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.
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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.
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.
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?
Additional Requirements
Before submitting your assessment, 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.
Grading Rubric:
1. Design patient-centered health interventions and timelines for care delivered through direct clinical interaction that is logged in the CORE ELMS system.
Passing Grade: Designs comprehensive, patient-centered health interventions and timelines for care that reflect patient needs and preferences and the availability of essential resources delivered through direct clinical interaction that is logged in the CORE ELMS system.
2. Make ethical decisions in designing patient-centered health interventions.
Passing Grade: Makes insightful ethical decisions in designing patient-centered health interventions, informed by relevant ethical considerations, the practical effects of specific actions, and the significance of key uncertainties.
3. Identify relevant health policy implications for the coordination and continuum of care.
Passing Grade: Identifies 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.
4. Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with the patient.
Passing Grade: Evaluates learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with the patient. Clearly explains the need for revisions to similar future sessions.
5. Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators.
Passing Grade: Evaluates patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators. Clearly explains the need for changes to enhance patient satisfactions and better align future sessions with Healthy People 2020 goals and leading health indicators.
RunningHead: CARE COORDINATION 1
CARE COORDINATION 8
Preliminary
Care Coordination Plan
Capella University
Alexander Ruche
Introduction
The role of care coordination is to ensure that there exists integrated services that meet the needs of individuals. The focus of care coordination lies in the delivery of recovery-focused and collaborative services that connect people to healthcare services. A key necessity for care coordination is the management of chronically sick patients. Chronically ill patients are a part of interconnected problems as they affect the social circles around them (Hannigan et. al., 2018). Just as it is complicated to the patients, so is it on service provision, hence mandating for family and friend to be a part of a multidisciplinary approach in relation to provision of care. Hence as a result, the issue on chronically ill patients is not one that can be handled by a single profession but rather one that requires a multidisciplinary approach and a care coordination plan to best deal with the health concerns (Hannigan et. al., 2018).
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a type of obstructive lung disease often characterized by long-term breathing problems and poor airflow resulting in difficulties when breathing. It tends to be characterized by shortness of breath as well as coughs accompanied with sputum production. Therefore, patients with COPD tend to present various complex health issues that demand for immediate pharmacological interventions (Hanania et. al., 2018). Care coordination assists in solving these complexities and in providing alternatives to quality health care. By offering a collaborative approach it is possible to address not only the patient’s needs in relation to the respiratory aspect of the disease but also in addressing the systemic effects and comorbidities associated with the illness (Hanania et. al., 2018). According to the Journal of Chronic Pulmonary Diseases, the most appropriate practices for care coordination for COPD include pulmonary rehabilitation, care integration, a holistic approach and an inclusion of a care transition model. These practices help to meet the complex needs of managing COPD. However, regardless of the clear goals in managing COPD, there still exist certain challenges (Hanania et. al., 2018). One such challenge is dealing with the hopelessness of the condition. Often physicians face uncertainties in diagnosing the disease, identifying its medications and hospitalizations. Even worse, patients in the past have shown non-compliance as a result of the disease’s complexity (Hanania et. al., 2018). All in all, an effective care coordination plan would help to effectively manage the condition of COPD.
Care Coordination Plan
To help attain success in the care coordination for Mr. Andrew Anderson a team of fifteen professionals will be selected. Although this team seems large, past research shows that a big number of people is important when creating diversity and expertise in COPD management. This team will compromise of nurses, pulmonologists and general experts all with a specific interest in COPD (Korpershoek et. al., 2017). The goal of the plan will be to create awareness around the disease, to offer a guideline based management, rehabilitation and self-management support program. The plan is also aimed at improving patient outcomes as evidenced in the attachment below:
PATIENTS NAME: Mr. Anderson
CONTACT: Private
ADDRESS: Private
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1.
Self-management behavior
a. Adherence to pharmacology- Consume prednisolone 30mg every day. Helps in reducing instances of exacerbation, failure of treatment, admission, and improves hypoxemia.
· Adhere to using albuterol (Combivent) 100 mcg/20 mcg after every 6 hours and must not exceed 6 actuations daily. Such helps to boost instances of dyspnea and activity tolerance during the daily exercise regimens (Korpershoek et. al., 2017).
· Take ciprofloxacin twice every day because it lowers instances of treatment failure
● Please note that medications will be collected at Walgreens Pharmacy located in Cutler Bay.
SCORE OF ADHERANCE
Excellent
Moderate
Poor
2.
Patient Education
a. Mr. Anderson will attend a smoking cessation program at Primax Rehabilitation Program. After the end of six months Mr. Anderson will have managed his smoking habits. By being part of the rehabilitation program, you will have modified the occurrence of the disease and lowered instances of contracting myocardial infarction and lung cancer. It is paramount to note that the effects of quitting smoking will not be evidenced until after several months of quitting (Jiménez-Ruiz et. al., 2015).
b. Enroll in a muscle relaxation program at the Pembroke Resource Center. Such will promote Mr. Anderson’s respiratory and psychological well-being. The center will offer activities like yoga, muscle relaxation and deep breathing exercises (Volpato, et. al., 2015).These exercises will be aimed at improving his breathing capacity and will be done every Monday and Friday.
c. Take part in the training of early detection of exacerbation at the Porta General Hospital as directed by the program coordinator. In the event of an exacerbation contact the care coordinator. While at the training you will be looked after by the lead physician and community nurse (May et. al., 2016).
Write date, day and time of attendance.
Smoking cessation program
Relaxation techniques
Early detection of exacerbation
●Rate the usefulness of every program in a percentage score: (e.g. 20%, 50%, 100%)
– Smoking cessation program:
– Relaxation technique
– Early detection of exacerbation
3.
Influenza Vaccination
After the first week, you will get the influenza vaccine from South Miami Hospital. The vaccine is very useful since influenza is termed as the second most common cause of COPD exacerbations. The vaccination will help reduce instances of attacks (Nici & ZuWallack, 2018).
4.
Involvement by the family
For effective management of COPD management, family intervention is important. Family will help in offering emotional support during the journey. They will also help in supporting smoking cessation and facilitate drug adherence. Mr. Anderson will involve his spouse in the training programs while attending the monthly COPD clinics with him. Such ensures not just support but will make it easier for the care coordinator to monitor the patient for best outcomes.
CONTACTS Signature
Care Coordinator: 734-755-602
Walgreens Pharmacy: 965-546-8300
Lead physician: 953-493-398
Local clinic: 955-412-0134
Pembroke Resource Center: 308-680-5075
Ambulance: 720-119-3647
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References
Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: findings from a cross-national mental health systems study. International Journal of Integrated Care, 18(3).
Hanania, N. A., Hawken, N., Gilbert, I., Martinez, F. J., Fox, K. M., Ross, M. M., … & Tervonen, T. (2018). What Symptomatic Patients with Asthma and Chronic Obstructive Pulmonary Disease (COPD) Find Important in Their Maintenance Inhaler Therapy: A Focus Group Study. In C37. OPTIMIZING ASTHMA CARE ACROSS DIVERSE PATIENTS (pp. A4863-A4863). American Thoracic Society.
Jiménez-Ruiz, C. A., Andreas, S., Lewis, K. E., Tonnesen, P., Van Schayck, C., Hajek, P., … Gratziou, C. (2015). Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. European Respiratory Journal, 46(1), 61-79. doi:10.1183/09031936.00092614
Korpershoek, Y., Bruins Slot, J., Effing, T., Schuurmans, M., & Trappenburg, J. (2017). Self-management behaviors to reduce exacerbation impact in COPD patients: a Delphi study. International Journal of Chronic Obstructive Pulmonary Disease, Volume 12, 2735-2746. doi:10.2147/copd.s138867
May, C. R., Cummings, A., Myall, M., Harvey, J., Pope, C., Griffiths, P., … Richardson, A. (2016). Experiences of long-term life-limiting conditions among patients and carers: what can we learn from a meta-review of systematic reviews of qualitative studies of chronic heart failure, chronic obstructive pulmonary disease and chronic kidney disease? BMJ Open, 6(10), e011694. doi:10.1136/bmjopen-2016-011694
Nici, L., & ZuWallack, R. (2018). Integrated care in chronic obstructive pulmonary disease and rehabilitation. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(3), 223-230.
Volpato, E., Banfi, P., Rogers, S. M., & Pagnini, F. (2015). Relaxation Techniques for People with Chronic Obstructive Pulmonary Disease: A Systematic Review and a Meta-Analysis. Evidence-Based Complementary and Alternative Medicine, 2015, 1-22. doi:10.1155/2015/628365
