Posted: September 4th, 2023

Care coordination is essential in the healthcare continuum

Introduction
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
(I HAVE UPLOADED MY ASSESSMENT 1 THAT INSTRUCTIONS ARE REFERRING TO. THIS ASSESSMENT IS EXPANDING ON THAT ASSESSMENT)
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.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.
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.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.
****REFERENCES CAN BE NO OLDER THAN 2018. PEER REVIEWED. ****
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.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: MAKE SURE EVERY POINT IS ADDRESSED.****
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.
1, Design patient-centered health interventions and timelines for a selected health care problem.
A. Address three health care issues.
B. Design an intervention for each health issue.
C. Identify three community resources for each health intervention.
2. Consider ethical decisions in designing patient-centered health interventions.
A. Consider the practical effects of specific decisions.
B. Include the ethical questions that generate uncertainty about the decisions you have made.
3. Identify relevant health policy implications for the coordination and continuum of care.
A. Cite specific health policy provisions.
4. 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.
A. Clearly explain the need for changes to the plan.
5. 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.
A. Use the literature on evaluation as guide to compare learning session content with best practices.
B. Align teaching sessions to the Healthy People 2030 document.Grading Requirements

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Introduction:

Care coordination is essential in the healthcare continuum as it ensures the seamless transition of care for patients. Nurses play a vital role in care coordination by providing knowledge and communication to ensure that patients receive optimal health care. This assessment aims to evaluate the preliminary care coordination plan developed in Assessment 1 using evidence-based practices (EBP) found in the literature. The selected health care problem is obesity. The paper will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. Changes to the plan based on EBP will be identified, and the plan will include elements of Healthy People 2030.

Design patient-centered health interventions and timelines for a selected health care problem:

A. Address three health care issues:

Weight management: A healthy diet and physical activity plan will be implemented to promote weight loss. The goal is to achieve a healthy BMI and waist circumference within six months.

Psychological well-being: A mental health assessment will be conducted to identify any underlying mental health issues. Counseling and psychotherapy sessions will be scheduled for patients with anxiety or depression.

Comorbidities: Patients with comorbidities such as hypertension, diabetes, or sleep apnea will receive appropriate medical management to control the disease.

B. Design an intervention for each health issue:

Weight management: The intervention will include a calorie-restricted diet with a deficit of 500-750 kcal/day and 150-300 minutes of moderate-intensity physical activity per week.

Psychological well-being: Counseling and psychotherapy sessions will be conducted by a mental health professional to manage anxiety or depression.

Comorbidities: Patients with comorbidities will receive appropriate medical management as per evidence-based guidelines.

C. Identify three community resources for each health intervention:

Weight management:
a. Local farmers’ markets and grocery stores offering fresh produce.

b. Local fitness centers, parks, and recreational facilities.

c. Online resources, such as apps and websites, for tracking food intake and physical activity.

Psychological well-being:
a. Local mental health clinics and providers.

b. Online counseling services and support groups.

c. Self-help resources, such as books and podcasts.

Comorbidities:
a. Local clinics and hospitals for specialized medical care.

b. Community health centers for low-cost healthcare.

c. Online resources, such as medical websites and support groups.

Consider ethical decisions in designing patient-centered health interventions:

A. Consider the practical effects of specific decisions:

In designing patient-centered health interventions, ethical considerations should be taken into account. For instance, patients should be involved in decision-making and have the autonomy to choose their preferred interventions. Respect for patients’ privacy and confidentiality should also be maintained, and their cultural beliefs and practices should be respected.

B. Include the ethical questions that generate uncertainty about the decisions you have made:

Ethical questions may arise when implementing interventions, such as weight loss programs, that require calorie restriction and physical activity. Some patients may have cultural or religious beliefs that prohibit certain foods or activities. In such cases, the care coordinator should work with the patient to find alternative options that align with their beliefs.

Identify relevant health policy implications for the coordination and continuum of care:

A. Cite specific health policy provisions:

The Affordable Care Act (ACA) has provisions that promote care coordination, patient-centered care, and prevention. The ACA also promotes the use of electronic health records (EHRs) to improve care continuity and reduce medical errors.

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:

A. Clearly explain the need for changes to the plan:

The care coordinator should explain the need for changes to the plan to the patient and family members.

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