See attachment

Complete an interactive simulation that includes interviews of a patient, family members, and experienced health care workers. Then, develop a care coordination strategy and a care plan for the patient based on the information gathered from the interviews.


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

Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.

The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions (such as congestive heart failure, pneumonia, asthma, and diabetes) and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.


Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. AHRQ.

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.

· To what extent does a needs assessment support nursing diagnoses?

· Which standards or benchmarks drive outcomes in your current professional practice?

· What action might you take in response to care plan goals or outcomes that are not being met?

To prepare for this assessment, complete the following simulation:


Care Coordination Scenario I


Challenge Details

New Case Email

Electronic Health Record

Patient Interview

Family Interviews

Case Strategy Email

Case Strategy Meeting

Case Strategy Meeting Recap Email



Care coordination is like a puzzle. Every patient has a unique set of medical, social, and cultural considerations. It’s up to the care coordination team to problem solve and figure out the best course of action for each patient. In this activity, the care coordinator is presented with one such “puzzle”: a patient who has specific family and religious concerns.

After completing the activity, you will be prepared to:

· Investigate a care coordination plan of action for a complex case that involves medical, social, and cultural considerations.

· Apply current health care standards to a care coordination scenario.

Challenge Details

Rebecca Snyder, 56, is the matriarch of a traditional Orthodox Jewish family. She is the mother of five, including two teenagers at home, and the grandmother of seven. She was brought into the emergency room at St. Anthony Medical Center last week with uncontrolled diabetes and hyperglycemia. The doctors discovered other problems, and unfortunately Mrs. Snyder was diagnosed with advanced ovarian cancer.

As a part of your care coordination internship at St. Anthony Medical Center, you are assigned to Mrs. Snyder’s case. Because she is the primary caregiver in her family, she and her family are especially ill-prepared for this serious diagnosis. You


Patient Name: Rebecca Snyder
DOB: 04/24/1953
Address: 1375 Cadburry Lane,
St. Louis Park MN 55402

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900

Insurance: Medicare
Primary Care Provider: Dr. Vereen, Vila

Contact Permissions:
David Snyder, husband (952) 493-9302
Avi Snyder, son (952) 783-0021

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900


H&P: Mrs. Snyder is a 56 year old obese Orthodox Jewish women with a PMH
of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She
admits to the ED with c/o hyperglycemia ranging from 230 to 389 for over 10 days,
frequent urination, malaise, and mild abdominal discomfort, dyspnea on exertion
and HTN on admission.

Family Hx.
Mother: Alive. History of HTN, DM, Dementia.
Father: Deceased. HX of MI, Colorectal CA
Sister: Alive. HX of Breast CA. s/p right mastectomy.

Meds on Adm: Metformin 1000 mg q hs., Lisinopril 20 mg QD. Prior to adm. Was
prescribed anti-anxiety medication but self d/c’d without taper due to c/o fatigue.
V/S: 36.7, 102, 171/93, 24. O2 Saturations 92%. On room air.

Neuro: A&O x3. Appropriate responses, anxious. c/o daily H/A with minimal relief
with NSIADS. Recent c/o blurred vision. Wears glasses.

Cardio: HRR. Tachycardic. No audible murmurs or c/o CP. EKG normal.

Respiratory: Lung sounds diminished in all fields. Sats 92% on RA. c/o dyspnea on
exertion for 6 weeks. See for care at Ferndale clinic. Occasionally sleeps in reclining
chair at hs. Obtain CXR.

GU: c/o frequent urination. Per pt. menses have not yet ceased. Menses irregular.
Occasional vaginal bleeding duration: 1-2 days.

GI: c/o constipation and abd fullness. Abd. Tenderness on exam. + mild acites.
Palpated pelvic mass. c/o tenderness.

POC: CBC, BMP, blood glucose ac/hs.
CXR, abd. Ultraound. V/S q 4 hr. Metoprolol 25 mg Q 4 hours for BP over 170/80.
Initiate insulin gtt at 2u/hr. Blood glucose check q 1 hr. Consider paracentesis.


Allergies: Sulfa

Medication: #6700891
Metformin 1000 mg po q hs for diabetes
Lisinopril 20 mg po qd for hypertension
Prosac 20 mg po BID (per pt., self d/c’d due to fatigue)
Xanax 0.25 prn anxiety hypercholesterolemia.
Pravastatin 40 mg po bid for hypercholesterolemia.
Advil 1 tab qd pain


RBC: 5.1 HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301

Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U


Abd CT showed multiple liver mass nodules too many to count. Suspected liver
Colonoscopy showed a 3.1 cm colorectal mass. Inva