NU 730 Unit 2 Care Coordination Plan Example

Course	NU 730 Systems-Based Practice
Unit	Unit 2
Paper type	Care coordination plan
Length	About 610 words, 5 pages
Format	APA 7 student paper
School	Herzing University
Program	MSN
Updated	October 2026

Free sample paper for NU 730 Unit 2

Care Coordination Plan for Adults Discharged Home After a COPD Exacerbation

Student Name

Department of Nursing, Herzing University

NU 730: Systems-Based Practice

Instructor Name

January 28, 2026

What this page is doingThe title names one population and one destination, which is what makes it possible to assign every step to a person. Coordination is graded on ownership, and a plan for all discharged patients would leave every step owned by no one in particular.

Care Coordination Plan for Adults Discharged Home After a COPD Exacerbation

The Population and the Problem

The population is adults hospitalized at a composite 250-bed hospital with a flare of chronic obstructive pulmonary disease (COPD) and sent home, with or without home health services. Last year the hospital discharged 214 such patients; 21% were readmitted within 30 days, above the national average for this condition, and COPD is one of the conditions whose readmission rate affects the hospital's Medicare payment. Readmissions after COPD exacerbations are driven by several factors that coordination can address: poor inhaler technique, medication changes not carried into the home, missed early follow-up, lack of pulmonary rehabilitation referral, and unrecognized early signs of a new exacerbation (Shah et al., 2016). Transitional care led by nurses, beginning in hospital and continuing at home, reduced readmissions among older adults in a randomized trial (Naylor et al., 1999). This plan assigns each step of the transition to a named role, with a deadline and a record that proves it happened.

Transitions in Order, Each With an Owner

The table lists each step, the responsible role, the timeframe, the information that must travel, and the record that shows it was done.

Step	Owner	Timeframe	Information that travels	Record that proves it
Identify patient as in population	Admitting RN	Within 12 hours of admission	COPD exacerbation flag	Care coordination flag in record
Inhaler technique assessment and teaching	Respiratory therapist	Day 1 and day before discharge	Devices used, errors, teach-back result	Respiratory therapy note
Medication reconciliation	Clinical pharmacist	Within 24 hours before discharge	Home list, discharge list, each change with reason	Reconciled medication list
Written action plan	Hospitalist or NP with RN	Day of discharge	Green, yellow, red zones; rescue pack instructions	Action plan scanned into record; copy with patient
Follow-up appointment	Unit clerk	Booked before discharge, within 7 days	Date, time, clinician, transport need	Appointment in scheduling system
Pulmonary rehabilitation referral	Discharging clinician	Day of discharge	Diagnosis, spirometry, oxygen needs	Referral order
Summary to primary care	Hospitalist	Within 24 hours of discharge	Diagnoses, medication changes, pending results, plan	Sent message receipt
Transition call	Transitional care nurse	48 to 72 hours after discharge	Symptoms, medications filled, inhaler use, appointment	Call note with checklist
Follow-up visit	Primary care clinician	Within 7 days	Reconciliation, action plan review, rehab status	Visit note
Home health visit (if ordered)	Home health nurse	Within 48 hours of discharge	Oxygen setup, inhaler technique, home safety	Home health start of care

When a Step Fails

A plan that only describes success is not a coordination plan. For each critical step, the plan names what happens when it fails. If the transition call reaches no one after three attempts over two days, the nurse calls the emergency contact and then notifies the primary care clinic to reach out. If the patient reports that a new medication has not been filled, the nurse contacts the pharmacy and, if cost is the barrier, the social worker or the manufacturer's assistance program the same day. If the follow-up visit is missed, the clinic's care coordinator reschedules within two business days and flags the patient for a home visit if a second visit is missed. If the patient reports yellow-zone symptoms on the call, the nurse follows the action plan with the patient and arranges a same-day or next-day clinic visit.

What this page is doingEach failure has a named response, so the plan does not assume that every call is answered and every prescription filled. Coordination that describes only the successful path is the reliable way this deliverable loses its central criterion.

Contact Points Scheduled, Not Hoped For

Each patient receives three planned contacts in the first 30 days: the transition call at 48 to 72 hours, the primary care visit within seven days, and a second call at day 14 to 21 from the transitional care nurse to check action plan use and rehabilitation enrollment. The transitional care nurse owns the patient on day three, the primary care clinician from day seven, and pulmonary rehabilitation, when the patient enrolls, from the first session. Patients are told the name and number of the person who owns them at each stage, printed on the action plan.

What the Next Setting Is Told

The primary care clinician receives the summary within 24 hours, with medication changes marked, pending results listed, and the action plan attached. Home health, when ordered, receives the reconciled medication list and the respiratory therapist's inhaler assessment. Pulmonary rehabilitation receives the referral with spirometry and oxygen needs. The patient receives the medication list, the action plan, the appointment, and the transitional care nurse's name. Prompt communication of discharge information to the next clinician is a recognized component of effective transitional care (Coleman et al., 2006).

Measuring the Plan

Process measures, reported monthly to the COPD coordination group: proportion of patients with each step completed and documented; proportion reached by the transition call; proportion seen within seven days. Outcome measures: 30-day readmission rate for COPD, emergency department visits within 30 days, and pulmonary rehabilitation enrollment within 90 days. The group reviews any readmission within two weeks to find which step, if any, failed.

References

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613-620. https://doi.org/10.1001/jama.281.7.613

Shah, T., Press, V. G., Huisingh-Scheetz, M., & White, S. R. (2016). COPD readmissions: Addressing COPD in the era of value-based health care. Chest, 150(4), 916-926. https://doi.org/10.1016/j.chest.2016.05.002

NU 730 Unit 2 instructions, in plain terms

In Unit 2 you design a care coordination plan for a specific population moving between settings, usually from hospital to home or community care. Expect to identify the population and its coordination risks, map the transitions, assign responsibility for each step, define what information travels and how, and say how you will judge whether it worked. Many versions ask you to use an evidence-based transitional care model, such as the Care Transitions Intervention or the Transitional Care Model. Check whether your section expects a table. Timeframes should be specific, such as within 72 hours, rather than soon. A plan for a population with a known readmission problem, such as COPD or heart failure, gives you clear outcomes to measure and a body of evidence to cite.

How this NU 730 Unit 2 example is built

The plan opens by naming the population and why it needs coordination, with the readmission risk stated briefly. The transitions table is the core: each row is a step with a role, a timeframe, the information that moves, and the documentation that shows completion. The failure section is what separates this plan from a discharge checklist, because it names a backup for every critical step. Scheduled contacts are listed with dates relative to discharge. The section on what the next setting is told describes the summary, the medication changes and the action plan, along with when each arrives. Measures are split into process and outcome, reported monthly to a named group. Each element connects to published transitional care evidence, so the choices are supported rather than assumed.

Reading the NU 730 Unit 2 rubric

The rubric Herzing uses here typically awards points for the population and needs assessment, the coordination strategies, roles and communication, evidence base, evaluation and writing. Population points require a defined group with specific risks. Strategy criteria reward concrete steps with timeframes. The roles and communication criterion often carries the most weight, giving full marks when every step has an owner and the information handoff is described, including to the receiving clinician. Evidence points go to plans grounded in tested models, such as Coleman and colleagues' care transitions trial. Evaluation criteria look for measurable process and outcome indicators with a reporting route. Writing points cover clear organization, a readable table where used, and APA 7 citations.

NU 730 Unit 2 help before you submit

The frequent weakness in a Unit 2 coordination plan is listing services the patient should receive without saying who arranges each one and by when. Another is a plan that ends at discharge, which misses coordination. Students often describe only what happens when everything goes right; a backup for missed calls or appointments is what graders look for. Information transfer is commonly left vague, such as send records to the doctor. Measures limited to readmission miss the process steps that show whether the plan was carried out. Citing a transitional care model without using its components is another gap. Finally, choose one population, because a plan for all chronic disease patients cannot be specific enough to earn the higher criteria.

Get a NU 730 Unit 2 example written to your instructions

Send the Unit 2 instructions and the rubric from your NU 730 classroom, plus the population and the settings your plan has to cover. We write a custom example with owners, time windows, information sets and failure paths written out, and return it in 24 to 48 hours. The first custom sample is free.

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NU 730 Unit 2 questions, answered

Which population makes a good coordination plan?

One with a predictable path and a known failure rate, which is why heart failure, chronic obstructive pulmonary disease, joint replacement and complex diabetes recur in this work. Published evidence exists for each, so you can justify the plan rather than assert it, and the transitions are documented well enough that your timeframes will be defensible.

How specific do the timeframes need to be?

Specific enough to schedule. A follow-up call within forty-eight hours of discharge is a plan; timely follow-up is not. Where evidence supports a particular window, cite it and use it. Where it does not, choose a window you can defend operationally and say what it assumes about staffing, because a rubric reading for feasibility will look for that assumption.

Is this the same as a discharge plan?

It overlaps but reaches further. A discharge plan usually ends when the patient leaves the building, while a coordination plan follows them into the next setting and back, covering the outpatient contact, the reconciliation, the community services and the point at which responsibility formally transfers. If your draft stops at the door, it has not yet met the criterion.

Where can I find a free NU 730 Unit 2 sample paper?

Read the complete NU 730 Unit 2 COPD coordination plan on this page at no cost, including the transitions table and backup steps. A custom plan can be written for another population, such as heart failure or post-stroke patients, if your section needs it.

What is the difference between a care coordination plan and a discharge plan?

A discharge plan prepares the patient to leave. A care coordination plan covers the weeks after, naming who calls, who sees the patient, what information reaches the next clinician and what happens when a step fails. This COPD sample covers the first 30 days.

NU 730 Unit 2 care coordination plan example