Assessment 1 Instructions: Preliminary Care Coordination Plan

Assessment 1 Instructions
Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Introduction
NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem.

Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Preparation
Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen health care concern.
Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.

Instructions
Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
Stroke.
Heart disease (high blood pressure, stroke, or heart failure).
Home safety.
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
Pain management.
Mental health.
Trauma.
Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3-4 pages in length.
Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the health care problem.
Identify available community resources for a safe and effective continuum of care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.
Analyze a health concern and the associated best practices for health improvement.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe specific goals that should be established to address a selected health care problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

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Solution

Preliminary Care Coordination Plan (Orthopedic Concerns Hip Replacement or Knee Replacement)

Analysis of the Health Concern and Recommended best Practices

The selected health concern under analysis is care coordination planning in the context of hip or knee replacement surgery. Ditton et al. (2020) noted that care coordination in hip or knee replacement surgery is a requisite step by the orthopedic surgeons and other involved healthcare professionals to reduce the high levels of postoperative pain experienced by patients, fast-track the return to normal functioning, boost the rehabilitation process, reduce length of hospital stay, ensure cost-effective health services and reduce the risk of complications and analgesic gaps. Therefore, adopting appropriate best practices to support care coordination and active management of an orthopedic surgery service is integral to supporting the successful realization of comprehensive care for hip or knee replacement.

Ideally, the adoption of evidence-based best practices is integral to improving outcomes for hip or knee replacement patients, involved healthcare providers, payers and the community at large. Ditton et al. (2020) established that the use of multimodal regimens that combines both anesthetic and analgesic agents can assist in the attainment of optimal outcomes in knee or hip replacement procedures. For instance, the usage of an extended-release local anesthetic (liposomal bupivacaine) for infiltration is steadily emerging as a best practice designed to provide safe, effective, coordinated and efficient perioperative analgesia for different kinds of surgical procedures involving hop or knee replacement. Aimed at achieving enhanced standard of care, strong emphasis in this new paradigm is placed on constant communication, commitment and coordination across the care continuum through the increased engagement of all members of the clinical care team namely: anesthesiologist, surgeon, physical therapist, pharmacist, and nursing staff (National Association of Orthopaedic Nurses, 2018). In another study, Dossett and Chesser (2017) asserted the provision of individualized treatment in line with the patient need and type of procedure is integral in ensuring the personalized implantation of knee and hip components. As a best practice, the personalized hip and knee joint replacement model is associated with proper positioning of knew and hip components to suit individual anatomy, attain high prosthetic performance, ensure enhanced surgical reproducibility and lead to a decline in complications.

The empirical study by Fedonnikov et al. (2020) recommended that prioritization of postoperative rehabilitation process and its management as a best practice that can immensely contribute to enhanced outcomes in patients undergoing hip or knee replacement. Strong focus in the postoperative rehabilitative process must be placed on ensuring constant communication with key parties including local health authorities, patients and their caregivers, regular local orthopedic follow-up, monitoring of patients’ satisfaction about rehabilitation and evaluation of the functional performance of patients who have undergone hop or knee replacement following the surgery (Jette et al., 2020). Varacallo et al. (2022) added that the pursuit of medical consultation, physical therapy and timely follow-up by the orthopedic surgeon and other key staff personnel is integral in identifying and responding to other medical comorbidities experienced by the hip or knee joint replacement patient, thereby reducing the risk of complications and readmissions as well as fostering adherence to prescribed medications and discharge plan.

Specific Goals aimed at addressing the Selected Health Care Problem

1. Preoperative Care

A key objective is to adopt evidence-based interventions aimed at achieving preoperative patient optimization by identifying and responding to medical issues and complications that could undermine success of the procedure. Some of the key interventions in preoperative care include nutrition assessment, VTE prophylaxis risk assessment and planning, anesthesia consultation, patient education, case management consultation, PreHab and neuromuscular electrical stimulation (National Association of Orthopaedic Nurses, 2018). Varacallo et al. (2022) highlighted that adoption of enhanced recovery programs for hip or knee replacements is aimed at contributing to positive improvements in patient outcomes and reduce the risk of complications following a hip or total knee replacement.

2. Adoption of total Knee Arthroplasty

Varacallo et al. (2022) described the total knee arthroplasty (TKA) as a widely adopted elective surgical treatment for end-stage degenerative osteoarthritis of the hip or knee. The key motivation behind adopting this cost-effective and consistently successful procedure in orthopedics is to contribute to enhanced quality of life, restore normal functioning, and alleviate pain associated with undergoing the hip or knee replacement procedures. In addition, Fedonnikov et al. (2020) illustrated that  care coordination is highly crucial based on how inter-professional teams must be actively and continuously involved in the care and support of hip or knee joint replacement patients.

3. Nonoperative Treatment modalities

Barrington et al. (2014) revealed that the adoption of non-operative treatment modalities (e.g. physical activity, weight loss, use of tramadol and physical therapy programs) for the treatment and management of symptomatic knee or hip osteoarthritis can be a realistic treatment options in the care continuum.

Available Community Resources

The growing availability and use of rehabilitation programs have helped to improve the pursuit of preoperative education, group therapy, patient selection and preoperative optimization, fast-track changes in rehab therapy needs, and foster adoption of quality improvement initiatives (Jette et al., 2020). Moreover, other community resources include the existence of integrated practice units (IPUs) tasked with providing holistic, high quality, evidence-based and patient-centered treatment and support to patients and their respective families (National Association of Orthopaedic Nurses, 2018). Equally, the provision of education programs and counseling sessions in the community could prove highly instrumental in encouraging and supporting strict adherence to prescribed treatment regime, supporting required behavioral transformations, compliance with prevention protocol and maximizing the patient’s outcomes and satisfaction with the available treatment interventions (Ditton et al., 2020).

References

Barrington, J.W., Sinatra, R., & Halaszynski, T.M. (2014).Perioperative pain management in hip and knee replacement surgery. American Journal of Orthopedics, 43(4), S1-S16. https://pubmed.ncbi.nlm.nih.gov/24911869/

Ditton, E., Johnson, S., Hodyl, N., Flynn, T., Pollack, M., Ribbons, K., Walker, F. R., & Nilsson, M. (2020). Improving Patient Outcomes Following Total Knee Arthroplasty: Identifying Rehabilitation Pathways Based on Modifiable Psychological Risk and Resilience Factors. Frontiers In Psychology, 11, 1061. https://doi.org/10.3389/fpsyg.2020.01061

Dossett, H. G., & Chesser, M. S. (2017). Improving Care and Reducing Length of Stay in Patients Undergoing Total Knee Replacement. Federal practitioner: for the health care professionals of the VA, DoD, and PHS, 34(10), 38–41.

Fedonnikov, A.S., Andriyanova, A.E., Kiselev, A.R., & Norkin, A.I. (2020).Rehabilitation Process Issues and Functional Performance after Total Hip and Knee Replacement. Healthcare, 9, 1126. https://doi.org/10.3390/healthcare9091126

Jette, D.U., Hunter, S.J., Langham, B., Radach, L.J., & Scatzitti, A.D., (2020).Physical Therapist Management of Total Knee Arthroplasty. Physical Therapy & Rehabilitation Journal, 100, 1603-1631. https://doi.org/10.1093/ptj/pzaa099

National Association of Orthopaedic Nurses, (2018).Best Practice Guideline Total Knee Replacement (Arthroplasty). https://www.lifespan.org/sites/default/files/lifespan-files/images/centers/total-joint-center/best-practice-guideline-for-total-knee-replacement-final-naon.pdf

Varacallo M., Luo T.D., Johanson N.A. (2022). Total Knee Arthroplasty Techniques. Treasure Island (FL): StatPearls Publishing.  https://www.ncbi.nlm.nih.gov/books/NBK499896/