Assessment 1 Instructions: Preliminary Care Coordination Plan

Develop a 3page 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

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

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.

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: 

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.

Document Format and Length

Your preliminary plan should be an APA scholarly paper, 3–4 pages in length. 

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. 

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 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.

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. 

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.

Portfolio Prompt: Save your presentation to your ePortfolio.

Assessment 2: Ethical and Policy Factors in Care Coordination

Select a community organization or group that you feel would be interested in learning about ethical and policy issues that affect the coordination of care. Then, develop and record a 10-12-slide, 20-minute presentation, with audio, intended for that audience. Create a detailed narrative script or speakers notes for your presentation, 4-5 pages in length.

Introduction

As coordinators of care, nurses must be aware of the code of ethics for nurses and health policy issues that affect the coordination of care within the context of the community. To help patients navigate the continuum of care, nurses must be proficient at interpreting and applying the code of ethics for nurses and health policy, specifically, the Affordable Care Act (ACA). Being knowledgeable about ethical and policy issues helps ensure that care coordinators are upholding ethical standards and navigating policy issues that affect patient care.

This assessment provides an opportunity for you to develop a presentation for a local community organization of your choice, which provides an overview of ethical standards and relevant policy issues that affect the coordination of care. Completing this assessment will strengthen your understanding of ethical issues and policies related to the coordination and continuum of care, and will empower you to be a stronger advocate and nursing professional.

It would be an excellent choice to complete the Vila Health: Ethical Decision Making activity prior to developing the presentation. The activity provides a helpful update on the ethical principles that will help with success in this assessment.

Preparation

Your nurse manager at the community care center is well connected and frequently speaks to a variety of community organizations and groups. She has noticed the good work you are doing in your new care coordination role and respects your speaking and presentation skills. Consequently, she thought that an opportunity to speak publicly about contemporary issues in care coordination would be beneficial for your career and has suggested reaching out to a community organization or support group to gauge their interest in hearing from you, as a care center representative, on a topic of interest to both you and your prospective audience.

You have agreed that this is a good idea and have decided to research a community organization or support group that might be interested in learning about ethical and policy issues related to the coordination of care. Your manager has suggested the following community organizations and support groups, but acknowledges that the choice is yours.

Homeless shelters.

Local religious groups.

Nursing homes.

Local community organizations (Rotary Club or Kiwanis Club).

To prepare for this assessment, you may wish to:

Research your selected community organization or support group.

Review the Code of Ethics for Nurses With Interpretive Statements and associated health policy issues, specifically, the ACA.

Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete.

Allocate sufficient time to rehearse your presentation before recording the final version for submission.

Recording Equipment Setup and Testing

Check that your audio speaker and PowerPoint software are working properly. You can record audio directly to your slides, using PowerPoint or other presentation software.

Note: Technical support about the use of PowerPoint, including voice recording and speaker notes, can be found on Campus's Microsoft Office Software page.

If using Kaltura, refer to the Using Kaltura tutorial for directions on recording and uploading your presentation in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@capella.edu to request accommodations.

Instructions

For this assessment:

Choose the community organization or support group that you plan to address.

Develop a PowerPoint with typed speaker notes (the script for your voice recording) and audio voice-over recording, intended for that audience. Video is not required.

Note: PowerPoint has a feature to type the speaker notes directly into the presentation. You are encouraged to use that feature or you may choose to submit a separate document. See Microsoft Office Software for technical support about the use of PowerPoint, including voice recording and speaker notes.

For this assessment, develop your presentation slides and speaker notes, then record your presentation. You are not required to deliver your presentation to an actual audience.

Presentation Format and Length

You may use PowerPoint (recommended) or other suitable presentation software to create your slides and add your voice over. If you elect to use an application other than PowerPoint, check with your faculty to avoid potential file compatibility issues.

Be sure that your slide deck includes the following slides:

Title slide. 

Presentation title.

Your name.

Date.

Course number and title.

References (at the end of your presentation).

Your slide deck should consist of 10–12 slides, not including a title and references slide with typed speaker notes and audio voice over. Your presentation should not exceed 20 minutes.

Create a detailed narrative script for your presentation, approximately 4 pages in length.

Supporting Evidence

Cite 3 credible sources from peer-reviewed journals or professional industry publications to support your presentation. Include your source citations on a references page appended to your narrative script.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Ethical and Policy Factors in Care Coordination 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.

Explain how governmental policies related to the health and/or safety of the community affect the coordination of care. 

Provide examples of a specific policy affecting the organization or group.

Refer to the assessment resources for help in locating relevant policies.

Be sure influential policies include the Health Insurance Portability and Accountability Act (HIPPA).

Identify national, state, and local policy provisions that raise ethical questions or dilemmas for care coordination. 

What are the implications and consequences of specific policy provisions?

What evidence do you have to support your conclusions?

Assess the impact of the code of ethics for nurses on the coordination and continuum of care. 

Consider the factors that contribute to health, health disparities, and access to services.

Consider the social determinants of health identified in Healthy People 2020 as a framework for your assessment.

Provide evidence to support your conclusions.

Communicate key ethical and policy issues in a presentation affecting the coordination and continuum of care for a selected community organization or support group. Either speaker notes or audio voice-over are included for a proficient score; both speaker notes and the audio voice over are included for a distinguished score. 

Present a concise overview.

Support your main points and conclusions with relevant and credible evidence.

Additional Requirements

Before submitting your assessment, proofread your presentation slides and speaker notes to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your presentation.

Assessment 3 Instructions: Care Coordination Presentation to Colleagues

Develop a 20-minute presentation for nursing colleagues highlighting the fundamental principles of care coordination. Create a detailed narrative script for your presentation, approximately 4 pages in length, and record a video of your presentation.

Introduction

Nurses have a powerful role in the coordination and continuum of care. All nurses must be cognizant of the care coordination process and how safety, ethics, policy, physiological, and cultural needs affect care and patient outcomes. As a nurse, care coordination is something that should always be considered. Nurses must be aware of factors that impact care coordination and of a continuum of care that utilizes community resources effectively and is part of an ethical framework that represents the professionalism of nurses. Understanding policy elements helps nurses coordinate care effectively.

This assessment provides an opportunity for you to educate your peers on the care coordination process. The assessment also requires you to address change management issues. You are encouraged to complete the Managing Change activity.

Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

Preparation

Your nurse manager has been observing your effectiveness as a care coordinator and recognizes the importance of educating other staff nurses in care coordination. Consequently, she has asked you to develop a presentation for your colleagues on care coordination basics. By providing them with basic information about the care coordination process, you will assist them in taking on an expanded role in helping to manage the care coordination process and improve patient outcomes in your community care center.

To prepare for this assessment, identify key factors nurses must consider to effectively participate in the care coordination process.

You may also wish to:

Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete.

Allow plenty of time to rehearse your presentation.

Recording Equipment Setup and Testing

Check that your recording equipment and software are working properly and that you know how to record and upload your presentation. You may use Kaltura (recommended) or similar software for your audio recording. A reference page is required. However, no PowerPoint presentation is required for this assessment.

If using Kaltura, refer to the Using Kaltura tutorial for directions on recording and uploading your video in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@capella.edu to request accommodations.

Instructions

Complete the following:

Develop a video presentation for nursing colleagues highlighting the fundamental principles of care coordination. Include community resources, ethical issues, and policy issues that affect the coordination of care. To prepare, develop a detailed narrative script. The script will be submitted along with the video.

Note: You are not required to deliver your presentation.

Presentation Format and Length

Create a detailed narrative script for your video presentation, approximately 4–5 pages in length. Include a reference list at the end of the script.

Supporting Evidence

Cite 3–5 credible sources from peer-reviewed journals or professional industry publications to support your video. Include your source citations on a references page appended to your narrative script. Explore the resources about effective presentations as you prepare your assessment.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Care Coordination Presentation to Colleagues 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.

Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes. 

Provide, for example, drug-specific educational interventions, cultural competence strategies.

Include evidence that you have to support your selected strategies.

Identify the aspects of change management that directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.

Explain the rationale for coordinated care plans based on ethical decision making. 

Consider the reasonable implications and consequences of an ethical approach to care and any underlying assumptions that may influence decision making.

Identify the potential impact of specific health care policy provisions on outcomes and patient experiences. 

What are the logical implications and consequences of relevant policy provisions?

What evidence do you have to support your conclusions?

Raise awareness of the nurse's vital role in the coordination and continuum of care in a video-recorded presentation. 

Fine tune the presentation to your audience.

Stay focused on key issues of import with respect to the effects of resources, ethics, and policy on the provision of high-quality, patient-centered care.

Adhere to presentation best practices.

Additional Requirements

Submit both your presentation video and script. The script should include a reference page. See Using Kaltura for more information about uploading multimedia files. You may submit the assessment only once, so be sure that both assessment deliverables are included.

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

Assessment 4: Final Care Coordination Plan

Introduction

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 to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

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.

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Instructions

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

For this assessment:

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 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 a selected health care problem. 

Address three health care issues.

Design an intervention for each health issue.

Identify three community resources for each health intervention.

Consider 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.

Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice. 

Clearly explain the need for changes to the plan.

Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document. 

Use the literature on evaluation as guide to compare learning session content with best practices.

Align teaching sessions to the Healthy People 2030 document.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

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.