Assessment 2: Patient Care Plan

Assessment 2: Patient Care Plan

Assessment 2: Patient Care Plan

Overview

Complete an interactive simulation in which you will interview a patient, family members, and experienced health care workers to gather information to support a care coordination strategy and develop a care plan for the patient.

Note: Each assessment in this course builds on your work in the preceding assessment; therefore, complete the assessments in the order in which they are presented.

Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

o Competency 1: Determine the influence of current health care legislation, policy, and research on evidence-based practice in assessment by care coordinators.

 Assess a patient’s condition from a coordinated-care perspective.
 Develop nursing diagnoses that align with patient assessment data.
o Competency 3: Determine appropriate care coordination performance measures for driving high-quality patient outcomes, based on current accrediting standards and benchmarks.
 Evaluate care coordination outcomes.
o Competency 4: Apply relevant evidence-based practices that reflect a shift toward a broader population health focus on patient outcomes.
 Determine appropriate nursing or collaborative interventions.
 Explain why a particular nursing intervention is indicated or therapeutic.
o Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
 Write clearly and concisely, using correct grammar and mechanics.
 Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Context

The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions such as congestive heart failure, pneumonia, asthma, and diabetes, and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.

Reference

Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. Retrieved from

Assessment 2: Patient Care Plan

Questions to Consider

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
o To what extent does a needs assessment support nursing diagnoses?
o Which accrediting standards or benchmarks drive outcomes in your current professional practice?
o What action might you take in response to care plan goals or outcomes that are not being met?

Required Resources

The following resources are required to complete your patient care plan.
o Vila Health: Care Coordination Scenario I | Transcript.
 Use this multimedia simulation to gather the information you will need to complete your plan.
o Patient Care Plan Template [DOCX].
 Use this template for your plan.

Suggested Resources

The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you must ensure that they are appropriate, credible, and valid. The MSN-FP6610 Introduction to Care Coordination Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.

Care Coordination

o GL?owacka, M. & Kalinowska, A. (2015). Shaping nursing professional skills with the use of the method of nursing process as well as diagnoses and nursing interventions according to ICNP oriented on the female patient with multiple sclerosis. Journal of Neurological & Neurosurgical Nursing, 4(2), 76–84.

 A study illustrating a holistic approach to patient care.
o Popejoy, L. L., Stetzer, F., Hicks, L., Rantz, M. J., Galambos, C., Popescu, M., … Marek, K. D. (2015). Comparing aging in place to home health care: Impact of nurse care coordination on utilization and costs. Nursing Economics, 33(6), 306–313.
 A study presenting additional evidence for effectiveness of nursing care coordination.
o Vanderboom, C. E., Thackeray, N. L., & Rhudy, L. M. (2015). Key factors in patient-centered care coordination in ambulatory care: Nurse care coordinators’ perspectives. Applied Nursing Research, 28(1), 18–24.
o Vu, M., White, A., Kelley, V. P., Kuca Hopper, J., & Liu, C. (2016). Hospital and health plan partnerships: The Affordable Care Act’s impact on promoting health and wellness [including commentary by F. Randy Vogenberg]. American Health & Drug Benefits, 9(5), 269–278.
 Results of a literature review examining the effects of the ACA on health and wellness programs.
Suggested Writing Resources
o APA Module.
o Academic Honesty & APA Style and Formatting.
o APA Style Paper Tutorial [DOCX].

Capella Resources

• Assessment Instructions
Note: Complete the assessments in this course in the order in which they are presented.
Preparation

To prepare for this assessment, complete the Vila Health: Care Coordination Scenario 1 simulation (linked in the Required Resources) to obtain the information you will need to:

o Develop a care coordination strategy for Mrs. Snyder and her family.
o Apply current accrediting standards and benchmarks as you determine the best way to develop this strategy.
o Develop a patient care plan.

Requirements

Develop a proactive, patient-centered care plan for the patient, using the information gained from your simulated interviews. Focus on care coordination and national care coordination initiatives.

Care Plan Format

Use the Patient Care Plan Template linked in the Required Resources.

Supporting Evidence

Cite 5 sources of scholarly or professional evidence to support your plan.

Developing the Care Plan

Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed.

o Assess the patient’s condition from a coordinated-care perspective.
 Consider the full scope of the patient’s needs.
 Include 5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.
o Develop nursing diagnoses that align with the patient assessment data.
 Write two goal statements for each diagnosis.
 Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific.
 Consider the psychosociocultural aspect of care.
o Determine appropriate nursing or collaborative interventions.
 List at least three nursing or collaborative interventions.
 Provide the rationale for each goal or outcome.
o Explain why each intervention is indicated or therapeutic.
 Cite applicable references that support each intervention.
o Evaluate care coordination outcomes.
 Indicate if the goals were met. If they were not met, explain why.
 Describe how you would revise the plan of care based on the patient’s response to the current plan.
o Write clearly and concisely, using correct grammar and mechanics.
o Express your main points and conclusions coherently.
o Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
o Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
• Complete an interactive simulation in which you will interview a patient, family members, and experienced health care workers to gather information to support a care coordination strategy and develop a care plan for the patient.

Assessment 2: Patient Care Plan

Patient Identifier:                                                         Patient Medical Diagnosis:

Nursing Diagnosis Assessment Data	Goals and Outcome	Nursing Interventions	Rationale	Outcome Evaluation and Re-Planning
Include 3–5 subjective and/or objective pieces of data that lead to the nursing diagnosis.	Two statements are required for each nursing diagnosis. Must be patient- and/or family-focused, measurable, time-specific, and reasonable.	List at least three nursing or collaborative interventions with rationale for each goal and outcome.	Provide a reason why an intervention is indicated or therapeutic; provide references.	Were the goals met? How would you revise the plan of care according the patient’s response to the current plan of care?

Patient Care Plan Scoring Guide

Patient Care Plan Scoring Guide
Criteria	Non-performance	Basic	Proficient	Distinguished
Assess a patient’s condition from a coordinated-care perspective.	Does not assess a patient’s condition.	Assesses the patient’s condition.	Assesses a patient’s condition from a coordinated-care perspective.	Assesses a patient’s condition from a coordinated-care perspective. Assessment data is comprehensive and supports a nursing diagnosis.
Develop nursing diagnoses that align with patient assessment data.	Does not develop nursing diagnoses.	Develops nursing diagnoses.	Develops nursing diagnoses that align with patient assessment data.	Develops nursing diagnoses that align with patient assessment data, include SMART goals, and address the psychosociocultural aspect of care.
Determine appropriate nursing or collaborative interventions.	Does not suggest nursing or collaborative interventions.	Suggests nursing or collaborative interventions.	Determines appropriate nursing or collaborative interventions.	Determines appropriate nursing or collaborative interventions. Provides concise, well-reasoned justification that is well supported by credible evidence, for each goal or outcome.
Explain why a particular nursing intervention is indicated or therapeutic.	Does not describe a chosen nursing intervention.	Describes a chosen nursing intervention.	Explains why a particular nursing intervention is indicated or therapeutic.	Explains why a particular nursing intervention is indicated or therapeutic. Provides clear, convincing rationale for the intervention, that is well supported by credible evidence.
Evaluate care coordination outcomes.	Does not state whether care coordination outcomes were met.	States whether care coordination outcomes were met.	Evaluates care coordination outcomes.	Evaluates care coordination outcomes. Provides logical, evidence-based reasons why goals were not met or only partially met, including an effective strategy for revising the care plan that addresses key uncertainties.
Write clearly and concisely, using correct grammar and mechanics.	Does not write clearly and concisely, using correct grammar and mechanics	Writing is not consistently clear or concise, or errors in grammar and mechanics inhibit effective communication.	Writes clearly and concisely, using correct grammar and mechanics.	Writes clearly and concisely. Grammar and mechanics are error-free.
Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.	Does not support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.	Main points, claims, and conclusions are not well supported. Sources lack relevance or credibility, or are incorrectly formatted.	Supports main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.	Supports main points, claims, and conclusions with relevant, credible, and convincing evidence. Source citations and references are error-free