OVERVIEW

Complete an interactive simulation in which you will interview a patient, family members, and experienced health care workers to gather information to support a care coordination strategy and develop a care plan for the patient.
Note: Each assessment in this course builds on your work in the preceding assessment; therefore, complete the assessments in the order in which they are presented.
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Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Determine the influence of current health care legislation, policy, and research on evidence-based practice in assessment by care coordinators.
  • Assess a patient’s condition from a coordinated-care perspective.
  • Develop nursing diagnoses that align with patient assessment data.
• Competency 3: Determine appropriate care coordination performance measures for driving high-quality patient outcomes, based on current accrediting standards and benchmarks.
  • Evaluate care coordination outcomes.
• Competency 4: Apply relevant evidence-based practices that reflect a shift toward a broader population health focus on patient outcomes.
  • Determine appropriate nursing or collaborative interventions.
  • Explain why a particular nursing intervention is indicated or therapeutic.
• Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
  • Write clearly and concisely, using correct grammar and mechanics.
  • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

ASSESSMENT INSTRUCTIONS

Note: Complete the assessments in this course in the order in which they are presented.

PREPARATION

To prepare for this assessment, complete the Vila Health: Care Coordination Scenario 1 simulation (linked in the Required Resources) to obtain the information you will need to:

• Develop a care coordination strategy for Mrs. Snyder and her family.
• Apply current accrediting standards and benchmarks as you determine the best way to develop this strategy.
• Develop a patient care plan.

Note: Remember that you can submit all—or a portion of—your draft to Smarthinking for feedback before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

REQUIREMENTS

Develop a proactive, patient-centered care plan for the patient, using the information gained from your simulated interviews. Focus on care coordination and national care coordination initiatives.

Care Plan Format

Use the Patient Care Plan Template linked in the Required Resources.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Care Plan

Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed.

• Assess the patient’s condition from a coordinated-care perspective.
  • Consider the full scope of the patient’s needs.
  • Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.
• Develop nursing diagnoses that align with the patient assessment data.
  • Write two goal statements for each diagnosis.
  • Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific.
  • Consider the psychosociocultural aspect of care.
• Determine appropriate nursing or collaborative interventions.
  • List at least three nursing or collaborative interventions.
  • Provide the rationale for each goal or outcome.
• Explain why each intervention is indicated or therapeutic.
  • Cite applicable references that support each intervention.
• Evaluate care coordination outcomes.
  • Indicate if the goals were met. If they were not met, explain why.
  • Describe how you would revise the plan of care based on the patient’s response to the current plan.
• Write clearly and concisely, using correct grammar and mechanics.
• Express your main points and conclusions coherently.
• Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
• Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Portfolio Prompt: You may choose to save your patient care plan to your ePortfolio.