NURS FPX 4050 Preliminary Care Coordination Plan Essay Example

Capella NURS FPX 4050 Assessment 4: Final Care Coordination PlanCapella NURS FPX 4050 Assessment 4: Final Care Coordination Plan

NURS FPX 4050 Preliminary Care Coordination Plan Assignment Brief


In this assignment, you will assume the role of a staff nurse at a community care center. Due to budget cuts, the facility’s dedicated case management staff has been relocated, and you are now tasked with the responsibility of care coordination. Your goal is to develop a 3-5 page preliminary care coordination plan for a selected health care problem. The chosen health concern for this plan is orthopedic issues, with a specific focus on hip replacement (Hip Arthroplasty).

Understanding Assignment Objectives:

The primary objective of this assignment is to strengthen your understanding of planning and coordinating care for community residents facing health challenges. By focusing on hip replacement, you will explore into the physical, psychosocial, and cultural aspects of this health concern. The assignment requires you to identify best practices for health improvement, establish specific goals, and pinpoint available community resources for a safe and effective continuum of care.

The Student’s Role:

As the staff nurse taking on the role of care coordination, you need to comprehend the intricacies of planning and implementing care for individuals with orthopedic concerns, specifically those undergoing hip replacement. Your task involves analyzing the health concern, identifying best practices supported by evidence, and creating specific, measurable, attainable, realistic, and time-bound (SMART) goals. Additionally, you will explore available community resources that contribute to a seamless continuum of care.

NURS FPX 4050 Preliminary Care Coordination Plan Essay Example


In community healthcare centers facing budget cuts and a shortage of case management staff, the importance of care coordination becomes even more critical. As a staff nurse, my nurse manager assigned me the role of care coordination, emphasizing the need to plan for the health needs of our community. In this care coordination plan, our main focus is on orthopedic concerns, specifically addressing hip replacement. This plan aims to understand the challenges related to hip replacement, taking into account the physical, psychosocial, and cultural aspects. Additionally, the paper will identify best practices to enhance the health of individuals undergoing hip replacement. The plan will also establish SMART goals and pinpoint community resources to ensure a seamless continuum of care for the affected community members.

Analysis of Health Concerns and Best Practices for Health Improvement

Hip replacement, also known as hip arthroplasty, is a surgical procedure where certain parts of the hip joint are replaced with artificial implants. This procedure is commonly recommended for individuals experiencing hip pain due to conditions like osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, osteonecrosis, or childhood hip disease. When severe pain hinders daily activities such as walking or bending, hip replacement becomes a preferred intervention. The best practices identified for improving health in individuals undergoing hip replacement address their physical, psychosocial, and cultural needs.

Following hip replacement, patients experience immobilization during the initial weeks, necessitating physical support. Caregiving nurses play a vital role in providing initial care to manage pain during the first week post-surgery. Additionally, physical therapists or mobility technicians are essential for initiating early mobilization, meeting the physical needs, and enhancing rehabilitation for those with hip replacement (Mazzei et al., 2020). The recovery journey after hip arthroplasty (HA) is influenced by various psychosocial factors such as depression, anxiety, resilience, and silent suffering. Addressing these psychosocial needs is crucial for improving the overall health of HA patients. Psychoeducation, led by psychologists or nurses, serves as an effective intervention by educating HA patients on coping strategies to enhance cognitive behavior therapy (Wei et al., 2020).

Recognizing that every patient belongs to a specific culture with unique beliefs and norms, it becomes important to consider cultural needs in the healthcare setting, particularly for patients undergoing HA. Cultural influences, including beliefs about pain, recovery, or hip replacement, can pose barriers to effective care coordination. To address this, culturally competent care should be provided, ensuring that culturally sensitive patients receive appropriate answers to their pain-related beliefs, thereby reducing anxiety (Beaulieu et al., 2019; White et al., 2019).

Moreover, language can be a cultural barrier, with some individuals using a cultural language that requires interpreters or interpretation services to overcome communication challenges (Beaulieu et al., 2019; White et al., 2019). Assumptions and points of uncertainty in HA include patients’ potential lack of trust in the procedure, fear of surgery, variations in recovery time, and the risk of surgical complications. Some patients may hesitate to undergo HA due to a lack of trust in the procedure and fear associated with surgery. Addressing these uncertainties through education and open communication is essential for ensuring informed decision-making and successful care coordination.

Specific Goals for Addressing Hip Replacement and Rehabilitation

Creating specific goals for addressing hip replacement and rehabilitation is crucial, and these goals are based on the SMART approach – Specific, Measurable, Attainable, Realistic, and Time-bound. Let’s break down these SMART goals:

Goal #1: Early Detection of Developmental Dysplasia of the Hip:

  • Specific: For patients who have had hip joint issues since childhood.
  • Measurable: Assess through x-rays once every six months.
  • Attainable and Realistic: To identify any hip joint dislocations.
  • Time-bound: Within six months, allowing for early detection and timely intervention to prevent the need for hip replacement (Williams, 2019).

Goal #2: Early Mobility Initiation Post-Hip Replacement:

  • Specific: Focus on patients who underwent hip replacement.
  • Measurable: Gradually increase walking distance or steps.
  • Attainable and Realistic: Follow the guidance of a physical therapist.
  • Time-bound: Within three months, achieve walking up to one mile or 5000 steps, aiding in the recovery process (None Aprisunadi et al., 2023).

Goal #3: Weight Management for Reduced Stress on Hip Joints:

  • Specific: Address stress on hip joints.
  • Measurable: Engage in 30 minutes of hip-joint-friendly exercise daily.
  • Attainable: Follow prescribed exercises from physical therapists.
  • Realistic: Manage weight effectively, reducing stress on hip joints.
  • Time-bound: Implement daily exercises for improved hip health (Güler, 2019).

These SMART goals provide a clear and practical roadmap for healthcare professionals and patients alike. They ensure that the goals are specific to hip-related concerns, measurable for progress tracking, attainable and realistic for successful implementation, and time-bound for achieving positive outcomes within a reasonable timeframe.

Community Resources for a Safe and Effective Continuum of Care

To ensure patients with HA receive continuous and effective care, it’s essential to make use of community resources. These resources play a key role in helping patients navigate their daily lives after hip replacement and gaining valuable knowledge. Some community services offer support and rehabilitation specifically tailored for post-hip replacement recovery.

A notable community resource is the American Academy of Orthopaedic Surgeons, where orthopedic surgeons offer insightful guidance and education to individuals dealing with orthopedic concerns. This organization provides online educational materials for patients, offering information essential for better orthopedic health, along with clinical guidelines for healthcare professionals (American Academy of Orthopaedic Surgeons, n.d.).

In addition to this, there are online support groups like WeChat community groups dedicated to hip replacement. These virtual communities prove effective in providing support to HA patients, serving as a source of motivation when individuals share their success stories (Zhang et al., 2021).

Moreover, rehabilitation centers specializing in hip replacement play a crucial role in supporting recovery. An example is the Mayo Clinic Rehabilitation Center (MCRC), which focuses on orthopedic care, including rehabilitation for hip replacement. The MCRC adopts a patient-centered approach to hip recovery, emphasizing the restoration of mobility, muscle strength, and normal functioning post-surgery (Mayo Clinic, n.d.).


In wrapping up, this assessment focuses on the initial steps of planning care coordination as a nurse in community healthcare. The primary health concern addressed here is hip replacement, also known as Hip Arthroplasty. By taking into account the physical, psychosocial, and cultural needs of patients undergoing this procedure, the assessment has identified several best practices. These practices include the engagement of mobility technicians, the implementation of psycho-education, the provision of culturally competent care, and the use of interpreters for individuals from diverse cultural backgrounds who may communicate in specific languages. Additionally, the assessment has laid out SMART goals to guide the care process and pinpointed community resources that can aid in providing comprehensive care to those undergoing hip replacement. By focusing on early detection, mobility initiation, weight management, and leveraging community resources, this plan aims to enhance the overall well-being of individuals undergoing hip replacement in the community healthcare setting.


American Academy of Orthopaedic Surgeons. (n.d.). American academy of orthopedic surgeons – AAOS.

Beaulieu, L., Addington, J., & Almeida, D. (2019). Behavior analysts’ training and practices regarding cultural diversity: The case for culturally competent care. Behavior Analysis in Practice, 12(3).

Güler, T. (2019). Early improvement in physical activity and function after total hip arthroplasty: Predictors of outcomes. Turkish Journal of Physical Medicine and Rehabilitation, 65(4), 379–388.

Mayo Clinic. (n.d.). Physical medicine and rehabilitation – overview.

Mazzei, C. J., Yurek, J. W., Patel, J. N., Poletick, E. B., D’Achille, R. S., & Wittig, J. C. (2020). Providing patient mobilization with a mobility technician improves staff efficiency and constrains cost in primary total hip arthroplasty. The Journal of Arthroplasty, 35(8), 1973–1978.

None Aprisunadi, Nursalam Nursalam, Mustikasari Mustikasari, Erlin Ifadah, & Elsi Dwi Hapsari. (2023). Effect of early mobilization on hip and lower extremity postoperative: A literature review. SAGE Open Nursing, 9, 237796082311678-237796082311678.

Wei, S., Li, L., Yang, X., Li, X., & Jiang, Q. (2020). Psychological interventions in the pain management after hip and knee arthroplasty: A mini-review. Annals of Joint, 5, 13–13.

White, J., Plompen, T., Tao, L., Micallef, E., & Haines, T. (2019). What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting. BMC Public Health, 19(1).

Williams, N. (2019). Improving early detection of developmental dysplasia of the hip. Australian Journal of General Practice, 47(9).

Zhang, X., Chen, X., Kourkoumelis, N., Gao, R., Li, G., & Zhu, C. (2021). A social media–promoted educational community of joint replacement patients using the WeChat app: Survey study. JMIR MHealth and UHealth, 9(3), e18763.

Detailed Assessment Instructions for the NURS FPX 4050 Preliminary Care Coordination Plan Essay Example

Develop a 3-page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.


NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem.

Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.


Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

  • Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
  • Allow plenty of time to plan your chosen health care concern.

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


Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan

Complete the following:

  • Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:

. Stroke.

. Heart disease (high blood pressure, stroke, or heart failure).

. Home safety.

. Pulmonary disease (COPD or fibrotic lung disease).

. Orthopedic concerns (hip replacement or knee replacement).

. Cognitive impairment (Alzheimer’s disease or dementia).

. Pain management.

. Mental health.

. Trauma.

  • Identify available community resources for a safe and effective continuum of care.

Document Format and Length

  • Your preliminary plan should be an APA scholarly paper, 3 pages in length.

. Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.

  • In your paper include possible community resources that can be used.
  • Be sure to review the scoring guide to make sure all criteria are addressed in your paper.

. Study the subtle differences between basic, proficient, and distinguished.

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

  • Analyze your selected health concern and the associated best practices for health improvement.

. Cite supporting evidence for best practices.

. Consider underlying assumptions and points of uncertainty in your analysis.

  • Describe specific goals that should be established to address the health care problem.
  • Identify available community resources for a safe and effective continuum of care.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

. Write with a specific purpose with your patient in mind.

. Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

Competencies Measured

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

  • Competency 1: Adapt care based on patient-centered and person-focused factors.

. Analyze a health concern and the associated best practices for health improvement.

  • Competency 2: Collaborate with patients and family to achieve desired outcomes.

. Describe specific goals that should be established to address a selected health care problem.

  • Competency 3: Create a satisfying patient experience.

. Identify available community resources for a safe and effective continuum of care.

  • Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

. Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

. Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

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