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 a hypothetical individual in your community as you consider the hypothetical 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.
Demonstration of Proficiency
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:
Complete the following:
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.
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.
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.
Analyze a health concern and the associated best practices for health improvement. | Does not identify a health concern and the associated best practices for health improvement. | Identifies a health concern and the associated best practices for health improvement. | Analyzes a health concern and the associated best practices for health improvement. | Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis. |
Describe specific goals that should be established to address a selected health care problem. | Does not describe specific goals that should be established to address a selected health care problem. | Identifies undefined goals that should be established to address a selected health care problem. | Describes specific goals that should be established to address a selected health care problem. | Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable. |
Identify available community resources for a safe and effective continuum of care. | Does not identify available community resources. | Identifies available community resources. | Identifies available community resources for a safe and effective continuum of care. | Identifies significant and available community resources for a safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health. |
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. | Does not organize content for ideas. Lacks logical flow and smooth transitions. | Organizes content with some logical flow and smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling. | Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. | 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. |
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. | Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly. | 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. | Applies APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. | Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly |
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