| Course | HCR 321 Advanced Concepts for Health Care Coordination |
|---|---|
| Module | Module 5 |
| Paper type | Evolving case study |
| Length | About 583 words, 5 pages |
| Format | APA 7 student paper |
| School | Arizona State University |
| Program | BS in Health Care Coordination |
| Updated | October 2026 |
Free sample paper for HCR 321 Module 5
Evolving Case, Part 2: One Plan for Mr. Ortiz, His Family and His Community Providers
Student Name
BS in Health Care Coordination, Arizona State University
HCR 321: Advanced Concepts for Health Care Coordination
Instructor Name
Month Day, Year
Evolving Case, Part 2: One Plan for Mr. Ortiz, His Family and His Community Providers
Where Part 1 Left Off
Mr. Ortiz, 71, with heart failure and diabetes, had been readmitted 19 days after his first discharge. In Part 1, the coordinator reconciled his medications, arranged Spanish-language teaching with an interpreter and piloted a follow-up call. Part 2 covers the next 30 days.
Working With the Client: A Person-Centered Plan
At a home visit with an interpreter, the coordinator asked Mr. Ortiz what mattered most. His answer was clear: to keep going to the senior center on weekdays, where he plays dominoes with friends, and not to become a burden on his daughter. This goal shaped the plan. Rather than a list of rules, the plan connected each task to his goal: daily weights so he could stay well enough to go to the center, a pill organizer so his daughter would not need to manage his medicines.
| His goal | Plan element | Who helps |
|---|---|---|
| Keep attending the senior center | Daily weight and symptom check each morning | Mr. Ortiz, with a scale and Spanish chart |
| Not burden his daughter | Weekly pill organizer filled by pharmacy | Community pharmacist |
| Stay out of the hospital | Nurse visits twice weekly for two weeks | Home health agency |
| Get to appointments | Scheduled rides | Medicaid transportation benefit |
Working With Providers and Stakeholders
Five parties needed to work from the same plan: the primary care physician, the cardiologist, a community pharmacist, a home health agency and the senior center staff, along with his daughter. The coordinator served as the communication hub, sending one updated plan to all after each change. In the Medicare demonstrations, being this kind of hub, along with face-to-face visits and close medication review, was what set apart the few programs that kept the sickest patients out of the hospital (Brown et al., 2012). The senior center agreed to remind him to take his midday pills with lunch, a small step that used a trusted community setting.
A Conflict to Resolve
The cardiologist recommended limiting fluids to 1.5 liters a day. Mr. Ortiz found this hard, especially on hot days walking to the center, and admitted ignoring it. Rather than reporting him as noncompliant, the coordinator arranged a three-way call. The cardiologist explained the reason, Mr. Ortiz explained his days and they agreed on a measured water bottle and an agreement that a gain of over two pounds overnight meant a phone call to the clinic that morning. Respecting his autonomy while keeping safety in view made the plan one he would follow.
Results at 30 Days
Mr. Ortiz was not readmitted. He weighed himself on 26 of 30 days, attended both follow-up appointments and kept going to the center. His daughter reported less worry. One problem remained: a ride arrived late once and he nearly missed a visit, so the coordinator added the clinic's direct number to his transportation account.
What the Literature Suggests About These Results
These results fit the evidence. In one trial, advanced practice nurses who planned discharges and then followed older patients at home cut readmissions (Naylor et al., 1999), and coaching patients to take an active role reduced rehospitalizations (Coleman et al., 2006). One patient's month is not proof, but the elements that helped him match those that work in trials.
Reflection
Working through both parts showed me that coordination is mostly relationships: earning the trust of the patient and family and keeping many professionals connected. The plan worked because it was his.
References
Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Affairs, 31(6), 1156-1166. https://doi.org/10.1377/hlthaff.2012.0393
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
HCR 321 Module 5 instructions, in plain terms
Part 2 of HCR 321's evolving case is the Module 5 paper, worth 50 points and longer than the others at 4 to 5 pages, excluding the title page and references. It continues the patient from Part 1 and applies the assigned readings for Module 5, which focuses on working with clients and with other service providers and stakeholders. As with Part 1, the case needs a minimum of three primary sources from outside the course, the course template and APA 7th edition. Keep every fact consistent with Part 1 and with the case your instructor supplies, and show how the situation develops. Module 5 is also when work on the VoiceThread final project begins, so plan your time across both.
How the HCR 321 Module 5 example is put together
Part 2 opens with a short reminder of where Part 1 ended, then describes a person-centered planning conversation and presents a table linking each plan element to the patient's own goal and to the person who helps. A section on providers and stakeholders shows the coordinator acting as the communication hub for five parties and a community setting, supported by evidence. A disagreement between the patient's wishes and a specialist's advice is resolved through a three-way conversation. Results at 30 days, including one remaining problem, are compared with evidence from trials, and a short reflection closes the case. The story stays consistent with Part 1 throughout. The patient's own words open the plan, which signals person-centered thinking from the first paragraph.
Where the marks sit in the HCR 321 Module 5 rubric
Part 2 earns up to 50 points on its Canvas rubric. Strong second-part case papers usually earn credit for continuity with Part 1, a person-centered plan built from the patient's own goals, clear roles for each provider and stakeholder, a realistic account of conflict or barriers and how they were handled, application of the module's readings to the case, at least three primary sources and correct length and format. They lose credit when the plan is generic, when the patient's voice is missing, when the paper repeats Part 1 rather than advancing the case and when stakeholders are listed without explaining how they work together.
HCR 321 Module 5 help with common mistakes
Reread Part 1 and your instructor's feedback before writing, and carry forward every relevant fact. Start the plan with the patient's goal in his or her own words. Use a table to show who does what. Include at least one realistic barrier or disagreement; cases with no problems read as unrealistic. Compare your patient's outcomes with what research would predict, and say what remains unsolved. Reflection should be specific to this case. The desk can review continuity between your two parts if you share both. End with what remains unresolved for the patient; honest loose ends make the case believable and show judgment about what coordination can and cannot fix in a month.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Arizona State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
More HCR 321 and BS in Health Care Coordination sample papers
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- HCR 321 Module 3: Module 3 Evolving Case, Part 1
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- HCR 321 Module 6: Module 6 Short Paper: Interprofessional Teamwork
- HCR 321 Module 7: Module 7 Short Paper: Implementing Care Coordination
- HCR 400 Module 5: Critical Appraisal: Systematic Review
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HCR 321 Module 5 questions, answered
Where can I find a free HCR 321 Module 5 sample paper?
This page carries a full HCR 321 Module 5 sample: Part 2 of an evolving case building one person-centered plan with family and community providers.
How long is HCR 321 Evolving Case Part 2?
Four to five pages, excluding the title page and references.
What is person-centered care planning?
Planning that starts from the patient's own goals and preferences and links each task to what matters to the patient.
What does a care coordinator do with multiple providers?
Acts as a communication hub, keeping one shared plan current and making sure each party knows its role.
Does Part 2 have to match Part 1 in HCR 321?
Yes. The evolving case follows the same patient, so facts and plans should continue consistently.