Assignment: Care Coordination Plan

Assignment: Care Coordination Plan

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Assignment: Care Coordination Plan

As a member of the nurse team, you have been asked to develop one component of the clinic.

The hospital leadership established these objectives for the clinic services:

Evaluate and maximize proper medication therapy.
Conduct regular diet, exercise, and stress management classes for the patients.
Monitor physiological indicators for the patients (lab work, weights, vital signs, ECGs).
Provide a case management system for patients in the program post-discharge.
The overall goals for the heart failure clinic are to:

Enroll greater than 90 percent of the patients with a primary or secondary diagnosis of HF prior to discharge.
Facilitate discharge planning to achieve 100 percent compliance with patient education prior to discharge (discharge planning).
Decrease readmission rates in this population by 5 percent over the next year.
The leadership team has asked you to provide them with an evidence-based plan for one of the components of the clinic. You may use any combination of documents (for example, a spreadsheet or a table) in addition to explanatory information to convey information clearly and succinctly.

Develop one: an Orientation Course Plan, a Discharge Education Plan, or a Care Coordination Plan.

An Orientation Course Plan:

Develop an evidence-based plan for health care delivery.
Include a comprehensive schedule of topics, objectives, key points, and patient resources for the orientation course.What are the components of an evidence-based education plan?
How will you know that patients will understand what to do?
What modalities will you use to deliver information?
How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
Identify specialized and supplementary material needs.
Apply professional and legal standards in support of a care plan.Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
Describe the accountability tools and procedures used to measure effectiveness.
How will you know if the patient education plan is successful?
What are the indicators of success or effectiveness?
A Discharge Education Plan:

Develop an evidence-based plan for health care delivery.Develop a discharge plan with objectives and resources, and tools for patients to monitor their progress.
How will you know that patients understand what to do?
What modalities will you use to deliver information?
How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
Apply professional and legal standards in support of a care plan.Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
Describe accountability tools and procedures used to measure effectiveness.
How will you know if the discharge plan is successful?
What are the indicators of success or effectiveness?
Care Coordination Plan:

Develop an evidence-based plan for health care delivery.Develop a procedure for coordinating services.Consider the needs of “outliers.” For example, someone with lung disease may need extra resources.
Who should be on the team?
When would the team be activated?
How would it be activated?
What is the time frame required to coordinate services?
How would the intervention plan be monitored for effectiveness?
Apply professional standards in support of a care plan.Explain the alignment to the most recent heart failure guidelines and specific professional standards.
Describe accountability tools and procedures used to measure effectiveness.How will you know if the care coordination plan is successful?
What are the indicators of success or effectiveness?
How will information be collected or communicated?
Additional Requirements
Written communication: Written communication should be free of errors that detract from the overall message.
APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
Length: The report should be 3 pages in content length, double-spaced.
Font and font size: Times New Roman, 12 point.
Number of resources: Support your plan with a minimum of three peer-reviewed resources, in addition to professional standards
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.