfully completing this homework, you will demonstrate your proficiency in the course competencies through the following homework scoring guide criteria:
1) Competency 1: Adapt care based on patient-centered and person-focused factors.
• Analyze a health concern and the associated best practices for health improvement.
2) Competency 2: Collaborate with patients and family to achieve desired outcomes.
• Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.
3) Competency 3: Create a satisfying patient experience.
• Identify available community resources for a safe and effective continuum of care.
4) Competency 4: Apply professional, scholarly communication strategies to lead patient-centered care.
• Write clearly and concisely in a logically coherent and appropriate form and style.
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.
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 homework, you may wish to:
o Review the homework instructions and scoring guide to ensure that you understand the work you will be asked to complete.
o Allow plenty of time to plan your patient clinical encounter.
o Be sure that you have a hypothetical patient in mind.
Instructions
Develop the Preliminary Care Coordination Plan
Complete the following:
1) 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.
2) Identify available community resources for a safe and effective continuum of care.
Format your homework according to the give formatting requirements:
• The answer must be using Times New Roman font (size 12), double spaced, typed, with one-inch margins on all sides.
• The response also includes a cover page containing the student's name, the title of the homework, the course title, and the date. The cover page is not included in the required page length.
• Also include a reference page. The references and Citations should follow APA format. The reference page is not included in the required page length.