Care coordination plan

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.
Introduction
The first step in any effective project is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. 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.
Preparation
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.
Scenario
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.
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 chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
· Select one of the health concerns in the  Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF]  Download Assessment 01 Supplement: Preliminary Care Coordination Plan [PDF] resource as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
· Identify available community resources for a safe and effective continuum of care.
Document Format and Length
· Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
· Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
· In your paper include possible community resources that can be used.
· Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
· Study the subtle differences between basic, proficient, and distinguished.
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.
· Describe specific goals that should be established to address the health care problem.
· Identify available community resources for a safe and effective continuum of care.
· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
· 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.
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.
· Analyze a health concern and the associated best practices for health improvement.
· Competency 2: Collaborate with patients and family to achieve desired outcomes.
· Describe specific goals that should be established to address a selected health care problem.
· 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.
· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
Collapse All
Criterion 1
Analyze a health concern and the associated best practices for health improvement.
Distinguished
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.
Proficient
Analyzes a health concern and the associated best practices for health improvement.
Basic
Attempts to analyze a health concern and the associated best practices for health improvement.
Non Performance
Does not analyze a health concern and the associated best practices for health improvement.
Criterion 2
Describe specific goals that should be established to address a selected health care problem.
Distinguished
Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable.
Proficient
Describes specific goals that should be established to address a selected health care problem.
Basic
Attempts to describe undefined goals that should be established to address a selected health care problem.
Non Performance
Does not describe specific goals that should be established to address a selected health care problem.
Criterion 3
Identify available community resources for a safe and effective continuum of care.
Distinguished
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.
Proficient
Identifies available community resources for a safe and effective continuum of care.
Basic
Attempts to identify available community resources.
Non Performance
Does not identify available community resources.
Criterion 4
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Distinguished
Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.
Proficient
Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Basic
Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.
Non Performance
Does not organize content for ideas. Lacks logical flow and smooth transitions.
Criterion 5
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Distinguished
Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.
Proficient
Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Basic
Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes and/or paraphrasing.
Non Performance
Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.
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