Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment

Assessment 2: Patient Care Plan: MSN6610 – Case Coordination Scenario

Assessment 2: Patient Care Plan

Assessment 2

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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

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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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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 https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html

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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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?
Resources
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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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.

MSN6610 – Case Coordination Scenario

Activity Log

Patient Interview

Rebecca Snyder

Patient

How are you feeling today, Mrs. Snyder?

Oy, I’ve been better, I guess! The pain medication is making me very sleepy. But

it’s controlling the pain. So I guess I can stand it for now. But when I go home I’m

not going to be able to be this out of it. Mostly I’m just worried sick about my family.

I’m the one who takes care of everything. And I mean everything–the cooking, the

cleaning, the dogs, rides to baseball practice for my sons… and my mother too.

She lives with us, and I take care of her because she’s not well. I just want to go

home so I can take care of everything like I’m supposed to!

Can you tell me about your family situation?

Well, David is my husband. We’ve been married for 36 years now! He used to be

an accountant, but last year he finally took the plunge and bought his own deli. His

dream come true. It’s going ok, but it’s a lot of work, and sometimes I don’t see him

all day because he’s working. And we have five children. Two of them are at home-

-my twin boys Eli and Isaac. They’re 14 and they’re really great kids… they’re both

on the baseball team and all kinds of activities, and I feel like I spend half my life

driving them places. And also taking care of their dogs… oy. We never had dogs

before, but the twins just begged us for years, so we got them two great big Golden

Retrievers. The deal was that they were supposed to take care of the dogs, but you

can imagine how that went! Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Then we have three grown kids. Our oldest son Oren lives in New Jersey and we

don’t see him enough. He’s married and has four children. Our daughter Devorah

lives close by and I see her every day. She has two beautiful little girls and she’s a

little overwhelmed, so I help her out as much as I can. And our other son, Avi… oy,

he’s a handful! He has a little boy and just split up from his lovely wife, which I keep

telling him is a terrible idea, but why would he listen to his mother? My husband

made him the assistant manager of the deli, and that’s been an absolute disaster–

especially because, well, I hope I’m not telling you too much, but he has a drinking

problem. That boy needs to learn some responsibility fast. The other member of my

household is my mother, who’s 87 years old and not in good health. She was doing

fine on her own until a few years ago, but now the dementia is getting worse and

she just can’t be alone anymore. Assessment 2: Patient Care Plan

Is there someone at home who can help take care of you?

Take care of me? Now that would be a change. I mean, I don’t want to complain.

We’re a very traditional family when it comes to women’s work and men’s work.

And that was completely my choice. I actually wasn’t raised Orthodox. My family

was somewhat observant, but not the way we are–we didn’t keep kosher growing

up, and my mother worked as soon as we were in elementary school. I met David

at a dance, and that was that. I married him and became Orthodox. So I chose this

lifestyle and the traditional gender roles that come with it. I couldn’t imagine it any

other way. So no, there’s no one who can take care of me, not really. David, he’s a

good man and he’ll do what he can, but he’s been working 15-hour days lately! I’m

sure my daughter can help me with medication and things like that, but she’s so

busy with her kids that I don’t want to burden her. We do have neighbors and

friends from our synagogue…I’m sure they’ll be sending us meals and looking in on

me, just like I’ve done for lots of other people over the years.

How is your home set up? Do you have to walk up and down stairs often?

Outside, it’s not a problem. There’s only one step up into the house. But we do

have a lot of stairs inside. David and I used to sleep in the first floor bedroom suite.

But then when my mother moved in, we moved into a bedroom upstairs. She uses

a walker and there’s no way we could move her into any other bedroom.

How are things going with your diabetes?

I know… I really need to control my diabetes better. I put on all this weight when I

had the twins and I’ve been gaining and losing the same 15 pounds for years, but I

just can’t seem to get it off. I run around so much, you’d think that would help… I

mean, I walk those dogs twice a day most of the time! But it’s just so hard to eat

right… and I know, I use food as a crutch when I get stressed out about my son Avi

and stuff like that, which happens pretty much all the time! And I know it would be

good for all of us to make changes in our diet, but that’s not easy. My husband is

the pickiest eater and my mother can only eat certain things, and three of my kids

are lactose intolerant, and now it turns out my baby granddaughter who’s at my

house every day has a nut allergy! And on top of all that I need to maintain a strict

kosher household. There’s too many food requirements already for me to add my

diabetes to the list. Assessment 2: Patient Care Plan

How do you feel about chemo and radiation?

I don’t know. To be honest, I’m worried sick about the pain and the nausea. I’m

terrible with pain! With all my kids, I wasn’t going to have an epidural, but every

single time I wimped out pretty much immediately. I kind of wonder if I should go

back on anti-anxiety pills, because I’m really upset about this… but I’m worried

those will make me really sleepy, which is why I stopped taking them.

But the thing is, my doctor says the chemo and radiation could prolong my life by a

couple of years potentially. Maybe even more. I know a number of people who

were supposed to die of cancer right away and they hung on for years! So that’s

what I need to do, right? (tears up) My family needs me. I’m honestly more scared

about what’s going to happen to my family when I’m gone. God will take care of

me, but who’s going to walk the dogs?

What questions do you have for me?

I’m so worried about my mother. Can you… I don’t know if it’s part of what you do,

but can you help me figure out what to do about her? I was determined to keep her

out of a home no matter what, and I still feel that way. But what if I can’t take care

of her anymore? My sister lives in Florida and I guess she could take her in, but I

don’t want to send my mother so far away when we’re her main support

system…and anyway, I frankly don’t think my sister has the patience to handle my

mother’s health problems. It’s probably too much to ask, but if you could give me

some advice about what to do for her…? This is really eating me up inside. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Family Interviews

David Snyder

Rebecca Synder’s Husband

Mr. Snyder, I have some questions for you about your wife’s care.

DAVID: So you’re from the hospital? Is my wife okay? Oh good. MITCH! NO, PUT

THAT DOWN! I’LL FINISH THAT ORDER! Okay. I’m sorry about that. I’m at my

deli. Things are kind of crazy here today. MITCH! I SAID, I’LL FINISH THAT

ORDER! GO WORK ON A DIFFERENT ORDER! I’m really sorry. You said you

had some questions about my wife? Look, maybe you should call my daughter

Devorah. I don’t know the first thing about taking care of someone with cancer. I

can’t even tell you how overwhelmed I feel. If I had any idea she was going to get

sick, I wouldn’t have opened this deli, that’s for sure. But it’s too late now… MITCH!

PUT THAT VERKAKTE SANDWICH DOWN! I SAID I’LL FINISH THE ORDER!

Look, like I said, I’m not good with this kind of thing and I’m completely

overwhelmed. I don’t have any idea how we’re going to manage this. I’ll try to help

though. What do you need to know?

DENISE: I’m going to stop you right there. Clearly Mr. Snyder is distracted right

now. You might want to talk with him later. But it also sounds like he’s really

overwhelmed, and from what Mrs. Snyder said, he might not be the best person to

talk to for insight about her care. Caregiving simply hasn’t been his role in the

relationship. I recommend you call someone else. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Devorah Kaufman

Rebecca Synder’s Daughter

What’s wrong?

I’m going to stop you right there. You can’t call Mrs. Snyder’s daughter. Refer back

to Rebecca Snyder’s electronic medical record. There’s a list of people she’s given

the hospital permission to speak with about her care. And there’s only two people

on that list–her husband David and her son Avi. I know–based on what you know

so far, that doesn’t make sense. Mrs. Snyder said that she was very close to her

daughter. When she wakes up, you might want to ask her if she’d like to update the

list so that you can talk to Devorah. In the meantime, you’ll have to talk to someone

else.

Avi Snyder

Rebecca Synder’s Son

Mr. Snyder, I have some questions for you about your mother’s care.

Oh, I’m so glad you called! My father’s way too upset to talk about this right now,

and frankly he doesn’t know the first thing about what my mom needs. My mother

probably gave you this big spiel about what a no-goodnick son I am, didn’t she?

Oh, never mind that. I know a lot more about what’s going on than my mother gives

me credit. What questions do you have for me?

How is your mother feeling about her illness?

Well, you can imagine, she’s certainly not happy about it! For one thing, she’s

worried sick about everyone else. She really does take care of everything in our

family, and she likes it that way. On top of everything she does, she insists on

taking care of my grandmother and keeping her out of a home. But she’s probably

told you all of that. What she probably hasn’t told you is how scared she is about

the chemo and the pain. I don’t think she’s particularly scared about death–I mean,

more than any of us are–but she’s always been terrified of doctors and pain. I

suspect she has a lower threshold for pain than most people. I know I do, and

maybe that’s a genetic thing? Anyways, one thing my mom might not have told you

is that she’s been off and on anti-anxiety meds for years, and unfortunately they

make her really tired so she hasn’t been able to stay on them. And pain is one of

her biggest fears. So I hope you and the doctors keep this in mind when you’re

putting together a plan for her. She’s not going to tell you how anxious she is about

her treatment, but believe me, she is. Assessment 2: Patient Care Plan

Is there anyone in the family who can help care for her?

Yeah…me! She’ll kick and scream because she thinks that’s a daughter’s role and

that I’m a no-goodnik. But my sister isn’t in a position to help all that much. I mean,

she’ll do what she can, but… well, okay, please don’t tell my mom this yet, but my

sister thinks she might be pregnant again. So she’s already got two little girls under

the age of four and possibly another one on the way, and she doesn’t seem to have

easy pregnancies. So if she’s actually pregnant, she’s not going to be able to help

all that much, and even if she’s not pregnant, she’s already overwhelmed with

parenthood. But I can help. And my little brothers can help out too. She’s always

complaining that they don’t do things like walk the dogs, but that’s because she

doesn’t make them. They’re 14 years old and they’re perfectly capable of cleaning

up after themselves and doing some of the cooking. Also, I’m sure my mother

hasn’t said anything, but she has a sister who lives in Florida who will be more than

willing to fly in and help. She and my Aunt Janet don’t get along all the time and I’m

sure my mom doesn’t want to burden her, but Aunt Janet is retired and has plenty

of money and would be on a plane in a minute if my mom would ask. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Can you describe the situation with your grandmother living in the home?

My Baubie needs to be in a nursing home. In my opinion, that should have

happened six months ago, even before my mom’s cancer diagnosis. I admire my

mother for taking on the role of caregiver, but there’s a point where it’s too much.

When my grandmother started needing help bathing and feeding herself, that’s

when she needed to move out, in my opinion. Also, my grandmother’s wandered

out the front door by herself a few times. She hasn’t gone far and she hasn’t gotten

lost, but I think there’s a good possibility that could happen.

How would your mother feel about a home health aide?

Oy! She’d kick and scream and tell us she can do it all herself. But she’d probably

go for it eventually. The problem with that is that I don’t know if they could afford for

someone to come in. When my dad was an accountant they had better insurance.

But now that my dad quit and started his own deli, they’re covered by insurance

through the Affordable Care Act. And thank God that’s available! But I don’t think it

covers home health care, does it? That’s something we need help figuring out.

Because the deli has been a huge financial burden for the family. Huge! It’s doing

pretty well, but all businesses are slow at first, and there’s just not that much

money coming in. And my mom has been adamant about not tapping into my

brothers’ college funds for her health care. Ugh! I really don’t know what we’re

going to do. I wish my mom were old enough for Medicare, but she’s only 56.

Do you think your mother would be open to help with her diabetes and nutrition?

Good luck with that! My sister and I have been on her case for years to start eating

better and she won’t listen to us. And my father is absolutely no help. He’s the

pickiest eater I know and goes nuts when my mother tries to make something more

healthy. He insists that she make pies and cookies even though my mom has no

willpower around those things, so they’re always in the house. And now that she

has cancer, I know that a healthier diet would make things a little easier for her, but

I just don’t see that happening. I see my mom just throwing in the towel and saying

that she’s dying anyway and she should be able to eat whatever she wants. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Is there anything else you’d like us to know about your mother’s care?

My father is having a really hard time coping with this. He’s coping by working

more, which is pretty much the opposite of what should be happening. My father is

completely ill-equipped to deal with this situation, both emotionally and in terms of

knowing how to be a caregiver. I wonder if there’s some kind of Jewish support

group we could find for him. And no one wants to talk about this, but there’s a

pretty good chance he’s going to be a single father to my little brothers. I think my

mother thinks that Devorah’s going to raise them, but I don’t think she can handle

that, especially if it turns out she’s pregnant again. Our family needs to have a

serious conversation about that, but we’re not so great at communication. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Case Strategy Meeting

Panel participants

Karen Wu

Dietician

Samantha Rockwell

Social Worker

Nora Jackson-Green

Case Manager

Panel Q & A

Do you think a home health care nurse is a viable solution?

Karen: I think that’s the best solution. It definitely sounds like Mrs. Snyder doesn’t have

anyone who can take care of her to the degree to she needs. She needs to have a home

health nurse working with her on her diabetes and to assess her for additional problems.

Samantha: That may be the case. But it sounds like they have financial concerns.

Nora: They have insurance under the Affordable Care Act. If home health care turns out

to be the best option, you’re going to need to do some research and find something that’s

covered by the family’s insurance. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Karen: I know finances are a concern. But if there’s any way to make it work, this sounds

like a clear-cut case where a home health care nurse is needed on a part-time basis. The

fact that she’s done such a poor job taking care of her diabetes is evidence that she’s not

going to be able to care for herself on her own.

It sounds like there may be some relatives who are able to help. To what degree should

we pursue that?

Nora: According to Mrs. Snyder’s son, she has a sister in Florida who may be able to

help.

Karen: But it sounds like Mrs. Snyder is reluctant to ask her sister for help.

Samantha: I agree that this sounds like a good potential option. Maybe you could discuss

this more with Avi? You might suggest that he give the sister a call.

Nora: And you probably should talk more with Avi about getting family members to pitch

in.

Samantha: Are you sure? It sounds like Mrs. Snyder isn’t on the best of terms with Avi.

Maybe we should try to communicate again with her husband.

Nora: Maybe. But so far her husband has been very uncommunicative and seems to be in

denial. Avi was very helpful on the phone. It’s possible her relationship with her son is

better than what she says it is.

Samantha: Regardless of who we talk to, I think we need to find some resources to help

the family out. This isn’t the first family with this problem. I recommend you contact Jewish

family resources in the Minneapolis area and find out what resources they have available

to help with this family Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Nora: That’s a very good idea, Samantha. And find out about possible resources through

their synagogue. The family seems to be strongly affiliated with the Orthodox Jewish

community in the area. It’s likely that there are informal support systems that can help the

family with things like meals and housekeeping.

What should be done about Mrs. Snyder’s mother?

Nora: I think this has to be a priority. Mrs. Snyder is her primary caregiver, and that’s not

sustainable anymore.

Karen: I agree. Mrs. Snyder needs to be able to focus on her own health care needs,

including diabetes care and nutrition. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Nora: There’s also the matter of the first floor room where her mother stays. Mrs. Snyder

is overweight and not in good shape. Once she’s exhausted from the chemo, those stairs

are going to be a real burden.

Samantha: But she’s quite adamant about her mother staying. We can’t make her get rid

of her mother.

Karen: No, but the case manager can strongly recommend this. And we can try to get

other family members on board. Avi certainly agrees that it’s time for the mother to live in

a facility.

Nora: If this is going to happen, we need to find a facility that the family can afford and

that Mrs. Snyder feels comfortable with. And it needs to be reasonably close to their

home.

Samantha: And it needs to cater to Jewish families.

How should we address the issue of Mrs. Snyder’s anxiety, especially in relation to pain?

Samantha: I’m so glad you’re addressing this. I’m afraid that medical providers sometimes

dismiss anxious patients as problem patients.

Nora: I agree. One thing we can do is educate Mrs. Snyder about pain relief options. She

needs to know that if something isn’t working, there are other drugs and other options.

Samantha: I also think she would benefit quite a bit from talking to a counselor about

anxiety. Especially since she hasn’t had success with anti-anxiety drugs. Or maybe she

would benefit from a support group. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Nora: Keep in mind that she has financial concerns. But I definitely agree that counseling

of some sort would help her.

Karen: I also think it would be helpful to talk with her about nutrition in relation to anxiety.

Obviously that’s not the only answer. But she might be able to address the anxiety in part

through dietary changes–and through exercise as well.

What can we do to help Mrs. Snyder with diabetes and nutrition issues?

Karen: This is so important. Improving her diet and getting the diabetes under control will

make her feel better. Good nutrition can help a patient feel much stronger during cancer

treatment. She needs to be eating foods that are easy to digest and that are high in

protein. Many cancer patients need to drink supplemental shakes to make sure they get

the nutrients they need. And it may not be realistic to get her down to an ideal weight, but

a moderate amount of weight loss may help her feel better and make it easier to control

the diabetes. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Samantha: I think we should try to get the family on board to help. It sounds like she’s

meeting resistance from her husband when she tries to cook better. That’s hard to get

around in such a traditional family.

Karen: I’m wondering if it’s possible to get a dietician to come to the Snyder’s home and

work with the family.

Nora: Maybe. But don’t forget that they have financial concerns.

Karen: At the very least, we need to make sure she talks to a diabetes educator before

she leaves the hospital.

How can we help the Snyder family adapt to this situation and to the possible loss of Mrs.

Snyder?

Samantha: We really need to identify some resources for the family.

Nora: It sounds like they need help communicating with each other. Mr. Snyder sounds

like he’s in denial. Nobody’s talking about things like finding a facility for the grandmother.

Or what’s going to happen to the two teenage boys if their mother passes away.

Samantha: I hear you. They have so many needs that I’m not sure where to start. I guess

the first thing to do would be to find out what resources are available in the Jewish

community. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.

Nora: Cancer support groups for the husband and the kids would be a big help too. I

know there are support groups available for teenagers who have parents with serious

illnesses.

Strategy Meeting Recap Email

Email you sent

Session Notes

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Assignment: Transitional Care Plan: MSN6610 – Case Coordination Scenario II

Assignment: Transitional Care Plan

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.

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. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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.
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.
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.

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.
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). 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]. Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment.
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.
• 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:
 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 Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment
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.
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.
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 Transitional Care Plan: MSN6610 – Case Coordination Scenario II Essay Assignment