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

Assess4050-4

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

Introduction
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.
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
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.
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 evidence based practice (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.
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
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.
• Design patient-centered health interventions and timelines for a selected health care problem.
o Address three health care issues.
o Design an intervention for each health issue.
o Identify three community resources for each health intervention.
• Consider ethical decisions in designing patient-centered health interventions.
o Consider the practical effects of specific decisions.
o Include the ethical questions that generate uncertainty about the decisions you have made.
• Identify relevant health policy implications for the coordination and continuum of care.
o Cite specific health policy provisions.
• 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.
o Clearly explain the need for changes to the plan.
• 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.
o Use the literature on evaluation as guide to compare learning session content with best practices.
o Align teaching sessions to the Healthy People 2030 document.
• Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
• Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Additional Requirements
Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.
Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.
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.
Course Competencies
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
• Competency 1: Adapt care based on patient-centered and person-focused factors.
o Design patient-centered health interventions and timelines for a selected health care problem.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
o 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.
• Competency 3: Create a satisfying patient experience.
o 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.
• Competency 4: Defend decisions based on the code of ethics for nursing.
o Consider ethical decisions in designing patient-centered health interventions.
• Competency 5: Explain how health care policies affect patient-centered care.
o Identify relevant health policy implications for the coordination and continuum of care.
• Competency 6: 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.
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 health care problem.
Distinguished
Designs patient-centered health interventions and timelines for a selected health care problem that includes community resources.
Proficient
Designs patient-centered health interventions and timelines for a selected health care problem.
Basic
Designs patient-centered health intervention for a selected health care problem.
Non Performance
Does not design patient-centered health interventions and timelines for a selected health care problem.
Criterion 2
Consider ethical decisions in designing patient-centered health interventions.
Distinguished
Considers insightful ethical decisions in designing patient-centered health interventions. These decisions are supported by the literature.
Proficient
Considers ethical decisions in designing patient-centered health interventions.
Basic
Considers ill-defined or ambiguous ethical decisions in designing patient-centered health interventions.
Non Performance
Does not consider ethical decisions in designing health interventions.
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 precise and accurate interpretations of relevant policy provisions. Makes valid, insightful inferences.
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 member, making changes based upon evidence-based practice.
Distinguished
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. Clearly explains the need for changes to the plan.
Proficient
Describes priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
Basic
Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member but does not use evidence-based practice to make changes to the plan.
Non Performance
Does not describe priorities that a care coordinator would establish when discussing the plan with a patient and family member.
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 the Healthy People 2030 document.
Distinguished
Uses 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. Clearly explains the need for any revisions.
Proficient
Uses 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.
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 the Healthy People 2030 document.
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 the Healthy People 2030 document.
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. Quotes and paraphrases correctly.
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.
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