The requirements outlined below correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so ensure that each point is addressed. To see how your work will be evaluated, read the performance-level descriptions for each criterion.

Create patient-centered health interventions and timelines for care delivered via direct clinical interaction and recorded in the CORE ELMS system.
Take care of three patient health issues.
Create an intervention for each health concern.
Determine three community resources for each health intervention so that the patient can make an informed choice about which resources to use.
When designing patient-centered health interventions, make ethical decisions.
Consider the real-world consequences of specific decisions.
Include any ethical concerns that have arisen as a result of your decisions.
Determine the health policy implications for coordination and the continuum of care.
Mention specific health-care policy provisions.
In collaboration with the patient, evaluate learning session outcomes and achievement of mutually agreed-upon health goals.
What would you change about the session?
How might plan revisions improve future outcomes?
Assess patient satisfaction with the care coordination plan, as well as progress toward Healthy People 2020 goals and leading health indicators.
What modifications would you suggest to improve patient satisfaction and better align the session with Healthy People 2020 goals and leading health indicators?