Develop an evidence-based plan for health care delivery.
Develop a procedure for coordinating services.
Consider the needs of “outliers.” For example, someone with lung disease may need extra resources.
Who should be on the team?
When would the team be activated?
How would it be activated?
What is the time frame required to coordinate services?
How would the intervention plan be monitored for effectiveness?
Apply professional standards in support of a care plan.
Explain the alignment to the most recent heart failure guidelines and specific professional standards.
Describe accountability tools and procedures used to measure effectiveness.
How will you know if the care coordination plan is successful?
What are the indicators of success or effectiveness?
How will information be collected or communicated?
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