Assignment: Transitional Care Plan

Assignment: Transitional Care Plan: MSN6610 – Case Coordination Scenario II

Assignment: Transitional Care Plan

Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care. Then, develop a transitional care plan, 4 pages in length, for the patient.
Note: Each assessment in this course builds on your work in the preceding assessment. Therefore complete the assessments in the order in which they are presented.
To help reduce care fragmentation, a care coordinator working with patients who suffer from chronic illnesses must share important clinical information with stakeholders so everyone has clear, shared expectations about their roles. Equally important, the care coordinator must work with the team to keep patients and their families up-to-date and to ensure that effective transitions and referrals take place. This assessment provides an opportunity for you to assume the role of care coordinator and recommend appropriate transitional care for a terminally ill patient.

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By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
o Competency 2: Evaluate current factors (such as population health, cost, interprofessional communications) affecting patient outcomes related to care coordination.
 Explain the importance of effective communications with other health care and community service agencies involved in the transition.
 Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
o Competency 3: Determine appropriate care coordination performance measures for driving high-quality patient outcomes, based on current accrediting standards and benchmarks.
 Explain the importance of each key element of a transitional-care plan.
o Competency 4: Apply relevant evidence-based practices that reflect a shift toward a broader population health focus on patient outcomes.
 Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
 Develop a strategy for ensuring an accurate provider understanding of the patient medication list, plan of care, and follow-up plan during a patient care transition.
o Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
 Write clearly and concisely, using correct grammar and mechanics.
 Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Relative to other facets of medical care, research to direct efforts to improve care coordination has lacked rigor. However, many groundbreaking health care organizations have acknowledged the perils of poorly coordinated care models and applied interventions to improve these models.
The objective of care coordination is to secure high-quality recommendations and transitions that aim for superior health care and guarantee that all involved providers, organizations, and patients have the necessary information and resources to make optimal patient care possible.

Questions to Consider
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
o What are the likely outcomes of poor care transitions among providers and health care settings?
o Why is effective communication such a vital component of transitional care?
o Where are communication breakdowns likely to occur?
 Why?
 Have you seen or experienced such breakdowns in your own practice setting?
Required Resources
The following resources are required to complete your transitional care plan.
o Vila Health: Care Coordination Scenario II | Transcript
 Use this multimedia simulation to gather the information you will need to complete your plan.
o APA Style Paper Template [DOCX].
 Use this template for your plan.

Suggested Resources
The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The MSN-FP6610 Introduction to Care Coordination Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.
Transitions of Care
o Alliance for Home Health Quality and Innovation. (2014). Improving care transitions between hospital and home health: A home health model of care transitions [PDF]. Available from
 An ADA-compliant PDF is available here.
o National Learning Consortium. (n.d.). Care coordination tool for transition to long-term and post-acute care [PDF]. Retrieved from
o Institute for Clinical Systems Improvement. (2017). Transition communications – Tools and resources. Retrieved from
o Institute for Healthcare Improvement. (2012). How-to guide: Improving transitions from the hospital to skilled nursing facilities to reduce avoidable rehospitalizations [PDF]. Retrieved from
o Joint Commission Center for Transforming Healthcare. (2014). Improving transitions of care: Hand-off communications [PDF]. Available from
 An analysis of the effects of handoff communications on transitional care.
 Find an ADA-compliant PDF here.
o New York State Department of Health. (2008). Suggested model for translational care planning. Retrieved from
o Shaver, K. (n.d.). Transitional care management: Better care for our patients [PDF]. Retrieved from
 A presentation of key points about the management of transitional care.
o Transition Care Plan Example [PDF].
Suggested Writing Resources
You are encouraged to explore the following writing resources. You can use them to improve your writing skills and as source materials for seeking answers to specific questions.
o APA Module.
o Academic Honesty & APA Style and Formatting.
o APA Style Paper Tutorial [DOCX].
Capella Resources
o ePortfolio.
• Assessment Instructions
In the previous assessment, you conducted simulated stakeholder interviews and collected information for a plan of care for Mrs. Snyder. Now, seven months later, her condition has deteriorated.
To prepare for this assessment, complete the Vila Health: Care Coordination Scenario 2 simulation (linked in the Required Resources) in which you will recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family. Completing this exercise will help you develop a transitional care plan for Mrs. Snyder.
Develop a transitional care plan for Mrs. Snyder.
Transitional Care Plan Format and Length
You may use a familiar transitional care plan format or template—for example, one used in your organization—or you may create your own. A link to an example is provided in the Suggested Resources.
o Format your transitional care plan in APA style; an APA Style Paper Tutorial is also linked in the Suggested Resources to help you. Be sure to include:
 A title page and reference page. An abstract is not required.
 A running head on all pages.
 Appropriate section headings.
o Your plan should be 4 pages in length, not including the title page and references page.
Supporting Evidence
Cite 4–5 sources of scholarly or professional evidence to support your plan.
Developing the Transitional Care Plan
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your transitional care plan addresses each point, at a minimum. Read the Transitional Care Plan Scoring Guide to better understand how each criterion will be assessed.
o Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
 Include elements such as emergency and advance directive information, medication reconciliation, plan of care, and available community and health care resources.
o Explain the importance of each key element of the transitional care plan.
 Identify potential effects of incomplete or inaccurate information on patient outcomes and the quality of care.
 Cite credible evidence to support your assessment of each element’s importance.
o Explain the importance of effective communications with other health care and community services agencies involved in the transition. Assignment: Transitional Care Plan
 Identify potential effects of ineffective communications on patient outcomes and the quality of care.
o Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
 Consider barriers inherent in such care settings as long-term care, sub-acute care, home care services, and home care with support.
 Identify at least three barriers.
o Develop a strategy for ensuring that the destination care provider has an accurate understanding of the patient medication list, plan of care, and follow-up plan.
 Cite credible evidence to support for your strategy.
o Write clearly and concisely, using correct grammar and mechanics.
 Express your main points and conclusions coherently.
 Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
o Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
Portfolio Prompt: You may choose to save your transitional care plan to your ePortfolio. Assignment: Transitional Care Plan


Discussion Questions (DQ)

  • Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
  • Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
  • One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
  • I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

  • Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
  • In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
  • Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
  • Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

  • Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
  • Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
  • I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

  • I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
  • As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
  • It is best to paraphrase content and cite your source.


LopesWrite Policy

  • For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
  • Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
  • Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
  • Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

  • The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
  • Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
  • If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
  • I do not accept assignments that are two or more weeks late unless we have worked out an extension.
  • As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.


  • Communication is so very important. There are multiple ways to communicate with me: 
    • Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
    • Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.



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