Assignment: Care Coordination Plan

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Assignment: Care Coordination Plan

Assignment: Care Coordination Plan

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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
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