The first step in any effective project or clinical patient encounter is planning. This assignment 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 a particular healthcare problem that a patient may experience.
You need to consider a 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
By successfully completing this assignment, you will demonstrate your proficiency in the following course
competencies and assignment 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 hypothetically with patients and family to achieve desired outcomes.
Establish mutually agreed-upon health goals for a care coordination plan in collaboration with the patient.
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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.
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 that an individual may experience within the community. You decide to prepare a preliminary
care coordination plan and proceed by identifying this hypothetical patient’s three priorities for health and by
investigating the resources available in your community for a safe and effective continuum of care.
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:
Heart disease (high blood pressure, stroke, or heart failure).
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
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