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This is the transcript for the
Vila Health: The Nurse’s Role in Care Coordination
. You can get information here.


Care coordination is one of the fastest growing and evolving trends in the nursing field. In order to be an effective care coordinator, it is important to understand the roles that case managers and other care coordination team members play in a health care setting. It is also valuable to understand how these roles have evolved—and continue to evolve— over time. In this activity, you will learn more about the role of care coordination in an acute care setting.

After completing the activity, you will be prepared to:

· Summarize the roles that case managers and other team members play in care coordination.

· Contextualize care coordination and today’s care coordination trends historically.


Congratulations! You have been just hired as a case management intern in the Care Coordination Department at St. Anthony Medical Center. Located in Minneapolis, St. Anthony is a 120-bed hospital in the Vila Health system, which operates facilities in several Midwest states. The Care Coordination Department manages patient cases throughout the entire hospital.

Since it’s your first day, your first task is to get oriented. Your preceptor will help you get started. To learn more about the roles that care coordinators play in nursing, you’ll be talking with experienced case managers, social workers, and other members of the team. You’ll also sit in on a coordination planning meeting.


It looks like you have an email from Denise McGladrey, your new preceptor. Click the icon to read it.

From: Denise McGladrey
Subject: Your first day

Welcome to St. Anthony! We’re so glad to have you on the Care Coordination team. As you know, I am going to be your preceptor. My job is to help you transition into your new role as case management intern and to offer you support. You should feel free to come to me with questions.

I have several meetings today, so I won’t be able to meet with you until this afternoon. In the meantime, since this is your first day, I want you to learn more about your role by talking with some of the people with whom you’ll be collaborating. I’d like for you to ask them questions about the case management role and the skills you’ll need to be successful. Most of the people you’ll be talking to have a good deal of experience, so I’d also like for you to ask questions about how the field has evolved over the years.

I’ve gone ahead and scheduled two interviews with you: one with Vicki Vasquez, who, as you know, is the Director of Case Management here at SAMC. The other interview will be with Samantha Rockwell, an exp

Complete an interactive simulation of the role of the nurse in health care coordination. Then, create a comprehensive patient needs assessment of 4-5 pages based on that simulation.


Note: Each assessment in this course builds on your work from preceding assessments; therefore, complete the assessments in the order in which they are presented.

Care coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment.

In the 2000 report To Err Is HumanBuilding a Safer Health System, the Institute of Medicine identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery.

Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice settings. Whether educating a patient about his or her medication and plan of care or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination.


Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press.

Note: Complete the assessments in this course in the order in which they are presented.


As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

· What are the key reasons for completing a patient needs assessment?

· Which types of information are likely to be most valuable for improving patient outcomes?

· What are the benefits of a multidisciplinary approach to coordinated care?

To prepare for this assessment, complete the following simulation:




Document Format: Margins are 1 in. (2.54 cm) on all sides.

All text in the document should be double-spaced.

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The title page is page 1.

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Full Title of Your Paper Comment by Author: APA Style: Sample Papers shows the title page for a student paper.

Learner’s Full Name (no credentials)

School of Nursing and Health Sciences, Capella University

Course Number: Course Name

Instructor’s Name

Month, Year Comment by Author: The due date


An abstract is useful in professional papers, but not always in learner assignments. In fact, unless you are instructed by your faculty or in the course syllabus, do not expect to use abstracts very often at Capella. If you are submitting for publication, remember to check with the journal or professional organization about their criteria for an abstract. The abstract tells your reader about the article, is brief, and stands alone, so no citations are included. The format for an abstract is a single paragraph (not indented on the first line) that follows the title page and is less than 250 words in length. A structured abstract will have a single paragraph without indentation but having labels (e.g., Objective, Method, Results, and Conclusions) on the same line as the text and bold. For published works, the publishing organization will give you guidance on these. However, for student papers, no abstract is needed unless the faculty request one or the assignment requires it. Remember, no citations. Comment by Author: See Academic Writer: Publication Manual §§ 2.9–2.10 (p. 38 in the APA manual) for more information on abstracts.

Keywords: include keywords in the abstract—they should be labeled like this, with the words all in lowercase and separated by commas. Only the first line is indented, like a regular paragraph. No period at the end.

APA Style Seventh Edition Paper Template: A Resource for Academic Writing Comment by Author: New in APA seventh style—this heading is a regular Level 1 and should be bold.

American Psychological Association (APA) style is one of the most popular methods used to cite sources in the social sciences, but it is not the only one. When writing papers in the programs offered at Capella University, you will likely use APA style. This document serves as an APA style resource for the seventh edition guidelines, containing valuable information that you can use when writing academic papers. For more information on APA style, refer to the Pu


Comprehensive Needs Assessment

Learner’s Name

Capella University

NURS-FPX6610: Introduction to Care Coordination

Instructor Name

August 1, 2019

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


Comprehensive Needs Assessment

A comprehensive health needs assessment of patients enables health care providers to

systematically use their resources to disperse care efficiently. In this paper, a comprehensive

needs assessment of a simulated patient is discussed to highlight the importance of

comprehensive needs assessments in identifying and reducing gaps in patient care and

implementing effective care coordination. This paper discusses the various dimensions of a

patient’s needs and the strategies to extract relevant patient information to understand these

needs to establish the significance of a health needs assessment. This paper also presents

effective evidence-based practices in care coordination and the importance of a multidisciplinary

approach to patient care for improving health care outcomes.

Current Gaps in Mr. Decker’s Care

Mr. Decker is a 79-year-old diabetic patient readmitted to one of Vila Health’s hospitals.

Initially admitted with a badly infected toe, Mr. Decker’s inability to adhere to medical

instructions after discharge has resulted in him being readmitted with sepsis. Mr. Decker’s

readmission can be attributed to the following gaps in care:

• Lack of an interdisciplinary approach to care: The inability of the health care provider to

ensure that factors such as diabetes and aging are given due consideration while dispersing


• Failure to ensure adequate post-discharge support: Lack of adequate efforts from the care

provider to ensure that the patient effectively carries out the post-discharge care instructions

• Lack of consideration for the patient’s financial standing: The patient’s poor financial

standing was not considered during the design and management of the patient’s care

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


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