Care coordination in nursing

ASSESSMENT 2 Introduction This assignment 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 assignment after Assignment 1 is successfully completed. Preparation In this assignment, you will evaluate the preliminary care coordination plan you developed in Assignment 1 using best practices found in the literature. To prepare for your assignment, 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. Instruction Note: You are required to complete Assignment1 before this assignment. For this assignment: Build on the preliminary plan, developed in Assignment 1, to complete a comprehensive care coordination plan. Document Format and Length Build on the preliminary plan document you created in Assignment 1. Your final plan should be a scholarly APA-formatted paper, 57 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 assignment, 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. 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 assignment 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. SCORING GUIDE Criterion 1: Design patient-centered health interventions and timelines for a selected health care problem. For a distinguished grade be sure to: Design patient-centered health interventions and timelines for a selected health care problem that includes community resources. Criterion 2: Consider ethical decisions in designing patient-centered health interventions. For a distinguished grade, be sure to: Consider insightful ethical decisions in designing patient-centered health interventions. These decisions are supported by the literature. Criterion 3: Identify relevant health policy implications for the coordination and continuum of care. For a distinguished grade, be sure to: Identify relevant health policy implications for the coordination and continuum of care, based on precise and accurate interpretations of relevant policy provisions. Makes valid, insightful inferences. Criterion 4: 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. For a distinguished grade, be sure to: Describes 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 explains the need for changes to the plan. Criterion 5: 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. For a distinguished grade, be sure to: 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. Clearly explains the need for any revisions. Criterion 6: Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. For a distinguished grade, be sure to: Exhibit strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly. Criterion 7: Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. For a distinguished grade, be sure to: Organize content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.