The requirements, outlined below, correspond to the grading criteria in the Final 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.

• Design patient-centered health interventions and timelines for care delivered through direct clinical interaction that is logged in the CORE ELMS system. 
  • Address three patient health issues.
  • Design an intervention for each health issue.
  • Identify three community resources for each health intervention, so the patient may make an informed decision about what resources to use.
• Make ethical decisions in designing patient-centered health interventions. 
  • Consider the practical effects of specific decisions.
  • Include the ethical questions that generate uncertainty about the decisions you have made.
• Identify relevant health policy implications for the coordination and continuum of care. 
  • Cite specific health policy provisions.
• Evaluate learning session outcomes and the attainment of mutually agreed-upon health goals, in collaboration with the patient. 
  • What aspects of the session would you change?
  • How might revisions to the plan improve future outcomes?
• Evaluate patient satisfaction with the care coordination plan and progress made toward Healthy People 2020 goals and leading health indicators. 
  • What changes would you recommend to improve patient satisfaction and better align the session with Healthy People 2020 goals and leading health indicators?