Rasmussen College Stroke Patients Care Coordination Plan Paper

Complete the preliminary care coordination plan you developed in Assessment 1. Present the plan to the patient in a face-to-face clinical learning session and collaborate with the patient in evaluating session outcomes and addressing possible revisions to the plan.

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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 for you to apply communication, teaching, and learning best practices to the presentation of a care coordination plan to the patient.

Demonstration of Proficiency

By 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 care.
  • Competency 2: Collaborate with patients and family to achieve desired outcomes.
    • Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with a patient.
  • Competency 3: Create a satisfying patient experience.
    • Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators.
  • Competency 4: Defend decisions based on the code of ethics for nursing.
    • Make 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.


In this assessment, you will complete the preliminary care coordination plan you developed in Assessment 1 and communicate the plan to the patient in a professional, culturally sensitive, and ethical manner.

To prepare for the assessment, consider the patient experience and how you will present the plan. Make sure you schedule time accordingly.

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