NURS FPX 4050 CSCC Preliminary Care Coordination Plan Discussion

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.

NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project or clinical patient encounter is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a hypothetical individual in your community as you consider the hypothetical patient’s unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the 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.

Demonstration of Proficiency

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.

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.

Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring 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.

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. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

Helpful links FOR ASSESSMENT 1

http://www.improvingchroniccare.org/index.php?p=Family_Care_Network&s=344

http://www.improvingchroniccare.org/index.php?p=San_Francisco_General_Hospital&s=347

Here is the link to “The Affordable Care Act 10 Years In: What Nursing Leaders Should Know”: https://www.sciencedirect.com/science/article/pii/S1541461220300896

http://www.improvingchroniccare.org/index.php?p=Family_Care_Network&s=344

http://www.improvingchroniccare.org/index.php?p=San_Francisco_General_Hospital&s=347

PLEASE INCLUDE ARTICLES ON THE AFFORADABLE CARE ACT

Stroke: Preliminary Care Coordination Plan Example Essay

Stroke is one of the two types of cerebrovascular accidents (CVAs). Stroke, usually acute, is defined as a compromise in the perfusion to the central nervous system either from ischemia or hemorrhage. According to Potter et al. (2020), stroke is the fourth leading cause of mortality in the United States (p.500). Stroke commonly occurs in patients with hypertension, diabetes, longstanding history of smoking, hyperlipidemia, and a family history of heart disease (Peate, 2021). Stroke has physical, psychological, and social sequelae on the survivors (McCoy et al., 2018). Therefore, nursing care is vital in promoting quality of life and life-sustaining in patients at risk of stroke or those with a stroke. This paper aims to develop a preliminary care plan for stroke patients through identifying physical, psychosocial, and cultural needs and community resources for stroke patients.

Physical Needs of Stroke Patients

Stroke is an acutely progressive disease that requires emergency care to prevent physical complications. Depending on the severity of perfusion compromise and time at diagnosis, stroke can cause irreversible damage to neuromuscular coordination and the sensory system. Acute stroke can cause a diminishing level of consciousness, language problems, dysarthria, muscle weakness, poor muscle coordination, visual deficits, swallowing difficulties, and facial paralysis.

When left untreated or diagnosed late, these physical and functional deficits can become permanent and will definitely impact the patient’s quality of life and lead to dependence on family and caregivers. These patients develop some neurological deficits and, in the worst-case scenario, can die. Recurrence of stroke is also common. Other complications in the long term include urinary tract infections, pneumonia, seizures, thromboembolism, and pressure sores. Therefore, care goals for physical needs aim at preventing these complications, preventing recurrence, increasing chances of survival, and preventing mortality from a stroke. Risk reduction and treatment of complications are thus important.

Psychosocial Needs

Stroke patients have poorer quality of life as compared with non-stroke patients due to neurological deficits, other complications, and limitations in activities of daily living. Common psychological problems are depression and anxiety. These physical, speech, and occupational limitations have significant impacts on the patient’s mental health. With these limitations, patients have to rely on their families and caregivers for sustenance.

Loss of social status in the family makes them dependent on others. As breadwinners of the family, parents lose their capacity to provide for others and care for themselves and have to depend on the children and spouses for activities of daily living. Nursing care goals aim at promoting the best life quality and preventing depression or anxiety that emanates from the patient’s new social and physical status. Occupational, psychical, and speech therapy aims to restore the patient’s functional capacities and improve the performance of daily living activities, thus reducing dependence and stress on the family.

Cultural Needs

Culture defines how patients and their families perceive illness, respond to illness, and care for the sick. Stroke is higher among blacks, who have the highest incidence of heart disease and related complications. Various cultural factors such as spirituality and health-seeking behavior play critical roles in response to care for stroke patients among black patients. The cultural fear of disability that comes with stroke affects the social meaning that patients and their families attach to stroke (Sanuade, 2018). This impacts their treatment and adherence to rehabilitative therapies.

Nursing care goals that aim at improving the care of patients in their diverse cultures lead to the best patient outcomes. Nursing care aim at understanding the sociocultural contexts of patients and providing care that would not undermine their cultures but encourage the uptake of interventions

Community Resources

Care for stroke patients is multifaced and may require a multidisciplinary approach for the best outcomes (Khaku & Tadi, 2021). Social support, whether from the nurses or the community social systems, is important. Community resources help stroke survivors, their families, and their caregivers to improve their quality of life.

Organizations such as the Stroke Support Association, American Stroke Association, The Stroke Network, American Stroke Foundation, and Family Caregiver Alliance empower stroke survivors and their caregivers with social support, patient education, and resources that assist them in recovery and rebuilding their lives with the disease (Sasso, 2021). Rehab Without Walls is an important community resource that provides personalized post-discharge care that addresses the physical, cognitive, and emotional needs of stroke survivors (Rehab Without Walls, n.d.).

Through various clinics in several states across the US, this organization provides family education, family involvement care, and setting long-term & real-world care goals. They also offer rehab services in various settings such as workplaces and schools. Other community resources include adult day care services, meal programs, and home health services.

Conclusion

Stroke is a debilitating illness that mostly afflicts individuals with known predispositions. Physical needs lead to psychological needs that are sometimes determined by cultural contexts. Competent nursing care focuses on addressing these needs in a culturally-sensitive manner and utilizes community resources for long-term care. Community resources include social support organizations, adult day care services, home care services, and meal programs.

References

Khaku, A. S., & Tadi, P. (2021). Cerebrovascular Disease. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430927/

McCoy, C. E., Langdorf, M. I., & Lotfipour, S. (2018). American Heart Association/American Stroke Association deletes sections from 2018 stroke guidelines. The Western Journal of Emergency Medicine, 19(6), 947–951. https://doi.org/10.5811/westjem.2018.9.39659

Peate, I. (Ed.). (2021). Fundamentals of applied pathophysiology: An essential guide for nursing and healthcare students (4th ed.). Wiley-Blackwell.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2020). Fundamentals of nursing (10th ed.). Elsevier – Health Sciences Division.

Rehab Without Walls. (n.d.). Stroke rehabilitation: Personalized stroke rehab addresses physical, cognitive, and emotional recovery. Rehab Without Walls. Retrieved August 17, 2022, from https://www.rehabwithoutwalls.com/services/stroke-rehabilitation/

Sanuade, O. (2018). Understanding the cultural meanings of stroke in the Ghanaian setting: A qualitative study exploring the perspectives of local community residents. Wellcome Open Research, 3, 87. https://doi.org/10.12688/wellcomeopenres.14674.2

Sasso, M. (2021, April 19). Community resources for survivors of stroke. Stroke Support Association. https://strokesupportassoc.org/community-resources-for-survivors-of-stroke-2/

Assessment 2 Instructions: Ethical and Policy Factors in Care Coordination

• Select a community organization or group that you feel would be interested in learning about ethical and policy issues that affect the coordination of care. Then, develop and record a 10-12-slide, 20-minute presentation, with audio, intended for that audience. Create a detailed narrative script for your presentation, 4-5 pages in length.

As coordinators of care, nurses must be aware of the code of ethics for nurses and health policy issues that affect the coordination of care within the context of the community. To help patients navigate the continuum of care, nurses must be proficient at interpreting and applying the code of ethics for nurses and health policy, specifically, the Affordable Care Act (ACA). Being knowledgeable about ethical and policy issues helps ensure that care coordinators are upholding ethical standards and navigating policy issues that affect patient care.

This assessment provides an opportunity for you to develop a presentation for a local community organization of your choice, which provides an overview of ethical standards and relevant policy issues that affect the coordination of care. Completing this assessment will strengthen your understanding of ethical issues and policies related to the coordination and continuum of care and will empower you to be a stronger advocate and nursing professional.

It would be an excellent choice to complete the Vila Health: Ethical Decision-Making activity prior to developing the presentation. The activity provides a helpful update on the ethical principles that will help with success in this assessment.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 4: Defend decisions based on the code of ethics for nursing.

• • Assess the impact of the code of ethics for nurses on the coordination and continuum of care.
• Competency 5: Explain how health care policies affect patient-centered care.

• • Explain how governmental policies related to the health and/or safety of a community affect the coordination of care.
  • Identify national, state, and local policy provisions that raise ethical questions or dilemmas for care coordination.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

• Communicate key ethical and policy issues in a presentation affecting the coordination and continuum of care for a selected community organization or support group. Either speaker notes or audio voice-over are included.

Preparation

Your nurse manager at the community care center is well connected and frequently speaks to a variety of community organizations and groups. She has noticed the good work you are doing in your new care coordination role and respects your speaking and presentation skills. Consequently, she thought that an opportunity to speak publicly about contemporary issues in care coordination would be beneficial for your career and has suggested reaching out to a community organization or support group to gauge their interest in hearing from you, as a care center representative, on a topic of interest to both you and your prospective audience.

You have agreed that this is a good idea and have decided to research a community organization or support group that might be interested in learning about ethical and policy issues related to the coordination of care. Your manager has suggested the following community organizations and support groups, but acknowledges that the choice is yours.

• Homeless shelters.
• Local religious groups.
• Nursing homes.
• Local community organizations (Rotary Club or Kiwanis Club).

To prepare for this assessment, you may wish to:

• Research your selected community organization or support group.
• Review the Code of Ethics for Nurses With Interpretive Statements and associated health policy issues, specifically, the ACA.
• Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete.
• Allocate sufficient time to rehearse your presentation before recording the final version for submission.

Note: Remember that you can submit all, or a portion of, your draft presentation to Smarthinking Tutoring 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.

Recording Equipment Setup and Testing

Check that your audio speaker and PowerPoint software are working properly. You can record audio directly to your slides, using PowerPoint or other presentation software.

Note: Technical support about the use of PowerPoint, including voice recording and speaker notes, can be found on Campus’s Microsoft Office Software page.

• If using Kaltura, refer to the Using Kaltura tutorial for directions on recording and uploading your presentation in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@capella.edu to request accommodations.

Instructions

For this assessment:

• Choose the community organization or support group that you plan to address.
• Develop a PowerPoint with typed speaker notes (the script for your voice recording) and audio voice-over recording, intended for that audience. Video is not required.

Note: PowerPoint has a feature to type the speaker notes directly into the presentation. You are encouraged to use that feature or you may choose to submit a separate document. See Microsoft Office Software for technical support about the use of PowerPoint, including voice recording and speaker notes.

For this assessment, develop your presentation slides and speaker notes, then record your presentation. You are not required to deliver your presentation to an actual audience.

Presentation Format and Length

You may use PowerPoint (recommended) or other suitable presentation software to create your slides and add your voice over. If you elect to use an application other than PowerPoint, check with your faculty to avoid potential file compatibility issues.

Be sure that your slide deck includes the following slides:

• Title slide.

• • Presentation title.
  • Your name.
  • Date.
  • Course number and title.
• References (at the end of your presentation).

Your slide deck should consist of 10–12 slides, not including a title and references slide with typed speaker notes and audio voice over. Your presentation should not exceed 20 minutes.

Create a detailed narrative script for your presentation, approximately 4–5 pages in length.

Supporting Evidence

Cite 3–5 credible sources from peer-reviewed journals or professional industry publications to support your presentation. Include your source citations on a references page appended to your narrative script.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Ethical and Policy Factors in Care Coordination 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.

• Explain how governmental policies related to the health and/or safety of the community affect the coordination of care.

• • Provide examples of a specific policy affecting the organization or group.
  • Refer to the assessment resources for help in locating relevant policies.
  • Be sure influential policies include the Health Insurance Portability and Accountability Act (HIPPA).
• Identify national, state, and local policy provisions that raise ethical questions or dilemmas for care coordination.

• • What are the implications and consequences of specific policy provisions?
  • What evidence do you have to support your conclusions?
• Assess the impact of the code of ethics for nurses on the coordination and continuum of care.

• • Consider the factors that contribute to health, health disparities, and access to services.
  • Consider the social determinants of health identified in Healthy People 2020 as a framework for your assessment.
  • Provide evidence to support your conclusions.
• Communicate key ethical and policy issues in a presentation affecting the coordination and continuum of care for a selected community organization or support group. Either speaker notes or audio voice-over are included for a proficient score; both speaker notes and the audio voice over are included for a distinguished score.

• Present a concise overview.
• Support your main points and conclusions with relevant and credible evidence.

Additional Requirements

Before submitting your assessment, proofread your presentation slides and speaker notes to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your presentation.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

HELPFUL LINKS

POLICY AND ETHICS

As you read the following, consider how policy and ethics relate to your current role and the role of the care coordinator.

• Bower, K. A. (2016). Nursing leadership and care coordination: Creating excellence in coordinating care across the continuum. Nursing Administration Quarterly, 40(2), 98–102.
• Collins, B. L. Saylor, J. (2018). The Affordable Care Act: 8 years later.Nursing Management, 49(8), 42–48.
• Connor, J. A., Antonelli, R. C., O’Connell, C. A., Bishop Kuzdeba, H., Porter, C., & Hickey, P. A. (2018). Measuring care coordination in the pediatric cardiology ambulatory setting. Journal of Nursing Administration, 48(2), 107–113.
• Lamb, G., Newhouse, R., Beverly, C., Toney, D. A., Cropley, S., Weaver, C. A., . . . Task Force Members. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook, 63(4), 521–530. NURS FPX 4050 CSCC Preliminary Care Coordination Plan Discussion
• Townsend, C. S., McNulty, M. Grillo-Peck, A. (2017). Implementing huddles improves care coordination in an academic health center. Professional Case Management, 22(1), 29–35.
• Zolotorofe, I., Fortini, R., Hash, P., Daniels, A., Orsolini, L., Mazzoccoli, A., & Gerardi, T. (2018). Return on investment for the baccalaureate-prepared RN in ambulatory care. JONA: The Journal of Nursing Administration, 48(3), 123–126.

ETHICS AND COMMUNITY CARE

As you read the following documents, focus on how ethics impacts community care, and consider the cultural implications.

• American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.
• Magelssen, M., Gjerberg, E., Lillemoen, L., Førde, R., Pedersen, R. (2018). Ethics support in community care makes a difference for practice. Nursing Ethics, 25(2), 165–173.

EFFECTIVE PRESENTATIONS

The following resources will help you create and deliver an effective presentation.

• Conquering Death by PowerPoint: The Seven Rules of Proper Visual Design.
  • This video is a primer on presentation design.
  • Approximate run time: 45:00.
• Creating a Presentation: A Guide to Writing and Speaking.
• This video addresses the primary areas involved in creating effective audiovisual presentations. You can return to this resource throughout the process of creating your presentation to view the tutorial appropriate for you at each stage.