Preliminary Care Coordination Plan
Topic: Total Right Knee Replacement Patient name: Mrs. B, She is 73 years old and lives in Conroe, Texas (Montgomery County) Please make sure all references are within the last 5 years. Please look at the uploaded grading rubric and try for the distinguished level if at all possible. Develop a 4-page preliminary care coordination plan for an individual in your community with whom you choose to work. Identify and list available community resources for a safe and effective continuum of care.The first step in any effective project or clinical patient encounter is planning. This provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for an individual in your community as you consider the patient’s unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the continuum of care.Demonstration of ProficiencyBy 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.Analyze a health concern and the associated best practices for health improvement.Competency 2: Collaborate with patients and family to achieve desired outcomes.Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.Competency 3: Create a satisfying patient experience.Identify available community resources for a safe and effective continuum of care.Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.Write clearly and concisely in a logically coherent and appropriate form and style.PreparationImagine 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.As you assume your expanded care coordination role, you have been tasked with addressing the specific health concerns of a particular individual within the community. You decide to prepare a preliminary care coordination plan and proceed by identifying the patient’s three priorities for health and by investigating the resources available in your community for a safe and effective continuum of care.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 patient clinical encounter.Be sure that you have a patient in mind that you can work with throughout the course.This assessment has two parts.Part 1: Develop the Preliminary Care Coordination Plan (uploaded document)Complete the following:Identify a health concern as the focus of your care coordination plan. Possible health concerns may include, but are not limited to:Orthopedic concerns (knee replacement).Identify available community resources for a and effective continuum of care. (community resources available in Montgomery County, Texas) Conroe Regional Hospital is where the surgery will take place.Part 2: Secure Individual Participation in the ActivityI have already secured the patient for participation.You can make up the dates if you will please.Complete the following:Contact local individuals who may be open to an interview and a care coordination plan addressing their health concerns. The person you choose to work with may be a colleague, community member, friend, or family member.Meet with the individual to describe the care coordination plan session that you intend to provide. Collaborate with the participant in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to the plan.Establish a tentative date and time for the care coordination plan session. Document the name of the individual and a single point of contact, either an e-mail address or a phone number.Document Format and LengthFor your care coordination plan, you may use the Care Coordination Plan Template [DOCX],.Your preliminary plan should be 3–4 pages in length. In a separate section of the plan, identify the person you have chosen to work with, and be sure to include his or her contact information.Mrs. B, 902 Melanie Park, Conroe Texas 77304 ,Document the community resources you have identified using the Community Resources Template [DOCX].Supporting Evidence Cite at least four 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 descriptions for each criterion to see how your work will be assessed.Analyze your selected health concern and the associated best practices for health improvement.Cite supporting evidence for best practices.Consider underlying assumptions and points of uncertainty in your analysis.Establish mutually agreed-upon health goals for the care coordination plan, in collaboration with the selected individual.Identify available community resources for a safe and effective continuum of care.Write clearly and concisely in a logically coherent and appropriate form and style.Write with a specific purpose with your patient in mind.Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.Additional RequirementsBefore submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.