For this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session and collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan.

NOTE: 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 for you to apply communication, teaching, and learning best practices to the presentation of a care coordination plan to the patient.

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. 

  Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with a patient.

• Competency 3: Create a satisfying patient experience. 

  Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators.

• 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.

Preparation

In this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the patient in a professional, culturally sensitive, and ethical manner.

To prepare for the assessment, consider the patient experience and how you will present the plan. Make sure you schedule time accordingly.

Instructions

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

For this assessment:

• Complete the preliminary care coordination plan you developed in Assessment 1.
• Present the plan to the patient in a face-to-face clinical learning session. Communicate in a professional, culturally sensitive, and ethical manner.
• Collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan.

Reminder: The time you spend presenting your final care coordination plan must be logged in the CORE ELMS system. The total time spent in securing individual participation in this activity in Assessment 1 and presenting your plan in this assessment must be at least three hours. The CORE ELMS link is located in the courseroom navigation menu.

Please be advised that the Volunteer Experience form requires that you provide the name and contact information for at least one individual with whom you worked as part of your direct clinical activity. Your faculty may reach out to this individual to verify that you have accurately documented and completed your clinical hours.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be 5–7 pages in length.

Supporting Evidence

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

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 care delivered through direct clinical interaction that is logged in the CORE ELMS system. 

  Address three patient health issues.
  Design an intervention for each health issue.
  Identify three community resources for each health intervention, so the patient may make an informed decision about what resources to use.

• Make 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.

• Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with the patient. 

  What aspects of the session would you change?
  How might revisions to the plan improve future outcomes?

• Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators. 

  What changes would you recommend to improve patient satisfaction and better align the session with Healthy People 2020 goals and leading health indicators?