Complete an interactive simulation of the role of the nurse in health care coordination. Then, create a comprehensive patient needs assessment of 4–5 pages based on that simulation.
Note: Each assessment in this course builds on your work from preceding assessments; therefore, complete the assessments in the order in which they are presented.
SHOW LESSCare coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment.
In the 2000 report To Err Is Human: Building a Safer Health System, the Institute of Medicine identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery.
Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice settings. Whether educating a patient about his or her medication and plan of care or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Develop patient assessments. 

Identify current gaps in a patient’s care.
Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.

Competency 2: Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role. 

Discuss societal, economic, and interprofessional factors most likely to affect patient outcomes.
Advocate for the benefits of a multidisciplinary approach to patient care.

Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards. 

Relate specific patient and care coordination outcome measures to professional standards.

Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings. 

Identify evidence-based practices for successful implementation of care coordination.

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.

Reference
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
Competency Map
CHECK YOUR PROGRESSUse this online tool to track your performance and progress through your course.

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Asssessment InstructionsNote: Complete the assessments in this course in the order in which they are presented.
Preparation
To prepare for this assessment, complete the following simulation:

Vila Health: The Nurse’s Role in Care Coordination.
This simulation explores the roles that case managers and other team members play in care coordination. Upon completion of the exercise, you should have a better understanding of care coordination trends and their historical contexts. Use the information available in this simulation to begin your assessment of the patient, Mr. Decker.
Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

Assessment 1 Example [PDF].
Requirements
Complete a comprehensive needs assessment for Mr. Decker, based on the information provided in the Vila Health simulation and your own research.
Comprehensive Needs Assessment Format and Length
Format your comprehensive needs assessment using APA style:

Use the APA Style Paper Template [DOCX] provided. Be sure to include: 

A title page and references page. An abstract is not required.
A running head on all pages.
Appropriate section headings.

See also the APA Style Paper Tutorial [DOCX] to help you in writing and formatting your needs assessment.
Your needs assessment should be 4–5 pages in length, not including the title page and references page.
Supporting Evidence
Cite 3–5 sources of scholarly or professional evidence to support your assessment.
Conducting the Assessment
The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your needs assessment addresses each point, at a minimum. Read the Comprehensive Needs Assessment Scoring Guide to better understand how each criterion will be assessed.

Identify current gaps in a patient’s care. 

Use an appropriate needs assessment tool to identify gaps. This tool may be one in use at your place of employment, one you locate for yourself, or one provided by faculty.
Consider the types of patient information that will be most useful in assessing the current level of care.

Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview. 

Consider the full range of interrelated needs that affect the patient’s health.

Discuss 3–5 societal, economic, and interprofessional factors most likely to affect patient outcomes. 

Consider the potential effects of these factors on outcomes.
Support your conclusions with evidence.

Relate specific patient and care coordination outcome measures to professional standards. 

Provide the rationale for measuring outcomes based on established agencies and organizations.
Describe the relationship between specific outcomes and the identified standards.

Identify evidence-based practices for successful implementation of care coordination. 

Use relevant and credible sources from the research literature.
Consider best practices for a population-health focus on patient outcomes.

Advocate for the benefits of a multidisciplinary approach to patient care. 

Provide the key points in your argument.
Support your assertions with evidence.

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 more difficult to focus on the substance of your needs assessment.

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 comprehensive needs assessment to your ePortfolio.Running head: COMPREHENSIVE NEEDS ASSESSMENT 1

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

Comprehensive Needs Assessment

Learner’s Name

Capella University

Introduction to Care Coordination

Comprehensive Needs Assessment

August, 2019

COMPREHENSIVE NEEDS ASSESSMENT 2

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

Comprehensive Needs Assessment

A comprehensive health needs assessment of patients enables health care providers to

systematically use their resources to disperse care efficiently. In this paper, a comprehensive

needs assessment of a simulated patient is discussed to highlight the importance of

comprehensive needs assessments in identifying and reducing gaps in patient care and

implementing effective care coordination. This paper discusses the various dimensions of a

patient’s needs and the strategies to extract relevant patient information to understand these

needs to establish the significance of a health needs assessment. This paper also presents

effective evidence-based practices in care coordination and the importance of a multidisciplinary

approach to patient care for improving health care outcomes.

Current Gaps in Mr. Decker’s Care

Mr. Decker is a 79-year-old diabetic patient readmitted to one of Vila Health’s hospitals.

Initially admitted with a badly infected toe, Mr. Decker’s inability to adhere to medical

instructions after discharge has resulted in him being readmitted with sepsis. Mr. Decker’s

readmission can be attributed to the following gaps in care:

• Lack of an interdisciplinary approach to care: The inability of the health care provider to

ensure that factors such as diabetes and aging are given due consideration while dispersing

care

• Failure to ensure adequate post-discharge support: Lack of adequate efforts from the care

provider to ensure that the patient effectively carries out the post-discharge care instructions

• Lack of consideration for the patient’s financial standing: The patient’s poor financial

standing was not considered during the design and management of the patient’s care

COMPREHENSIVE NEEDS ASSESSMENT 3

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

To ensure that Mr. Decker’s physiological, social, religious, and psychological needs are

effectively addressed, the needs assessment tool adopted is the Patient Centered Assessment

Method. The method is an integrated needs assessment tool that assesses patients’ physical,

social, psychological, and mental well-being needs. The tool was selected because it iRunning head: ABBREVIATED TITLE OF YOUR PAPER 1
ABBREVIATED TITLE OF YOUR PAPER 4

Full Title of Your Paper
Learner’s Full Name (no credentials)
Capella University
Course Title
Assignment Title
Month, Year
Abstract
[Add text here. Delete this page if not required.]

Keywords: [Add keywords here.]
Title of Paper
[Add text here, using heading levels as appropriate.]
References
[List references here.]




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