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Develop a 3-4-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.

NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project or clinical patient encounter is planning. This assessment 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.

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.

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.     
  • 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.

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.

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.

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.

This assessment has two parts.

Part 1: Develop the Preliminary Care Coordination Plan

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:     
  • Stroke.
  • Heart disease (high blood pressure, stroke, or heart failure).
  • Home safety.
  • Pulmonary disease (COPD or fibrotic lung disease).
  • Orthopedic concerns (hip replacement or knee replacement).
  • Cognitive impairment (Alzheimer’s disease or dementia).
  • Pain management.
  • Mental health.
  • Trauma.
• Identify available community resources for a safe and effective continuum of care.

Part 2: Secure Individual Participation in the Activity

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 Length

For your care coordination plan, you may use the Care Coordination Plan Template [DOCX], choose a format used in your own organization, or choose a format you are familiar with that adequately serves your needs for this assessment.

• 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.
• Document the community resources you have identified using the Community Resources Template [DOCX].

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 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 Requirements

Before 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.

CORE ELMS

Important note: The time you spend securing individual participation in this activity and the time you spend presenting your final care coordination plan to the patient in Assessment 4 must total at least three hours. Be sure to log your time in the CORE ELMS system. The CORE ELMS link is located in the courseroom navigation menu.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

 

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Write a 4-5 page evidence-based proposal to support the need for a nurse informaticist in an organization who would focus on improving health care outcomes.

As you begin to prepare this assessment, you are encouraged to complete the Team Perspectives of the Nurse Informaticist activity. Completion of this will help you succeed with the assessment as you explore the nurse informaticist’s role from the different perspectives of the health care team. Completing activities is also a way to demonstrate engagement.

Nurses at the baccalaureate level in all practice areas are involved in nursing informatics through interaction with information management and patient care technologies. Nurses must not only demonstrate knowledge of and skills in health information and patient care technologies, but also how to use these tools at the bedside and organizational levels. Moreover, nurses need to recognize how information gathered from various health information sources can impact decision making at the national and state regulatory levels.

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: Describe nurses’ and the interdisciplinary team’s role in informatics with a focus on electronic health information and patient care technology to support decision making.     
  • Define nursing informatics and the role of the nurse informaticist.
  • Explain how the nurse collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.
  • Justify the need for a nurse informaticist in a health care organization.
• Competency 2: Implement evidence-based strategies to effectively manage protected health information.     
  • Explain evidence-based strategies that the nurse and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).
• Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies.     
  • Follow APA style and formatting guidelines for citations and references.
  • Create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.

Scenario

For this assessment, assume you are a nurse attending a meeting of your state’s nurses’ association. A nurse informaticist conducted a presentation on her role and its impact on positive patient and organizational outcomes in her workplace. You realize that your organization is undergoing many technological changes. You believe this type of role could provide many benefits to your organization.

You decide to pursue proposing a nurse informaticist role in your organization. You speak to your chief nursing officer (CNO) and human resources (HR) manager. These individuals ask you to prepare a 4–5 page evidence-based proposal to support the new role. In this way, they can make an informed decision as to whether the addition of such a role could justify the return on investment (ROI). They need your proposal before an upcoming fiscal meeting.

Preparation

To successfully prepare for this assessment, you will need to complete these preparatory activities:

• Review assessment resources and activities.
• Conduct independent research on the nursing knowledge and skills necessary to interact with health information and patient care technology.     
  • Focus your research on current resources available through peer-reviewed articles, professional websites, government websites, professional blogs, wiki pages, job boards, et cetera.
  • Consult the BSN Program Library Research Guide for help in identifying scholarly and authoritative sources. 
• Interview peers in your network who are considered information technology experts.     
  • Ask them about how information technology advances are impacting patient care at the bedside, at the organizational level, and beyond.

Proposal Format

The Chief Nursing Officer (CNO) and Human Resources (HR) manager have asked you to include the following headings in your proposal and to be sure to address the bullets underneath each heading:

Nursing Informatics and the Nurse Informaticist

• What is nursing informatics?
• What is the role of the nurse informaticist?

Nurse Informaticists and Other Health Care Organizations

• What is the experience of other health care organizations with nurse informaticists?
• How do these nurse informaticists interact with the rest of the nursing staff and the interdisciplinary team?

Impact of Full Nurse Engagement in Health Care Technology

• How does fully engaging nurses in health care technology impact:     
  • Patient care?
  • Protected health information (security, privacy, and confidentiality)?
  • Workflow?
  • Costs and return on investment?

Opportunities and Challenges

• What are the opportunities and challenges for nurses and the interdisciplinary team with the addition of a nurse informaticist role?     
  • How can the interdisciplinary team collaborate to improve quality care outcomes through technology?

Summary of Recommendations

• What are 3–4 key takeaways from your proposal about the recommended nurse informaticist role that you want the CNO and the HR manager to remember?

Additional Requirements

• Written communication: Ensure written communication is free of errors that detract from the overall message.
• Submission length: 4–5 double-spaced pages, in addition to a title page and references page.
• Font: Times New Roman, 12 point.
• Citations and References: Cite a minimum of 3 current scholarly and/or authoritative sources to support your ideas. In addition, cite a minimum of 1 current professional blog or website to support your central ideas. Current means no more than five years old.
• APA formatting: Be sure to follow APA formatting and style guidelines for citations and references. For an APA refresher, consult the APA Style and Format page on Campus.

 

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