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. you will evaluate the preliminary care coordination plan you developed in Assessment 1 ( file attached) using best practices found in the literature. 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.

  • 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.

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