Preliminary Care Coordination Plan

Nurses are vital to care coordinators. Patient care is holistic and requires the collaboration of various healthcare providers, nurses, patients, and their families. One of the prerequisites for accurate coordination is extensive knowledge of care coordination.

Preliminary Care Coordination Plan

The care providers then relay the information to other stakeholders and outline their care coordination roles. The care provider’s ability to manage the problems effectively determines the success of their community interactions and health. This essay analyzes care coordination concepts in pain management.

Selected Health Concern and the Associated Best Practices for Health Improvement

Pain management is an area that has many problems and ethical issues surrounding it. Pain accompanies most healthcare conditions, and the intensity, severity, and duration differ based on personal characteristics and the pain etiology. Pain management faces many issues due to tolerance and opioid addiction, affecting all health domains.

McCabe (2018) notes that physical pain can be disabling and limit daily activities, cause psychosocial pain, and affect the social interaction of individuals. Pain aggravates the management of conditions such as cancer when patients take many medications with various side effects, such as nausea and vomiting. Yet, they do not feel their therapeutic effectiveness because the pain does not cease. Thus, pain management needs to be addressed owing to the many issues associated with the problem.

Various institutions have come together to manage the issue of pain. The WHO developed the pain management ladder to assess the pain level, which outlines the management interventions for the specific pain level (McGuire & Slavin, 2020). WHO developed the ladder to manage cancer pain, but it can be used to manage all other health conditions. Patient pain assessment tools for all populations have been developed over time.

They help healthcare providers assess pain from patient reports and even from their facial expressions (Gregory, 2019). The tools have helped ensure quality care delivery. The primary assumption in pain management is that it refers to physical pain because the pain in other domains may present as other symptoms, such as fear and depression.

The prescription drug monitoring program (PDMP) is a national program that was developed to manage prescription drugs. The technology helps care providers to trace prescription drugs, especially opioids and benzodiazepines (Manders & Abd-Elsayed, 2020). The care providers also use the technology to determine the include and rates of opioid addiction and enroll them in management programs. Scholars argue that the technology has helped predict and prevent opioid use addiction in patients with prolonged opioid analgesics use.

Another integral evidence-based strategy is the management algorithm supported by clinical decision support systems. Care providers assess patients to determine their needs and then manage them depending on the algorithm’s instructions.

Pangarkar et al. (2020) note that various clinical pain management algorithms have been developed to help manage pain in cancer, ballistic injuries (in veterans), and other chronic diseases such as acute renal injury. Patient assessment (using current tools) is integral to their management hence the need for patient clinic visits and assessment.

Specific Goals That Should be Established to Address Pain

There are various goals when addressing the healthcare problem. The first goal is to ensure pain control and relief while taking the lowest possible medication doses. Meaningful pain control increases functional abilities and the quality of life. Adequate pain control requires care collaboration between patients and their primary care providers.

Moreover, the goal is based upon continuous assessment and therapy change for effective pain management. The second goal is medication and other interventions adherence. Poor medication adherence is associated with many factors, such as perceived effectiveness, negligence, forgetfulness, and medication side effects (Swarm et al., 2019).

The third goal is utilizing pharmacologic and non-pharmacologic pain management interventions for effective pain management. Pain management should entail corresponding and effective pain management interventions. Some duos have been found more effective than single therapies using medications or non-pharmacologic pain interventions. For example, massage can be used in musculoskeletal pain in addition to pharmacologic interventions. The two methods used together produce superior effects. Other interventions include acupuncture and yoga for back pain.

The fourth goal is the holistic care of patients. Pain management, especially chronic and severe pain, requires opioid analgesic interventions. This goal aims to ensure that pain management interventions do not affect other aspects of patient health (Cohen et al., 2020).

These include addiction and dependence, and undesirable side effects. The goals will also entail social support for patients to promote their psychological welfare. Holistic care affects the effectiveness of other interventions, such as medication adherence. These goals are vital in pain management and will help ensure all interventions and efforts are in tandem with population needs.

Community Resources

Various society groups focus on patients and support them in patient management. Groups such as cancer (Cancer Care) and veteran affairs support groups (Veterans In Pain) help patients recover from the pain and painful experiences. The groups offer social support to individuals with pain and underlying medical condition. These institutions enhance care continuity at home. Most of these organizations are accessible online, and they provide online resources that help in decision-making.

Other non-profit organizations have been developed in communities to aid in pain management. Organizations such as US Pain Foundation and The Pain Community help individuals with pain conditions access medical care and effective prescriptions (Savoy, 2022).

They also support them financially and emotionally to increase their utilization of pain management interventions and thus improve their quality of life. Other organizations, such as the Pelvic Pain Society, offer care specific to their target population. These organizations provide evidence-based strategies and pain management interventions to their target populations.

They provide online resources where they teach patient interventions such as addiction assessment and best prescription practices. They also offer room for social support when individuals interact and share their experiences. Community centers and parks are essential community resources, often underrated for their effectiveness in pain management and mental health stability (Savoy, 2022). Community centers increase access to other individuals, especially the elderly population, and helps these patients meet social needs.


Pain management is surrounded by many ethical and legal issues surrounding medications and other interventions. Nurses play a significant role in care coordination and ensuring patients receive the care they need. Care coordination also ensures care continuity in the community.

Community resources such as pain management organizations and support groups are integral in meeting patients’ cultural and social needs, hence managing the holistic patient. Care coordination is a vital nurse’s role, and succeeding in the role enhances the success of care interventions.


  • Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, B. C., Chen, Y., Hooten, W. M., Laker, S. R., Wasan, A. D., Kennedy, D. J., Sandbrink, F., King, S. A., Fowler, I. M., Stojanovic, M. P., Hayek, S. M., & Phillips, C. R. (2020). Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine21(7), 1331-1346.7.
  • Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard34(9), 70-4.
  • Manders, L., & Abd-Elsayed, A. (2020). Mandatory review of prescription drug monitoring programs before issuance of a controlled substance results in overall reduction of prescriptions including opioids and benzodiazepines. Pain Physician23(3), 299.
  • McCabe, M. J. (2018). Ethical issues in pain management. Ethics in Hospice Care: Challenges to Hospice Values in a Changing Health Care Environment, 25-32.
  • McGuire, L. S., & Slavin, K. (2020). Revisiting the WHO analgesic ladder for surgical management of pain. AMA Journal of Ethics22(8), 695-701.
  • Pangarkar, S. S., Kang, D. G., Sandbrink, F., Bevevino, A., Tillisch, K., Konitzer, L., & Sall, J. (2019). VA/DoD clinical practice guideline: diagnosis and treatment of low back pain. Journal of General Internal Medicine34(11), 2620-2629.
  • Savoy, M. L. (2022). Systems-Based Practice in Chronic Pain Management. Primary Care: Clinics in Office Practice49(3), 485-496.
  • Swarm, R. A., Paice, J. A., Anghelescu, D. L., Are, M., Bruce, J. Y., Buga, S., & Gurski, L. A. (2019). Adult cancer pain, version 3.2019, NCCN clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network17(8), 977-100

Preliminary Care Coordination Plan Assignment Instructions

Develop a 3-4 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:


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

Develop the Preliminary Care Coordination Plan

Complete the following:

Document Format and Length

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.

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.

Competencies Measured

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

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.

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:


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.


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

Your preliminary plan should be an APA scholarly paper, 3–4 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.

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.

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.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

**Please follow guidelines for a Distinguished** on the scoring guide