NURS-FPX4900 Assessment 3: Assessing the Problem – Technology, Care Coordination, and Community Resources Considerations

Course

NURS-FPX4900: Capstone Project for Nursing (BSN level).

Overview

This third capstone assessment builds directly on the problem analyzed in Assessments 1 and 2 by examining how healthcare technology, care coordination, and community or population resources influence outcomes for the chosen patient, family, or population. The assessment evaluates current technology use and coordination processes, identifies gaps and opportunities, and considers how community resources can be integrated into a more cohesive plan of care. This analysis prepares the foundation for designing a targeted, feasible intervention in later capstone work.

Assessment Type and Length

• Individual written assessment (academic paper, APA style).

• 5–7 page paper (excluding title page and reference list), double-spaced.

Practicum and Preparation

Continue using the same patient, family, or population and practice setting from prior assessments. Spend approximately 2 additional direct practicum hours focusing on how technology, care coordination mechanisms, and community resources are currently used to address the problem and how they could be improved. Activities may include shadowing care coordination processes, reviewing electronic systems, or consulting with case managers, social workers, or community partners. Practicum time must be recorded in the Capella Academic Portal Volunteer Experience Form.

Suggested Preparation Steps

1. Clarify the clinical workflows or transitions of care central to the problem, such as hospital discharge, primary care follow-up, chronic disease management, or telehealth visits.

2. Identify technologies used by the population, including electronic health records, patient portals, telehealth platforms, remote monitoring devices, mobile health applications, or clinical decision support tools.

3. Map current care coordination roles and processes, noting how information is shared and where breakdowns occur.

4. Identify relevant community resources such as education programs, support groups, home health services, community health workers, public health agencies, or social services.

5. Use practicum hours to observe how patients and staff interact with technology, coordination processes, and community resources and to identify barriers.

Assignment Instructions

Write a 5–7 page paper evaluating how healthcare technology, care coordination, and community resources currently relate to the selected patient, family, or population health problem and how they could be optimized to improve quality, safety, and cost outcomes. Organize the paper with clear headings, integrate current scholarly sources, and follow current APA style.

Required Paper Sections

1. Introduction and Problem Recap

• Recap the practice setting, population, and health problem from Assessments 1 and 2.

• Explain why effective technology use, care coordination, and community resource integration are essential for addressing the problem.

• End with a purpose statement focused on these three domains.

2. Current Use of Healthcare Technology

• Describe technologies currently used in the setting, such as EHR functions, patient portals, telehealth, remote monitoring, or mobile applications.

• Explain how these technologies support or fail to support key care processes like education, medication management, symptom monitoring, and information sharing.

• Identify strengths and limitations related to usability, access, training, and workflow integration.

• Support the analysis with recent evidence.

3. Care Coordination Processes

• Describe how care coordination currently occurs across settings or services.

• Identify key coordination roles and tools used by nurses, case managers, social workers, pharmacists, or community health workers.

• Analyze where communication or coordination breaks down and how this affects quality, safety, and patient experience.

• Discuss evidence-based strategies to improve continuity of care.

4. Community and Population Resources

• Identify relevant community resources that support the population.

• Explain how these resources are connected, or not connected, to care in the practice setting.

• Analyze barriers such as transportation, eligibility, language, digital access, or awareness.

• Use evidence to demonstrate how community resources improve outcomes.

5. Ethical, Legal, and Policy Considerations

• Discuss ethical and legal issues related to technology and coordination, including privacy, confidentiality, equity, and data security.

• Identify relevant organizational policies and external regulations such as HIPAA or telehealth standards.

• Explain how these considerations influence decisions in the capstone project.

6. Opportunities to Optimize Technology, Care Coordination, and Community Resources

• Propose realistic opportunities to improve technology use, coordination, and resource integration.

• Explain how these improvements enhance quality, safety, and cost outcomes.

• Prioritize feasible, high-impact opportunities.

7. Implications for the Capstone Intervention

• Synthesize findings into a clear direction for the capstone intervention.

• Identify technologies, coordination mechanisms, and community resources to be leveraged.

• Link these strategies to measurable outcomes such as adherence, symptom control, readmissions, or patient experience.

8. Conclusion

• Summarize how technology, care coordination, and community resources shape the problem and outcomes.

• Reinforce how this analysis informs the planned capstone intervention.

Practicum Documentation

• Record the 2 direct practicum hours for this assessment in the Capella Academic Portal Volunteer Experience Form.

• Briefly describe how practicum time was used without including identifiable information.

Many adults with poorly controlled type 2 diabetes have access to patient portals and glucose monitoring tools, yet these technologies are often underutilized in daily self-management. Combining remote monitoring, scheduled telehealth visits, and proactive nurse follow-up can transform existing tools into a coordinated support system. Community-based education programs and peer support further strengthen care by addressing behavioral and social barriers to disease management.

Evidence indicates that integrating digital health technologies with structured care coordination and community-based support significantly improves chronic disease outcomes. Telehealth platforms and remote monitoring are most effective when paired with proactive nurse follow-up and referrals to community education and support programs, leading to improved self-management, reduced acute care use, and enhanced patient engagement (Hu & Wang, 2019).

1. Pal, K., Eastwood, S. V., Michala, E., Farmer, A. J., Smith, C. T., & Murray, E. (2019). Computer-based diabetes self-management interventions for adults with type 2 diabetes: A systematic review and meta-analysis. Diabetologia, 62(6), 970–978. https://doi.org/10.1007/s00125-019-4840-5

2. Bashi, N., Karunanithi, M., Fatehi, F., Ding, H., & Walters, D. (2017). Remote monitoring of patients with heart failure: An overview of systematic reviews. Journal of Medical Internet Research, 19(1), e18. https://doi.org/10.2196/jmir.6571

3. Naylor, M. D., & Keating, S. A. (2008). Transitional care. American Journal of Nursing, 108(9 Suppl), 58–63. https://doi.org/10.1097/01.NAJ.0000336420.34946.3a

4. Hu, Y., & Wang, Y. (2019). Use of telehealth in chronic disease management: A systematic review. International Journal of Nursing Studies, 97, 105–118. https://doi.org/10.1016/j.ijnurstu.2019.05.013

5. World Health Organization. (2020). WHO guideline: Recommendations on digital interventions for health system strengthening. https://apps.who.int/iris/handle/10665/311941

6. Kruse, C. S., Lee, K., Watson, J. B., Lobo, L. G., Stoppelmoor, A. G., & Oyibo, S. E. (2020). Measures of effectiveness, efficiency, and quality of telemedicine in the management of chronic disease: A systematic review. Journal of Medical Internet Research, 22(8), e16487. https://doi.org/10.2196/16487