Completion of this instructional unit indicates a basic understanding of care coordination and transition management and the role of the patient centered medical home as a means of improving health care.on the safety and quality of patient care.
Challenge 1 I Challenge 2 I Challenge 3
Upon completion of the challenges required for this instructional unit, you will be able to:
- Define care coordination.
- Discuss the Patient Centered Medical Home model holds as a means to improve health care in America by transforming how primary care is organized and delivered.
- Cite examples of social determinants of health.
- Describe screening instruments can aid nurses in identifying social determinants of health in a primary care setting.
- Evaluate the utility of screening instruments for nurses in primary care settings working with underserved populations.
- Demonstrate an appreciation of the impact of living according to the core values may have for nurses working in primary care settings with underserved populations.
Challenge 1: Care Coordination and Transition Management
Professional nursing defines care coordination as:
“Care coordination promotes greater quality, safety, and efficiency in care, resulting in improved healthcare outcomes and is consistent with nursing’s whole person, patient-centered framework of care. A knowledgeable healthcare professional deliberately designated to coordinate care is necessary to effectively utilize resources within the set of complex health systems and multiple providers in accordance with patient and family care needs.”
Work through the elearning module to realize the impact of care coordination on the quality of health care and more.
To complete this challenge, work through the Care Coordination and Transition Management (Part 1) elearning module and answer a series of questions.
Take the quiz!
Challenge 2: Assessing Clients’ Social Determinants of Health
This challenge invites you to synthesize the information learned about cross setting communication to evaluate the viability of resources for care coordination and transition management. Work through the elearning module and pay particular attention to the EveryONE Project Toolkit and the Health-Related Social Needs Screening Tool.
To complete this challenge, evaluate tools that are used to assess for the Social Determinants of Health per the instructions that follow:
- Return to the elearning module and re-examine the EveryONE Project Toolkit and the Health-Related Social Needs Screening Tool that are used to assess for the Social Determinants of Health.
- Based on your evaluation of these tools, decide which tool you believe uses language compatible with health literacy and is more intuitive to implement for nurses in primary care working with the underserved.
Challenge 3: Care Coordination and Ignatian Values
As a Jesuit university, Loyola University Chicago embraces a set of values representative of the Society of Jesus (Jesuits). These values are:
- Cura Personalis
- Latin phrase meaning “care for the person,” cura personalis is having concern and care for the personal development of the whole person. This implies a dedication to promoting human dignity and care for the mind, body and spirit of the person.
- Latin phrase meaning “care for the person,” cura personalis is having concern and care for the personal development of the whole person. This implies a dedication to promoting human dignity and care for the mind, body and spirit of the person.
- Magis
- Latin meaning the “more,” magis embodies the act of discerning the greater good in a given situation to better glorify or serve God. Magis does NOT mean to always do or give “more” to the point of exhaustion. Magis is the value of striving for the better, striving for excellence.
- Latin meaning the “more,” magis embodies the act of discerning the greater good in a given situation to better glorify or serve God. Magis does NOT mean to always do or give “more” to the point of exhaustion. Magis is the value of striving for the better, striving for excellence.
- Finding God in All Things
- This may be the one phrase that sums up Ignatian Spirituality. It invites a person to search for and find God in every circumstance of life; God is present everywhere and can be found in all of creation.
- This may be the one phrase that sums up Ignatian Spirituality. It invites a person to search for and find God in every circumstance of life; God is present everywhere and can be found in all of creation.
- Men and Women for Others
- This value embodies a spirit of giving and providing service to those in need and standing with the poor and marginalized. We are encouraged to pursue justice on behalf of all persons.
- Service with a focus on social justice
- Global awareness
- This value embodies a spirit of giving and providing service to those in need and standing with the poor and marginalized. We are encouraged to pursue justice on behalf of all persons.
Consider the Ignatian core values as you watch and listen to the message of the video.
To complete this challenge, compose a reflection that attends to the following prompts:
- Describe how you perceive care coordination and transition management to align with the Ignatian core values.
- Discuss the impact of living out these core values as a nurse working in a primary care setting with underserved populations.
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