Demonstration of Proficiency

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 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.
 

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