a concept map depicting how the health services available in a community contribute to the care coordination process

Gap Analysis Assignment

Create a concept map depicting how the health services available in a community contribute to the care coordination process, write a narrative description of your concept mapping process, and write an analysis of current gaps in coordinated care, 6–8 pages in length, within your unit or organization (or the hypothetical practice setting provided).

Note: The assessments in this course build upon the work you have completed in the previous assessments. Therefore, complete the assessments in the order in which they are presented.

Inaccessible and unaffordable health care has created gaps in services and has been linked to unfavorable patient outcomes. The care coordinator is equipped to recognize how gaps in care affect individual, community, and population outcomes. Health care resources vary from one setting to another. As a care coordinator, it is necessary that you consider community resources while formulating a plan of care.

This assessment provides an opportunity for you to examine how external stakeholder agencies and organizations contribute to coordinated care, and the care coordinator’s role in closing gaps in care and improving health care outcomes.

Context

Care coordination is often complicated and is comprised of a wide array of social, cultural, financial, and legal implications. The best-laid care plans may not come to fruition due to lack of resources.

In addition, key stakeholders involved in a patient care delivery team vary from one health care setting to another. Efficient and successful coordinated care takes into account the entire health care professional team. Evidence suggests that engaging all vested stakeholders creates a quality environment, leading to improved patient outcomes.

In Assessment 2, you will build on the work you completed in Assessment 1. Note: If you chose the hypothetical practice setting as the basis for your work in Assessment 1, continue to use that setting for this assessment.

Preparation

For this assessment, you will continue in your role as external health care efficiency consultant to your care coordination unit or organization.

Your program evaluation report was well received by the administration. As an addendum to your report, you have been asked to follow up on your previous work with an analysis of potential gaps in coordinated care.

To prepare for this assessment, consider how collaboration with various external health care agencies and organizations contributes to successfully coordinated care. Examples of external agencies and organizations include:

  • Health departments.
  • Hospitals and satellite units.
  • Ambulatory surgery centers.
  • Outpatient dialysis units and birthing centers.
  • Clinics (inpatient, outpatient, walk-in, urgent care).
  • Community health centers.
  • Physicians’ offices.
  • Mobile health care units.
  • Nursing homes and other long-term care facilities.
  • Hospice centers.

Assessment Submissions

For this assessment, you will submit the following three documents:

  1. A concept map illustrating the relationships between available health services and resources and the care coordination process.
  2. A narrative description of your concept-mapping process.
  3. A written gap analysis of potential gaps in care within your unit or organization (or the hypothetical setting provided).

Requirements

Analyze potential gaps in care within your unit or organization. Note: You may continue using your own unit or organization for the gap analysis, or you may use the same hypothetical practice setting provided in the first assessment.

Gap Analysis Format and Length

Format your document using APA style.

  • Use the APA Style Paper Template (linked in Required Resources). An APA Style Paper Tutorial is also provided (linked in Suggested Resources) to help you in writing and formatting your gap analysis. Be sure to include:
    • A title page and references page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
  • Your gap analysis should be 6–8 pages in length, not including the title page and references page.

 

Supporting Evidence

Cite at least 5–7 sources of credible, scholarly or professional evidence to support your analysis.

Conducting Your Gap Analysis

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your gap analysis addresses each point, at a minimum. You may also want to read the Gap Analysis Scoring Guide to better understand how each criterion will be assessed.

  • Explain how the health services and resources available in your local community or a community that you are familiar with contribute to the care coordination process throughout the continuum of care.
    • Examine the types of care support provided and the potential impact on care coordination.
    • Create a concept map, based on your analysis of support provided, illustrating the relationships between available health services and resources and the care coordination process. Concept mapping offers a robust way to visually illustrate relationships between concepts and ideas.
    • Write a narrative description of your concept mapping process.
    • Examples of health services and resources include:
      • Primary care.
      • Emergency care.
      • Dental and vision care.
      • Physical and occupational therapy.
      • Mental health services.
      • Home health care.
      • Health promotion and illness prevention services.
      • Chronic disease management.
      • Immunization and laboratory services.
      • Health technologies (telemedicine/telehealth, wireless and portable devices, self-service kiosks).
      • Counseling and addiction treatment.
      • Hospice and palliative care.

Note: You may find it useful to refer to the Concept Maps page, linked in Suggested Resources, to gain a greater understanding about creating and utilizing this tool.

  • Explain how the needs of patients, individual communities, and populations can directly influence the success or failure of a care coordination plan after it is implemented.
    • Consider both positive and negative influences.
    • Provide evidence to support your assertions and conclusions.
  • Identify gaps in community health services and resources.
    • Consider the needs of patients, individual communities, or populations throughout the care continuum.
  • Identify applicable clinical guidelines and standards from national policy or regulatory organizations as evidence for gaps. For example:
    • Agency for Healthcare Research and Quality (AHRQ).
    • Institute for Healthcare Improvement (IHI).
  • Write clearly and concisely, using correct grammar and mechanics.
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your analysis.
  • Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using current APA style.
    • Is your supporting evidence clear and explicit?
    • How or why does particular evidence support a claim?
    • Will your audience see the connection?

Additional Requirements

Be sure to submit the following three documents for this assessment:

  • Your concept map.
  • A narrative description of your concept-mapping process.
  • Your gap analysis.

Be sure that you have used the APA Style Paper Template to format your gap analysis and that your document includes:

  • A title page and references page.
  • A running head on all pages.
  • Appropriate section headings.

 

Hypothetical Practice Setting

The new Director of Case Management, with support from the director of Nursing, is planning to implement a new care coordination model with the goal of meeting national benchmarks. The current model focuses on individual tasks as each unit relies on a social worker and care coordinator for discharge planning and care coordination. Work typically occurs in silos, so little collaboration takes place between the social worker and care coordinator. A recent Joint Commission survey conducted at the hospital reported multiple patient safety infractions in coordinated care that must be corrected. Major infractions include the lack of:

  • A patient needs assessment.
  • Goal setting.
  • Planning.
  • Implementation and evaluation of an individualized plan of care.
  • A discharge planning protocol.
  • Basic components identified in national and regulatory health care practices in the current standard of nursing practice.
  • Interdisciplinary communication and teamwork when coordination patient care In addition, many patients who require acute care are uninsured and their stay is unreimbursable.

The current hospital length of stay (LOS) and readmission rates have negatively impacted reimbursement. Patient post-discharge surveys and Hospital Consumer Assessment of Healthcare Providers Systems (HCAPS) scores are below national benchmark data. Readmission rates are 35 percent higher than national norms

 

Gap Analysis Scoring Guide

Criteria Non-performance Basic Proficient Distinguished
Explain how the health services and resources available in a community contribute to the care coordination process throughout the continuum of care. Does not provide an explanation of how the health services and resources available in a community contribute to the care coordination process throughout the continuum of care. Provides an explanation of how the health services and resources available in a community contribute to the care coordination process throughout the continuum of care, based on a cursory analysis and unsubstantiated claims or assumptions. Explains how the health services and resources available in a community contribute to the care coordination process throughout the continuum of care. Explains how the health services and resources available in a community contribute to the care coordination process throughout the continuum of care. Clearly illustrates of the key relationships and draws logical, plausible conclusions from available information.
Explain how the needs of patients, individual communities, and populations can directly influence the success or failure of a care coordination plan after it is implemented. Does not provide an explanation of how the needs of patients, individual communities, and populations can directly influence the success or failure of a care coordination plan after it is implemented. Provides an explanation of how the needs of patients, individual communities, and populations can directly influence the success or failure of a care coordination plan after it is implemented, based on unsubstantiated claims or assumptions. Explains how the needs of patients, individual communities, and populations can directly influence the success or failure of a care coordination plan after it is implemented. Explains how the needs of patients, individual communities, and populations can directly influence the success or failure of a care coordination plan after it is implemented. Identifies both positive and negative influences and offers an astute, well-reasoned explanation supported by an insightful synthesis of credible evidence.
Identify gaps in community health services and resources. Does not identify gaps in community health services and resources. Identifies inconsequential gaps in community health services and resources or gaps inferred from a limited or superficial comparison of needs, services, and resources. Identifies gaps in community health services and resources. Identifies gaps in community health services and resources. Makes logically sound, valid inferences based on an insightful synthesis of relevant information.
Identify applicable clinical guidelines and standards from national policy or regulatory organizations as evidence for gaps. Does not identify applicable clinical guidelines and standards from national policy or regulatory organizations as evidence for gaps. Identifies clinical guidelines and standards from national policy or regulatory organizations as evidence for gaps that lack clear applicability. Identifies applicable clinical guidelines and standards from national policy or regulatory organizations as evidence for gaps. Identifies applicable clinical guidelines and standards from national policy or regulatory organizations as evidence for gaps. Provides clear and explicit justification for the applicability of specific guidelines and standards.
Write clearly and concisely, using correct grammar and mechanics. Does not write clearly and concisely, using correct grammar and mechanics. Writing is not consistently clear or concise, or errors in grammar and mechanics inhibit effective communication. Writes clearly and concisely, using correct grammar and mechanics. Writes clearly and concisely. Grammar and mechanics are error-free.
Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style. Does not support main points, claims, and conclusions with relevant and credible evidence, formatting citations and references using current APA style. Evidence is not persuasive or explicitly supportive of main points, claims, or conclusions. Sources lack relevance or credibility, or are incorrectly formatted. Supports main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using current APA style. Supports main points, claims, and conclusions with relevant, credible, and convincing evidence. Combines the skillful application of error-free source citations with a perceptive and accurate synthesis of the evidence.

 

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