Capella University NURS FPX 4050 Final Care Coordination Plan Discussion

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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. Capella University NURS FPX 4050 Final Care Coordination Plan Discussion

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

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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. 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. Assessment 4 Instructions: Final Care Coordination Plan • • • • 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 2020 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. Capella University NURS FPX 4050 Final Care Coordination Plan Discussion

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 2020. 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. Assessment 4 Instructions: Final Care Coordination Plan

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 2020 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 2020 document. Assessment 4 Instructions: Final Care Coordination Plan

Use the literature on evaluation as guide to compare learning session content with best practices. • Align teaching sessions to the Healthy People 2020 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. • Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course. Running head: PRELIMINARY CARE COORDINATION PLAN Preliminary Care Coordination Plan Yailin Mur Fernandez Capella University NURS-FPX4050: Coordinating Patient-Centered Care Stroke Care Coordination January, 2021 1 PRELIMINARY CARE COORDINATION PLAN Preliminary Care Coordination Plan Care coordination is a critical practice, especially among individuals experiencing chronic conditions. Capella University NURS FPX 4050 Final Care Coordination Plan Discussion

Effective care coordination requires the collaboration of various individuals such as the clinicians, the family members, and the therapists, among others. Individuals who engage in coordinated care can cope with their health conditions regardless of how severe it is. Coordinated care enables the person to avoid deterioration in health since he or she tends to avoid unnecessary procedures and tests. Besides, effective care coordination enables all the patients’ needs to be addressed without missing any of the critical practices. Developing a care coordination plan enables the patients to follow the right procedure in engaging in various care practices, thus reducing admissions and readmissions to various healthcare facilities. Based on the understanding of the benefits of care coordination, various aspects have been addressed where some of them involve the health concern identified, best practices, care coordination goals, and community resources available. Health Concern Identified Stroke is among the most common chronic conditions in society. The condition tends to affect the patient both physically and mentally, leading to the health condition’s deterioration. According to the Center for Disease Control and Prevention (CDC), approximately 800,000 individuals develop stroke per year in the United States (Centers for Disease Control, 2020). Among these individuals, some of them experience stroke for their first time, while others experience it more than once. In this case, those who experience the condition for the first time are considered approximately 610,000, while those who develop the illness more than once are deemed to be roughly 185,000 (Centers for Disease Control, 2020). According to the CDC, approximately 87% of the individuals who develop stroke per year usually experience an 2 PRELIMINARY CARE COORDINATION PLAN 3 ischemic stroke. This is the condition whereby the blood is blocked from flowing to the brain. Stroke is associated with various effects in which the brain’s impaired part determines the severity of the condition. Due to the impairment that one develops, the patient has to be provided with special needs. Individuals who live with stroke experience different types of impairments, including visual, motor, cognitive, and language issues. Best Practices Care coordination among individuals with stroke is conducted after the patient has been discharged from the hospital. Due to the severity of the stroke, the patient’s living conditions usually change since he or she has to adhere to dietary restrictions, several new medications, and rehabilitation goals. Depending on the severity of the patient’s condition, individuals with mild stroke may not display significant change from which they had previously, while those with severe illness may rely on special care. Individuals experiencing severe illness have to visit skilled nursing facilities after discharge from hospitals or engage in an acute rehabilitation program. After completing the rehabilitation program or leaving the skilled nursing facility, the patient is provided with long-term services depending on the person’s recovery level. For the patients to cope with their condition, they have to be given good access to community resources, primary care management, and caregivers’ support. Patients with stroke have to be provided with different kinds of rehabilitation therapy where some of which involve speech therapy, occupational therapy, and physical therapy. In this case, occupational therapy involves assisting the patient in learning how to adapt to the changes in a new living condition involving various activities of daily living (ADL). Individuals who help the patients cope with such illness teach them to apply adaptive equipment to optimize their independence. More than 70% of the people who have experienced stroke have to be supported PRELIMINARY CARE COORDINATION PLAN 4 with ADLs. Besides, physical therapists assist the patient in developing the ability to walk, stand, lie down, and sit as he or she was before experiencing the illness (Bettger et al., 2017). Capella University NURS FPX 4050 Final Care Coordination Plan Discussion

Physical therapists assist the patients in learning these aspects by engaging them in various physical activities. Moreover, speech therapists help stroke survivors who have been negatively affected in terms of swallowing, cognitive, and language aspects. This therapist sometimes collaborates with a nutritionist to help the patient understand the types of foods he or she is supposed to be eating. The three therapists sometimes collaborate to ensure that the patients learn effectively to cope with their conditions. Goals During care coordination, the individuals involved usually have different goals. In this case, there are several individuals who take part in assisting stroke patients with care coordination. Some of these individuals include psychologists, primary care therapists, rehabilitation physicians, neurologists, nutritionists, nurses, and case managers. Before the patient is discharged from various healthcare facilities, these professionals have to collaborate in preparing the patient’s care plan (Bettger et al., 2017).

During the care plan preparation, these professionals have to indicate the equipment or items that the patient needs. The goals of collaborating involves ensuring that the patient has been provided with appropriate durable medical equipment (DME), organizing for the stroke education programs, arranging for continued outpatient therapy, preparing home health services, revisits to the healthcare facility, and providing with various medications for the patient to use at home (Lutz et al., 2017). Each of the professionals involved has a particular goal for the patient to meet. For example, the physical therapist’s goal is to ensure that the patient does not rely more on the support from family members, especially during movements. Besides, the goal of the nurse is to assist the patient to PRELIMINARY CARE COORDINATION PLAN 5 engage in various ADLs.

If it is challenging for the patients to be revisiting the facility for checkups, the family members can organize with the healthcare professionals for the patient to be taken to a suitable facility from where he or she can be assisted. Community Resources Available For stroke patients to effectively cope with their condition, they are supposed to have good access to community resources. The community resources also enable caregivers to effectively and efficiently provide the patient with various necessities. Some of the community resources available for patients with stroke include education programs, stroke support groups, vocation rehabilitation, wheelchairs, and daycare programs. In cases where the caregiver is fixed with various activities such as at the workplace, respite and daycare programs have to be availed to the patient (Kitzman et al., 2017).

Wheelchairs are provided to patients who experience mobility problems. The stroke support team ensures that stroke patients live in a safe environment that cannot contribute to the deterioration of the patient’s health condition. Besides, the education programs enable stroke patients to understand how to engage in various activities such as managing their conditions, carrying out physical activities, eating healthy diets, and understanding the stroke symptoms that need healthcare professionals’ attention.

Conclusion

Patients with stroke need much attention, and therefore it is necessary for care coordination. During care coordination, various healthcare professionals have to take part to enable the patient to cope with the condition. Since most stroke patients experience the condition in their entire life, close monitoring is always necessary depending on the severity of their condition. PRELIMINARY CARE COORDINATION PLAN References Bettger, J. P., Thomas, L., Liang, L., Xian, Y., & Peterson, E. D. (2017). Hospital variation in functional recovery after stroke. Circulation: Cardiovascular Quality and Outcomes, 10(1), e002391. Centers for Disease Control. (2020). Stroke Facts. Retrieved from https://www.cdc.gov/stroke/facts.htm. Kitzman, P., Hudson, K., Sylvia, V., Feltner, F., & Lovins, J. (2017). Care coordination for community transitions for individuals post-stroke returning to low-resource rural communities. Journal of community health, 42(3), 565-572. Lutz, B. J., Young, M. E., Creasy, K. R., Martz, C., Eisenbrandt, L., Brunny, J. N., & Cook, C. (2017). Improving stroke caregiver readiness for transition from inpatient rehabilitation to home. The Gerontologist, 57(5), 880-889. 6 …

NURS-FPX – Nursing FlexPath

• NURS-FPX4010 Leading People, Processes, and Organizations in Interprofessional Practice
• NURS-FPX4020 Improving Quality of Care and Patient Safety
• NURS-FPX4030 Making Evidence-Based Decisions
• NURS-FPX4040 Managing Health Information and Technology
• NURS-FPX4050 Coordinating Patient-Centered Care
• NURS-FPX4060 Practicing in the Community to Improve Population Health
• NURS-FPX4900 Capstone Project for Nursing
• NURS-FPX5003 Health Assessment and Promotion for Disease Prevention in Population-Focused Health
• NURS-FPX5005 Introduction to Nursing Research, Ethics, and Technology
• NURS-FPX5007 Leadership for Nursing Practice
• NURS-FPX6011 Evidence-Based Practice for Patient-Centered Care and Population Health
• NURS-FPX6016 Quality Improvement of Interprofessional Care
• NURS-FPX6020 Biopsychosocial Concepts for Advanced Nursing Practice 1
• NURS-FPX6021 Biopsychosocial Concepts for Advanced Nursing Practice 1
• NURS-FPX6025 MSN Practicum
• NURS-FPX6026 Biopsychosocial Concepts for Advanced Nursing Practice 2
• NURS-FPX6030 MSN Practicum and Capstone
• NURS-FPX6103 The Nurse Educator Role
• NURS-FPX6105 Teaching and Active Learning Strategies
• NURS-FPX6107 Curriculum Design, Development, and Evaluation
• NURS-FPX6109 Integrating Technology into Nursing Education
• NURS-FPX6111 Assessment and Evaluation in Nursing Education
• NURS-FPX6210 Leadership and Management for Nurse Executives
• NURS-FPX6212 Health Care Quality and Safety Management
• NURS-FPX6214 Health Care Informatics and Technology
• NURS-FPX6216 Advanced Finance and Operations Management
• NURS-FPX6218 Leading the Future of Health Care
• NURS-FPX6410 Fundamentals of Nursing Informatics
• NURS-FPX6412 Analysis of Clinical Information Systems and Application to Nursing Practice
• NURS-FPX6414 Advancing Health Care Through Data Mining
• NURS-FPX6416 Managing the Nursing Informatics Life Cycle
• NURS-FPX6610 Introduction to Care Coordination
• NURS-FPX6612 Health Care Models Used in Care Coordination
• NURS-FPX6614 Structure and Process in Care Coordination
• NURS-FPX6616 Ethical and Legal Considerations in Care Coordination
• NURS-FPX6618 Leadership in Care Coordination
• NURS-FPX8010 Executive Leadership in Contemporary Nursing
• NURS-FPX8012 Nursing Technology and Health Care Information Systems
• NURS-FPX8014 Global Population Health
• NURS-FPX8030 Evidence-Based Practice Process for the Nursing Doctoral Learner
• NURS-FPX8045 Doctoral Writing and Professional Practice
• NURS-FPX9100 Defining the Nursing Doctoral Project
• NURS-FPX9901 Nursing Doctoral Project 1
• NURS-FPX9902 Nursing Doctoral Project 2
• NURS-FPX9903 Nursing Doctoral Project 3
• NURS-FPX9904 Nursing Doctoral Project 4
• NURS-FPX9980 Doctoral Project Development