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.

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

• 4 page essay in which you analyze your current writing practices.
  Introduction
  The writing process is just that: a process. However, many learners are not aware of the steps to take in the process and do not schedule enough time to allow for all the steps in the process. As you work through this course, you will focus on learning the process involved in writing, writing well, and in being successful with your writing.
  The first assessment will help you consider your own writing practices, and the steps you can take to improve your writing skills throughout this course, as well as in future courses, and in your professional life.
  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: Analyze rhetorical situations in writing to produce sound written work.
    • Describe a personal approach to writing assessments.
    • Explain current revising and editing processes for completing assessments.
    • Describe the type of feedback from previous instructors.
  • Competency 4: Apply accepted style conventions and written expression skills.
    • Discuss the decision to enroll in a university program.
    • Explain a plan for managing time to complete course assessments.
    • Describe personal awareness of writing tools available.
    • Describe any challenges or concerns about completing the course.
    • Write content clearly and logically with correct use of grammar, spelling, and APA format.
  • Overview
    This assessment will help you think about your current writing process and the specific areas where you might improve. In the rest of the course assessments, you will apply tools and strategies designed to support better writing.
    Instructions
    Write a 4 page essay that reflects on your current process and strategies for writing your assessments. You do not need to include references, but you do need to format this assessment following APA guidelines.
    In your essay, address the following:
  • Discuss your decision to enroll in the Nursing program.
    • Why did you decide the time was right?
    • What are you hoping or expecting to learn in your courses?
    • How do you see your personal and nursing professional expectations aligning with your program outcomes?
  • Describe how you typically write your assessments.
    • Do you pre-write before you create a first draft?
    • If so, what are the steps you take in your pre-writing process?
    • If not, why is this not a part of your writing process?
  • Explain your current process for revising and editing your assessments.
    • What seems to be working well?
    • What does not seem to be working well?
  • Describe the type of feedback you have received from instructors.
  • Explain your plan for managing your time in order to complete your course assessments.
    • How much time each week are you able to devote to your courses?
  • Describe your awareness of the tools available to help you with your writing.
    • Have you used the school Writing Center in the past? Why or why not?
    • Have you used tools for writing help outside of the school Writing Center? If so, which ones? For what purposes did you seek outside writing help?
  • Describe any challenges or concerns you have about this course.
    • What do you think will be the most challenging thing for you to do in a writing course?
    • How do you plan to deal with and overcome the obstacles and difficulties you described?
  • Additional Requirements
  • Style and Format: Use current APA style and include a title page.
  • Length: Compose  s4 page (double-spaced).

Clinical Question – Formulate a clinical question using the PICOT format.

P: Patient Population
I: Intervention or area on Interest
C: Comparison intervention or group
O: Outcome
T: Time
Ex: “In acute care hospitals (patient population), how does having a rapid response team (intervention) compared with not having a response team (comparison) affect the number of cardiac arrests (outcome) during a three-month period (time)?”

REFERENCES, IN-TET CITATION

PEER VIEW WITHIN 3 YEARS OR LESS THAN 3 YEARS

An important role of nursing is to provide health promotion and disease prevention. Review the 2020 Topics and Objectives on the Healthy People website. Choose a topic of interest that you would like to address, in conjunction with a population at-risk for the associated topic. Submit the topic and associated group to your instructor for approval.

Create a 15-20-slide PowerPoint presentation for your topic and focus group. Include speaker notes and citations for each slide, and create a slide at the end for References.

Address the following:

1. Describe the approved topic and associated population your group has selected. Discuss how this topic adversely affects the population. How does health disparity affect this population?
2. Explain evidence-based approaches that can optimize health for this population. How do these approaches minimize health disparity among affected populations?
3. Outline a proposal for health education that can be used in a family-centered health promotion to address the issue for the target population. Ensure your proposal is based on evidence-based practice.
4. Present a general profile of at least one health-related organization for the selected focus topic. Present two resources, national or local, for the proposed education plan that can be utilized by the provider or the patient.
5. Identify interdisciplinary health professionals important to include in the health promotion. What is their role? Why is their involvement significant?

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 and public health content.

Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style