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For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using
best practices found in the literature.
NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.
Care coordination is the process of providing a smooth and seamless transition of care as part of the health
continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms,
safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and
communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health
and disease prevention to create a safe environment conducive to improving and maintaining the health of
individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and
maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.
This assessment provides an opportunity to research the literature and apply evidence to support what
communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health
care problem.
You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment.
Completing course activities before submitting your first attempt has been shown to make the difference between
basic and proficient 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 1: Adapt care based on patient-centered and person-focused factors.
Design patient-centered health interventions and timelines for a selected health care problem.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe priorities that a care coordinator would establish when discussing the plan with a patient and
family member, making changes based upon evidence-based practice.
Competency 3: Create a satisfying patient experience.
Use the literature on evaluation as a guide to compare learning session content with best practices,
including how to align teaching sessions to the Healthy People 2030 document.
Competency 4: Defend decisions based on the code of ethics for nursing.
Consider ethical decisions in designing patient-centered health interventions.
Competency 5: Explain how health care policies affect patient-centered care.
Identify relevant health policy implications for the coordination and continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA
format.
Organize content so ideas flow logically with smooth transitions; contains few errors in
grammar/punctuation, word choice, and spelling.
Course Navigation
Assessment 4 Instructions: Final Care Coordination Plan &ndash...
Preparation
In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using
best practices found in the literature.
To prepare for your assessment, you will research the literature on your selected health care problem. You will
describe the priorities that a care coordinator would establish when discussing the plan with a patient and family
members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of
Healthy People 2030.
Note: Remember that you can submit all, or a portion of, your 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.
Instructions
Note: You are required to complete Assessment 1 before this assessment.
For this assessment:
Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination
plan.
Document Format and Length
Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-
formatted paper, 5–7 pages in length, not including title page and reference list.
Supporting Evidence
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030
resources. Cite at least three credible sources.
Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Final 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.
Design patient-centered health interventions and timelines for a selected health care problem.
Address three health care issues.
Design an intervention for each health issue.
Identify three community resources for each health intervention.
Consider ethical decisions in designing patient-centered health interventions.
Consider the practical effects of specific decisions.
Include the ethical questions that generate uncertainty about the decisions you have made.
Identify relevant health policy implications for the coordination and continuum of care.
Cite specific health policy provisions.
Describe priorities that a care coordinator would establish when discussing the plan with a patient and family
member, making changes based upon evidence-based practice.
Clearly explain the need for changes to the plan.
Use the literature on evaluation as a guide to compare learning session content with best practices, including
how to align teaching sessions to the Healthy People 2030 document.
Use the literature on evaluation as guide to compare learning session content with best practices.
Align teaching sessions to the Healthy People 2030 document.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
5/11/2021 Assessment 4 Instructions: Final Care Coordination Plan &ndash...
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation,
word choice, and spelling.
Additional Requirements
Before submitting your assessment, proofread your final care coordination plan 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. Submissions to the ePortfolio will be part of your final
