Nurses have a powerful role in the coordination and continuum of care. All nurses must be cognizant of the care coordination process and how safety, ethics, policy, physiological, and cultural needs affect care and patient outcomes. As a nurse, care coordination is something that should always be considered. Nurses must be aware of factors that impact care coordination and of a continuum of care that utilizes community resources effectively and is part of an ethical framework that represents the professionalism of nurses. Understanding policy elements helps nurses coordinate care effectively. Scenario Your nurse manager has been observing your effectiveness as a care coordinator and recognizes the importance of educating other staff nurses in care coordination. Consequently, she has asked you to develop a presentation for your colleagues on care coordination basics. By providing them with basic information about the care coordination process, you will assist them in taking on an expanded role in helping to manage the care coordination process and improve patient outcomes in your community care center. To prepare for this assessment, identify key factors nurses must consider to effectively participate in the care coordination process. You may also wish to: Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete. Allow plenty of time to rehearse your presentation. Presentation Format and Length Create a detailed narrative script for your video presentation, approximately 4–5 pages in length. Include a reference list at the end of the script. Supporting Evidence Cite 3–5 credible sources from peer-reviewed journals or professional industry publications to support your video. Include your source citations on a references page appended to your narrative script. Explore the resources about effective presentations as you prepare your assessment. Grading Requirements The requirements outlined below correspond to the grading criteria in the Care Coordination Presentation to Colleagues 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. Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes. Provide, for example, drug-specific educational interventions, cultural competence strategies. Include evidence that you have to support your selected strategies. Identify the aspects of change management that directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care. Explain the rationale for coordinated care plans based on ethical decision making. Consider the reasonable implications and consequences of an ethical approach to care and any underlying assumptions that may influence decision making. Identify the potential impact of specific health care policy provisions on outcomes and patient experiences. What are the logical implications and consequences of relevant policy provisions? What evidence do you have to support your conclusions? Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation. Fine tune the presentation to your audience. Stay focused on key issues of import with respect to the effects of resources, ethics, and policy on the provision of high-quality, patient-centered care. Adhere to presentation best practices. RUBRIC-By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria: Competency 2: Collaborate with patients and family to achieve desired outcomes. Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes. Competency 3: Create a satisfying patient experience. Identify the aspects of change management that directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care. Competency 4: Defend decisions based on the code of ethics for nursing. Explain the rationale for coordinated care plans based on ethical decision making. Competency 5: Explain how health care policies affect patient-centered care. Identify the potential impact of specific health care policy provisions on outcomes and patient experiences. Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care. Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation.

3-5 credible citaions
needs reference page and title page

Build a slide presentation (PowerPoint preferred) of the hypothetical health promotion plan you developed in the first assessment. Then, implement your health promotion plan by conducting a hypothetical face-to-face educational session addressing the health concern and health goals of your selected group. How would you set goals for the session, evaluate session outcomes, and suggest possible revisions to improve future sessions?

This assessment provides an opportunity for you to apply teaching and learning concepts to the presentation of a health promotion plan.
Note: This is the second part of a two-part assessment. You must complete Assessment 1 before completing this assessment.

For this assessment, you will conclude the clinical learning activity you began in Assessment 1.
You will resume the role of a community nurse tasked with addressing the specific health concern in your community. This time, you will present, via educational outreach, the hypothetical health promotion plan you developed in Assessment 1 to your fictitious audience. In this hypothetical scenario, you will simulate the presentation as though it would be live and face-to-face. You must determine an effective teaching strategy, communicate the plan with professionalism and cultural sensitivity, evaluate the objectives of the plan, revise the plan as applicable, and propose improvement for future educational sessions. To engage your audience, you decide to develop a PowerPoint presentation with voice-over and speaker notes to communicate your plan.
Remember that your first assessment (Assessment 1) MUST be satisfactorily completed to initiate this assessment (Assessment 4).
Please review the assessment scoring guide for more information.
To prepare for the assessment, you may wish to review the health promotion plan presentation assessment and scoring guide to ensure that you understand all requirements.

INSTRUCTIONS:
Complete the following:
Prepare a 10–12 slide PowerPoint presentation with a voice-over and detailed speaker notes that reflects your hypothetical presentation. This presentation is the implementation of the plan you created in Assessment 1. The speaker notes 4 pages long should be well organized. Be sure to include a transcript of the voice-over (please refer to the PowerPoint tutorial). The transcript can be submitted on a separate Word document.
Simulate the hypothetical face-to-face educational session addressing the health concern and health goals of your selected community individual or group.
Imagine collaborating with the hypothetical participant(s) in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to improve future sessions.
As you begin to prepare this assessment, you are encouraged to complete the Vila Health: Conducting an Effective Educational Session activity. The information gained from completing this activity will help you succeed with the assessment as you consider key issues in conducting an effective educational session for a selected audience. Completing activities is also a way to demonstrate engagement.
Presentation Format and Length
You may use Microsoft PowerPoint (preferred) or other suitable presentation software to create your presentation. If you elect to use an application other than PowerPoint, check with your faculty to avoid potential file compatibility issues.
The number of content slides in your presentation is dictated by nature and scope of your health promotion plan. Be sure to include title and references slides per the following:
Title slide:
Health promotion plan title.
Your name.
Date.
Course number and title.
References (at the end of your presentation).
Be sure to apply correct APA formatting to your references.
Supporting Evidence
Support your plan with at least three professional or scholarly references, published within the last 5 years, which may include peer-reviewed articles, course study resources, and Healthy People 2030 resources.
Graded Requirements
The requirements outlined below correspond to the grading criteria in the assessment 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.
Present your health promotion plan to your hypothetical audience.
Tailor the presentation to the needs of your hypothetical audience.
Adhere to scholarly and disciplinary writing standards and APA formatting requirements.
Evaluate educational session outcomes and the attainment of agreed-upon health goals in collaboration with participants.
Which aspects of the session would you change?
How might those changes improve future outcomes?
Evaluate educational session outcomes in terms of progress made toward Healthy People 2030 objectives and leading health indicators.
What changes would you recommend to better align the session with Healthy People 2030 objectives and leading health indicators?
Organize content with clear purpose/goals and with relevant and evidence-based sources (published within 5 years).
Slides are easy to read and error free. Detailed audio and speaker notes are provided. Audio is clear, organized, and professionally presented.

RUBRIC-
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
Competency 3: Evaluate health policies, based on their ability to achieve desired outcomes.
Evaluate educational session outcomes in terms of progress made toward Healthy People 2030 objectives and leading health indicators.
Competency 4: Integrate principles of social justice in community health interventions.
Evaluate educational session outcomes and the attainment of agreed-upon health goals in collaboration with hypothetical participants.
Competency 5: Apply professional, scholarly communication strategies to lead health promotion and improve population health.
Present a health promotion plan to a hypothetical individual or a group within a community.
Organize content with clear purpose/goals and with relevant and evidence-based sources (published within 5 years).
Slides are easy to read and error free. Detailed audio, transcript, and speaker notes are provided. Audio is clear, organized, and professionally presented.
Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies.
Deliver a professional, effective audio tutorial on a selected quality indicator that engages new nurses and motivates them to accurately report quality data in a timely fashion.
Follow APA style and formatting guidelines for citations and references.

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.

The first step in any effective project is planning. This assessment 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.

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.
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

During care coordination, nurses should ensure that they are creating patient-centered goals. A great way to achieve this is by using SMART (Specific, Measurable, Attainable, Relevant, Timely) goals. SMART goals provide direction for patient-centered care coordination.
SMART goals must be effective, meaningful, achievable, and collaborative in nature. Key stakeholders (such as the individual, group, or community; possibly significant others; and you, the nurse) must be taken into account.
Often the best way to patient-centered functional goals is simply to ask the target group, “What are your goals?” Doing this will help you to improve adherence, satisfaction, and outcomes. Consider the following when developing SMART goals:
Specific: Goals will specify who will be responsible, what is to be achieved, where the activity is located, and why it is important or beneficial.
Measurable: Goals must specify criteria for measuring progress against them. This helps you to stay on track, reach milestones, and motivate the stakeholders.
Attainable: Setting attainable goals serves to motivate the individual or group.
Relevant: Key stakeholders must see how a specific goal is relevant to them.
Timely: To be most effective, goals must be structured around a specific time frame to motivate individuals to begin working on their goals.
After developing a mutually agreed-upon goal, SMART objectives are developed to help guide activities. Objectives help to determine whether the goals have been achieved and if revisions need to be made for future educational sessions.
SMART objectives must be:
Specific: Objectives need to be concrete, detailed, and well-defined so that you know what exactly is going to occur and what to expect.
Measurable: A way to determine how the goal was met or if it needs revision.
Achievable: The objective must be appropriate and feasible for those involved. Ask: What’s the patient’s learning style? For example, does the patient prefer reading printed materials, viewing audiovisual materials, or watching demonstrations?
Realistic: It must take into consideration constraints such as resources, personnel, cost, education level, learning style, reading level and comprehension level. What language do they speak? How much does the individual or group like to know? Ask: Can the patient read or comprehend instructions or follow directions? Do they prefer reading printed materials, viewing audiovisual materials, or demonstrations?
Time-bound: A time frame helps set boundaries around the objective. Ask: How long will it take to obtain the objective? Objectives may be process- or outcome-oriented.
Outcome objectives can be short-term, intermediate, or long-term:
Short-term objectives can be achieved after implementing certain activities or interventions. Change may be in cognitive (knowledge), psychomotor (demonstration), and values (attitude).
Intermediate outcome objectives provide a sense of progress toward reaching long-term objectives. This could be behavior and policy change.
Long-term objectives occur after the program has been implemented. It may take more than a month. These can be changes in mortality, moribundity, and quality of life.

Example of a SMART goal:
Walk for 30 minutes a day, seven days a week.
Example of a SMART objective:
By the end of the week, patient will have walked 3.5 hours.
Example of an evaluation of a SMART objective:
The patient will complete a daily log of miles each week.
Additional Resources
The additional resources on the following reading list will help you in establishing SMART goals and objectives in collaboration with educational session participants:

RUBRIC:
Provides a perceptive analysis of a health concern and the associated best practices for health improvement. Provides credible evidence for best practices and articulates underlying assumptions and points of uncertainty in the analysis.

Describes specific goals that should be established to address a selected health care problem. Ensures that the goals are realistic, measurable, and attainable.

Identifies significant and available community resources for a safe and effective continuum of care. Provides a comprehensive list of resources, with credible evidence of their contribution toward improving community health.

Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.

Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly