Develop a 3-4-page preliminary care coordination plan for an individual in your community with whom you choose to work. 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 patient in mind that you can work with throughout the course.

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.

This assessment has two parts.

Part 1: 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.

Part 2: Secure Individual Participation in the Activity

Complete the following:

• Contact local individuals who may be open to an interview and a care coordination plan addressing their health concerns. The person you choose to work with may be a colleague, community member, friend, or family member.
• Meet with the individual to describe the care coordination plan session that you intend to provide. Collaborate with the participant in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to the plan.
• Establish a tentative date and time for the care coordination plan session. Document the name of the individual and a single point of contact, either an e-mail address or a phone number.

Document Format and Length

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 person you have chosen to work with, and be sure to include his or her contact information.
• 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.
• Establish mutually agreed-upon health goals for the care coordination plan, in collaboration with the selected individual.
• 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.

CORE ELMS

Important note: The time you spend securing individual participation in this activity and the time you spend presenting your final care coordination plan to the patient in Assessment 4 must total at least three hours. Be sure to log your time in the CORE ELMS system. The CORE ELMS link is located in the courseroom navigation menu.

Grading Rubric

1.   Analyze a health concern and the associated best practices for health improvement. 

Passing Grade:  Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis. 

2.  Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.

Passing Grade:   Establishes mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient. Ensures the goals are realistic, measurable, and attainable. 

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

Passing Grade:  Identifies significant and available community resources for a safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health. 

4.  Write clearly and concisely in a logically coherent and appropriate form and style. 

Passing Grade:  Writes clearly and concisely in a logically coherent and appropriate form and style. Main points, ideas, arguments, or propositions are well-developed and engaging. Adheres to all applicable disciplinary and scholarly writing standards. 

  

2 or 3 paragraphs, 2 citations, 2 references. Can I get it in 2 or 3 hrs. chat with me please

number 6. Please answer the question.

Scenario : A 45 year old woman is 10 days status post partial small bowel resection for Crohn Disease and has been recuperating at home. She suddenly develops severe shortness of breath, becomes weak, and her blood pressure drops to 80/40 mmHg (previous readings 130/80 mmHg). The pulse oximetry is 89% on room air. While waiting for the Emergency Medical Service ( EMS) to arrive, the APRN places EKG leads and the EKG demonstrates right ventricular strain.

Question: Explain why a large pulmonary embolus causes right ventricular strain; relate it to the scenario.

MINIMUM OF15 POWER POINT SLIDES WITH DETAIL SPEAKER NOTES ON EACH.  REFERENCE PAGE IS NOT INCLUDED IN THE 15 POWER POINT SLIDES.

 

Case Study:

A patient presents in the ER with a severely low hemoglobin and hematocrit count. Symptomatology includes listlessness, pale, pallor, and hypotensive. The initial assumption is blood loss via the gastrointestinal tract.

As either an FNP or an AG-ACNP student, provide an initial evaluation for either a pediatric or an adult patient. In addition, include the following in your presentation:

1. The presentation of the patient
2. A list of possible conditions that present similarly based on the patient’s symptoms
3. A list of treatment modalities
4. A rationale explaining the possible conditions
5. A rationale explaining the treatment

 

Refer back to the interview and evaluation you conducted in the Topic 2 Family Health Assessment assignment. Identify the social determinates of health (SDOH) contributing to the family’s health status. In a 750-1,000-word paper, create a plan of action to incorporate health promotion strategies for this family. Include the following:

1. Describe the SDOH that affect the family health status. What is the impact of these SDOH on the family? Discuss why these factors are prevalent for this family.
2. Based on the information gathered through the family health assessment, recommend age-appropriate screenings for each family member. Provide support and rationale for your suggestions. 
3. Choose a health model to assist in creating a plan of action. Describe the model selected. Discuss the reasons why this health model is the best choice for this family. Provide rationale for your reasoning.
4. Using the model, outline the steps for a family-centered health promotion. Include strategies for communication.

Cite at least three peer-reviewed or scholarly sources to complete this assignment. Sources should be published within the last 5 years and appropriate for the assignment criteria.

Part 1 attached, please use the paper from part 1 to answer and respond for this paper. 

Preparation

You have been presented with a number of patient case files in the Evidence-Based Patient-Centered Care media piece. You reviewed each case, selected one case for further research, and created draft evidence-based concept map to illustrate an approach to individualized care for the patient. In this assessment, you will build upon and refine your draft concept map and develop a supporting narrative.

Create your concept map and narrative as separate documents. Be sure to note the areas where you need to include your evidence-based support and where you need to make clear your strategies for communicating information to the patient and the patient’s family.

Note: Many organizations use the spider style of concept maps (see the Taylor & Littleton-Kearney article for an example). Also, if a specific style of concept map is used in your current care setting, you may use it in this assessment.

Create your concept map and narrative as separate documents. Be sure to note the areas where you need to include your evidence-based support and where you need to make clear your strategies for communicating information to the patient and the patient’s family.

Requirements

Note: The requirements outlined below correspond to the grading criteria in the scoring guide, so be sure to address each point. In addition, you may want to review the performance level descriptions for each criterion to see how your work will be assessed.

Supporting Evidence and APA Style

Integrate relevant evidence from 3–5 current scholarly or professional sources to support your assertions.

• Apply correct APA formatting to all in-text citations and references.
• Attach a reference list to your narrative.

Concept Map

• Develop a concept map for the individual patient, based upon the best available evidence for treating your patient’s health, economic, and cultural needs.

Narrative

Develop a narrative (2–4 pages) for your concept map.

• Analyze the needs of your patient and their family, and determine how those needs will influence a patient-centered concept map.      
  • Consider how your patient’s economic situation and relevant environmental factors may have contributed to your patient’s current condition or affect their future health.
  • Consider how your patient’s culture or family should influence your concept map.
• Justify the value and relevance of the evidence you used as the basis of your concept map.      
  • Explain why your evidence is valuable and relevant to your patient’s case.
  • Explain why each piece of evidence is appropriate for both the health issue you are trying to correct and for the unique situation of your patient and their family.
• Propose relevant and measurable criteria for evaluating the degree to which the desired outcomes of your concept map were achieved.      
  • Explain why your proposed criteria are appropriate and useful measures of success.
• Explain how you will communicate specific aspects of the concept map to your patient and their family in an ethical, culturally sensitive, and inclusive way. Ensure that your strategies:      
  • Promote honest communications.
  • Facilitate sharing only the information you are required and permitted to share.
  • Are mindful of your patient’s culture.
  • Enable you to make complex medical terms and concepts understandable to your patient and their family, regardless of language, disabilities, or level of education.

Additional Requirements

• Be sure to include both documents when you submit your assessment.

Grading Rubric:

1. Design an individualized, patient-centered concept map, based upon the best available evidence for treating a patient’s specific health, economic, and cultural needs.

Passing Grade: Designs an individualized, patient-centered concept map, based upon the best available evidence for treating a patient’s specific health, economic, and cultural needs, and identifies assumptions on which the plan is based.

2. Analyze the needs of a patient, and those of their family, with regard to how those needs will influence a patient-centered concept map.

Passing grade: Analyzes the needs of a patient, and those of their family, with regard to how those needs will influence a patient-centered concept map. Identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).

3. Justify the value and relevance of evidence used as the basis of a patient-centered concept map.

Passing grade: Justifies the value and relevance of evidence used as the basis of a patient-centered concept map, and impartially considers conflicting data and other perspectives

4. Propose relevant and measurable criteria for evaluating the outcomes of a patient-centered concept map.

Passing grade: Proposes relevant and measurable criteria for evaluating the outcomes of a patient-centered concept map, and acknowledges challenges specific to such an evaluation process. 

5. Develop a strategy for communicating with patients and their families in an ethical, culturally sensitive, and inclusive way.

Passing grade: Develops a strategy for communicating with patients and their families in an ethical, culturally sensitive, and inclusive way, and identifies assumptions on which the strategy is based. 

6. Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

Passing Grade: Integrates relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style. Citations are error-free.