SCENARIO

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.

Grading Requirements

Develop a 3-4 page preliminary care coordination plan for HEART DISEASE. 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.

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.

o Describe specific goals that should be established to address the health care problem.

o Identify available community resources for a safe and effective continuum of care.

REFERENCES TO PICK FROM. PLEASE PICK AT LEAST 3

Agency for Healthcare Research and Quality. (2018, August). Care Coordination. Retrieved

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AHA. (2018, April 18). American heart association recommendations for physical activity in

adults and kids. Retrieved February 3, 2022, from

AHA News. (2019). Environment, culture, other social determinants play big role in heart health.

American Heart Association. Retrieved February 3, 2022, from

American Heart Association. (n.d.). Healthy living. Retrieved February 3, 2022, from

CDC. (2021, December 9). WISEWOMAN. Centers for disease control and prevention. Retrieved

February 3, 2022, from

Centers for Disease Control. (2018, March 2). Best practices for cardiovascular disease

prevention programs. Centers for disease control and prevention. Retrieved February 3,

2022, from

Centers for Disease Control. (2021, September 27). Heart disease facts. Centers for disease

control and prevention. Retrieved February 3, 2022, from

Cervoni, B. (2021). Normal cholesterol levels by age. verywell health. Retrieved February 3,

2022, from

7

Metkus, T. (2020). Heart disease and diet. MedlinePlus. Retrieved February 3, 2022, from

Penn, A. (2019, October 11). Heart disease treatment:diet is better than surgery. Shortform.

Retrieved February 3, 2022, from

YMCA. (2022). Blood pressure self-monitoring. Retrieved February 3, 2022, from