Assessment 4 Instructions

Assessment 4 Instructions: Final Care Coordination Plan

● For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.


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.


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.

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. ● 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.

Activity: Vila Health: Cultural Competence



● Vila Health: Cultural Competence Cultural competence is a skill set for care coordinators that is crucial to the provision of

patient-centered care and satisfying patient experiences. Each individual comes with a unique set of cultural experiences and an identity shaped by their cultural upbringing. Even if a patient comes from a similar background as you, their cultural background may be completely different. If patients come from a very diverse background, you must still approach their care by identifying and prioritizing their unique cultural needs. Often nurses will focus on treating all patients the same. However, we know that from a cultural and even biological standpoint, treating all patients the same may result in harm. Because nurses are to provide care without harm, cultural competence is a necessary skill.

Dr. Lawrence: Hi, Camila, my name is Dr. Lawrence, and I hear you’ve been having some trouble.

Camila My stomach is killing me!

Dr. Lawrence: Well, we’re going to get you fixed up. Nurse, let’s get an A1C and glucose level.

Emilio Boggio: Will do. Camila, we’re going to take good care of you, okay?

Treatment The results come in from Camila’s tests. Her A1C is 7.5 and her glucose level is 330. That confirms what Dr. Lawrence suspected: Camila has diabetes mellitus type 2. She’s going to have to make some significant lifestyle changes, and she’s going to have to adhere to a medication regimen. She may even have to have insulin injections.

Dr. Lawrence: All right, diabetes mellitus type 2 diagnosis is confirmed. Let’s get that glucose level stabilized first, and some IV fluids.

Emilio Boggio: On it. I’ll make a plan to meet with her later for some education and a plan for her ongoing treatment. And a referral to the diabetes educator, of course.

milio: [slightly condescending tone] Well, good morning, Mrs. Flores, how are you feeling today?

Camila: A lot better. But I don’t know what I’m going to do now. I have diabetes? I have to change everything I eat?

Emilio: Now, don’t you worry, we’ll help you. It’s not as hard as it sounds. You will have to pay more attention to what you eat, and that might be hard at first, but you’ll get used to it.

Camila: I already pay attention to what I eat.


Emilio: Oh, of course you do. But this is different. Let’s take an example. Have you heard of the Mediterranean diet?

Camila: Of course.

Emilio: Well, it’s not important that you know why it’s the Mediterranean diet. But you’ll learn more, and basically when you follow that diet you’ll have a good deal of success with managing your glucose levels.

Camila: [irritated] It’s because it’s based on foods found in countries on the Mediterranean coast.

Emilio: Well, look at you! See, you’ll have no trouble with this. You’ll just have to count calories like you’ve never counted before! I’m sure you like rice and beans, right?

Camila: No, I don’t.

Emilio: So that’s going to help. Rice and beans are both good carbohydrates that raise your blood sugar in a predictable fashion.

Camila: I said I don’t like them. I need different options.

Emilio: [at the same time] Now, I’ve got all kinds of educational materials that will help you get going on this. We’ll talk more later, but right now we should probably talk about how you’ll be checking your sugars!

Lucas: Hello, Ms. Flores, how are you feeling?

Camila: A lot better. But I don’t know what I’m going to do now. I have diabetes? I have to change everything I eat?

Lucas: Well, that’s what I’m here to talk with you about. It’s true, you’re probably going to have to make some lifestyle changes. But I’m here to give you the information you need and work with you so that you can make those changes without too much effort. And I don’t just mean today; we’ll be talking more in the days ahead, and I’ll be available until you feel like you’ve got a good handle on your diet and checking your sugars and so on.

Camila: Okay. So what are we talking about?

Lucas: So how much do you feel like you already know about diabetes?

Camila: I’ve gotta give up sugar, right?

Lucas: I’d say it’s more like your job now is going to be to monitor the carbohydrates you take in. Diabetes is when your body doesn’t use insulin properly. Have you heard of insulin?

Camila: Sure, it’s what I’ll have to inject, right?



Lucas: Not necessarily. What you’ll be doing is eating in such a way that your blood sugar doesn’t go up so high. Insulin is a hormone that your body produces to process blood sugar. When you have diabetes, your body releases more and more but it still can’t keep your blood sugar at the right level. So when you eat a diet that keeps your blood sugar a little more steady, you’ll also avoid having too much insulin in your system—or not enough.

Camila: Okay. That makes sense.

Lucas: So what do you like to cook?

Camila: I like steak! And potatoes. I know, not a very good Latina, right? I should eat all rice and beans.

Lucas: [laughs] Well, rice and beans are good, in moderation. But vegetables are also really good. And again, you don’t have to give up anything or only eat one thing. We’ll work together to create a diet that works for you, that you like, and that also just happens to manage your insulin better.

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