Assessment 4 Instructions: Final Care Coordination Plan

Assessment 4 Instructions: Final Care Coordination Planfor This Assess

For this assessment, you will simulate implementation of the preliminary care coordination plan you developed in Assessment 1. The presentation would be structured for the hypothetical patient. You are required to complete this assessment after Assessment 1 is successfully completed. 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. 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.

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. 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. Design patient-centered health interventions and timelines for care delivered through direct clinical interaction that is logged in the CORE ELMS system. Competency 2: Collaborate with patients and family to achieve desired outcomes.

Use the literature on evaluation as a guide to compare learning session content with best practices. Competency 3: Create a satisfying patient experience. Describe what the literature says about effective care coordination and patient satisfaction versus experience, including how to align teaching sessions to the Healthy People 2020 document. Competency 4: Defend decisions based on the code of ethics for nursing. Make 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.

In this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the hypothetical patient in a professional, culturally sensitive, and ethical manner. To prepare for the assessment, consider the patient experience and how you would present the plan. Note: Remember that you can submit all, or a portion of, your 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.

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan. Document Format and Length

Your final plan should be 5–7 pages in length, building on your initial plan. Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources.

Grading Requirements

Design patient-centered health interventions and timelines for care. Address three patient health issues, creating an intervention for each, and identify three community resources for each intervention to help the patient make informed decisions. Consider ethical decisions in designing interventions, including ethical questions that generate uncertainty about the decisions made. Identify relevant health policy implications for the care continuum, citing specific health policy provisions. Explore what the literature says about evaluation in care coordination and potential plan revisions to improve outcomes.

Additionally, include insights from literature on effective care coordination and patient satisfaction versus experience, as well as how to align teaching sessions with the Healthy People 2020 goals. Before submitting, proofread your plan to minimize errors, ensuring clarity and professionalism. Save your presentation to your ePortfolio, as submissions will be part of your final Capstone course.

Use the scoring guide to understand assessment evaluation criteria.

Paper For Above instruction

Effective care coordination is fundamental to providing holistic, patient-centered healthcare that improves outcomes and enhances patient satisfaction. Developing a comprehensive care coordination plan requires an understanding of the patient's unique needs, evidence-based intervention strategies, community resources, ethical considerations, and the influence of health policies. This paper delineates the process of implementing a final care coordination plan for a hypothetical patient, emphasizing the integration of these core elements to optimize health outcomes within a community setting.

Introduction

Care coordination serves as a critical component in the continuum of healthcare, aiming to facilitate seamless transitions between different levels of care and providers (McDonald et al., 2013). Nurses, positioned at the frontline of patient advocacy and education, must develop tailored interventions that address individual health issues in a culturally competent, ethically sound manner. This plan builds upon an initial preliminary framework established in Assessment 1, utilizing current literature, health policies, and community resources to formulate effective, patient-centered interventions.

Patient-Centered Interventions and Timelines

Addressing three specific health concerns—hypertension, diabetes mellitus type 2, and medication non-adherence—the plan proposes targeted interventions that encompass education, lifestyle modifications, medication management, and follow-up schedules. For hypertension, the intervention involves individualized blood pressure monitoring, dietary counseling, and lifestyle coaching, with follow-up assessments scheduled bi-weekly over three months (Whelton et al., 2018). Diabetes management includes nutritional education, blood glucose monitoring training, and regular endocrinology consultations every month for six months (American Diabetes Association, 2021). Addressing medication non-adherence involves pharmacological education, simplifying regimens when possible, and employing reminder systems, with weekly check-ins for the initial month (Coleman et al., 2017).

Community Resources

For each intervention, three community resources are recommended. For hypertension, local clinics offering free blood pressure screenings, community health education programs, and nutritionist services available through local health departments are invaluable (CDC, 2020). Diabetes management can benefit from community-based programs like diabetes education centers, peer support groups, and pharmacy-led medication counseling (ADA, 2021). To combat medication non-adherence, resources include medication assistance programs, patient education workshops in community centers, and mobile health clinics providing medication delivery and counseling (Kebede et al., 2020).

Ethical Considerations in Intervention Design

Decisions in designing patient-centered care must adhere to the American Nurses Association’s Code of Ethics, which emphasizes respect for patient autonomy, beneficence, non-maleficence, and justice (ANA, 2015). Ethical dilemmas often arise when resources are limited or when cultural beliefs conflict with medical advice. For example, respecting a patient's cultural preference for traditional medicine may require compromise and culturally sensitive education rather than outright dismissal of non-conventional practices. Ensuring informed consent and respecting patient choices are central to ethical care provision (Peden et al., 2018). Ethical questions include whether to disclose all risks associated with interventions, balancing benefits against potential harms, and how to allocate resources fairly.

Health Policy Implications

Health policies significantly influence the feasibility and scope of care coordination. The Affordable Care Act (ACA) promotes patient-centered medical homes and incentivizes care coordination through accountable care organizations (Centers for Medicare & Medicaid Services, 2020). Policies encouraging the integration of community health workers and telehealth initiatives expand access, especially in underserved areas (Bach & Squires, 2019). Revisions aimed at reducing healthcare disparities—such as funding for culturally competent services and expanding Medicaid—can further improve care continuity. Recognizing these policies informs intervention design, ensuring compliance and maximizing resource effectiveness.

Lessons from Literature and Plan Revisions

The literature underscores that effective care coordination enhances patient satisfaction and health outcomes, yet satisfaction is often distinguished from overall patient experience, which encompasses emotional, informational, and functional aspects (Street et al., 2019). Regular communication, culturally sensitive education, and active patient engagement are keys to success. Alignment with Healthy People 2020’s goals stresses reducing health disparities, increasing access to preventive services, and promoting health literacy (USDHHS, 2020). Future revisions include incorporating patient feedback, utilizing technology for real-time monitoring, and emphasizing team-based approaches to adapt to evolving patient needs (Bates et al., 2014).

Conclusion

In sum, implementing a comprehensive, ethically sound, and culturally competent care coordination plan enhances health outcomes and patient satisfaction. Integrating community resources, aligning with policies, and continuous evaluation based on current literature ensures that care delivery is patient-centered, efficient, and equitable. As healthcare evolves, nurses’ roles in care coordination remain vital, demanding ongoing education and adherence to ethical principles and policy frameworks to serve diverse populations effectively.

References

• American Diabetes Association. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S1–S232.
• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. ANA Publishing.
• Bach, P. B., & Squires, D. (2019). Policy Trends in Telehealth. Journal of Healthcare Policy, 34(2), 45-59.
• Bates, D. W., Cohen, M., Leape, L. L., et al. (2014). Reducing Diagnostic Errors Through Health IT. JAMA, 311(20), 2096–2097.
• Centers for Disease Control and Prevention (CDC). (2020). Community Health Resources for Hypertension. CDC Reports.
• Coleman, E. A., et al. (2017). Improving Medication Adherence. Annals of Internal Medicine, 167(9), 703–708.
• McDonald, K. M., et al. (2013). Care Coordination and Quality Improvement. Agency for Healthcare Research and Quality.
• Peden, M., et al. (2018). Ethical Challenges in Cultural Competence. Nursing Ethics, 25(4), 480–490.
• Street, R. L., et al. (2019). Patient Perceptions of Care Coordination. Patient Experience Journal, 6(2), 101–112.
• U.S. Department of Health and Human Services (USDHHS). (2020). Healthy People 2020 Objectives. HHS Publications.