CONGESTIVE HEART FAILURE

Create a precise road map plan, 5–7 pages in length, to improved care coordination for a population of your choosing.

A population-based approach to care coordination offers an effective means of improving outcomes and delivering more cost-effective, patient-centered care. Care coordinators must have the knowledge and skills to employ collaborative, evidence-based strategies in the provision of care within diverse populations.

This assessment provides an opportunity for you to examine the care coordination needs of a population of your choice and develop a plan to best utilize all community resources to enhance care for this group.

Health care landscapes continue to evolve. Populations migrate toward health and wellness. Families settle and form a community to meet health and social needs for individuals and families.

Unseen health care barriers, such as communication and cultural obstacles, the lack of leadership support, shortage of resources, and undefined roles and accountability all influence the quality and safety of health care delivery. Care coordination involves the identification of barriers in order to develop a safe plan of care.

A care coordination role currently exists that supports population health from a community resource perspective. This role is designed to cross traditional health care delivery boundaries by utilizing city, state, and national resources to support the well-being of specific populations.

For this assessment, you will assume this role of care coordinator for a community and choose the population you wish to support. Examples of populations include veterans, congestive heart failure (CHF) patients, HIV patients, and the homeless in need of care.

After a thorough assessment of your chosen population, you have decided that the population is in dire need of improved care coordination. Now you need to develop a plan to best utilize all community resources to enhance care for this group, turning barriers to health care into opportunities for new collaborative and innovative partnerships.

Create a precise road map to improved care coordination for your selected population. Take a program evaluation approach to this work, choosing any program evaluation tool from AHRQ, CMS, IHI or a specialty organization to help you gather ideas for your road map.

Access to acute care facilities for CHF patients.

Explains the benefits to a population of improved coordinated care, based on current standards of nursing practice. Presents a cogent, articulate explanation based on insightful, evidence-based conclusions and the legal and ethical dimensions of population-level care coordination.

Analyzes specific health care options that support improved patient outcomes. Draws justifiable conclusions based on patient needs and a consistently accurate interpretation of the evidence.

Identifies stakeholders in a population, other than those comprising the population. Makes logically sound, valid inferences about stakeholder interests based on an insightful synthesis of relevant information.

Articulates a collaborative, concise, and inspirational vision, involving stakeholders, of improved coordinated care for a population that reflects keen insight into specific need and aligns with an organization’s mission, vision, values, and goals.

Describes new collaborative partnerships that could be formed to enhance coordinated care. Paints a comprehensive, detailed picture of these partnerships, their benefits, implementation strategies, and potential outcomes.

Provides recommendations for implementing improvements in coordinated care. Draws rational, fully-justified conclusions based on an insightful synthesis of credible evidence.

Supports main points, claims, and conclusions with relevant, credible, and convincing evidence. Combines the skillful application of error-free source citations with a perceptive and accurate synthesis of the evidence