Design patient-centered health interventions and timelines for care delivered through direct clinical interaction that is logged in the CORE ELMS system
For this assessment, you will implement the preliminary care coordination plan you developed in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session and collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan.
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 for you to apply communication, teaching, and learning best practices to the presentation of a care coordination plan to the patient.
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 care delivered through direct clinical interaction that is logged in the CORE ELMS system.
- Competency 2: Collaborate with patients and family to achieve desired outcomes.
- Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with a patient.
- Competency 3: Create a satisfying patient experience.
- Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators.
- Competency 4: Defend decisions based on the code of ethics for nursing.
- Make 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.