Patient-Centered Care Coordination and Transition Plan
Develop a Patient-Centered Care Management & Transition Plan for a specific patient of your choice. Based on the research you have completed in this course, the work with the care coordinator, discharge planner, care manager and/or preceptor, your personal experience within the RN-MSN program, and your professional practice experiences, develop a plan for the ongoing care coordination and transitional care of this at risk patient. The care coordination and transition plan must facilitate smooth transitions of the patient between anticipated levels of care (e.g., home care, acute care, rehabilitation, other).
Part 1 – Patient/Family/Caregiver Assessment

Describe in detail how you will assess the patient and family/caregiver. Including references, address the following elements:
Quality of life
Ability to complete ADLs/IADLs
Primary language and ability to communicate. Consider need for assistive devices and language translation services
Health literacy, including the ability to understand the care plan and treatments
Cognitive ability
Social Determinants of Health (SDOH) including
Financial – ability to afford medications, healthy foods
Transportation
Support system
Employment, hobbies
Spiritual beliefs/values
Cultural practices/beliefs
Environmental safety concerns such as fall hazards, neighborhood safety (high crime, lack of resources, no sidewalks etc.)
Evidence-based screening or assessment tools may be described in this section and attached to the plan in the Appendix.
Health Care Model

Choose a model for the delivery of care or create your own model based on current established models for health care delivery. Models for health care delivery which are evidence-based and incorporate an interprofessional team should be utilized. Describe the critical factors or elements of the model and how they would be applied to the patient and family/caregivers at risk.

Care Coordination and Transitions Management Plan
Based on the assessment data and health care model, develop a Care Coordination and Transitions Management Plan for the chosen at-risk patient.

Describe in detail the care delivery personnel that will be involved.
The interprofessional team and their roles should be described in detail and include the communication strategies to be utilized to assure a patient-centered approach to care.
Briefly describe pharmacological and integrative therapeutics for the at-risk patient and how medication reconciliation would occur.

Describe in detail the standards of care for the at-risk patient.

Describe strategies to engage the patient, family and caregiver in the treatment plan. Address what strategies you will use with families that do not speak English, have no access to computers or smartphones or are un or underinsured.

Address what is needed to assure that the patient/family achieves the optimal health outcome e.g. what resources are needed? What education/teaching is needed? Other factors to address?

Provide a detailed description of a real-life community resource and the services provided. How would this resource be helpful to the at-risk patient, family and caregivers? Include a personal communication from a key person employed by this resource.

Expected Outcomes
Based on the above data and standards of care, what are the expected outcomes for the patient, family/caregiver? What does optimal health look like for the patient?