For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

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Introduction

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Preparation

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of  Healthy People 2030.

Instructions

Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

· Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

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

· Design patient-centered health interventions and timelines for a selected health care problem.

· Address three health care issues.

· Design an intervention for each health issue.

· Identify three community resources for each health intervention.

· Consider ethical decisions in designing patient-centered health interventions.

· Consider the practical effects of specific decisions.

· Include the ethical questions that generate uncertainty about the decisions you have made.

· Identify relevant health policy implications for the coordination and continuum of care.

· Cite specific health policy provisions.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

· Clearly explain the need for changes to the plan.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

· Use the literature on evaluation as guide to compare learning session content with best practices.

· Align teaching sessions to the Healthy People 2030 document.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

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

Context

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

Course Competencies

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Adapt care based on patient-centered and person-focused factors.

· Design patient-centered health interventions and timelines for a selected health care problem.

· Competency 2: Collaborate with patients and family to achieve desired outcomes.

· Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.

· Competency 3: Create a satisfying patient experience.

· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.

· Competency 4: Defend decisions based on the code of ethics for nursing.

· Consider ethical decisions in designing patient-centered health interventions.

· Competency 5: Explain how health care policies affect patient-centered care.

· Identify relevant health policy implications for the coordination and continuum of care.

· Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Hello, this assignment will continue in week 5, the participant could be a nurse that work in my unit (Med surgical), , and you can pick: (anemia, gastritis, diverticulitis) as a medical diagnosis or something else, just make sure to follow the instructions.

Assignment Overview: 

The Week 3 Assignment is part of a scaffolded assignment and serves as the basis for creation of the Week 5 Assignment.

For the Week 3 Assignment: Nursing Grand Rounds Presentation Part 1: Holistic Assessment, you will meet with and assess a selected participant and complete the accompanying Holistic Assessment Form.  In Week 5, you will complete the Nursing Grand Rounds Part 2: Presentation, which is a teaching presentation.

For the Week 5 Assignment, you will use the data collected in the Week 3 Assignment to create a PowerPoint presentation designed to educate your selected participant about an identified medical condition they are experiencing. The Week 3 Assignment data will be used as a foundation for creating the patient-centered teaching presentation due in Week 5.

Assignment Directions: 

· Identify an participant known to you who has a current medical health condition. The participant must be 18 years or older and legally capable of consenting to participate in this activity. The participant  CANNOT be a family member or a client you have cared for in your professional nursing practice. Using a client or patient who was assigned to receive care from you by an employer, agency, facility, or any organization will result in earning a score of zero (0) points for the assignment.

· Be sure the participant is diagnosed with a medical health condition that meets the assignment requirements. The participant’s medical health condition cannot be congenital (i.e., present at birth). Instead, the medical health condition must have a pathophysiology. The medical condition also must be a primary health alteration (e.g., cyclic vomiting syndrome), and not simply a sign or symptom that is a manifestation of a primary medical disorder (e.g., hyponatremia, dehydration, nausea, vomiting, etc.).

· Complete the  Holistic Assessment Form  for the selected participant, then upload the completed form to the Dropbox by the end of Week 3. The form should be typed. The course faculty will review and grade the form for completion and accuracy and will approve the participant/medical condition you have selected as the focus for the Week 5 Assignment.  Be sure you have approval from course faculty before you begin working on the Week 5 Assignment: Nursing Grand Rounds Part 2: Presentation. 

· After successfully completing the Week 3 Assignment and obtaining faculty approval of the selected participant/medical condition, follow the instructions for completing the Week 5 Assignment: Nursing Grand Rounds Part 2: Presentation.