Assessment 1 Instructions: Preliminary Care Coordination Plan

Develop 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].
• You can use real or fictitious names/addresses for the community resources you identify
  • The type of resource, not the name, is what you need to pay attention to for this assessment.
• 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.

The first step of the evidence-based practice process is to evaluate a nursing practice environment to identify a nursing problem in the clinical area. When a nursing problem is discovered, the nurse researcher develops a clinical guiding question to address that nursing practice problem.

For this discussion question, you will create a clinical guiding question known as a PICOT question. The PICOT question must be relevant to a nursing practice problem (coordination of health care, assessment, education, patient support, trauma prevention, recovery, health screenings, etc.).

After reviewing the relevant topic materials:

1. Select a nursing practice problem of interest.
2. Develop a PICOT question using the template and example provided below.
3. Identify two articles, one qualitative and one quantitative, related to the problem of interest. Provide an APA-formatted reference for each article, and explain how each relates to your PICOT question. Be sure to identify which article is qualitative and which article is quantitative. These articles may be used in this week’s assignment.

PICOT question intervention format:

In_______________(Population), how does _______________ (Intervention) compared to _______________ (Comparison) affect _______________ (Outcome) within______________(Time, optional)?

Example: In critically ill patients in an Intensive Care Unit (ICU) (P), how do daily 2% chlorhexidine cloth baths (I) compared to daily disposable non-antimicrobial cloth baths (C) affect the incidence of health care-associated infections (HAIs) (O)?

In responses to peers, provide feedback related to peers’ PICOT questions and their associated articles.

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to “RN-BSN Discussion Question Rubric” and “RN-BSN Participation Rubric,” located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively.

 Resources To Use:

• McGonigle, D., & Mastrian, K. G. (2022). Nursing informatics and the foundation of knowledge (5th ed.). Jones & Bartlett Learning.
  • Chapter 9, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making” (pp. 191–204)
  • Chapter 12, “Electronic Security” (pp. 251–265)
  • Chapter 13, “Achieving Excellence by Managing Workflow and Initiating Quality Projects”
• Agency for Healthcare Research and Quality. (n.d.a). Health IT evaluation toolkit and evaluation measures quick reference guideLinks to an external site.. Retrieved January 26, 2022, from https://digital.ahrq.gov/health-it-evaluation-toolkit
• Agency for Healthcare Research and Quality. (n.d.b). Workflow assessment for health IT toolkitLinks to an external site.. Retrieved January 26, 2022, from https://digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit

Louis, I. (2011, August 17). Software development life cycleLinks to an external site. (SDLC) [Video file]. Retrieved from https://www.youtube.com/watch?v=xtpyjPrpyX8

For this assignment, imagine you are a nurse director on a unit where a new nursing documentation system is to be implemented. You want to ensure that the system will be usable and acceptable for the nurses impacted. You realize you need a nurse leader, probably one with nursing informatics skills, to be on the implementation team.  For this assignment, you will develop a role description for the nurse leader that you will be recruiting for this Documentation System Project Team.

• The role description should be based on the SDLC stages/steps and tasks and should clearly define how this individual will participate in and impact each of the following steps. Have a heading for each step and have 2-3 bullets under each heading:
  • Planning and requirements definition
  • Analysis
  • Design of the new system
  • Implementation
  • Post-implementation support
• Use APA format and include a title page and reference page (thus include citations and references)

Prepare

• Review the steps of the Systems Development Life Cycle (SDLC) and reflect on the scenario presented.
• Consider the benefits and challenges associated with involving a nurse leader on an implementation team for health information technology.