For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.Demonstration of ProficiencyBy 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.Design patient-centered health interventions and timelines for a selected health care problem.Competency 2: Collaborate with patients and family to achieve desired outcomes.Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.Competency 3: Create a satisfying patient experience.Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document.Competency 4: Defend decisions based on the code of ethics for nursing.Consider ethical decisions in designing patient-centered health interventions.Competency 5: Explain how health care policies affect patient-centered care.Identify relevant health policy implications for the coordination and continuum of care.Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.PreparationIn this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2020.Note: Remember that you can submit all, or a portion of, your 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.InstructionsNote: You are required to complete Assessment 1 before this assessment.For this assessment:Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.Document Format and LengthBuild on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA formatted paper, 5–7 pages in length, not including title page and reference list.Supporting EvidenceSupport your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2020 resources. Cite at least three credible sources.Grading RequirementsThe requirements, outlined below, correspond to the grading criteria in the Final 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.Design patient-centered health interventions and timelines for a selected health care problem.Address three health care issues.Design an intervention for each health issue.Identify three community resources for each health intervention.Consider ethical decisions in designing patient-centered health interventions.Consider the practical effects of specific decisions.Include the ethical questions that generate uncertainty about the decisions you have made.Identify relevant health policy implications for the coordination and continuum of care.Cite specific health policy provisions.Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.Clearly explain the need for changes to the plan.Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2020 document.Use the literature on evaluation as guide to compare learning session content with best practices.Align teaching sessions to the Healthy People 2020 document.Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.Additional RequirementsBefore submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

As you have observed, each member of Mayor Keller’s task force views the need for change from his or her role in the community and specialization perspective. Whether their issues stem from a lack of teaching staff and resources to training for employees, task force members are committed to addressing the learning and development needs of Grand City’s children, students, and citizens. With such myriad needs, how should the mayor’s task force prioritize these issues to enact both educational and community change? For this Discussion, you will evaluate programs within your specialization to determine target areas of improvement for educational and social change in Grand City. To prepare: Review all Learning Resources for this module. Think about the meaning of educational change, the impact of data collection on change initiatives, and the impact of positive social and educational change on all individuals in a community. Review the Grand City data and media for this module as well as your analysis of the data from the Module 1 Discussion 1. Consider what programs are most critical in supporting Grand City’s children and students, including both those in early childhood programs and K–12 schools. Think about how data supports the need for change initiatives. How might a successful change in those programs impact the community as a whole? Hargreaves and Fullan (2013) note the difference between business capital and professional capital. Reflect on the concept of capital, your investment in your own education, and the benefits you anticipate in your career and in the lives of the children you reach. Review Walden University’s mission and vision for social change. Imagine you are on the Grand City task force representing your specialization, and consider the areas needing improvement or change. How might you propose the task force address those areas? What impact might such changes have on social change in the Grand City community? A response that explains: At least three target areas that are in need of improvement or change in your specialization A rationale for each area supported with specific data from Grand City How and why targeting these areas would be most effective in supporting positive change within both your specialization and the Grand City community For this Discussion, and all scholarly writing in this course and throughout your program, you will be required to use APA style and provide reference citations. Learning Resources Note: To access this module’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Required Readings Fullan, M. (2016). The new meaning of educational change (5th ed.). New York, NY: Teachers College Press. Chapter 1, “A Brief History of Educational Change” (pp. 3–17) Chapter 2, “The Meaning of Educational Change” (pp. 18–38) Gonzalez-Sancho, C., & Vincent-Lancrin, S. (2016). Transforming education by using a new generation of information systems. Policy Futures in Education, 14(6), 1-18. doi: 10.1177/1478210316649287 Mandinach, E. B., Parton, B., Gummer, E.S., & Anderson, R. (2015). Ethical and appropriate data use requires data literacy. Phi Delta Kappan, 96(5), 25-27. doi: 10.1177/0031721715569465 Hargreaves, A., & Fullan, M. (2013). The power of professional capital. Learning Forward, 34(3), 36–39. Retrieved from http://www.michaelfullan.ca/wp-content/uploads/2013/08/JSD-Power-of-Professional-Capital.pdf Walden University. (2017b). Who we are. Retrieved from https://www.waldenu.edu/about/who-we-are Review this site for information on Walden University’s mission and vision and its focus on social change. Walden University (n.d.). APA course paper template (APA 7th ed.). Retrieved February 2, 2016, from http://academicguides.waldenu.edu/writingcenter/templates/general Required Media Grand City Community Walden University has created a simulated community known as Grand City. This community is being used in various other courses, as well as this one. The community consists of several locations that will be useful in completing some of the assignments in this course. When you use a resource within the Grand City community in this course, instructions will be provided pertaining to which location and resource you are to view. The community may be viewed at the link provided in the citation. Go to the Grand City Community and click into City Hall to view the following for this module: Laureate Education (Producer). (2017a). Grand City opening task force meeting [Video file]. Baltimore, MD: Author. Laureate Education (Producer). (2016b). Grand City education and demographic data files [PDF]. Baltimore, MD: Author. Optional Resources Meyer-Looze, C. L. (2015). Creating a cycle of continuous improvement through instructional rounds. International Journal of Educational Leadership Preparation, 10(1), 29–45. Roberts-Holmes, G., & Bradbury, A. (2016). The datafication of early years education and its impact upon pedagogy. Improving Schools, 1–10. doi:10.1177/1365480216651519