A care coordination role currently exists that supports population health from a community resource perspective.

PREPARATION

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.

Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking for feedback, before you submit the final version for this assessment. However, be mindful of the turnaround time of 24–48 hours for receiving feedback, if you plan on using this free service.

REQUIREMENTS

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.

Road Map Format and Length

Format your road map using APA style.

• Use the APA Style Paper Template, linked in the Required Resources. An APA Style Paper Tutorial is also provided (linked in the Suggested Resources) to help you in writing and formatting your road map. Be sure to include:
  • A title page and references page. An abstract is not required.
  • A running head on all pages.
  • Appropriate section headings.
• Your road map should be 5–7 pages in length, not including the title page and references page.

Supporting Evidence

Cite 5–7 sources of scholarly or professional evidence to support your road map.

Developing the Road Map

Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your road map addresses each point, at a minimum. You may also want to read the Population-Based Care Coordination Scoring Guide to better understand how each criterion will be assessed.

• Explain the benefits to the population of improved coordinated care, based on current standards of nursing practice.
  • What baseline local-, state- or national-level statistics can you find related to care needs for this population.
  • What are the ethical and legal considerations for this population at the city, state, and national level?
• Analyze specific health care options that support improved patient outcomes.
  • For example, free clinics for a homeless population or access to acute care facilities for CHF patients.
  • How do these options support improved outcomes?
  • What evidence supports your conclusions?
• Identify the stakeholders, other than those comprising this population.
  • What interest do these stakeholders have in health outcomes and the provision of care?
• Articulate a collaborative vision, involving stakeholders, of improved coordinated care for this population.
  • Consider the organization’s mission, vision, values, and goals.
• Describe the new collaborative partnerships that you would form to enhance coordinated care.
  • Who do you want on your new community care coordination team, and why?
  • What care delivery organizations should partner with?
    • Why should this happen?
    • How could this happen?
    • What are the potential outcomes for patients with these new partnerships?
• What is your strategy for first approaching these organizations?
  • Who will you attempt to contact first?
  • What will be your first suggestion when you make contact to create a win-win partnership for all stakeholders?
• Provide your final recommendations for implementing improvements in coordinated care.
  • What assumptions underlie your recommendations?
  • What evidence supports your recommendations?
• 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 for them to focus on the substance of your evaluation.
• Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
  • Is your supporting evidence clear and explicit?
  • How or why does particular evidence support a claim?
  • Will your audience see the connection?

Additional Requirements

Be sure that you have used the APA Style Paper Template to format your road map and that your document includes:

• A title page and references page.
• A running head on all pages.
• Appropriate section headings.

In addition, be sure that:

• Your road map is approximately 5–7 pages in length, not including the title page and references page.
• You have cited 5–7 sources of relevant and credible scholarly or professional evidence to support your road map.

Portfolio Prompt: You may choose to save your road map to your ePortfolio.