Step 1: View the following video: Why care continuity means never discharging patients:https://www.youtube.com/watch?v=mx08kmDxgmMStep 2: Review the Continuity and Coordination of Care by the World Health Organization: https://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?ua=1Step 3: Read the following article – How important is continuity of care. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083711/pdf/381.pdfStep 4: View the following video: Communicating with Doctors as a New Nurse or Nursing Student Tips:https://www.youtube.com/watch?v=Jr4gfgZzMjcContinuity of care is defined as the sound, timely, smooth, unfragmented and seamless transition of a client from one area within the same healthcare facility, from one level of care to a higher and more intense level of care or to a less intense level of care based on the client's status and level of acuity, from one healthcare facility to another healthcare facility and also any discharges to the home in the client's community.Maintaining the continuity of care requires that the nurse, and other members of the healthcare team, identify current client needs and then move the client to the appropriate clinical area, to the appropriate level of care, and to the appropriate healthcare facility in a timely and effective manner.The Nurse’s role in Continuity of Care:Coordinate care with the interprofessional teamAct as a liaison and be a client advocateComplete admission, transfer, discharge, and post-discharge prescriptionsInitiate, revise, and evaluate the plan of careReport the client’s statusCoordinate discharge planningFacilitate referrals and use of community resources.Communication, collaboration and cooperation among and between appropriate healthcare team members and the client are essential components of the continuity of careInitial Discussion Assignment:Part 1: Create a detailed scenario in which a patient with frequent re-admissions for Chronic Obstructive Pulmonary Disease (COPD) is successfully integrated into a care plan that exhibits continuity of care from admission to successful discharge to home with follow-up visits and monitoring. You are not allowed to simply agree or disagree in your responses to the initial postings. All responses must have evidence-based reasons why you agree or disagree and must be supported by research. At least one evidence-based article must be referenced.Part 2: Your patient has transitioned home; however, during a follow-up visit you notice that the patient is having a mild exacerbation and you need to notify the patients doctor for possible admission. Create a detailed ISBAR report prior to calling the physician.

Review your problem or issue and the study materials to formulate a PICOT question for your capstone project change proposal. A PICOT question starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention used to address the problem must be a nursing practice intervention. Include a comparison of the nursing intervention to a patient population not currently receiving the nursing intervention, and specify the timeframe needed to implement the change process. Formulate a PICOT question using the PICOT format (provided in the assigned readings) that addresses the clinical nursing problem.The PICOT question will provide a framework for your capstone project change proposal.In a paper of 500-750 words, clearly identify the clinical problem and how it can result in a positive patient outcome.Describe the problem in the PICOT question as it relates to the following:Evidence-based solutionNursing interventionPatient careHealth care agencyNursing practicePrepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.My capstone topic is the role of the nurse in telehealth in the management of chronic diseases.Thanks