Care Coordination Plan

Care Coordin" rel="nofollow">ination Plan Order Description THIS WILL NOT BE USED FOR AN ACTUAL CLINIC SETTING> The hospital where you work has an issue with in" rel="nofollow">increased readmissions within" rel="nofollow">in 30 days of discharge. After examin" rel="nofollow">inin" rel="nofollow">ing the core measures, it was found that heart failure was the most common core measure disease process experiencin" rel="nofollow">ing the highest rate of readmissions. The leadership team has given your team the charge of developin" rel="nofollow">ing a nurse-run outpatient heart failure clin" rel="nofollow">inic. The purpose of this clin" rel="nofollow">inic is to ensure that discharge education is presented to the patient in" rel="nofollow">in an orderly, consistent manner and complies with evidence-based practice protocols. Sin" rel="nofollow">ince these patients may be discharged from a variety of areas in" rel="nofollow">in the facility, havin" rel="nofollow">ing the heart failure clin" rel="nofollow">inic staff take ownership of the process will improve both consistency and compliance. There are cardiologists that in" rel="nofollow">interact with the staff and patients, but the day-to-day operations of the clin" rel="nofollow">inic are designed and supported by the nurses as they in" rel="nofollow">interact with appropriate members of the other health care team disciplin" rel="nofollow">ines promotin" rel="nofollow">ing the best care for the heart failure patients. Care Coordin" rel="nofollow">ination Plan: •Develop an evidence-based plan for health care delivery. ?Develop a procedure for coordin" rel="nofollow">inatin" rel="nofollow">ing services. ?Consider the needs of "outliers." For example, someone with lung disease may need extra resources. ?Who should be on the team? ?When would the team be activated? ?How would it be activated? ?What is the time frame required to coordin" rel="nofollow">inate services? ?How would the in" rel="nofollow">intervention plan be monitored for effectiveness? •Apply professional standards in" rel="nofollow">in support of a care plan. ?Explain" rel="nofollow">in the alignment to the most recent heart failure guidelin" rel="nofollow">ines and specific professional standards. ?Describe accountability tools and procedures used to measure effectiveness. ?How will you know if the care coordin" rel="nofollow">ination plan is successful? ?What are the in" rel="nofollow">indicators of success or effectiveness? ?How will in" rel="nofollow">information be collected or communicated?