Develop a 3-4-page preliminary care coordination plan for an individual in your community who has stroke. 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 assessment 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.

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.
  • Analyze a health concern and the associated best practices for health improvement.
• 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.
• Competency 3: Create a satisfying patient experience.
  • Identify available community resources for a safe and effective continuum of care.
• Competency 6: 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.

2.

Final Care Coordination Plan

Complete the preliminary care coordination plan you developed in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session and collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan.

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 for you to apply communication, teaching, and learning best practices to the presentation of a care coordination plan to the patient.

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 care.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
  • Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with a patient.
• Competency 3: Create a satisfying patient experience.
  • Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators.
• Competency 4: Defend decisions based on the code of ethics for nursing.
  • Make 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.

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