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Identify available community resources for a safe and effective continuum of care.

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Preliminary Care Coordination Plan
A key aspect of the care coordination process is effective planning that answers the following questions:
• What is the best approach to planning for care?
• What are the essential steps in the process?
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 assignment 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.
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.
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.
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.
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. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
o Stroke.
o Heart disease (high blood pressure, stroke, or heart failure).
o Home safety.
o Pulmonary disease (COPD or fibrotic lung disease).
o Orthopedic concerns (hip replacement or knee replacement).
o Cognitive impairment (Alzheimer’s disease or dementia).
o Pain management.
o Mental health.
o Trauma.
• 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.
o 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.
o 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 descriiptions for each criterion to see how your work will be assessed.
• Analyze your selected health concern and the associated best practices for health improvement.
o Cite supporting evidence for best practices.
o 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.
o Write with a specific purpose with your patient in mind.
o Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
During care coordination, nurses should ensure that they are creating patient-centered goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable, Relevant, Timely) goals. SMART goals provide direction for patient-centered care coordination.
SMART goals must be effective, meaningful, achievable, and collaborative in nature. Key stakeholders (such as the individual, group, or community; possibly significant others; and you, the nurse) must be taken into account.

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