Please read attached and confirm.
Assessment 1 Instructions: Preliminary
Care Coordination Plan
● Develop a 3-4 page preliminary care coordination plan for a selected health care
problem. Include physical, psychosocial, and cultural considerations for this health care
problem. Identify and list available community resources for a safe and effective
continuum of care.
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 begin to
prepare this assessment, 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 assessment. Completing formatives is
also a way to demonstrate engagement.
To prepare for this assessment, you may wish to:
● Review the assessment instructions and scoring guide to ensure that you understand
the work you will be asked to complete.
● Allow plenty of time to plan your chosen health care concern.
Develop the Preliminary Care Coordination Plan
Complete the following:
● 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.
○ Trauma.
● 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
Assessment 2 Instructions: Ethical and
Policy Factors in Care Coordination
● Select a community organization or group that you feel would be interested in
learning about ethical and policy issues that affect the
● coordination of care. Then, develop and record a 10-12-slide,
20-minute presentation, with audio, intended for that
audience. Create a detailed narrative script or speakers notes for
your presentation, 4-5 pages in length.
● ***Provide a prompt to read from for presentation****
Preparation
Your nurse manager at the community care center is well connected
and frequently speaks to a variety of community organizations and
groups. She has noticed the good work you are doing in your new
care coordination role and respects your speaking and presentation
skills. Consequently, she thought that an opportunity to speak publicly
about contemporary issues in care coordination would be beneficial
for your career and has suggested reaching out to a community
organization or support group to gauge their interest in hearing from
you, as a care center representative, on a topic of interest to both you
and your prospective audience.
You have agreed that this is a good idea and have decided to
research a community organization or support group that might be
interested in learning about ethical and policy issues related to the
coordination of care. Your manager has suggested the following
community organizations and support groups, but acknowledges that
the choice is yours.
● Homeless shelters.
● Local religious groups.
● Nursing homes.
● Local community organizations (Rotary Club or Kiwanis Club).
To prepare for this assessment, you may wish to:
● Research your selected community organization or support
group.
● Review the Code of Ethics for Nurses With Interpretive
Statements and associated health policy issues, specifically, the
ACA.
● Review the assessment instructions and scoring guide to ensure
you understand the work you will be asked to complete.
● Allocate sufficient time to rehearse your presentation before
recording the final version for submission.
Instructions
For this assessment:
● Choose the community organization or support group that you
plan to address.
● Develop a PowerPoint with typed speaker notes (the script for
your voice recording) and audio voice-over recording, intended
for that audience. Video is not required.
Note: PowerPoint has a feature to type the speaker notes directly into
the presentation. You are encouraged to use that feature or you may
choose to submit a separate document. See Microsoft Office Software
for technical support about the use of PowerPoint, including voice
recording and speaker notes.
Assessment 3 Instructions: Care
Coordination Presentation to Colleagues
Develop a 20-minute presentation for nursing colleagues
highlighting the fundamental principles of care coordination.
Create a detailed narrative script for your presentation,
approximately 4-5 pages in length, and record a video of
your presentation.
Introduction
Nurses have a powerful role in the coordination and continuum of
care. All nurses must be cognizant of the care coordination
process and how safety, ethics, policy, physiological, and cultural
needs affect care and patient outcomes. As a nurse, care
coordination is something that should always be considered.
Nurses must be aware of factors that impact care coordination
and of a continuum of care that utilizes community resources
effectively and is part of an ethical framework that represents the
professionalism of nurses. Understanding policy elements helps
nurses coordinate care effectively.
This assessment provides an opportunity for you to educate your
peers on the care coordination process. The assessment also
requires you to address change management issues. You are
encouraged to complete the Managing Change activity.
Completing course activities before submitting your first attempt
has been shown to make the difference between basic and
proficient assessment.
reparation
Your nurse manager has been observing your effectiveness as a care coordinator and
recognizes the importance of educating other staff nurses in care coordination. Consequently,
she has asked you to develop a presentation for your colleagues on care coordination basics.
By providing them with basic information about the care coordination process, you will assist
them in taking on an expanded role in helping to manage the care coordination process and
improve patient outcomes in your community care center.
To prepare for this assessment, identify key factors nurses must consider to effectively
participate in the care coordination process.
You may also wish to:
● Review the assessment instructions and scoring guide to ensure you understand the
work you will be asked to complete.
● Allow plenty of time to rehearse your presentation.
instructions
Complete the following:
● Develop a video presentation for nursing colleagues highlighting the fundamental
principles of care coordination. Include community resources, ethical issues, and policy
issues that affect the coordination of care. To prepare, develop a detailed narrative
script. The script will be submitted along with the video.
Note: You are not required to deliver your presentation.
Presentation Format and Length
Create a detailed narrative script for your video presentation, approximately 4-5 pages in length.
Include a reference list at the end of the script.
Supporting Evide
Assessment 4 Instructions: Final Care
Coordination Plan
● For this assessment, you will evaluate the preliminary care coordination plan you
developed in Assessment 1 using best practices found in the literature.
Introduction
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.
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 2030.
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 2030 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.
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