For this assessment, you will develop the final care coordination strategy you based on your health care concern and population in Assessment 2 using best practices found in the literature.
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Introduction
This assessment builds on your initial care coordination infographic by providing an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for your selected health care problem.
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Note: You are required to complete this assessment only after Assessment 2 is successfully completed.
Professional Context
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.
Please watch the following brief video message for an overview of what to keep in mind as you complete your Care Coordination Strategy.
· Final Care Coordination Strategy.
Preparation
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.
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In this assessment, you will evaluate the preliminary care coordination infographic you developed in Assessment 2 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 strategy based upon evidence-based practice and discuss how the strategy includes elements of Healthy People 2030.
Instructions
Build on your preliminary care infographic and selected health concern and population and create a detailed comprehensive final care coordination strategy.
It is suggested that you use the following outline to organize your 5–7 page paper, including headings:
· Design patient-centered health interventions and timelines for your selected healthcare problem.
o Address three patient healthcare issues related to your selected healthcare problem and patient population
§ Example: Healthcare problem: Type 1 diabetes in pediatric patients.
§ Health issues.
§ Depression.
§ Exercise.
§ Poor glucose control.
o Design an intervention for each health issue.
o Identify three community resources for each health intervention.
o Establish timelines for implementing these interventions.
o Include evidence to support your ideas.
· Consider the ethical decisions in designing patient-centered health interventions for your selected healthcare problem.
o Include the ethical questions that generate uncertainty about the decisions you have made.
o Include evidence to support your ideas.
· Identify relevant health policy implications for the coordination and continuum of care of your selected healthcare problem and population.
o Cite specific health policy provisions.
o Include evidence to support your ideas.
· Describe the priorities a care coordinator would establish when discussing the plan with a patient and family members.
o Include evidence to support your ideas
· Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.
o Clearly explain the need for the changes to the plan.
The requirements, outlined above correspond to the grading criteria in the Final Care Coordination Strategy 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.
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Format and Length
· Write a 5–7 page APA-formatted scholarly paper (excluding title page and reference list).
· Include five evidence-based resources.
· Properly cite evidence throughout your paper.
Good luck with your care coordination plan!
Practicum Hours Submission
· Use Capella Academic Portal to submit your practicum hours.
· You must complete any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.
· Failure to complete the required practicum hours will result in a non-performance for this assessment.
Please review the BSN Practicum Campus page for more information and instructions on how to log your hours.
Nursing Reflection Journal: Four Spheres of Care
Reflective Journaling
Reflective journaling serves as a powerful tool for self-reflection during your academic journey. Reflective journaling enables you to assess your performance and to develop the regular practice of self-reflection. During your practicum, you’ll complete four reflective journal entries, each aligned with one of the four spheres of care.
For your first entry, you can choose any of the four spheres, but you will need to complete all four by the end of the course. Remember that you’ll need to submit your completed nursing reflection as part of the final assessment for the course.
Instructions
Complete your first entry in 100–400 words in the Nursing Reflection Journal: Four Spheres of Care activity. You do not need to include scholarly resources or a reference list. Your reflections should be your own original thoughts. Please do not include patient or clinic identifying information.
As you complete your practicum hours (total of 40 hours required), it is good practice to complete a reflection journal entry every 10 hours. Take a moment to review the four spheres of care and the assigned readings for each assessment. This can help you focus your practicum time on specifics of learning and experiencing the courseroom content.
AACN Definition of the Four Spheres of Care
Wellness and disease prevention: This sphere emphasizes health promotion, as well as the treatment of minor uncomplicated diseases or injuries for those not experiencing chronic illness or life-limiting conditions. Prenatal care, screenings, immunizations, and health promotion are some examples of care in this sphere (AACN, 2021). Nursing knowledge and competency in disease prevention and addressing social determinants of health are vital to promoting wellness across populations.
Chronic disease management: This sphere encompasses caring for those with one or more chronic diseases and preventing adverse outcomes associated with them. Specialized nursing care is often needed for this population due to the complex needs, along with integrated interprofessional team-based care. Four in 10 Americans have two or more chronic diseases, and those diagnosed with multiple comorbidities are projected to increase.
Regenerative and restorative care: This sphere includes critical and trauma care, complex acute care, acute exacerbations of chronic disease, and care of unstable patients who are typically in acute care hospital settings (AACN, 2021). This sphere includes the acute management of illness, such as a stroke or mental health crisis, and progression through the rehabilitative phase. Nursing skills and management of these populations are resource-intensive and specialized.
Hospice and palliative care: The final sphere relates to competencies surrounding palliative care in advanced illness and hospice care at the end of life. All registered nurses provide generalist palliative care in compassionate and patient-centered care while managing pain and other symptoms associated with advanced, progressive illness. The End-of-Life Nursing Education Consortium has mapped its Competencies and Recommendations for Educating Nursing Students competencies to the new AACN Essentials to assist educators in this endeavor.
Reflection Questions
By the end of your practicum, make sure that you have answered each of these questions.
· Wellness and disease prevention: Reflect on the health promotion disease prevention interventions you witnessed in your practicum site, as it relates to the social determinants of health most prevalent in your community. What did you see? What does this time mean to you as a professional nurse in your role?
· Chronic disease management: Reflect on the integration of interprofessional team-based care as it relates to chronic disease management in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
· Regenerative and restorative care: Reflect on the acute management of illnesses such as stroke, mental illness, and falls in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
· Hospice and palliative care: Reflect on end-of-life nursing and advanced illness and hospice care in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
Reference
American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Essentials/Essentials-Executive-Summary.pdf
Completion Checklist
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Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Create a patient centered strategy to achieve desired health outcomes.
o Design patient-centered health interventions and timelines for a selected healthcare problem.
o Describe priorities that a care coordinator would establish when discussing the plan with a patient and family members.
· Competency 2: Apply the code of ethics for nursing to care coordination decisions.
o Consider the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, supporting ideas with the literature.
· Competency 3: Explain how health care policies affect the coordination of patient centered care.
o Identify relevant health policy implications for the coordination and continuum of care.
o Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.
· Competency 5: Apply professional, scholarly communication strategies to lead patient-centered care.
o Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
o Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
o Complete any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
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Criterion 1
Design patient-centered health interventions and timelines for a selected healthcare problem.
Distinguished
Designs patient-centered health interventions and timelines for a selected healthcare problem that includes community resources.
Proficient
Designs patient-centered health interventions and timelines for a selected healthcare problem.
Basic
Designs patient-centered health intervention for a selected healthcare problem.
Non Performance
Does not design patient-centered health interventions and timelines for a selected healthcare problem.
Criterion 2
Consider the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, supporting ideas with the literature.
Distinguished
Considers the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, including ethical questions that generate uncertainty about the decisions made. Ideas are supported by the literature.
Proficient
Considers the ethical decisions in designing patient-centered health interventions for a selected healthcare problem, supporting ideas with the literature.
Basic
Considers ethical decisions.
Non Performance
Does not consider the ethical decisions in designing patient-centered health interventions for a selected healthcare problem or support ideas with the literature.
Criterion 3
Identify relevant health policy implications for the coordination and continuum of care.
Distinguished
Identifies relevant health policy implications for the coordination and continuum of care, based on accurate interpretations of policy provisions and supporting evidence.
Proficient
Identifies relevant health policy implications for the coordination and continuum of care.
Basic
Identifies health policy implications that are inconsistent with the goals and objectives for the coordination and continuum of care.
Non Performance
Does not identify relevant health policy implications for the coordination and continuum of care.
Criterion 4
Describe priorities that a care coordinator would establish when discussing the plan with a patient and family members.
Distinguished
Describes priorities that a care coordinator would establish when discussing the plan with a patient and family members, including evidence to support ideas.
Proficient
Describes priorities that a care coordinator would establish when discussing the plan with a patient and family members.
Basic
Identifies priorities that a care coordinator would establish when discussing the plan with a patient and family members.
Non Performance
Does not describe priorities that a care coordinator would establish when discussing the plan with a patient and family members.
Criterion 5
Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.
Distinguished
Uses the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030. Explains the need for changes to the plan.
Proficient
Uses the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to Healthy People 2030.
Basic
Discusses evaluation but does not use the literature as a guide to compare learning session content with best practices, or does not include how to align teaching sessions to Healthy People 2030.
Non Performance
Does not use the literature on evaluation as a guide to compare learning session content with best practices, and does not include how to align teaching sessions to Healthy People 2030.
Criterion 6
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Distinguished
Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Correctly uses quotes and paraphrasing.
Proficient
Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Basic
Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes, and/or paraphrasing.
Non Performance
Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.
Criterion 7
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Distinguished
Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.
Proficient
Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Basic
Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.
Non Performance
Does not organize content for ideas. Lacks logical flow and smooth transitions.
Criterion 8
Complete any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.
Distinguished
Completes any remaining practicum hours, for a total of 40 hours, along with a detailed description of activities, approved by your preceptor to Capella Academic Portal.
Proficient
Completes any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Submits practicum hour documentation to Capella Academic Portal.
Basic
Completes any remaining practicum hours, for a total of 40 hours, approved by your preceptor. Documents activities in Capella Academic Portal, but not detailed.
Non Performance
Total hours submitted does not equal 40 hours. Does not submit practicum hour documentation to Capella Academic Portal.