Develop a Patient-Centered Care Management & Transition Plan for a specific patient of your choice. Based on the research you have completed in this course, the work with the care coordinator, discharge planner.

Patient centered Care coordination

Develop a Patient-Centered Care Management & Transition Plan for a specific patient of your choice. Based on the research you have completed in this course, the work with the care coordinator, discharge planner, care manager and/or preceptor, your personal experience within the RN-MSN program, and your professional practice experiences, develop a plan for the ongoing care coordination and transitional care of this at risk patient. The care coordination and transition plan must facilitate smooth transitions of the patient between anticipated levels of care .
Part 1 – Patient/Family/Caregiver Assessment
Describe in detail how you will assess the patient and family/caregiver. Including references, address the following elements:
Quality of life
Ability to complete ADLs/IADLs
Primary language and ability to communicate. Consider need for assistive devices and language translation services
Health literacy, including the ability to understand the care plan and treatments
Cognitive ability
Social Determinants of Health  including