NURSFPX 4050 Capella University Care Coordination Plan Assignment
NURSFPX 4050 Capella University Care Coordination Plan Assignment
NURSFPX 4050 Capella University Care Coordination Plan Assignment
Plan goal and objective:
People all across the world have been worried about their mental health for a very long time. Yet, the relevant parties in the healthcare sector have not paid the issue much attention. According to the results of several experts, in any given year, roughly 43.8% of adults in the United States will self-report having a mental health issue. Mental health issues are difficult to detect with the naked eye, and even if a person is good at masking their disease’s symptoms, it nevertheless manifests itself in practically every aspect of their life. Due to the fact that the underlying problem or symptoms are not always physical, patients have access to a very small number of services. It is thought that those with evident health concerns in their capacity to perform various jobs are not taken into consideration, therefore patients with mental health issues are subject to the premise that health facilities or resources are not necessary.
SMART Goals:
The acronym SMART stands for “specific, measurable, attainable, and relevant” when referring to a set of goals. It is crucial that you utilize techniques that are geared towards attaining your objectives when you are in the planning stage of drafting a care plan. A SMART goal template could be useful to utilize throughout this process:
Specific: It is crucial that the objectives you have set for the patient be unquestionably clear-cut and unquestionable.
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Measurable: You must establish some metrics to determine whether the patient is moving closer to these objectives in order to judge whether or not the patient is making progress in that direction.
Achievable: It shouldn’t be impossible for them to achieve their objective.
Realistic: Their objectives must be both feasible and pertinent to the overall treatment strategy in order to be considered realistic.
Time-sensitive: The patient’s goals should state when they should start working towards them and when they should stop (which can be flexible).
Preliminary Coordination Plan:
One of the most important factors in ensuring a people’s socioeconomic and political status, as well as their general well-being, is maintaining strong mental health. No of your age, gender, sexual orientation, race, political affiliation, or any other characteristic, this is true. Several studies have illuminated the crucial role that the care coordinator plays in both the long- and short-term outcomes of continuum care for mental health. The following is a breakdown of these metrics: The preliminary plan for care coordination in mental health places a strong emphasis on core competencies as well as how the objectives, available resources in the community, and interdisciplinary approaches are organized to accomplish the desired results. One needs to have a thorough awareness of the many facets of mental health, the primary symptoms that are related to it, and the activities that can be taken to enhance the continuum of treatment in order to be able to build such a plan. Each and every one of these illnesses need to be classified because there is a continuum in the severity of mental problems. For instance, one in five people in the United States suffers from a mental illness of some kind (Jones et al., 2018). To ensure the patient’s health and well-being, a thorough review of their mental health difficulties is necessary, which may include Any Mental Health or Severe Mental Health. In order to meet this need, this evaluation must be completed (Gong et al., 2020).
These two important groups have the power to influence the potential usage of early care coordination strategies. Ideal Techniques The environment, a person’s upbringing, drug, and substance use, certain components of a person’s biology or genetics, and any other important characteristics that predispose persons to mental instability are risk factors for mental health. The interests, behavioral patterns, and treatments for mental health that focus on the body as well as the emotions connected to it are often considered to be the most effective. The National Collegiate Athletic Association (NCAA) believes that holistic health practices that continue to integrate treatment for both individuals and the greater community should be at the center of best practices for health care. This is the NCAA’s point of view. Using a collaborative framework is one of the competencies listed in the best practices for mental health, particularly in relation to the use of patient-centered or person-centered treatment programs. On the other hand, working in tandem and collaboratively with the families of the patients to set mutually agreeable health intervention goals is one way to improve the outcomes of a health intervention. Nurses and other health professionals seek to fulfill their purpose of giving patients a fulfilling and uplifting experience while they are under their care by utilizing patient-centered care models that are intended to appeal to the patient’s mind, body, and spirit (Malikov et al., 2020). Each of the aforementioned elements will be present in some form or another in a comprehensive care strategy. Yet, in order to safeguard themselves against potential risks like drug use and the existence of stressful situations or surroundings, patients should be required to participate in self-care interventions like literacy lessons. The paradigm of patient-centered care is regarded as a fundamental capability. In order to change the patient’s mental health concerns, this paradigm puts the patient in a more favorable position and draws on their core values and beliefs. The preliminary care coordination plan for the mental health issue will include techniques to achieve the intended results as well as the use of the resources that are available for the patient’s well-being and long-term outcomes (Gray et al., 2019).
Also, this plan will include strategies for achieving the targeted results. Those who provide medical treatment have a responsibility to encourage the adoption of best practices that are consistent with patient-centered methodologies. These behaviors include being around others who have a good outlook, having a healthy self-image, being aware of the resources that are available to them, and being aware of the legal rights to which they are entitled. The coordination plan will benefit from the application of these best practices, and the patients will experience the desired results.
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Assessment 1: Preliminary Care Coordination Plan
Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.
Introduction
NOTE: You are required to complete this assessment before Assessment 4.
The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem.
Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.
As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.
Preparation
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:
Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen health care concern.
Instructions
Note: You are required to complete this assessment before Assessment 4.
Develop the Preliminary Care Coordination Plan
Complete the following:
Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
Stroke.
Heart disease (high blood pressure, stroke, or heart failure).
Home safety.
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
Pain management.
Mental health.
Trauma.
Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.
Grading Requirements
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.
Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the health care problem.
Identify available community resources for a safe and effective continuum of care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
Additional Requirements
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.
Portfolio Prompt: Save your presentation to your ePortfolio.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide 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 with patients and family to achieve desired outcomes.
Describe specific goals that should be established to address a selected health care problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Resources: Care Coordination Fundamentals
You may review the following:
Improving Chronic Illness Care. (n.d.). Care coordination: Background. http://www.improvingchroniccare.org/index.php?p=Background&s=350
This resource provides background information of care coordination. Think about how this information applies to your community and patients as you read the case study of Ms. G., which highlights the importance of care coordination.
McGee, B. T., & Breslin, S. E. (2020, May). The Affordable Care Act 10 years in: What nursing leaders should know. Nurse Leader.
Cleveland, K. A., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses. The Online Journal of Issues in Nursing, 24(19). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-24-2019/No2-May-2019/Affordable-Care.html
Resources: Writing SMART Goals for Care Coordination
During care coordination, nurses should ensure that they are creating patient-centered goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable, Relevant, Timely) goals. SMART goals provide direction for patient-centered care coordination.
SMART goals must be effective, meaningful, achievable, and collaborative in nature. Key stakeholders (such as the individual, group, or community; possibly significant others; and you, the nurse) must be taken into account.
Often the best way to patient-centered functional goals is simply to ask the target group, “What are your goals?” Doing this will help you to improve adherence, satisfaction, and outcomes. Consider the following when developing SMART goals:
Specific: Goals will specify who will be responsible, what is to be achieved, where the activity is located, and why it is important or beneficial.
Measurable: Goals must specify criteria for measuring progress against them. This helps you to stay on track, reach milestones, and motivate the stakeholders.
Attainable: Setting attainable goals serves to motivate the individual or group.
Relevant: Key stakeholders must see how a specific goal is relevant to them.
Timely: To be most effective, goals must be structured around a specific time frame to motivate individuals to begin working on their goals.
After developing a mutually agreed-upon goal, SMART objectives are developed to help guide activities. Objectives help to determine whether the goals have been achieved and if revisions need to be made for future educational sessions.
SMART objectives must be:
Specific: Objectives need to be concrete, detailed, and well-defined so that you know what exactly is going to occur and what to expect.
Measurable: A way to determine how the goal was met or if it needs revision.
Achievable: The objective must be appropriate and feasible for those involved. Ask: What’s the patient’s learning style? For example, does the patient prefer reading printed materials, viewing audiovisual materials, or watching demonstrations?
Realistic: It must take into consideration constraints such as resources, personnel, cost, education level, learning style, reading level and comprehension level. What language do they speak? How much does the individual or group like to know? Ask: Can the patient read or comprehend instructions or follow directions? Do they prefer reading printed materials, viewing audiovisual materials, or demonstrations?
Time-bound: A time frame helps set boundaries around the objective. Ask: How long will it take to obtain the objective? Objectives may be process- or outcome-oriented.
Outcome objectives can be short-term, intermediate, or long-term:
Short-term objectives can be achieved after implementing certain activities or interventions. Change may be in cognitive (knowledge), psychomotor (demonstration), and values (attitude).
Intermediate outcome objectives provide a sense of progress toward reaching long-term objectives. This could be behavior and policy change.
Long-term objectives occur after the program has been implemented. It may take more than a month. These can be changes in mortality, moribundity, and quality of life.
Example of a SMART goal:
Walk for 30 minutes a day, seven days a week.
Example of a SMART objective:
By the end of the week, patient will have walked 3.5 hours.
Example of an evaluation of a SMART objective:
The patient will complete a daily log of miles each week.
Additional Resources
The following additional resources will help you in establishing SMART goals and objectives in collaboration with educational session participants:
Centers for Disease Control and Prevention. (n.d.) Develop SMART objectives. https://www.cdc.gov/phcommunities/resourcekit/evaluate/smartobjectives.html
Centers for Disease Control and Prevention. (n.d.) Resources. https://www.cdc.gov/phcommunities/resourcekit/resources.html
This site has a template for you to use as a guide.
MacLeod. L. (2012). Making SMART goals smarter. Physician Executive, 38(2), 68-70.
Resources: Additional Resources for Further Exploration
You may use the following optional resources to further explore topics related to the competencies.
Improving Chronic Illness Care. (n.d.). Care coordination: Family Care Network: Developing agreements between primary care and specialty groups. http://www.improvingchroniccare.org/index.php?p=FamilyCareNetwork&s=344
The Family Care Network case study highlights the importance of care coordination. Look for similarities with your own practice and community.
Improving Chronic Illness Care. (n.d.). Care coordination: San Francisco General Hospital: Connectivity through electronic referral. http://www.improvingchroniccare.org/index.php?p=SanFranciscoGeneralHospital&s=347
The San Francisco General Hospital case study addresses how care coordination can change patient outcomes. This is a great resource as you think about care coordination in your community.
Activity: Care Coordination Planning
CARE COORDINATION PLANNING
A key aspect of the care coordination process is effective planning that answers the following questions:
What is the best approach to planning for care?
What are the essential steps in the process?
Click the linked Care Coordination Planning title above to complete a media piece to gain insight into the most important considerations when preparing to develop a care coordination plan.
Preliminary Care Coordination Plan Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Analyze a health concern and the associated best practices for health improvement.
Does not analyze a health concern and the associated best practices for health improvement.
Attempts to analyze 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.
Attempts to describe 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.
Attempts to identify 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 c
