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Document Format: Margins are 1 in. (2.54 cm) on all sides.

All text in the document should be double-spaced.

The font is 12-point Times New Roman. Other choices are 11-point Arial and 11-point Calibri.

The title page is page 1.

There is no running head for learner assignments. (See Academic Writer: Publication Manual §§ 2.1–2.24 for paper requirements.)

Full Title of Your Paper Comment by Author: APA Style: Sample Papers shows the title page for a student paper.

Learner’s Full Name (no credentials)

School of Nursing and Health Sciences, Capella University

Course Number: Course Name

Instructor’s Name

Month, Year Comment by Author: The due date


An abstract is useful in professional papers, but not always in learner assignments. In fact, unless you are instructed by your faculty or in the course syllabus, do not expect to use abstracts very often at Capella. If you are submitting for publication, remember to check with the journal or professional organization about their criteria for an abstract. The abstract tells your reader about the article, is brief, and stands alone, so no citations are included. The format for an abstract is a single paragraph (not indented on the first line) that follows the title page and is less than 250 words in length. A structured abstract will have a single paragraph without indentation but having labels (e.g., Objective, Method, Results, and Conclusions) on the same line as the text and bold. For published works, the publishing organization will give you guidance on these. However, for student papers, no abstract is needed unless the faculty request one or the assignment requires it. Remember, no citations. Comment by Author: See Academic Writer: Publication Manual §§ 2.9–2.10 (p. 38 in the APA manual) for more information on abstracts.

Keywords: include keywords in the abstract—they should be labeled like this, with the words all in lowercase and separated by commas. Only the first line is indented, like a regular paragraph. No period at the end.

APA Style Seventh Edition Paper Template: A Resource for Academic Writing Comment by Author: New in APA seventh style—this heading is a regular Level 1 and should be bold.

American Psychological Association (APA) style is one of the most popular methods used to cite sources in the social sciences, but it is not the only one. When writing papers in the programs offered at Capella University, you will likely use APA style. This document serves as an APA style resource for the seventh edition guidelines, containing valuable information that you can use when writing academic papers. For more information on APA style, refer to the Publication Manual of the American Psychological Association, also referred to as the APA manual (American Psychological Association, 2020b). Comment by Author: Another important resource for Capella learners is Academic Writer.

The first section of this paper shows how an introduction effectively introduces the reader to the topic of the paper. In APA style, an introduction never gets a heading. For example, this section did not begin with a heading titled “Introduction,” unlike the following section, which is titled “Writing an Effective Introduction.” The following section will explain in greater detail a model that can be used to effectively write an introduction in an academic paper. The remaining sections of the paper will continue to address APA style and effective writing concepts, including section headings, organizing information, the conclusion, and the reference list. Comment by Author: See also Academic Writer: Introduction.

Writing an Effective Introduction Comment by Author: Level 1 section heading

An effective introduction often consists of four main components, including (a) the position statement, thesis, or hypothesis, which describes the author’s main position; (b) the purpose, which outlines the objective of the paper; (c) the background, which is general information needed to understand the content of the paper; and (d) the approach, which is the process or methodology the author uses to achieve the purpose of the paper. This information will help readers understand what will be discussed in the paper. It can also serve as a tool to grab the reader’s attention. Authors may choose to briefly reference sources that will be identified later in the paper as in this example (American Psychological Association, 2020a; American Psychological Association, 2020b). The Writing Center has developed the acronym POETS to help describe the proper writing style for submissions. POETS is the acronym for purpose, organization, evidence, tone, and sentence structure (Capella Writing Center, n.d.). There will be more on this later. Comment by Author: This is the format for a complex list within a sentence. The items begin with lowercase letters and are separated by appropriate punctuation.

Related items can also be set off from the text and presented as numbered or bulleted lists. For more information on lists, see Academic Writer: Lists. Comment by Author: When you have two sources with the same author and date, use a lowercase a, b, c, after the year and alphabetize the sources in the reference list according to the title. For the same author but no date, use n.d.-a and n.d.-b as the date. See Academic Writer: Alphabetizing the Reference List for more information.

In an introduction, the writer will often present something of interest to capture the reader’s attention and introduce the issue. Adding an obvious statement of purpose helps the reader know what to expect, while helping the writer to focus and stay on task. For example, this paper will address several components necessary to effectively write an academic paper, including how to write an introduction, how to write effective paragraphs, and how to effectively use APA style.

Level 1 Section Heading Is Centered, Bold, and Title Case Comment by Author: Something new in APA seventh style—all headings are double-spaced, bold, and written in title case. See Academic Writer: Heading Levels.

Using section headings can be an effective method of organizing an academic paper. Section headings are not required according to APA style; however, they can significantly improve the quality of a paper by helping both the reader and the author, as will soon be discussed. Comment by Author: In POETS, this is the O for organization. See Writing Center: Organization.

Level 2 Section Heading Is Aligned Left, Bold, and Title Case

The heading style recommended by APA consists of five levels (APA, 2020b, pp. 47–48). This document contains multiple levels to demonstrate how headings are structured according to APA style. Immediately before the previous paragraph, a Level 1 section heading was used. That section heading describes how a Level 1 heading should be written, which is centered, bold, and using uppercase and lowercase letters (also referred to as title case). For another example, see the section heading “Writing an Effective Introduction” on page 3 of this document. The heading is centered and bold and uses uppercase and lowercase letters. If used properly, section headings can significantly contribute to the quality of a paper by helping the reader, who wants to understand the information in the document, and the author, who desires to effectively describe it.

Section Heading Purposes Comment by Author: This is a Level 3 heading. Notice it is aligned left, bold, italic, and title case. The paragraph begins on a new line. See Academic Writer: Heading Levels.

Section Headings Help the Reader. Section headings serve multiple purposes, including helping the reader understand what is being addressed in each section, maintain an interest in the paper, and choose what they want to read. For example, if the reader of this document wants to learn more about writing an effective introduction, the previous section heading clearly states that is where information can be found. When subtopics are needed to explain concepts in greater detail, different levels of headings are used according to APA style. Comment by Author: This is a Level 4 heading—it is indented, bold, and title case. The heading ends in a period, and the text begins on the same line as the heading.

Section Headings Help the Author. Section headings not only help the reader; they also help the author organize the document during the writing process. Section headings can be used to arrange topics in a logical order, and they can help an author manage the length of the paper. In addition to an effective introduction and the use of section headings, each paragraph of an academic paper can be written in a manner that helps the reader stay engaged. Comment by Author: Level 4 heading

Section Headings Can Demonstrate Fine Detail. Short papers and assignments may not require or need a Level 5 heading, but these will be indented, bold, italic, and title case and end with a period. Note the text starts on the line at the end of the heading following the period. Comment by Author: Level 5 heading

How to Write Effective Paragraphs Comment by Author: The Writing at Capella multimedia presentation will help you understand the POETS model.

Capella University’s Writing Center (n.d.) has adopted a new set of writing standards to assist learners in their goals to improve their scholarly writing. It is based on five skills known by the mnemonic POETS. In other words, a well-developed Capella paper will demonstrate the following standards. The paper will have a clear purpose statement, be logically organized, utilize current and appropriate evidence that is properly cited, maintain a scholarly tone, and demonstrate proper grammar and writing mechanics in the sentence structure (Capella Writing Center, n.d.). Academic writing is sometimes considered dry and boring. A learning experience may need that formula to encourage learning in different ways as the learner moves from passive learner to active scholar. This growth, according to Gilmore et al. (2019), requires the writer to not only think but also to write differently. Comment by Author: Notice the et al. here—this article has four authors. In APA seventh style, any source with three or more authors will use et al. for every citation, eliminating the need to remember when this appropriate. For more information, see Academic Writer: Citing References in Text.

Bias-Free Language

In the seventh edition of the APA manual, another focus is on eliminating bias in language in order to provide a more inclusive tone in scholarly writing. While long considered a grammar issue, it is acceptable in APA to utilize they as a singular pronoun (APA, 2020b). In fact, there is an entire chapter of the manual dedicated to ways to reduce bias in scholarly writing. It is important to use an appropriate level of specificity in descriptions and use sensitivity with the use of labels. Other sections include guidelines on age, disability, gender, race and ethnicity, sexual orientation, socioeconomic status, and participation in research. Be aware of intersectionality, a term used to describe a person based on their identified multiple identities, interconnectivity, social context, power relations, complexity, social justice, and inequalities that can result in oppression (Cole, 2019; Hopkins, 2017). Comment by Author: See Academic Writer: Intersectionality for the guidelines. Comment by Author: Note the two citations—in a single set of parentheses and separated by a semicolon. The citations are listed alphabetically.

Considering Direct Quotations

Another important point to consider is the use of direct quotations in papers. While plagiarism is considered an academic integrity issue, many learners are concerned with issues such as self-plagiarism and unintentional plagiarism, and there are others who may go as far as purchasing papers for submission (Colella & Alahmadi, 2019). As a learner travels along their chosen academic pathway, their writing skills and mechanics are expected to improve. It is imperative that the learner transition from finding information and quoting the author word for word to using the information to support an idea, paraphrase, and then synthesize and express the findings in one’s own words. Having said that, there are situations in which quotations may be appropriate, so it is important to cite them properly. According to the seventh edition of the APA manual, “When quoting directly, always provide the author, year, and page number of the quotation in the in-text citation in either parenthetical or narrative format” (APA, 2020b, p. 270). If there are not page numbers, identify the location in another manner (such as a paragraph number). Comment by Author: Notice the quotation marks around the quoted text and the placement of the punctuation after the parenthetical citation. See Academic Writer: Quotation Marks for more on the use of quotation marks.

Notice that the above quote contains fewer than 40 words. There is a different style for quotes containing 40 words or more. These longer quotes use a block quotation format:

Do not use quotation marks to enclose a block quotation. Start a block quotation on a new line and indent the whole block 0.5 in. from the left margin. If there are additional paragraphs within the quotation, indent the first line of each subsequent paragraph an additional 0.5 in. Double-space the entire block quotation; do not add extra space before or after it. Either (a) cite the source in parentheses after the quotation’s final punctuation or (b) cite the author and year in the narrative before the quotation and place only the page number in parentheses after the quotation’s final punctuation. Do not add a period after the closing parenthesis in either case. (APA, 2020b, p. 272) Comment by Author: Notice there is no period after this citation in a block quote—it looks odd, but it is APA style. See Academic Writer: Quotation Marks.


A summary and conclusion section, which can also be the discussion section of an APA style paper, is the final opportunity for the author to make a lasting impression on the reader. The author can begin by restating opinions or positions and summarizing the most important points that have been presented in the paper. For example, this paper was written to demonstrate to readers how to effectively use APA style when writing academic papers. Various components of an APA style paper that were discussed or displayed in the form of examples include a title page, introduction section, levels of section headings and their use, the POETS format, bias-free language, in-text citations, a conclusion, and the reference list.

References Comment by Author: Remember all headings are bold.

American Psychological Association. (2020a). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://doi.org.apa.org/ethics/code/index.aspx

American Psychological Association. (2020b). Publication manual of the American Psychological Association (7th ed.). Comment by Author: This is something new in APA seventh style—you no longer need the location of the publisher for print books. Also note that if the author is the publisher, it is only listed as the author. This guideline is found on page 324 of the APA manual.

Capella University. (n.d.). Writing Center. https://campus.capella.edu/writing-center/home

Cole, N. L. (2019, October 13). Definition of intersectionality: On the intersecting nature of privileges and oppression. ThoughtCo. https://www.thoughtco.com/intersectionality-definition-3026353

Colella, J., & Alahmadi, H. (2019). Combating plagiarism from a transformation viewpoint. Journal of Transformative Learning, 6(1), 59–67. https://jotl.uco.edu/index.php/jotl/article/view/184

Gilmore, S., Harding, N., Helin, J., & Pullen, A. (2019). Writing differently. Management Learning, 50(1), 3–10. https://doi.org/10.1177/1350507618811027

Hopkins, P. (2017). Social geography I: Intersectionality. Progress in Human Geography, 43(5), 937–947. https://doi.org/10.1177/0309132517743677

Appendix Comment by Author: See Academic Writer: Publication Manual § 2.14 for more on appendices.

Tips for the Reference List

· Always begin a reference list on a new page. It should be placed before any appendices, figures, or tables and titled References.

· Set a hanging indent that starts with the second line and is double-spaced. You can look in the Paragraph menu of Microsoft Word for formatting the hanging indent so that you will not have to tab the indent. It gives the text a smoother look that remains consistent, even if you make edits.

· The reference list is in alphabetical order by the first author’s last name. A reference list only contains sources that are cited in the body of the paper, and all sources cited in the body of the paper must be included in the reference list. If you did not cite it, do not list it.

· The reference list above contains an example of how to cite a source when two documents are written in the same year by the same author.

· The lowercase letters are used after the date to differentiate the sources. The “a” reflects the alphabetical order in the reference list—not whether it appeared first in the text.

· The year is also displayed using this method for the corresponding in-text citations, as in the following sentence: The author of the first citation (American Psychological Association, 2020b) is also the publisher; therefore, the word Author is no longer used in the seventh edition.

· DOI is the digital object identifier.

· It can be found on the first page of an article, on the copyright page of a book, in the database record of a work, or by searching Crossref.

· Even if the book is in print, if there is a DOI, use it.

· Always use the hyperlink format for a DOI—it will always start with https://doi.org/ and will be followed by a number. If the DOI is not in this format, convert it. Do not alter this format, and do not add a final period.

· There is a short DOI service at http://shortdoi.org/.

· URL is the uniform resource locator.

· If there is no DOI, the URL should be used in the reference.

· Copy and paste the URL directly into your list.

· Do not add a period at the end.

· Do use “Retrieved from” before a URL.

· The Colella and Alahmadi reference is an example of how to cite a source using a URL. Please note that you will not use the Capella link that is often provided in the courseroom. If the URL contains a database title, such as EBSCO or ProQuest, or the name Capella, do not use that in your citation as it will only work for Capella learners and faculty.

· For examples and further information on references go to:

· Academic Writer: Sample References.

· Academic Writer: Reference List.

I need this by Friday

This is the transcript for the
Vila Health: The Nurse’s Role in Care Coordination
. You can get information here.


Care coordination is one of the fastest growing and evolving trends in the nursing field. In order to be an effective care coordinator, it is important to understand the roles that case managers and other care coordination team members play in a health care setting. It is also valuable to understand how these roles have evolved—and continue to evolve— over time. In this activity, you will learn more about the role of care coordination in an acute care setting.

After completing the activity, you will be prepared to:

· Summarize the roles that case managers and other team members play in care coordination.

· Contextualize care coordination and today’s care coordination trends historically.


Congratulations! You have been just hired as a case management intern in the Care Coordination Department at St. Anthony Medical Center. Located in Minneapolis, St. Anthony is a 120-bed hospital in the Vila Health system, which operates facilities in several Midwest states. The Care Coordination Department manages patient cases throughout the entire hospital.

Since it’s your first day, your first task is to get oriented. Your preceptor will help you get started. To learn more about the roles that care coordinators play in nursing, you’ll be talking with experienced case managers, social workers, and other members of the team. You’ll also sit in on a coordination planning meeting.


It looks like you have an email from Denise McGladrey, your new preceptor. Click the icon to read it.

From: Denise McGladrey
Subject: Your first day

Welcome to St. Anthony! We’re so glad to have you on the Care Coordination team. As you know, I am going to be your preceptor. My job is to help you transition into your new role as case management intern and to offer you support. You should feel free to come to me with questions.

I have several meetings today, so I won’t be able to meet with you until this afternoon. In the meantime, since this is your first day, I want you to learn more about your role by talking with some of the people with whom you’ll be collaborating. I’d like for you to ask them questions about the case management role and the skills you’ll need to be successful. Most of the people you’ll be talking to have a good deal of experience, so I’d also like for you to ask questions about how the field has evolved over the years.

I’ve gone ahead and scheduled two interviews with you: one with Vicki Vasquez, who, as you know, is the Director of Case Management here at SAMC. The other interview will be with Samantha Rockwell, an experienced social worker who you’ll be coordinating with quite a bit in the near future. You’ll also have the opportunity to schedule interviews with your choice of a number of other team members.

I’ll be catching up with you later. Have a great day!


Schedule Interviews

It looks like you need to speak with Mackenzie, Crystal, and Joyce about this incident—and then find some strategies for motivating them to succeed. You should go talk with each of them now.

Seth Patterson

Case Manager

Can you please describe your role in the department?

Seth: I coordinate care for all kinds of people in the hospital. They tend to give me cases involving older adults, since that’s my background, but for the most part all the case managers need to be equipped to work with all kinds of cases. I worked with geriatric patients almost exclusively with another hospital. Other case managers come to me sometimes when they need geriatric resources or have questions about how to help elderly patients.

In your opinion, what are some of the most important things a new case manager needs to know?

Seth: Here’s a tip: make yourself a master list of phone numbers! I can help you get started with that. After a while, you figure out who to call at each insurance company when you really need to get something done, or who to call at various social service agencies to get accurate information about resources, and so forth. I can’t even tell you how much time my list saves me!

What are some of the biggest mistakes case managers make?

Seth: One of the biggest problems case managers have is with coordinating transfers from one facility to another—especially when you’re talking about older adults, because moving them can be very risky. When patients go to the wrong facilities, that can be traumatic for the patient and costly for the hospital. It’s important to do your research and find the best possible facilities for patients so they don’t have to be moved again. That can be a real challenge because of insurance issues… ugh! It’s incredibly frustrating when the best facility for someone isn’t covered by insurance. But that’s just part of our jobs…. negotiating stuff like that with insurance companies on behalf of our patients’ best interests. It’s also really important to figure out whether sending somebody home is a good idea. Sometimes home health care is the best solution, but sometimes it’s not, depending on the family situation and all kinds of factors you need to consider.

In your experience, how has care coordination changed?

Seth: Dealing with insurance companies and Medicare and federal regulations and all of that… it just gets more complicated all the time. I like to think that I’m an advocate for our patients, helping them navigate through all this red tape and regulation. If it’s this hard for me to navigate things, I can only imagine how hard it is for the patients—especially if they’re elderly or have language barriers and stuff like that.

What are the some of the most important trends in care coordination?

Seth: Electronic medical records are revolutionizing what we do. And overall this is a good thing. I mean, a big part of what we do is to try to prevent fragmentation of care, and EMRs make a world of difference with that. On the other hand, as someone who’s worked with elderly people, I know what a problem EMRs can pose to patients who aren’t technologically literate. I’ve heard and seen horror stories. One of the nurses at a clinic where I used to work, she told me about this elderly woman who had elevated blood sugar levels. Her manager wouldn’t let her call the woman to get a retest because the clinic wanted to push people into using the new patient portal. You know, because of meaningful use issues? If enough people didn’t use the portal, the clinic could lose funding. Well, this woman was in her 80s, and lo and behold, she never looked at her electronic record and wound up at the hospital with a blood sugar level over 600!

Nora Jackson-Green

Case Manager

Can you please describe your role in the department?

Nora: Oh boy, where do I even get started? I don’t want to sound melodramatic, but sometimes I feel like I’m a human life raft. The medical system is this massive sea of confusing information. And sometimes there’s dangerous sea monsters who are more interested in getting paid than helping a patient get to land. My job is to navigate the patients through all this choppy water so they don’t drown.

In your opinion, what are some of the most important things a new case manager needs to know?

Nora: Case managers need to know how to communicate with the patients and their families! They need to make sure that families truly have the resources they need to help care for a patient. It’s not enough to ask patients what they need, because a lot of times they don’t know what they need. Or they totally underestimate how much physical and emotional work goes into caring for a loved one. It’s our job to anticipate their needs before a crisis happens. And as Baby Boomers like me get older, it’s going to be more and more important to know how to help families navigate these kinds of situations. We’re not a society that’s set up to help people who are old and sick! So it’s up to us to make sure people get what they need.

What are some of the biggest mistakes case managers make?

Nora: Case managers really need to be on the lookout for red flags that something’s wrong, or that something’s not going to go smoothly. Because otherwise, patients who really need our help can fall through the cracks. We don’t always have a lot of time with the patients, so we need to pay attention to all kinds of details. If a patient is showing any possible signs of dementia, for example, that’s a red flag. We need to investigate further. If a patient is taking a potentially dangerous drug, or if they show signs of prescription drug dependency, we need to follow up and not just send that patient home. It’s kind of like being a detective, only you don’t know exactly what you’re looking for.

In your experience, how has care coordination changed?

Nora: Well, I think the whole health care system has changed in that there’s so much more emphasis on accountability. We have to prove we’re doing a good job. Care coordination has evolved with the emphasis on outcomes and quality. It used to be that care coordination was a more unofficial part of what nurses did. Now, it’s being recognized more and more as a critical job duty, and that’s because coordinated care leads to better outcomes.

What are the some of the most important trends in care coordination?

Nora: Like I said, the emphasis on outcomes and quality has really changed care coordination. We’re constantly being evaluated on patient outcomes. There are direct financial consequences for the hospital if our outcomes aren’t good. That means that care coordination is taken more seriously, because it absolutely has to be.

Vicki Vasquez

Director of Case Management

Can you please describe your role in the department?

Vicki: Well, the part of my job that I like the most is serving as a role model and mentor to the team members in this department. I’ve worked in care coordination for a long time. So if someone feels like they’re up against a brick wall and can’t figure out how to help a patient, I can put on my coach hat. I enjoy that. A more challenging part of my job is working with the bureaucracy to make sure that patients get what they need and that the hospital gets paid. Health care law and regulations change all the time. You’ll be shocked at how much they change. As the leader of this department I have to make sure I’m 100% on top of these changes—especially since St. Anthony is an Accountable Care Organization. The hospital is constantly evaluated on 33 quality indicators, and our ability to manage complicated cases is essential if we’re going to keep our rank up.

In your opinion, what are some of the most important things a new case manager needs to know?

Vicki: There’s a lot you need to know to be an effective case manager. One of the most crucial skills is problem solving. If you’re looking for a job where there are clear-cut answers in a guidebook, well, maybe you should be an accountant or something. Every case is like a puzzle that needs a unique solution, and a lot of times, even the best solutions need troubleshooting.

And a big part of learning how to solve these problems is looking at patients holistically. You know what I mean by holistically, right? That means you have to look at the whole situation and understand how all the parts of the situation fit together. You have to look at the whole picture—health history, psychological factors, family situation, financial situation, ethnic and religious factors. There are all kinds of barriers to care you can miss if you don’t look at how the factors fit together.

What are some of the biggest mistakes case managers make?

Vicki: I think different case managers tend to make different mistakes. Like I said, it’s really important to understand patients holistically. When case managers focus exclusively on medical issues to the exclusion of a patient’s family or social situation, that’s a big miss. And another serious error that case managers can make is exceeding their scope of practice. It’s very important not to overstep boundaries and make decisions that belong to physicians or other members of the team. And that’s an easy trap to fall into… like, for example, it can be very tempting to make a decision about changing a patient’s medication or dosage without consulting the primary physician. Maybe the physician is hard to reach that day, and maybe it seems very obvious to the case manager that a medication needs to be discontinued. But those kinds of decisions can lead to critical errors and liability issues. Case managers absolutely need to respect the primary physician’s role as the team lead. And sometimes, like it or not, they need to follow orders.

In your experience, how has care coordination changed?

Vicki: We’re starting to understand care coordination as a specialized job duty in a way that we didn’t before. There’s always been care coordination. Nurses did that as a part of their jobs, and they still do. But now we have full time case managers, and schools are offering coursework and formal training in care coordination.

What are the some of the most important trends in care coordination?

Vicki: Well, the health care system as a whole has gone through some major paradigm shifts. From the perspective of our work, I think the most important trend has to do with value-based payments. The hospital’s ability to receive reimbursement is directly tied to quality and patient outcomes—especially since we’re an Accountable Care Organization. Because of this, care coordination professionals play a crucial role in overseeing care to prevent errors. And overall, this is a positive change that improves patient care. But it does add a new level of pressure on case managers.

Samantha Rockwell

Social Worker

Can you please describe your role in the department?

Samantha: I consult with case managers to make sure that they’re considering all the social issues that impact a patient’s ability to get the care they need and to manage their care. I meet with patients and find out what’s going on in their lives… their financial situations, their family situations, possible barriers to care, anything really that might impact their ability to get care. I also work with case managers to help locate appropriate resources for clients

In your opinion, what are some of the most important things a new case manager needs to know?

Samantha: Case managers need to remember that care coordination is a transdisciplinary field. You have to be able to collaborate effectively with an interdisciplinary team. In fact, I would say that collaboration is possibly the most important skill that a case manager needs. You work with all kinds of people both inside and outside the hospital, and with insurance companies and families too. Nobody expects case managers to have all the answers, but they need to know who to work with and how to work with people to get these answers.

What are some of the biggest mistakes case managers make?

Samantha: When case managers overlook barriers to care, that’s a big problem. Sometimes case managers have blind spots when it comes to identifying these barriers. A few years ago, I worked with a case manager that just didn’t seem to understand transportation barriers. She would set up follow up care for patients way out in the suburbs. But a lot of our patients, they rely on public transit and can’t get out that far. Or they’re old and they don’t drive, or they don’t feel comfortable driving on freeways to new places. I don’t know why it never occurred to her that this could be a problem.

In your experience, how has care coordination changed?

Samantha: There’s a lot more awareness of the importance of looking at patients’ needs as they relate to sociological issues. This kind of awareness has been around informally for a long time—I mean, nurses have always been aware of these kinds of issues, and social workers have been employed by hospitals for a long time. But now social workers are being brought in more routinely to assess situations, as opposed to bringing us in later after something goes wrong. There are a lot of opportunities for social workers to go into care coordination right now, and that’s exciting.

What are the some of the most important trends in care coordination?

Samantha: Thanks to the Affordable Care Act, most people have access to medical care now. We used to see a lot of uninsured patients in the hospital, and now uninsured patients are the exception. This is a good change, of course—a very good change. But it also brings challenges. We’re working with people now who have little or no experience with the health care system. They need to be educated on how to work effectively with us. A lot of people don’t realize how things like deductibles work, and that health insurance doesn’t cover every single expense. And the Affordable Care Act also has led to more people in the system from lower socioeconomic groups. These people tend to have more barriers to care. We have to anticipate that some people will need more guidance through the system than others.

Lucas Branch

Diabetes Educator

Can you please describe your role in the department?

Lucas: I work with case managers to make sure that patients get the information they need about diabetes care and prevention. When appropriate, I provide patients with resources to help them manage their diabetes. Often I help patients who are diagnosed with a chronic condition and who also have diabetes, since that new condition might mean they have to make changes in their diabetes management plan. I also talk with patients who have prediabetes or risk factors.

In your opinion, what are some of the most important things a new case manager needs to know?

Lucas: From my perspective, case managers need to be aware that it’s critical to provide patients with accurate information—and explain to them how to use it. With diabetes, there’s so much misinformation out there. Some patients underestimate the danger of diabetes and think it’s no big deal. Others are completely terrified and think it’s a death sentence, and they don’t realize they have the power to manage it. And that’s true of other medical conditions as well. People rely way too much on Dr. Internet to get the information they need. A case manager needs to make sure that patients have real information they can use.

What are some of the biggest mistakes case managers make?

Lucas: As a team, it’s so important to do everything we can to prevent fragmentation of care. Fragmentation brings costs up and quality down, and it can be really dangerous. We need to make sure patients aren’t getting conflicting information or medication from different providers.

In your experience, how has care coordination changed?

Lucas: That’s a better question for someone like Nora, who’s been working in this field for so much longer than me! But even in the short time I’ve been here, I can see how much more care goes into managing patient transfers. We do a lot more investigating now to make sure patients are going to the right facilities.

What are the some of the most important trends in care coordination?

Lucas: The team mentality has made a really big difference. The idea that you bring in a diabetes educator, you bring in a dietician, you coordinate with a social worker…. that kind of interdisciplinary thinking leads to much better outcomes.

Karen Wu


Can you please describe your role in the department?

Karen: I work with patients to make sure they have the information they need about nutrition in relation to their conditions. I educate, and give suggestions. A lot of patients have no idea what a difference changes in their diet and exercise can make. People often feel really overwhelmed by the prospect of changing their diet and health habits, so I help them come up with realistic strategies for making changes.

In your opinion, what are some of the most important things a new case manager needs to know?

Karen: I think case managers need to manage how overwhelming it can be for patients to be in the hospital. Someone gets diagnosed with a chronic or a terminal illness, and then they suddenly get all this information about all this stuff they need to do—medication, physical therapy, doctor’s appointments, changes in diet and exercise, so much! Case managers should help make the process feel more manageable for the patient, not less.

What are some of the biggest mistakes case managers make?

Karen: Not following up with patients. I mean, we don’t have unlimited time, so we can’t be checking up on people constantly. But we need to do things like schedule follow-up phone calls. I can’t tell you how many times a case manager has called and there was a mix-up of some kind.

In your experience, how has care coordination changed?

Karen: The fact that a dietician is brought in on such a regular basis is a big change! The role of nutrition used to be glossed over. Or doctors and nurses would tell people to make changes in their diet without giving them enough information about how to make realistic changes. These days, we work together as a team to identify all the things we can help the patient do to achieve a better outcome.

What are the some of the most important trends in care coordination?

Karen: I think there’s more awareness to barriers to care. That’s definitely true for nutrition. There are very real barriers that make it hard for people to get nutritious food, like food deserts. For people who rely on food shelves, it can be very difficult to meet special dietary needs. And culture and ethnicity can play a huge role too. Some traditional ethnic food is actually a lot healthier than the typical American diet, but that’s not always the case. Care coordination teams are getting better at identifying these kinds of barriers and identifying solutions.


It looks like you have another email from Denise McGladrey, your new preceptor.

Patient Meeting Email


From: Denise McGladrey
Subject: Patient meeting

I see you’ve been busy meeting with team members to learn more about care coordination roles and trends. Thank you so much for doing that!

I have another task for you that will help you get oriented. There’s going to be a meeting this afternoon to discuss care coordination strategies for a patient. Here’s the background: a 79-year-old man named Fred Decker was seen here two weeks ago with a badly infected toe. After the infection cleared up, he was sent home with instructions. Unfortunately, he and his family weren’t able to follow the instructions, and he returned to the hospital three days later with an infection that was even worse—and now he has sepsis. As you know, that’s a serious red flag. Care coordinators need to be seriously concerned with readmission rates, as these reflect poorly on the hospital and impact our ability to be reimbursed by Medicare.

Mr. Decker is responding well to antibiotics, thankfully. This afternoon, several members of the team are having a meeting to discuss his care.

Here’s what I want you to do. Go to the meeting, and just listen. At future meetings throughout your internship, you’ll offer your feedback, but for today, I just want you to be a “fly on the wall.” Afterwards, you’ll meet with me. I’ll ask you some questions about the meeting and provide you with some feedback.

Thanks for all your hard work!


Panel Discussion

It looks like you’ll be listening in on a meeting.

Vicki: So, Seth, you were the case coordinator who was working with Mr. Decker and his family. Can you tell me what happened?

Seth: Well, as you know, Mr. Decker came in with a badly infected toe. He was diagnosed with diabetes last year. It sounds like he hasn’t been treating it effectively.

Vicki: Why do you say that?

Lucas: I spoke with Mr. Decker and his wife. It sounds like he’s been forgetting to take his insulin. He said that’s only happened twice, but I got the sense from his wife that it happens fairly often. Plus they both told me his diet hasn’t changed much since the diagnosis. He’s lost about 10 pounds, which is great. But he’s still in the obese range.

Vicki: That’s too bad. Was the toe infection related to the diabetes?

Seth: It was probably a factor. He cut his toe while walking his dog. His wife washed the cut and put a bandage on it. But it got worse. A nephew finally took him to his primary physician, since he and his wife don’t drive on freeways anymore. The physician sent Mr. Decker to the hospital.

Vicki: So explain to me what happened when Mr. Decker came here the first time.

Seth: Mr. Decker was given antibiotics and the infection started to clear up after a two-day stay. Medicare wanted to send him home with antibiotics. We weren’t aware that his toe wound had progressed and he had developed a more resistant infection.

Vicki: That’s too bad. Samantha, what was your involvement in this case?

Samantha: I met with Mr. and Mrs. Decker. I was definitely concerned that Mr. Decker wouldn’t take the antibiotics if we sent him home. He also needed to treat the infection site twice a day. Mrs. Decker assured us that us that she would take care of her husband and make sure the infection was treated. But I was leery because it doesn’t sound like the diabetes or the original cut was treated very well.

Vicki: So why was he sent home?

Seth: Well, for one thing, we talked to the Deckers’ nephew—the one who drove him to the doctor and the hospital. He said that his wife was a stay-at-home mom and that she could stop by twice a day to take care of Mr. Decker. Apparently this couple lives in the same neighborhood as the Deckers. Also, the Deckers’ daughter was planning to fly in from California later that week to take care of him.

Vicki: Did that happen?

Seth: No. Apparently there was a last-minute emergency at the daughter’s workplace, so she wasn’t able to come. And it’s unclear to me how often the nephew and his wife stopped by.

Samantha: Yeah. I spoke with the nephew. Apparently his wife wasn’t happy about being volunteered for this situation. It sounds like she only stopped by a few times.

Vicki: So now Mr. Decker is back. It sounds like he is responding well to the new round of antibiotics.

Seth: Thankfully, yes. At first we thought an amputation might be necessary. But he’s doing remarkably well. He might be able to go home next week—except that we know that’s not a realistic option.

Vicki: So what’s next?

Samantha: The Deckers don’t have the resources to pay for much that Medicare won’t cover. A rehabilitation center might be a good option, but it will be a challenge to find one they can afford. Other options would be home health care or an outpatient infusion center.

Vicki: Seth and Samantha, what are your thoughts about the outpatient infusion center?

Seth: At this point, I think that’s the best option. Mr. Decker doesn’t need rehabilitation. He just needs someone to administer the antibiotics.

Samantha: I actually think a skilled nursing facility might be the better option. We’ve seen that the Deckers aren’t able to handle this themselves, and that they don’t have a good enough support system to help. The infusion center would only help with the antibiotics. We need to make sure the infection site is cared for and that he gets some help with his diabetes as well.

Seth: But that’s an expensive option they may not be able to afford—and I don’t think that level of care is necessary.

Samantha: But I just can’t picture sending Mr. Decker home yet. I’m afraid he’ll wind up back here again—or worse.

Post Discussion Interview

So, you were a fly on the wall for the meeting about Fred Decker. It looks like he’ll be cleared to leave the hospital next week. The team needs to recommend a course of action for him. What do you think should happen next?

That’s certainly one option. But what if the Deckers can’t afford it?

If the Deckers might have difficulty affording a rehabilitation facility, what step do you recommend next?

Research options. Look for a rehabilitation facility that they can afford.

Good point. Forget it—let’s go with the outpatient infusion center.

That’s certainly one option. Let’s assume the outpatient infusion center is covered by Medicare. Do you have all the information you need before recommending this option?

In the conversation among your colleagues, Seth favored the outpatient infusion center. What step do you recommend next?

Seth is right. Send Mr. Decker to the outpatient infusion center.

There’s an important question that nobody asked.

I would definitely do this. It sounds like Mr. Decker might not do so well at home yet. Make some phone calls. However, be prepared for the possibility that they won’t be able to afford a rehabilitation facility. You’ll need to consider other options as well—like an outpatient infusion center.

Do you think Seth made the right choice in recommending that Mr. Decker be sent home after his first hospital visit?

Yes. There was reason to believe that Mr. Decker had enough help—his daughter was coming, and his nephew said they would help.

No. he should have stayed in the hospital.

Don’t give up so easily. Make some phone calls and look for a facility they can afford. I have my doubts that this patient is ready to go home yet. You may be right, and you might need to go with the outpatient infusion center, but see what’s out there first.

Do you think Seth made the right choice in recommending that Mr. Decker be sent home after his first hospital visit?

Yes. There was reason to believe that Mr. Decker had enough help—his daughter w

I need this by Friday

Complete an interactive simulation of the role of the nurse in health care coordination. Then, create a comprehensive patient needs assessment of 4-5 pages based on that simulation.


Note: Each assessment in this course builds on your work from preceding assessments; therefore, complete the assessments in the order in which they are presented.

Care coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment.

In the 2000 report To Err Is HumanBuilding a Safer Health System, the Institute of Medicine identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery.

Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice settings. Whether educating a patient about his or her medication and plan of care or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination.


Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press.

Note: Complete the assessments in this course in the order in which they are presented.


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.

· What are the key reasons for completing a patient needs assessment?

· Which types of information are likely to be most valuable for improving patient outcomes?

· What are the benefits of a multidisciplinary approach to coordinated care?

To prepare for this assessment, complete the following simulation:

Vila Health: The Nurse’s Role in Care Coordination

This simulation explores the roles that case managers and other team members play in care coordination. Upon completion of the exercise, you should have a better understanding of care coordination trends and their historical contexts. Use the information available in this simulation to begin your assessment of the patient, Mr. Decker.

Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

Assessment 1 Example [PDF]


Complete a comprehensive needs assessment for Mr. Decker, based on the information provided in the Vila Health simulation and your own research.

Comprehensive Needs Assessment Format and Length

Format your comprehensive needs assessment using APA style:

· Use the 
APA Style Paper Tutorial [DOCX]
 provided. Be sure to include:

. A title page and references page. An abstract is not required.

. A running head on all pages.

. Appropriate section headings.

· Your needs assessment should be 4–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your assessment.

Conducting the Assessment

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your needs assessment addresses each point, at a minimum. Read the Comprehensive Needs Assessment Scoring Guide to better understand how each criterion will be assessed.

· Identify current gaps in a patient’s care.

. Use an appropriate needs assessment tool to identify gaps. This tool may be one in use at your place of employment, one you locate for yourself, or one provided by faculty.

. Consider the types of patient information that will be most useful in assessing the current level of care.

· Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.

. Consider the full range of interrelated needs that affect the patient’s health.

· Discuss 3–5 societal, economic, and interprofessional factors most likely to affect patient outcomes.

. Consider the potential effects of these factors on outcomes.

. Support your conclusions with evidence.

· Relate specific patient and care coordination outcome measures to professional standards.

. Provide the rationale for measuring outcomes based on established agencies and organizations.

. Describe the relationship between specific outcomes and the identified standards.

· Identify evidence-based practices for successful implementation of care coordination.

. Use relevant and credible sources from the research literature.

. Consider best practices for a population-health focus on patient outcomes.

· Advocate for the benefits of a multidisciplinary approach to patient care.

. Provide the key points in your argument.

. Support your assertions with evidence.

· 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 more difficult to focus on the substance of your needs assessment.

· 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 comprehensive needs assessment to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Develop patient assessments.

. Identify current gaps in a patient’s care.

. Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.

· Competency 2: Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role.

. Discuss societal, economic, and interprofessional factors most likely to affect patient outcomes.

. Advocate for the benefits of a multidisciplinary approach to patient care.

· Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.

. Relate specific patient and care coordination outcome measures to professional standards.

· Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.

. Identify evidence-based practices for successful implementation of care coordination.

· 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.

I need this by Friday


Comprehensive Needs Assessment

Learner’s Name

Capella University

NURS-FPX6610: Introduction to Care Coordination

Instructor Name

August 1, 2019

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


Comprehensive Needs Assessment

A comprehensive health needs assessment of patients enables health care providers to

systematically use their resources to disperse care efficiently. In this paper, a comprehensive

needs assessment of a simulated patient is discussed to highlight the importance of

comprehensive needs assessments in identifying and reducing gaps in patient care and

implementing effective care coordination. This paper discusses the various dimensions of a

patient’s needs and the strategies to extract relevant patient information to understand these

needs to establish the significance of a health needs assessment. This paper also presents

effective evidence-based practices in care coordination and the importance of a multidisciplinary

approach to patient care for improving health care outcomes.

Current Gaps in Mr. Decker’s Care

Mr. Decker is a 79-year-old diabetic patient readmitted to one of Vila Health’s hospitals.

Initially admitted with a badly infected toe, Mr. Decker’s inability to adhere to medical

instructions after discharge has resulted in him being readmitted with sepsis. Mr. Decker’s

readmission can be attributed to the following gaps in care:

• Lack of an interdisciplinary approach to care: The inability of the health care provider to

ensure that factors such as diabetes and aging are given due consideration while dispersing


• Failure to ensure adequate post-discharge support: Lack of adequate efforts from the care

provider to ensure that the patient effectively carries out the post-discharge care instructions

• Lack of consideration for the patient’s financial standing: The patient’s poor financial

standing was not considered during the design and management of the patient’s care

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


To ensure that Mr. Decker’s physiological, social, religious, and psychological needs are

effectively addressed, the needs assessment tool adopted is the Patient Centered Assessment

Method. The method is an integrated needs assessment tool that assesses patients’ physical,

social, psychological, and mental well-being needs. The tool was selected because it is action

oriented. It facilitates the addressal of patients’ holistic needs, expanding beyond the realm of

physiological health care to address their psychosocial needs (Maxwell et al., 2018).

Informational Needs for Patient’s Optimal Care:

An effective assessment of Mr. Decker’s current care needs depends on the following

types of information:

• Mr. Decker’s clinical information, namely age, allergies, weight, current diagnosis, and

medical history (Kelley et al., 2013)

• Personal information such as his schedules, preferences, typical behaviors, and interests,

which will provide clarity on how Mr. Decker’s care needs are to be addressed (Kelley et al.,


Strategy for Gathering Additional Necessary Assessment Data

As a personal interview does not help gather all the information necessary for the

adequate delivery of care, the following data collection strategies are formulated:

• Thoroughly scanning Mr. Decker’s activities across social media platforms to collect

information about his behavior patterns, his daily routines, and the significant events he has

been a part of will help provide clarity on his personalized needs and the various interrelated

factors affecting his care.

• In-depth interviews with close relatives and friends about Mr. Decker’s habits, nature, and

recent activities will help understand the factors that affect care and facilitate personalized

care measures that suit his situation.
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


• The electronic health record systems at Mr. Decker’s preceding health care providers are

important sources of clinical information. Health information exchange systems are set up to

access Mr. Decker’s longitudinal clinical data from different health care providers to get

clarity on the various factors such as diabetes and aging that have a bearing on his current

condition. The clinical history will help ensure that Mr. Decker’s care addresses these

interrelated factors and facilitates a holistic treatment.

Societal, Economic, and Interdisciplinary Factors Affecting Patient Care

The factors affecting Mr. Decker’s health care outcomes are the following:

• Aging: The physiological changes that occur in an aging person present immense challenges

in the diagnosis, treatment, and recovery of geriatric patients (above 60 years of age) with

sepsis. Geriatric patients usually show atypical, non-specific symptoms such as altered

mental status, lethargy, dehydration, loss of appetite, and weakness, making the diagnosis

challenging. Being an inflammatory consequence to an infection, sepsis is conventionally

diagnosed using systemic inflammatory response syndrome criteria, which are not normally

met by geriatric patients. According to Clifford et al. (2016), geriatric patients undergo

pharmacokinetic changes, namely degeneration in the ability to absorb, metabolize,

distribute, and eliminate drugs. These pharmacokinetic changes have significant implications

on the treatment of sepsis and, consequently, result in the need for special considerations

while treating geriatric patients. Also, geriatric adults usually witness immunosenescence

(changes in the immune system), which impedes the swiftness of the recovery process

in geriatric patients (Clifford et al., 2016).

• Financing for health care: Mr. Decker is a 79-year-old man whose accessibility to health care

depends primarily on Medicare, the national insurance health care program. Although

Medicare covers hospitalization and medical insurance, the level of care depends on the type

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


of insurance plan opted. The 2019 cost estimates for Medicare stand at 437 U.S. dollars as

the premium per month for the hospital insurance plan (Part A) and 135.50 U.S. dollars as

the premium per month for the medical insurance plan (Part B), with higher costs for other

high-end plans (U.S. Centers for Medicare and Medicaid Services, n.d.). Mr. Decker’s dismal

income status has affected the nature of the Medicare plan he could afford, thus impacting

care outcomes.

• Social support: Mr. Decker has limited social support in the form of an aged wife who lives

with him, a daughter who visits them occasionally, and his nephew and nephew’s wife, who

offer occasional assistance. This limited social support has had a significant bearing on his

ability to carry out the care instructions laid out by the care providers. Many studies provide

evidence about the impact of social support on health outcomes. In a study by Schöllgen et

al. (2011), the participants interviewed reported that increased social support was associated

with functional and subjective improvements in health (as cited in Rapoza et al., 2016). A

study conducted by White et al. (2009) found that geriatric adults with insufficient social

support reported poorer health outcomes than geriatric adults who were satisfied with their

present social support (as cited in Rapoza et al., 2016). The inadequacy of social support in

Mr. Decker’s case has been the basis for the worsening of his health condition from a simple

toe wound to sepsis.

• Diabetes: The fact that Mr. Decker is also diabetic has impacted his care by making him

vulnerable to contracting infections at a higher rate and facing increased chances of

prolonged mortality as a result of sepsis. This can be substantiated by the fact that diabetes

causes a decline in the functioning of a patient’s immune cells, diminishing the ability to

clear bacterial formations and increasing infection complications (Frydrych et al., 2017).

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


Relating Patient Care and Care Coordination Outcomes to Professional Standards

The outcomes of patient care and care coordination can be accounted for by measuring

the patient safety and quality outcomes of patient care and care coordination. Patient safety

outcomes for specific patient care coordination are measured against the standards laid out in the

National Quality Forum’s safety report for 2017 and The Joint Commission’s National Patient

Safety Goals for 2019. The rationale for measuring safety outcomes based on the National

Quality Forum’s safety report is the comprehensiveness of the report and the credibility of the

forum, whose primary focus is the development of safety measures (National Quality Forum,

n.d.). The rationale for selecting The Joint Commission’s National Patient Safety Goals as a

standard for patient safety is that the goals are developed based on the suggestions of a highly

interdisciplinary advisory group and the analysis of national sentinel event data (Armstrong,

2014). The quality outcomes of care coordination will be measured using the Care Coordination

and Transition Management Logic Model for registered nurses as the standard (Haas & Swan,

2014a). The rationale is that the logic model not only lays out care coordination quality outcomes

but also offers holistic linkages between nurse competencies, care coordination, and outcomes

(Haas & Swan, 2014b). Also, the logic model offers an innovative approach for interprofessional

teams focusing on patient-centered care (Haas & Swan, 2014a).

The Joint Commission annually releases patient safety goals, which have been deemed

nationally as qualitative standards for patient safety. Some significant standards for patient safety

are identification of a patient by both name and date of birth, dispersal of the right test results to

the right patient, accurate labeling of medicines, medical device alarms going off in real time,

and ensuring infection prevention, which will set the right benchmark for ensuring effective

patient safety outcomes (The Joint Commission, 2019). In terms of The Joint Commission’s

standards for patient safety, the care to Mr. Decker was characterized by 100% infection

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


prevention during acute care, accurate administration of medicines with no adverse effect on the

body, and a successful operation without any complication. Some important care coordination

quality outcomes defined by the Care Coordination and Transition Management Logic Model are

the needs assessment’s taking into account patient needs, preferences, and goals; transmission of

the patient’s care plan with zero errors; constant updating of care coordination plans; evidence-

based practices’ achieving treatment outcomes of 80%; and optimal understanding of the

interdisciplinary roles between team members (Haas & Swan, 2014b). On this front, the specific

patient care coordination witnessed 70% treatment outcomes, the patient’s care plan was able to

accommodate 90% of the patient’s needs and preferences, and the care plan was updated in a

timely manner with zero issues reported within the cross disciplinary team.

Evidence-Based Practices for Successful Implementation of Patient Care Coordination

The following evidence-based practices have been identified to be effective in

implementing successful care coordination for patients with sepsis:

• GENeralized Early Sepsis Intervention Strategies (GENESIS) is an initiative launched for

the continuous improvement of the quality of care for patients with sepsis. GENESIS is a

comprehensive program with highly pertinent treatment measures such as implementing

institutional assessments for the prevalence of sepsis and mortality, identifying sepsis emergencies,

executing 6-hour sepsis bundle interventions via highly coordinated sepsis teams, and implementing

feedback. In their study on the impact of GENESIS on a treatment group of 4,801 patients, Cannon

et al. (2012) found an average in-hospital mortality reduction of 14% and a reduction in the duration

of stay of 5.1 days in comparison to patient groups that did not receive treatment under GENESIS

(as cited in Perez, 2015).

• Another effective practice can be the adoption of a centrally coordinated, multifaceted

quality improvement program implemented by many hospitals in Brazil (Noritomi et al.,

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


2014). Noritomi et al. (2014), in their study of 10 private hospitals implementing the

program, found the initiative to include two phases. The first phase comprised establishing a

local committee, setting up a screening procedure for the early detection of sepsis, carrying

out proven treatments, establishing guidelines for empirical-based antimicrobial therapy,

formulating specific routines for swift laboratory sampling, and establishing routines to

enable the efficient administration of antibiotics. The second phase included the collection

of data and creation of reports on the rate of compliance and mortality in line with the

benchmarks set by the hospital. This practice is a promising one to adopt as Noritomi et al.

(2014) found that the studied hospitals showed a decrease in mortality rates from 55%

before the implementation of program to 26% after the implementation of the program.

Best Practices from the Perspective of Population Health on Patient Outcomes

From the population standpoint of improving the health outcomes of geriatric patients

with sepsis, the following care practices are found to be credible and effective:

• As geriatric patients show atypical, nonspecific symptoms (Clifford et al., 2016), a study by

Singer et al. (2016) found the sequential organ failure assessment score a valuable tool in

determining signs of organ disfunction and mortality and, thus, helpful in the diagnosis of

sepsis. Singer et al. (2016) found that the sequential organ failure assessment score has

widespread familiarity in the clinical care community and serves as an acceptable marker for

mortality risks.

• The Surviving Sepsis Campaign guidelines, which are widely accepted, formulate the Sepsis

Six bundle as a best practice for the treatment of sepsis (Lat et al., 2018). Hancock (2015)

describes the Sepsis Six bundle as an early intervention program that calls for each patient to

receive three diagnostic and three therapeutic steps to treatment within the hour of

recognition of the health condition (as cited in Lat et al., 2018).

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


Benefits of Multidisciplinary Approach to Patient Care

Mr. Decker is an old patient with multiple diagnoses and several complex and multiple

needs. A multidisciplinary approach to health care through effective consultation and

collaboration involving Mr. Decker, family support, and interdisciplinary teams serves as the

only approach that can address the complex multimorbidity, social issues, and psychological

issues faced by him (Department of Health & Human Services, n.d.). This multidisciplinary

approach to patient care can also reduce the gaps due to societal, economic, and interprofessional

factors. The approach is built on egalitarian-based collaboration between interdisciplinary teams

that helps break the hierarchy existing in traditional health care organizations and, thus, improves

the satisfaction of employees in the workplace (Hughes, 2018).

The adoption of a multidisciplinary approach to patient care ensures improved patient

outcomes. In their study on improving operating room efficiency, Oyderk et al. (1988) found

that the adoption of multidisciplinary operating room teams improved turnover time by 16

minutes and considerably decreased delays when compared with operating room teams that are

not multidisciplinary, resulting in reduced hospitalization costs (as cited in Epstein, 2014). This

study supports the argument that a multidisciplinary approach to patient care helps reduce the

duration of stay, reduce hospitalization costs, and improve patient satisfaction.


A comprehensive needs assessment of patient care is presented in this paper through the

case of Mr. Decker. This paper successfully identifies the various interrelated factors, such as

aging, diabetes, social support, and financial conditions, that need to be addressed for a patient to

achieve optimal care. The studies presented in the paper have identified credible standards for

the specific care coordination outcomes to draw measures from. This paper successfully

identifies holistic and judicious evidence-based practices for managing sepsis. Finally, a strong

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.


case for a multidisciplinary approach to care coordination is presented with empirical evidence.

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.



Armstrong, G. (2014). Nursing and quality: A historical perspective. In G. Lamb (Ed.), Care

coordination: The game changer: How nursing is revolutionizing quality care (pp. 13–




Clifford, K. M., Dy-Boarman, E. A., Haase, K. K., Maxvill, K. H., Pass, S., & Alvarez, C. A.

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