evelop a 3-4 page 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.

NOTE: You are required to complete this assessment before Assessment 4.

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.

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.

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.

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 patient clinical encounter.
• Be sure that you have a hypothetical patient in mind.

Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Instructions

Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan

Complete the following:

• 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.
• Identify available community resources for a safe and effective continuum of care.

Document Format and Length

You can use the linked templates as a guide for the needs of your hypothetical patient who has a selected health care problem.

For your care coordination plan, you may use the Care Coordination Plan Template [DOCX], choose a format used in your own organization, or choose a format you are familiar with that adequately serves your needs for this assessment.

• Your preliminary plan should be 3–4 pages in length. In a separate section of the plan, identify the hypothetical person you have chosen to work with.
• Document the community resources you have identified using the Community Resources Template [DOCX].

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

• Analyze your selected health concern and the associated best practices for health improvement.
  • Cite supporting evidence for best practices.
  • Consider underlying assumptions and points of uncertainty in your analysis.
• Identify a hypothetical individual who would benefit from a care coordination plan.
• Document goals for the care coordination plan.
• Identify available community resources for a safe and effective continuum of care.
• Write clearly and concisely in a logically coherent and appropriate form and style.
  • Write with a specific purpose with your patient in mind.
  • Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

 

Answer these essay questions:

Essay #1: Case Study: Echo Electronics

Paul Sanchez is the production manager for Echo Electronics, a small company that makes and distributes communications equipment. Paul’s direct subordinates are the supervisors of the four production departments in the company’s manufacturing plant. Six months ago, the engineering manager at Echo Electronics proposed a plan to install new computerized workstations to increase productivity in the plant. It seemed to be a good idea to Paul, and he welcomed the change. The CEO also approved the plan, and the new equipment was installed immediately.

Three months later, Paul was surprised and disappointed to find that the expected increase in productivity did not occur. In fact, productivity and quality actually decreased. The marketing manager told Paul that several of their best customers complained about receiving Echo equipment that was defective. Paul does not believe that the problem lies with the new workstations. Technicians from the firm that built the workstations recently checked them and found that they were operating properly. Paul talked to someone at another company that uses the workstations, and his contact reported that they were having great success with them.

When Paul discussed the problem with his four production supervisors, he found that they shared his concern but did not agree among themselves about the cause of the problem. Reasons given for the decline in performance included poor design of the workstations, inadequate training of the production workers who operate them, and lack of financial incentives for increasing productivity. The supervisors also told Paul that the production workers have strong feelings about the workstations. Morale declined, and two employees quit because they were upset about the changes made in the way the work is done.

This morning, Paul received a phone call from the CEO who just received the production figures for last month and was calling to express concern about them. The CEO indicated that the problem was Paul’s to solve, but he must take immediate steps to deal with it. The CEO wants to know by next week what steps Paul will take to reverse the decline in productivity and product quality.

 Questions

1. What actions could Paul have taken to prevent the problem?
2. What steps should Paul take now to deal with the problem?

Essay #2: Case Study: Alvis Corporation

Kathy McCarthy was the manager of a production department in Alvis Corporation, a firm that manufactures office equipment. The workers are not unionized. After reading an article that stressed the benefits of participative management, Kathy believed that these benefits could be realized in her department if the workers were allowed to participate in making some decisions that affect them. Kathy selected two decisions for an experiment in participative management.

The first decision involved vacation schedules. Each summer the workers are given two weeks’ vacation, but no more than two workers can go on vacation at the same time. In prior years, Kathy made this decision herself. She would first ask the workers to indicate their preferred dates, then she considered how the work would be affected if different people were out at the same time. It was important to plan a vacation schedule that would ensure adequate staffing for all of the essential operations performed by the department. When more than two workers wanted the same time period, and they had similar skills, she usually gave preference to the workers with the highest productivity.

The second decision involved production standards. Sales had been increasing steadily over the past few years, and the company recently installed some new equipment to increase productivity. The new equipment would make it possible to produce more with the same number of workers. The company had a pay incentive system in which workers received a piece rate for each unit produced above a standard amount. Separate standards existed for each type of product, based on an industrial engineering study conducted a few years earlier. Top management wanted to readjust the production standards to reflect the fact that the new equipment made it possible for the workers to earn more without working any harder. The savings from higher productivity were needed to help pay for the new equipment.

Kathy called a meeting of her 15 workers an hour before the end of the work day and explained that she wanted them to discuss the two issues and make recommendations. Kathy figured that the workers might be inhibited about participating in the discussion if she were present, so she left them alone to discuss the issues. Besides, Kathy had an appointment to meet with the quality control manager. Quality problems had increased after the new equipment was installed, and the industrial engineers were studying the problem in an attempt to determine why quality had gotten worse rather than better.

When Kathy returned to her department just at quitting time, she was surprised to learn that the workers recommended keeping the standards the same. She had assumed they knew the pay incentives were no longer fair and would set a higher standard. The worker speaking for the group explained that their base pay had not kept up with inflation, and the higher incentive pay restored their real income to its prior level.

On the vacation issue, the group was deadlocked. Several of the workers wanted to take their vacations during the same two-week period and could not agree on who should go. Some workers argued that they should have priority because they had more seniority, while others argued that priority should be based on productivity, as in the past. Because it was quitting time, the group concluded that Kathy would have to resolve the dispute herself. After all, wasn’t that what she was being paid for?

Questions

1. Were the two decisions appropriate for a group decision procedure according to the Vroom–Yetton model?
2. What mistakes were made in using participation, and what could have been done to avoid the difficulties the manager encountered?
3. Where these two decisions appropriate ones for introducing participation into the department?

Essay #3: What are the potential benefits of delegation, and when is it most likely to be successful?  What are some guidelines on what to delegate? Why do some managers find it so difficult to delegate or share power?  Write an essay on Steve Jobs style of functioning? Did he delegate his job effectively?

Essay #4: Case Study: National Products

Susan Thomas is the vice president for human resources at National Products, a manufacturing company with 500 employees. The company has an opening for a general manager in one of its product divisions, and the president asked Susan to review the backgrounds of three department managers who are interested in being promoted to this position. She is expected either to recommend one of the three internal candidates or to begin recruitment of external candidates. The internal candidates are Charley Adams, Bill Stuart, and Ray Johnson. The following information about each candidate was obtained from performance records, interviews with the candidates, and discussions with the boss of each candidate.

Charley Adams

Charley Adams has been a production manager for the past eight years. He is an easygoing person who loves to swap jokes and tell stories. Charley stresses the importance of cooperation and teamwork. He is uncomfortable with conflict, and he tries to smooth it over quickly or find an acceptable compromise.

Before becoming a manager, Charley was always willing to take on extra assignments for his boss and to provide helpful advice to less experienced coworkers in his department. Charley is proud of his reputation as a “good team player” and a loyal “company man.” It is important to Charley to be liked and appreciated by people in the organization.

Charley comes from a cultural background emphasizing the importance of close family ties. He holds frequent Sunday dinners at which the entire Adams clan gathers for an afternoon of swimming, baseball, eating, and singing. On Saturdays, Charley likes to play golf with friends, including some of the other managers in the company.

Charley wants his department to have a good performance record, but he is reluctant to jeopardize relations with subordinates by pushing them to improve their performance beyond current levels, which he believes are adequate. When Charley gives out performance bonuses to subordinates, he usually tries to give something to everyone.

Bill Stuart

Bill Stuart has been the manager of an engineering department for three years. He was promoted to that position because he was the best design engineer in the company and was ambitious to further his career by going into management. At the time, Bill had little understanding of what the job would be like, but he saw it as both an opportunity and a challenge.  Bill grew up as somewhat of a loner. He still feels awkward around people he doesn’t know well, and he dislikes social functions such as cocktail parties and company picnics. As a design engineer, Bill preferred assignments where he could work alone rather than team projects. He is impatient with bureaucratic authority figures and he is critical of corporate policies that he regards as too restrictive. Bill gets along well with his present boss, because he is left alone to run his engineering group in his own way.

Bill likes challenging assignments, and he tries to save the most difficult and interesting design projects for himself. Although Bill usually performs these tasks effectively, his preoccupation with them sometimes takes time away from some of his managerial responsibilities, such as developing and mentoring subordinates.

Ray Johnson

Ray Johnson has been a corporate marketing manager for five years. He grew up in a poor ethnic neighborhood where he learned to be tough in order to survive. He has worked hard to get where he is, but for Ray, good performance has been a way to get ahead rather than something he enjoys for its own sake.

Ray lives in a large house with a big swimming pool in the best part of town, and he likes to throw big parties at his home. He wears expensive clothes, drives a luxury car, and he belongs to the best country club. Ray is married, but fancies himself as quite a playboy and has had many affairs, including some with female employees.

Ray views the organization as a political jungle, and he is quick to defend himself against any threats to his reputation, authority, or position. He tries to undermine or discredit anybody who criticizes or opposes him. He keeps a tight control over the operations of his department, and he insists that subordinates check with him before taking any action that is not routine.

Questions

1. What are the dominant motives for each candidate?
2. What are the implications of these traits for the success of each candidate if selected for the general manager position?
3. Should Susan recommend one of these candidates for the position, or look for external candidates?

Subjective
Mark, a 48 year-old male, presents to the office with mild-to-moderate chest pressure with radiation to his back. Mark reports that he was awakened from sleep at 0700 with chest pressure. Initially described as soreness across his anterior chest and through to his back. He rates his pain +6/10. He felt as though if he could just belch, he would feel better. His wife drove him to the office to be here when it opened at 0900. She tried to convince Mark to go to the emergency room, but he emphatically refused, insisting on going to the office first. Upon arrival to the office, you take Mark back to an examination room and instruct the receptionist to call 911.

Past medical/surgical history: Diabetes mellitus type 2

Family history: He has a family history of premature coronary artery disease. His father died of acute myocardial infarction (AMI) at age 45. One brother died of AMI at age 49.

Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother’s death 2 years ago. He has put on 25 pounds in the past 2 years and is generally sedentary

Medications: Metformin XR 500mg daily, Last A1C was 7.4

Allergies: Latex

Objective

General: Anxious and shows Levine’s sign as you enter the office room. He is slightly diaphoretic.
Vital signs: BP 192/96, P: 102, RR-22, T-98.8, SpO2 is 90%
ECG: ST segment depression and T wave inversion in leads II and III
CV: Heart tones are muffled with an S3 gallop. Hands and feet are cool to touch. Radial pulses are 2+. Pedal and posterior tibial pulses are 1+. Neck vein distention of 5cm with HOB at 90 degrees.
Respiratory: Rhonchi in upper lobes bilaterally and a non-productive cough
Abdomen: Positive bowel sounds in all 4 quadrants, soft, non-tender, no masses felt.

The provider sent the patient immediately to the Emergency Department. Upon arrival and within 2 hours of arrival for care, troponin was 6 ng/dl, Chemistry panel: Na, K, CL were WNL, BUN 20, Creatinine 0.8, serum glucose 189.

Question answers should be based on evidence found in readings and from peer-reviewed literature. At least two sources must be used and cited in APA format for each question. Only one source can be a textbook. Resources should generally be within 5 years unless you are explaining the pathophysiology of a disease or providing pertinent background information.

Discussion Questions:

1. Describe the similarities and differences of necrosis and apoptosis in regards to the above clinical scenario and diagnosis.
2. What is the role of hydrostatic and oncotic pressure in regulation of blood pressure for this patient?
3. Explain the role of free radicals and myocardial death

 

Discussion: Legal and Ethical Considerations for Group and Family Therapy

Considering the Health Insurance Portability and  Accountability Act (HIPPA), the idea of discussing confidential  information with a patient in front of an audience is probably quite  foreign to you. However, in group and family therapy, this is precisely  what the psychiatric mental health nurse practitioner does. In your  role, learning how to provide this type of therapy within the limits of  confidentiality is essential. For this Discussion, consider how limited  confidentiality and other legal and ethical considerations might impact  therapeutic approaches for clients in group and family therapy. 

 

To prepare:

Review this week’s Learning Resources and consider the insights they provide on group and family therapy.

View the media, Legal and Ethical Issues for Mental Health  Professions, Volume I, and reflect on legal and ethical considerations  for group and family therapy and individual therapy.

 Post an explanation of how legal and ethical  considerations for group and family therapy differ from those for  individual therapy. 

Then, explain how these differences might impact  your therapeutic approaches for clients in group and family therapy.  

Support your rationale with evidence-based literature. 

Link to download the media Legal and Ethical Issues for Mental Health  Professions:

https://waldenu.kanopy.com/product/legal-and-ethical-issues-mental-health-pro

Implementation Plan

For this section of your research proposal assignment, you will focus on the implementation plan, which includes considerations for ethics, recruitment practices, and a plan for how you will collect your data. Please note that you will not explain how to analyze your data in this section, but rather how you will go about collecting the data.

The following components must be addressed:

• Explain how you will ensure your research is conducted in an ethical manner 
• Include a copy of an informed consent that will be included for participants of your research proposal project (see pp. 202–203 for a sample) 
• Explain how you will recruit participants for your study, and how your recruitment process will remain ethical. Be sure to address any incentives (if applicable) 
• Explain what quantitative data you will collect and how you will go about collecting this data (survey, questionnaire, observation, etc.) 

APA formatting, references, and citations are required.

Your research project implementation plan should be included as part of your final submission for your research proposal project in week 7 and your research proposal presentation in week 8. Use the feedback you receive from your instructor on your implementation plan to modify and improve before submission of your final project in weeks 7 and 8.