Introduction

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.

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

Preparation

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.

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
.

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.

· 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.

Context

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.

Personal Review of Management and Leadership in Nursing

This assignment comprises of writing a paper which covers the six main learning outcomes of this course. Using your textbook and the results of your personality test, you will answer the question prompts below in narrative form (no Q & A and no bulleted lists). Please follow all the APA 7th edition rules.

Instructions:

1. Take the 

Myers-Briggs Type IndicatorLinks to an external site.
 assessment to examine your individual strengths and experiences in preparation for assuming management and leadership roles.

https://www.16personalities.com/free-personality-test

2. Write 5-6 pages using the headings and corresponding prompts below, which you should used in your paper:

I.
Leadership and Management Theory

· How can you apply a leadership and management theory to achieve high quality nursing care for your patients and collaborate effectively with your health care team? Identify the citation(s) for the leadership or management theory you chose in answering this question.

· Are you more of a leader or a manager? Please explain why you feel this way. In view of your results of the personality test, how can you strengthen aspects of your personality to grow more in leadership or in management? Which competencies do you need to strengthen to become the leader or manager you want to become?

II.
Change Theory

· How do you deal with change at your practice setting? What personality traits would you utilize to promote change in your facility and how did you decide which traits you would use? Are there traits that you would not agree with and why do you think they appear?

III.
Communication Style

· What did you learn about yourself taking the personality test? Which type of communicator are you? What are areas that you can strengthen to be more effective? To be more therapeutic? What are some barriers to effective communication styles which you have observed in yourself? Note: You may need to read between the lines in the results, as your communication style is not measured directly.

IV.
Performance Improvement and Quality Improvement

· How can you manage both performance improvement and quality improvement at the same time? Answer this using your understanding of your results of the personality test and your textbook/lectures about leadership and management.

· How can you apply the principles of performance improvement and/or quality improvement into your practice? Choose one principle and explain how you can implement it at your workplace.

V.
Evidence-based Practice and Improvement

· Evidence-based practice (EBP) has been emphasized all throughout your BSN program. How does EBP relate to achieving desirable performance outcomes and quality improvement?

VI.
Supervision Style

· Compare and contrast effective and ineffective supervision styles which you have observed in your workplace. When doing so, make sure to apply principles of delegation, authority, responsibility, and accountability.

3. Your paper should be

. a total of 5-6 pages of the body (not including the cover and reference page)

. sourced with two (2) scholarly references within the last five years.

. written in the formatting and citation style of 

APA, 7th editionLinks to an external site.

· Be sure to 

meet with a writing tutorLinks to an external site.
 after you have an outline/paper to ensure a quality submission.

· Follow the 

template


 Download template
carefully, as it is already pre-formatted in APA for you.

Read the following case study and answer the reflective questions. Please provide evidence-based rationales for your answers. APA, 7th ed. must be followed.

Citation and references

 30 D again

A 68-year-old client lives alone and is independent with all ADLs, has no restrictions for mobility, and is competent, and oriented x4. The client is on a fixed income, but has enough to manage a modest lifestyle. The client has family and social supports but is very independent and is proud of her self-reliance. The client’s height is 5’ 6”, weight is 210 lb. / 95.25 kg.

Please answer the following:

• What is the client’s BMI?
• Identify what screening tools you would use to assess nutritional and exercise knowledge, and why?
• One Outcome/Intervention/Rationale:
  • Identify one outcome/goal that is reasonable, measurable and realistic. Identify 1 nursing intervention for the outcome and give rationale for the intervention.
• Identify what weakness in the client’s life may be impacting the client’s activity and diet?
• What referrals would you make and why?

(Use references for your responses, not just opinion.)