MSN6610 – Case Coordination Scenario II Essay Paper

Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care. Then, develop a transitional care plan, 4 pages in length, 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.
To help reduce care fragmentation, a care coordinator working with patients who suffer from chronic illnesses must share important clinical information with stakeholders so everyone has clear, shared expectations about their roles. Equally important, the care coordinator must work with the team to keep patients and their families up-to-date and to ensure that effective transitions and referrals take place. This assessment provides an opportunity for you to assume the role of care coordinator and recommend appropriate transitional care for a terminally ill patient.MSN6610 – Case Coordination Scenario II Essay Paper

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By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
o Competency 2: Evaluate current factors (such as population health, cost, interprofessional communications) affecting patient outcomes related to care coordination.
 Explain the importance of effective communications with other health care and community service agencies involved in the transition.
 Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
o Competency 3: Determine appropriate care coordination performance measures for driving high-quality patient outcomes, based on current accrediting standards and benchmarks.
 Explain the importance of each key element of a transitional-care plan.MSN6610 – Case Coordination Scenario II Essay Paper
o Competency 4: Apply relevant evidence-based practices that reflect a shift toward a broader population health focus on patient outcomes.
 Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
 Develop a strategy for ensuring an accurate provider understanding of the patient medication list, plan of care, and follow-up plan during a patient care transition.
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
Relative to other facets of medical care, research to direct efforts to improve care coordination has lacked rigor. However, many groundbreaking health care organizations have acknowledged the perils of poorly coordinated care models and applied interventions to improve these models.MSN6610 – Case Coordination Scenario II Essay Paper
The objective of care coordination is to secure high-quality recommendations and transitions that aim for superior health care and guarantee that all involved providers, organizations, and patients have the necessary information and resources to make optimal patient care possible.

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 What are the likely outcomes of poor care transitions among providers and health care settings?
o Why is effective communication such a vital component of transitional care?
o Where are communication breakdowns likely to occur?
 Why?MSN6610 – Case Coordination Scenario II Essay Paper
 Have you seen or experienced such breakdowns in your own practice setting?
Resources
Required Resources
The following resources are required to complete your transitional care plan.
o Vila Health: Care Coordination Scenario II | Transcript
 Use this multimedia simulation to gather the information you will need to complete your plan.
o APA Style Paper 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 will need to 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.MSN6610 – Case Coordination Scenario II Essay Paper
Transitions of Care
o Alliance for Home Health Quality and Innovation. (2014). Improving care transitions between hospital and home health: A home health model of care transitions [PDF]. Available from http://ahhqi.org/images/uploads/AHHQI_Care_Transitions_Tools_Kit_r011314.pdf
 An ADA-compliant PDF is available here.
o HealthIT.gov National Learning Consortium. (n.d.). Care coordination tool for transition to long-term and post-acute care [PDF]. Retrieved from https://www.healthit.gov/sites/default/files/nlc_ltpac_carecoordinationtool.pdf
o Institute for Clinical Systems Improvement. (2017). Transition communications – Tools and resources. Retrieved from http://www.rarereadmissions.org/areas/transcomm_resources.html
o Institute for Healthcare Improvement. (2012). How-to guide: Improving transitions from the hospital to skilled nursing facilities to reduce avoidable rehospitalizations [PDF]. Retrieved from http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/STAARHowtoGuide_TransitionsSNFsReduceRehospitalizations.pdf
o Joint Commission Center for Transforming Healthcare. (2014). MSN6610 – Case Coordination Scenario II Essay Paper Improving transitions of care: Hand-off communications [PDF]. Available from http://www.centerfortransforminghealthcare.org/assets/4/6/handoff_comm_storyboard.pdf
 An analysis of the effects of handoff communications on transitional care.
 Find an ADA-compliant PDF here.
o New York State Department of Health. (2008). Suggested model for translational care planning. Retrieved from https://www.health.ny.gov/professionals/patients/discharge_planning/discharge_transition.htm
o Shaver, K. (n.d.). Transitional care management: Better care for our patients [PDF]. Retrieved from http://www.joslin.harvard.edu/Transitional_Care_PP_SUNY_Upstate_show_Oct_7_call.pdf
 A presentation of key points about the management of transitional care.
o Transition Care Plan Example [PDF].
Suggested Writing Resources
You are encouraged to explore the following writing resources. You can use them to improve your writing skills and as source materials for seeking answers to specific questions.
o APA Module.
o Academic Honesty & APA Style and Formatting.
o APA Style Paper Tutorial [DOCX].
Capella Resources
o ePortfolio.MSN6610 – Case Coordination Scenario II Essay Paper
• Assessment Instructions
Preparation
In the previous assessment, you conducted simulated stakeholder interviews and collected information for a plan of care for Mrs. Snyder. Now, seven months later, her condition has deteriorated.
To prepare for this assessment, complete the Vila Health: Care Coordination Scenario 2 simulation (linked in the Required Resources) in which you will recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family. Completing this exercise will help you develop a transitional care plan for Mrs. Snyder.
Requirements
Develop a transitional care plan for Mrs. Snyder.
Transitional Care Plan Format and Length
You may use a familiar transitional care plan format or template—for example, one used in your organization—or you may create your own. A link to an example is provided in the Suggested Resources.
o Format your transitional care plan in APA style; an APA Style Paper Tutorial is also linked in the Suggested Resources to help you. Be sure to include:MSN6610 – Case Coordination Scenario II Essay Paper
 A title page and reference page. An abstract is not required.
 A running head on all pages.
 Appropriate section headings.
o Your plan should be 4 pages in length, not including the title page and references page.
Supporting Evidence
Cite 4–5 sources of scholarly or professional evidence to support your plan.
Developing the Transitional Care Plan
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your transitional care plan addresses each point, at a minimum. Read the Transitional Care Plan Scoring Guide to better understand how each criterion will be assessed.MSN6610 – Case Coordination Scenario II Essay Paper
o Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
 Include elements such as emergency and advance directive information, medication reconciliation, plan of care, and available community and health care resources.
o Explain the importance of each key element of the transitional care plan.
 Identify potential effects of incomplete or inaccurate information on patient outcomes and the quality of care.
 Cite credible evidence to support your assessment of each element’s importance.MSN6610 – Case Coordination Scenario II Essay Paper
o Explain the importance of effective communications with other health care and community services agencies involved in the transition. Assignment: Transitional Care Plan
 Identify potential effects of ineffective communications on patient outcomes and the quality of care.
o Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
 Consider barriers inherent in such care settings as long-term care, sub-acute care, home care services, and home care with support.
 Identify at least three barriers.
o Develop a strategy for ensuring that the destination care provider has an accurate understanding of the patient medication list, plan of care, and follow-up plan.
 Cite credible evidence to support for your strategy.
o Write clearly and concisely, using correct grammar and mechanics.
 Express your main points and conclusions coherently.
 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.
Portfolio Prompt: You may choose to save your transitional care plan to your ePortfolio. Assignment: Transitional Care Plan MSN6610 – Case Coordination Scenario II Essay Paper

MORE INFO 

Importance of Case Coordination in Nursing

Introduction

The nursing profession is constantly evolving. In fact, it’s estimated that new nursing practices emerge every three years. One of these newer practices is case coordination, which involves supporting the patient and family through their recovery process by providing support services such as case management and education. Case coordination can help improve a patient’s outcomes by reducing unnecessary hospitalizations or readmissions; reduce costs associated with emergency room visits; and increase efficiency in the delivery of care.”

Improved patient outcomes

The case coordinator is the patient’s advocate. They can help to ensure that the patient receives appropriate care, identify problems and resolve them, and ensure that their needs are met.

Increased staff efficiency

• Increased staff efficiency – In the traditional model, a nurse is required to double-check every patient record and determine if any changes have been made since their last review. This can be time consuming and stressful for both nurses and patients, especially if there are many records to review. The case coordination model reduces this stress by allowing nurses to focus on one patient at a time instead of having multiple tasks at once.

• Reduced documentation errors – A key benefit of case coordination is that it reduces documentation errors caused by confusion about what information should be included in a particular chart or report (e.g., an admission note). As each item is completed, another nurse will ensure that all relevant information has been recorded correctly before moving onto the next step in the process

Delivery of cost-effective care

Case coordination is one of the most cost-effective ways to provide care. It can prevent errors and other problems that are expensive to fix, such as medical mistakes.

Patient safety

Case coordination is a process that helps ensure patient safety. It involves the coordination of multiple healthcare providers, including nurses and physicians, who work together to help ensure that each patient receives proper care.

In many cases, case coordination can prevent medical errors from occurring and improve patient outcomes. For example, if a nurse knows that one doctor is reviewing a particular case for discharge and another doctor will be attending to it later on in the shift (or even later), then this information allows them to have an organized system for providing care for their patients during those periods when no other providers are available at the same time as needed. This means fewer interruptions between visits by different physicians or nurses who need information from each other before proceeding with treatment plans or tests; less confusion over what should happen next; better communication between caregivers regarding expectations/goals; etc…

An effective case coordinator can help ensure a patient’s success.

A well-coordinated case is one that involves a coordinated approach to the patient’s care. It can be thought of as a roadmap for how you will treat a patient, including all of their visits and medications. This helps ensure that everyone involved knows what their role is in order to provide the best possible treatment plan for your patient.

It also allows you to make sure that each provider has access to all relevant information so they can make informed decisions about treatment options, which can reduce errors or improve outcomes for patients. And since this information is shared across different facilities, it means less time spent searching for things like lab results or test results—which saves both time and money!

Conclusion

As we’ve seen, case coordination can help ensure a patient’s success. It is not only an essential component of nursing practice, but also one that can improve the quality of care delivered to patients in many ways. If you are interested in learning more about this topic or want to become part of an organization that supports case coordination training programs for nurses, consider checking out our website! We also provide resources for other healthcare professionals who wish to learn how their role might be enhanced through collaboration with those who care for patients on their wards.