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.

 

Journaling provides a valuable tool for recording, reflecting on, and reviewing your learning. This approach provides an opportunity for you to “connect the dots” and observe the relationships between and among activities, interactions, and outcomes.

Unlike a personal journal of thoughts and feelings, this leadership journal is a record of your activities, assessments, and learning related to this academic experience.

Journal entries should include a record of the number of hours spent with your nurse leader each week.

Write a journal entry of 750-1,500 words on the subject of example, including the following:

1. Practicum Activities Reflection: Provide observations and thoughts on the activities in your practicum setting during Topics 11-12.
2. Application of Leadership: Describe how you have seen your preceptor show his or her credibility in the workplace. Explain how this credibility helps to foster a community of trust.
3. Practicum Project Preparation: What measures have you put into place to measure successful outcomes for your project once implemented? Are these measures sustainable?
4. Leadership Video Reflection: Reflect on at least two things you learned from the “Servant Leadership – Issue of Servant” video.

Use the “Leadership Journal Template” to complete this assignment.

APA format is not required, but solid academic writing is expected. 

  

I need between 100-120 words for each assignment, and I want individual references with each response. Please, no plagiarized work

Module 1

DQ 1  Outcome measures are significant in showing the worth of the Doctor of Nursing Practice’s role in health care. Identify a practice-level outcome study or project and describe the expectation of its effect on health care. Which outcome measure do you think aligns with your DPI project (Quality Improvement Project)? Why? Provide examples and literature support.

DQ 2  In this week’s readings, theories of accident causation, human error, foresight, resilience, and system migration were discussed. Identify a safety theory and propose quality measures to improve patient safety. Which theory or framework are you using to guide your DPI Project’s intervention and outcome? Please define what constructs of your chosen DPI Project theory will help you change/improve clinical practice to improve a specific patient outcome? Provide examples and literature support.

Resources

Henneman, E. A. (2017). Recognizing the ordinary as extraordinary: Insight into the “way we work” to improve patient safety outcomes. American Journal of Critical Care, 26(4), 272–277. doi:10.4037/ajcc2017812

Smith, S. A., Yount, N., & Sorra, J. (2017). Exploring relationships between hospital patient safety culture and Consumer Reports safety scores. BMC Health Services Research, 17,1-9. doi:10.1186/s12913-017-2078-6

Module 2

DQ 1  Discuss economic methodology, including the concept of cost-based analysis. If you will not be addressing this in your DPI Project, provide an example of a program where it could be used to show outcomes. Provide examples and literature support.

DQ 2   Discuss a change theory and how it can be or has been applied in nursing practice to integrate care delivery sustainability. How will you use change theory in the design of your project to support the sustainability of your practice improvement intervention? Provide examples and literature support.

Resources

Uluskan, M., McCreery, J. K., & Rothenberg, L. (2018). Impact of quality management practices on change readiness due to new quality implementations. International Journal of Lean Six Sigma, 9(3), 351-373. doi:10.1108/IJLSS-05-2017-0049

Steele Gray, C., Wilkinson, A., Alvaro, C., Wilkinson, K., & Harvey, M. (2015). Building resilience and organizational readiness during healthcare facility redevelopment transitions: Is it possible to thrive? HERD: Health Environments Research & Design Journal, 9(1), 10-33. doi:10.1177/1937586715593552

Allen, B. (2016). Effective design, implementation and management of change in healthcare. Nursing Standard, 31(3), 58. doi:10.7748/ns.2016.e10375

Module 3

DQ 1   New health care delivery models are being presented to accommodate the shift in health care objectives. Many of these models are community-based and focused on improving quality outcomes, population health, and reducing readmissions to acute care settings.

1. Describe a new health care delivery model and discuss whether or not it is sustainable.

2. How will you use a health care delivery model in the design of your project to support the sustainability of your practice improvement intervention? 

Provide examples and literature support.

DQ 2   Two major models of care exist: for-profit and not-for-profit. Does one or the other provide more ethical care? Why or why not? Provide examples and literature support.

Resources

Largent, E. A. (2016). Health care organizations and the power of procedure. American Journal of Bioethics, 16(1), 51–53. doi:10.1080/15265161.2015.1115155

Graber, A., Carter, S., Bhandary, A., & Rizzo, M. (2017). The case for enrolling high-cost patients in an ACO. HEC Forum, 29(4), 359-365. doi:10.1007/s10730-017-9333-4

Kirby, J. (2016). Balancing legitimate critical-care interests: Setting defensible care limits through policy development. American Journal of Bioethics, 16(1), 38-47. doi:10.1080/15265161.2015.1115141

Module 4

DQ 1   Explore a country that provides universal health care. What are its health outcomes? How do these outcomes compare to those in the United States? Should universal health care be a concept that the Doctor of Nursing Practice should support? Why or why not? As a nurse leader, how would you integrate your faith and work into any health care delivery concept? Provide examples and literature support.

DQ 2   The Commonwealth Fund provides an international review of health care systems. Read the Commonwealth Fund report, International Profiles of Health Care Systems, 2017. Discuss what knowledge you gained from reading the report and describe any changes you would apply to the U.S. health care system. What is the DNP’s role in the policy needed to enact the changes you identified? Provide examples and literature support.

Resources

Ruggles, B. M., Xiong, A., & Kyle, B. (2019). Healthcare coverage in the US and Japan: A comparison. Nursing, 49(4), 56-60. doi:10.1097/01.NURSE.0000553277.03472.d8

expenditure growth under single-payer systems: Comparing South Korea and Taiwan. Value in Health Regional Issues, 15, 149-154. doi:10.1016/j.vhri.2018.03.002

Rajfur, P., & Hys, K. (2018). Management of the healthcare system in Germany and France. Medical Science Pulse, 12(4), 55-60. doi:10.5604/01.3001.0012.7213 

Module 5

DQ 1   Review one of the tutorials on quality measures from the AHRQ: National Quality Measures Clearinghouse website. Provide an overview of what you reviewed and its application in your practice. Provide examples and literature support.

DQ 2   Review “How Can Healthcare Organizations Implement Patient-Centered Care,” and discuss evaluation models that can drive large-scale cultural transformation in health care or in your current practice. What are the strengths and weaknesses of these models? Provide examples and literature support.

Resources

Bokhour, B. G., Fix, G. M., Mueller, N. M., Barker, A. M., Lavela, S. L., Hill, J. N.,…VanDeusen Lukas, C. (2018). How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation. BMC Health Services Research, 18(168). doi:10.1186/s12913-018-2949-5

Nel, H. (2018). A comparison between the asset-oriented and needs-based community development approaches in terms of systems changes. Practice: Social Work in Action, 30(1), 33-52. doi:10.1080/09503153.2017.1360474

Lindau, S. T., Vickery, K. D., Choi, H., Makelarski, J., Matthews, A., & Davis, M. (2016). A community-powered, asset-based approach to intersectoral urban health system planning in Chicago. American Journal of Public Health, 106(10), 1872-1878. doi:10.2105/AJPH.2016.303302 

Module 6

DQ 1  The Doctor of Nursing Practice/Advanced Practice Nurse role empowers nurses to create programs for improving quality outcomes. What barriers need to be alleviated to increase the DNP/APN role in health care change? Provide examples and literature support.

DQ 2   Patient-centered care has been shown to increase positive patient outcomes. Provide an example of how collaboration within the health care team (interprofessional collaboration) has enhanced patient outcomes in your practice. Provide literature support.

Resources

Will, K. K., Johnson, M. L., & Lamb, G. (2019). Team-based care and patient satisfaction in the hospital setting: a systematic review. Journal of Patient-Centered Research and Reviews, 6(2), 158-171. doi:10.17294/2330-0698.1695

Brown, L., & Overly, F. (2016). Simulation-based interprofessional team training. Clinical Pediatric Emergency Medicine, 17(3), 179-184. doi:10.1016/j.cpem.2016.06.001

Van der Biezen, M., Wensing, M., Poghosyan, L., Van der Burgt, R., & Laurant, M. (2017). Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study. BMC Health Services Research, 17, 1-9. doi:10.1186/s12913-017-2548-x

Barratt, J., & Thomas, N. (2018). Nurse practitioner consultations in primary health care: A case study-based survey of patients’ pre-consultation expectations, and post-consultation satisfaction and enablement. Primary Health Care Research & Development, 20, 1-8. doi:10.1017/S1463423618000415

Module 7

DQ 1   Utilize the National Committee for Quality Assurance (NCQA) website to examine the criteria that a Patient Centered Medical Home (PCMH) must meet to be credentialed. What is the value of the PCMH to patient outcomes? How does the NCQA website help you define and measure the results of your DPI Project intervention on patient outcomes? Provide examples and literature support.

DQ 2   What are some of the current assessment tools to improve patient understanding and adherence to prescribed treatment? What assessment tools are available to determine a level of health literacy and how can these tools help improve patient outcomes? Provide examples and literature support.

Resources

Read Chapter 6 in Outcome Assessment in Advanced Practice Nursing 4e.

Tucker, C., Arthur, T., & Roncoroni, J. (2013). Patient-centered, culturally sensitive health care. American Journal of Lifestyle Medicine, 9(1), 63-77. doi:10.1177/1559827613498065

URL: https://journals-sagepub-com.lopes.idm.oclc.org/doi/full/10.1177/1559827613498065

Park, Y., & Martin, E. G. (2018). Geographic disparities in access to nursing home services: Assessing fiscal stress and quality of care. Health Services Research, 53, 2932-2951. doi:10.1111/1475-6773.12801

Barsell, J., Everhart, R. S., Miadich, S. A., & Trujillo, M. A. (2018). Examining health behaviors, health literacy, and self-efficacy in college students with chronic conditions. American Journal of Health Education, 49(5), 305-311.

Nguyen, T. H., Park, H., Han, H-R., Chan, K. S., Paasche-Orlow, M. K., Haun, J., & Kim, M. T. (2015). State of the science of health literacy measures: Validity implications for minority populations. Patient Education & Counseling, 98(12), 1492-1512. doi:10.1016/j.pec.2015.07.013

Module 8

DQ 1   Discuss effective means for translating and disseminating research by discussing the role of the DPI Project (Quality Improvement) and the opportunities for its dissemination. Include a discussion of the role of inter-professional collaboration. Provide examples and literature support.

DQ 2   Discuss recent health care innovations in your practice and your role in implementation. Provide examples and literature support.

Resources

Hassan, A., Scherer, E. A., Pikcilingis, A., Krull, E., McNickles, L., Marmon, G.,…Fleegler, E. (2015). Improving social determinants of health: Effectiveness of a web-based intervention. American Journal of Preventive Medicine, 49(6), 822-831. doi:10.1016/j.amepre.2015.04.023 

Curtis, K., Fry, M., Shaban, R., & Considine, J. (2016). Translating research findings to clinical nursing practice. Journal of Clinical Nursing, 26(5-6), 862-872. doi:10.1111/jocn.13586

Tympanic Membrane and Thyroid Gland

Using the classroom resources or Online Library,  research the tympanic membrane and the thyroid gland. In a Microsoft  Word document of 4-5 pages formatted in APA style, address each of the  following criteria.

• Two focused health assessment histories 
  • One assessment related to the tympanic membrane and the other focused on the thyroid gland.
  • The assessments can be hypothetical patients or patients you have  had in the past (remember HIPAA if you are describing a previous  patient).
• A description of the normal and abnormal findings of the tympanic membrane.
• Information on how to examine the thyroid gland using both the anterior and posterior methods.
• A concise note in the subjective, objective, assessment (be sure to  include the NANDA diagnosis as well as the medical diagnosis), and plan  (SOAP) format with each patient’s encountered findings.
  • For a review of SOAP notes:
  • SOAP Documentaion
• Information about laboratory/diagnostic tests used for screening clients with tympanic membrane or thyroid gland issues. 
  • Include the expected normal results for each test.

On a separate references page, cite all sources using APA format. Please note that the title and reference pages should not be included in the total page count of your paper.

• Use this APA Citation Helper as a convenient reference for properly citing resources.
• This handout will provide you the details of formatting your essay using APA style.
• You may create your essay in this APA-formatted template.