Assignment Prompt & Instructions
**files (3)**
– ## HCM340ModuleTwoAnnotatedBibliographyTemplate4.docx
– ## MilestoneOne.docx
– ## FinalProjectMilestoneOne.docx
**## HCM340ModuleTwoAnnotatedBibliographyTemplate4.docx**
[Note: To complete this template, replace the bracketed text with your own content. This is a working document that will be used throughout the term. Remember, this paper is to be written in your own words, do not copy and paste information from the internet.
**Only one resource is required for each section of the Module Two assignment, but additional resources may be needed for full credit in the final project.** **Remove this note and all others in the template before you submit your assignment**.]
## HCM 340 Annotated Bibliography
[Your First and Last Name]
[Course Number and Name]
[Your Instructor’s Name]
[Date Assignment Is Due]
## Annotated Bibliography
**I: Describe a specific gap in the delivery of healthcare. Include the specific population affected by the gap**.
I. [Title of Resource.]
a. [Give the APA formatted reference.] Examples of APA Formatting:
a.
**Print Book General Format**:
i. Author, A. A. (Date).
_Title of book_. Source.
b.
**Webpage General Format**:
i. Author, A. A. (date).
_Title of webpage/document_. Website. https://www.someaddress.com/full/url
c.
**Journal Article With a DOI General Format:**
i. Author, A. A., & Author, B. B. (Date). Title of article.
_Title of Journal_,
_Volume_(Issue), page numbers. DOI
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**II. Briefly describe the history of this gap in access to healthcare. Has this been an issue historically, or is it a modern issue?**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**III. Explain the impact that the socioeconomic background of the population has on their access to healthcare.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**IV: Describe how the healthcare delivered to the population is affected by the gap in access.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**V: Predict any potential implications if this gap in a is not addressed.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**## MilestoneOne.docx**
2
**HCM 340 Milestone One**
Danitza Fernandez-Andes
Southern New Hampshire University
Health Care Delivery System
Dr.Dalona Griffin
May 24, 2026
**HCM 340 Milestone One**
**Introduction**
This paper examines a gap in quality related to care coordination for individuals with chronic illnesses. It will describe the specific gap and the affected population, briefly outline the history of the issue, explain the impact of socioeconomic background, describe how the gap affects healthcare delivery, and predict potential implications if the gap is not addressed. Care coordination fragmentation remains a persistent quality issue in U.S. healthcare, particularly for adults managing multiple chronic conditions.
**Gap**
A major gap in the delivery of healthcare exists in the fragmentation of care coordination for individuals with chronic illnesses. This gap primarily affects adults with multiple chronic conditions (MCC), such as diabetes, heart disease, and arthritis (Joo, 2023). Fragmented care occurs when patients receive services from multiple providers with poor communication and a lack of integrated care planning, resulting in disjointed treatment. This leads to poorer patient outcomes compared to well-coordinated care. Adults with chronic illnesses are particularly vulnerable because their conditions require ongoing management across specialties, yet the healthcare system often fails to provide seamless coordination (Joo, 2023).
**History**
The gap in care coordination for people with chronic illnesses is a longstanding structural issue rather than a recent development. The U.S. healthcare system was originally designed to address acute, short-term conditions. Over decades of policy reforms, this misalignment has persisted despite various attempts at improvement (Bierman et al., 2021). The Agency for Healthcare Research and Quality (AHRQ) has recognized these ongoing failures in caring for individuals with multiple chronic conditions, highlighting that the problem has deep roots in the historical structure of care delivery (Bierman et al., 2021).
**Socioeconomic Background**
Socioeconomic background significantly impacts access to coordinated care for individuals with chronic illnesses. Low-income and safety-net populations face additional barriers such as low health literacy, transportation difficulties, language barriers, and limited access to specialists. These challenges make care coordination even more difficult and worsen health outcomes (Nguyen et al., 2021). Lower socioeconomic status often means reliance on under-resourced safety-net systems, where structural inequities compound the effects of fragmented care. Individuals with higher socioeconomic resources are better able to navigate the system or access supplementary support (Nguyen et al., 2021).
**Affected**
The gap in care coordination negatively affects the healthcare delivered to individuals with chronic illnesses. Fragmentation is associated with higher rates of emergency department visits, avoidable hospitalizations, uncontrolled symptoms, medication errors, increased diagnostic testing, and diminished patient functioning (Joo, 2023; McMenamin et al., 2023). Without effective coordination, patients experience duplicated efforts, gaps in communication among providers, and suboptimal management of their conditions. Models that emphasize team-based and nurse practitioner-led coordinated care have shown better outcomes, underscoring the current deficiencies in standard delivery (McMenamin et al., 2023).
**Implications**
If this gap in care coordination is not addressed, several serious implications are likely. Patients will continue to face fragmented, duplicated, and burdensome healthcare experiences, leading to preventable adverse events, increased caregiver fatigue, and escalating healthcare costs (Watson et al., 2024). Broader effects may include higher overall system strain, reduced quality of life for those with chronic illnesses, and continued inefficiencies. Without systemic changes toward person-centered and coordinated care planning, these issues will persist and potentially worsen as the population with multiple chronic conditions grows (Watson et al., 2024).
**References**
Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda.
_Health Services Research, 56_(1), 973–979.
[https://doi.org/10.1111/1475-6773.13863](https://doi.org/10.1111/1475-6773.13863)
Joo, J. Y. (2023). Fragmented care and chronic illness patient outcomes: A systematic review.
_Nursing Open, 10_(6), 3460–3473.
[https://doi.org/10.1002/nop2.1607](https://doi.org/10.1002/nop2.1607)
McMenamin, A., Turi, E., Schlak, A. E., & Poghosyan, L. (2023). A systematic review of outcomes related to nurse practitioner-delivered primary care for multiple chronic conditions.
_Medical Care Research and Review, 80_(6), 563–581.
[https://doi.org/10.1177/10775587231186720](https://doi.org/10.1177/10775587231186720)
Nguyen, K. H., Fields, J. D., Cemballi, A. G., Desai, R., Gopalan, A., Cruz, T., Shah, A., Akom, A., Brown, W., Sarkar, U., & Lyles, C. R. (2021). The role of community-based organizations in improving chronic care for safety-net populations.
_The Journal of the American Board of Family Medicine, 34_(4), 698–708.
[https://doi.org/10.3122/jabfm.2021.04.200591](https://doi.org/10.3122/jabfm.2021.04.200591)
Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Carney, M. T., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-centered care planning for people living with or at risk for multiple chronic conditions.
_JAMA Network Open, 7_(10), Article e2439851.
[https://doi.org/10.1001/jamanetworkopen.2024.39851](https://doi.org/10.1001/jamanetworkopen.2024.39851)
a.
**## FinalProjectMilestoneOne.docx**
Final Project Milestone One: Topic Selection
[**Listen**](https://app.readspeaker.com/cgi-bin/rsent?customerid=9568&url=https%3A%2F%2Flearn.snhu.edu%2Fd2l%2Flms%2Fdropbox%2Fuser%2Ffolder_submit_files.d2l&lang=en_us&readid=d2l_read_element_1)
Top of Form
| | |
| — | — |
| Hide Assignment Information |
| Turnitin™ | |
| This assignment will be submitted to Turnitin™. |
| Instructions | |
| | | |
| — | — |
| | Possible Points: <br>**60**<br>For this assignment, select a topic from the list provided in the Milestone One Guidelines and Rubric document. Explain why the chosen topic represents a gap in healthcare. Analyze the specific population impacted by the issue.<br>Submit your assignment here. Use the Milestone One Template to complete this assignment. Make sure you’ve included all the required elements by reviewing the <br>[guidelines and rubric](https://learn.snhu.edu/d2l/common/dialogs/quickLink/quickLink.d2l?ou=2262862&type=content&rcode=snhu-3033437). | |
| | |
| |
Hide Rubrics
**Rubric Name: HCM 340 Milestone One Rubric**
| | | | | |
| — | — | — | — | — |
| **Criteria** | **Meets Expectations** | **Partially Meets Expectations** | **Does Not Meet Expectations** | **Criterion Score** |
| Introduction: Gap | 18 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap | 13.5 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe a specific gap in the delivery of healthcare to a specific population | Score of Introduction: Gap,<br>/ 18 |
| Introduction: History | 18 points<br>Briefly describes the history of this gap in access to healthcare | 13.5 points<br>Describes the history of this gap in access to healthcare, but description is verbose or contains inaccuracies | 0 points<br>Does not describe the history of this gap in access to healthcare | Score of Introduction: History,<br>/ 18 |
| Introduction: Socioeconomic Background | 18 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare | 13.5 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare, but explanation is cursory or illogical | 0 points<br>Does not explain the socioeconomic background has on a population’s access to healthcare | Score of Introduction: Socioeconomic Background,<br>/ 18 |
| Introduction: Affect | 18 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | 13.5 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | Score of Introduction: Affect,<br>/ 18 |
| Introduction: Implications | 18 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | 13.5 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed, but predictions are unrealistic or unrelated | 0 points<br>Does not predict any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | Score of Introduction: Implications,<br>/ 18 |
| Clear Communication | 5 points<br>Consistently and effectively communicates in an organized way to a specific audience | 3.75 points<br>Shows progress toward meeting expectations, but communication is inconsistent or ineffective in a way that negatively impacts understanding | 0 points<br>Shows no evidence of consistent, effective, or organized communication | Score of Clear Communication,<br>/ 5 |
| Citations and Attributions | 5 points<br>Uses citations for ideas requiring attribution, with consistent minor errors | 3.75 points<br>Uses citations for ideas requiring attribution, with major errors | 0 points<br>Does not use citations for ideas requiring attribution | Score of Citations and Attributions,<br>/ 5 |
Total
Score of HCM 340 Milestone One Rubric,
/ 100
**Overall Score**
**Meets Expectations**
76 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Partially Meets Expectations**
1 point minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Does Not Meet Expectations**
0 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
| | |
| — | — |
| | |
Bottom of Form
## image1.gif
**## FinalProjectMilestoneOne.docx**
Final Project Milestone One: Topic Selection
[**Listen**](https://app.readspeaker.com/cgi-bin/rsent?customerid=9568&url=https%3A%2F%2Flearn.snhu.edu%2Fd2l%2Flms%2Fdropbox%2Fuser%2Ffolder_submit_files.d2l&lang=en_us&readid=d2l_read_element_1)
Top of Form
| | |
| — | — |
| Hide Assignment Information |
| Turnitin™ | |
| This assignment will be submitted to Turnitin™. |
| Instructions | |
| | | |
| — | — |
| | Possible Points: <br>**60**<br>For this assignment, select a topic from the list provided in the Milestone One Guidelines and Rubric document. Explain why the chosen topic represents a gap in healthcare. Analyze the specific population impacted by the issue.<br>Submit your assignment here. Use the Milestone One Template to complete this assignment. Make sure you’ve included all the required elements by reviewing the <br>[guidelines and rubric](https://learn.snhu.edu/d2l/common/dialogs/quickLink/quickLink.d2l?ou=2262862&type=content&rcode=snhu-3033437). | |
| | |
| |
Hide Rubrics
**Rubric Name: HCM 340 Milestone One Rubric**
| | | | | |
| — | — | — | — | — |
| **Criteria** | **Meets Expectations** | **Partially Meets Expectations** | **Does Not Meet Expectations** | **Criterion Score** |
| Introduction: Gap | 18 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap | 13.5 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe a specific gap in the delivery of healthcare to a specific population | Score of Introduction: Gap,<br>/ 18 |
| Introduction: History | 18 points<br>Briefly describes the history of this gap in access to healthcare | 13.5 points<br>Describes the history of this gap in access to healthcare, but description is verbose or contains inaccuracies | 0 points<br>Does not describe the history of this gap in access to healthcare | Score of Introduction: History,<br>/ 18 |
| Introduction: Socioeconomic Background | 18 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare | 13.5 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare, but explanation is cursory or illogical | 0 points<br>Does not explain the socioeconomic background has on a population’s access to healthcare | Score of Introduction: Socioeconomic Background,<br>/ 18 |
| Introduction: Affect | 18 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | 13.5 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | Score of Introduction: Affect,<br>/ 18 |
| Introduction: Implications | 18 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | 13.5 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed, but predictions are unrealistic or unrelated | 0 points<br>Does not predict any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | Score of Introduction: Implications,<br>/ 18 |
| Clear Communication | 5 points<br>Consistently and effectively communicates in an organized way to a specific audience | 3.75 points<br>Shows progress toward meeting expectations, but communication is inconsistent or ineffective in a way that negatively impacts understanding | 0 points<br>Shows no evidence of consistent, effective, or organized communication | Score of Clear Communication,<br>/ 5 |
| Citations and Attributions | 5 points<br>Uses citations for ideas requiring attribution, with consistent minor errors | 3.75 points<br>Uses citations for ideas requiring attribution, with major errors | 0 points<br>Does not use citations for ideas requiring attribution | Score of Citations and Attributions,<br>/ 5 |
Total
Score of HCM 340 Milestone One Rubric,
/ 100
**Overall Score**
**Meets Expectations**
76 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Partially Meets Expectations**
1 point minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Does Not Meet Expectations**
0 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
| | |
| — | — |
| | |
Bottom of Form
## image1.gif
**## HCM340ModuleTwoAnnotatedBibliographyTemplate4.docx**
[Note: To complete this template, replace the bracketed text with your own content. This is a working document that will be used throughout the term. Remember, this paper is to be written in your own words, do not copy and paste information from the internet.
**Only one resource is required for each section of the Module Two assignment, but additional resources may be needed for full credit in the final project.** **Remove this note and all others in the template before you submit your assignment**.]
## HCM 340 Annotated Bibliography
[Your First and Last Name]
[Course Number and Name]
[Your Instructor’s Name]
[Date Assignment Is Due]
## Annotated Bibliography
**I: Describe a specific gap in the delivery of healthcare. Include the specific population affected by the gap**.
I. [Title of Resource.]
a. [Give the APA formatted reference.] Examples of APA Formatting:
a.
**Print Book General Format**:
i. Author, A. A. (Date).
_Title of book_. Source.
b.
**Webpage General Format**:
i. Author, A. A. (date).
_Title of webpage/document_. Website. https://www.someaddress.com/full/url
c.
**Journal Article With a DOI General Format:**
i. Author, A. A., & Author, B. B. (Date). Title of article.
_Title of Journal_,
_Volume_(Issue), page numbers. DOI
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**II. Briefly describe the history of this gap in access to healthcare. Has this been an issue historically, or is it a modern issue?**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**III. Explain the impact that the socioeconomic background of the population has on their access to healthcare.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**IV: Describe how the healthcare delivered to the population is affected by the gap in access.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**V: Predict any potential implications if this gap in a is not addressed.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**## MilestoneOne.docx**
2
**HCM 340 Milestone One**
Danitza Fernandez-Andes
Southern New Hampshire University
Health Care Delivery System
Dr.Dalona Griffin
May 24, 2026
**HCM 340 Milestone One**
**Introduction**
This paper examines a gap in quality related to care coordination for individuals with chronic illnesses. It will describe the specific gap and the affected population, briefly outline the history of the issue, explain the impact of socioeconomic background, describe how the gap affects healthcare delivery, and predict potential implications if the gap is not addressed. Care coordination fragmentation remains a persistent quality issue in U.S. healthcare, particularly for adults managing multiple chronic conditions.
**Gap**
A major gap in the delivery of healthcare exists in the fragmentation of care coordination for individuals with chronic illnesses. This gap primarily affects adults with multiple chronic conditions (MCC), such as diabetes, heart disease, and arthritis (Joo, 2023). Fragmented care occurs when patients receive services from multiple providers with poor communication and a lack of integrated care planning, resulting in disjointed treatment. This leads to poorer patient outcomes compared to well-coordinated care. Adults with chronic illnesses are particularly vulnerable because their conditions require ongoing management across specialties, yet the healthcare system often fails to provide seamless coordination (Joo, 2023).
**History**
The gap in care coordination for people with chronic illnesses is a longstanding structural issue rather than a recent development. The U.S. healthcare system was originally designed to address acute, short-term conditions. Over decades of policy reforms, this misalignment has persisted despite various attempts at improvement (Bierman et al., 2021). The Agency for Healthcare Research and Quality (AHRQ) has recognized these ongoing failures in caring for individuals with multiple chronic conditions, highlighting that the problem has deep roots in the historical structure of care delivery (Bierman et al., 2021).
**Socioeconomic Background**
Socioeconomic background significantly impacts access to coordinated care for individuals with chronic illnesses. Low-income and safety-net populations face additional barriers such as low health literacy, transportation difficulties, language barriers, and limited access to specialists. These challenges make care coordination even more difficult and worsen health outcomes (Nguyen et al., 2021). Lower socioeconomic status often means reliance on under-resourced safety-net systems, where structural inequities compound the effects of fragmented care. Individuals with higher socioeconomic resources are better able to navigate the system or access supplementary support (Nguyen et al., 2021).
**Affected**
The gap in care coordination negatively affects the healthcare delivered to individuals with chronic illnesses. Fragmentation is associated with higher rates of emergency department visits, avoidable hospitalizations, uncontrolled symptoms, medication errors, increased diagnostic testing, and diminished patient functioning (Joo, 2023; McMenamin et al., 2023). Without effective coordination, patients experience duplicated efforts, gaps in communication among providers, and suboptimal management of their conditions. Models that emphasize team-based and nurse practitioner-led coordinated care have shown better outcomes, underscoring the current deficiencies in standard delivery (McMenamin et al., 2023).
**Implications**
If this gap in care coordination is not addressed, several serious implications are likely. Patients will continue to face fragmented, duplicated, and burdensome healthcare experiences, leading to preventable adverse events, increased caregiver fatigue, and escalating healthcare costs (Watson et al., 2024). Broader effects may include higher overall system strain, reduced quality of life for those with chronic illnesses, and continued inefficiencies. Without systemic changes toward person-centered and coordinated care planning, these issues will persist and potentially worsen as the population with multiple chronic conditions grows (Watson et al., 2024).
**References**
Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda.
_Health Services Research, 56_(1), 973–979.
[https://doi.org/10.1111/1475-6773.13863](https://doi.org/10.1111/1475-6773.13863)
Joo, J. Y. (2023). Fragmented care and chronic illness patient outcomes: A systematic review.
_Nursing Open, 10_(6), 3460–3473.
[https://doi.org/10.1002/nop2.1607](https://doi.org/10.1002/nop2.1607)
McMenamin, A., Turi, E., Schlak, A. E., & Poghosyan, L. (2023). A systematic review of outcomes related to nurse practitioner-delivered primary care for multiple chronic conditions.
_Medical Care Research and Review, 80_(6), 563–581.
[https://doi.org/10.1177/10775587231186720](https://doi.org/10.1177/10775587231186720)
Nguyen, K. H., Fields, J. D., Cemballi, A. G., Desai, R., Gopalan, A., Cruz, T., Shah, A., Akom, A., Brown, W., Sarkar, U., & Lyles, C. R. (2021). The role of community-based organizations in improving chronic care for safety-net populations.
_The Journal of the American Board of Family Medicine, 34_(4), 698–708.
[https://doi.org/10.3122/jabfm.2021.04.200591](https://doi.org/10.3122/jabfm.2021.04.200591)
Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Carney, M. T., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-centered care planning for people living with or at risk for multiple chronic conditions.
_JAMA Network Open, 7_(10), Article e2439851.
[https://doi.org/10.1001/jamanetworkopen.2024.39851](https://doi.org/10.1001/jamanetworkopen.2024.39851)
a.
**## FinalProjectMilestoneOne.docx**
Final Project Milestone One: Topic Selection
[**Listen**](https://app.readspeaker.com/cgi-bin/rsent?customerid=9568&url=https%3A%2F%2Flearn.snhu.edu%2Fd2l%2Flms%2Fdropbox%2Fuser%2Ffolder_submit_files.d2l&lang=en_us&readid=d2l_read_element_1)
Top of Form
| | |
| — | — |
| Hide Assignment Information |
| Turnitin™ | |
| This assignment will be submitted to Turnitin™. |
| Instructions | |
| | | |
| — | — |
| | Possible Points: <br>**60**<br>For this assignment, select a topic from the list provided in the Milestone One Guidelines and Rubric document. Explain why the chosen topic represents a gap in healthcare. Analyze the specific population impacted by the issue.<br>Submit your assignment here. Use the Milestone One Template to complete this assignment. Make sure you’ve included all the required elements by reviewing the <br>[guidelines and rubric](https://learn.snhu.edu/d2l/common/dialogs/quickLink/quickLink.d2l?ou=2262862&type=content&rcode=snhu-3033437). | |
| | |
| |
Hide Rubrics
**Rubric Name: HCM 340 Milestone One Rubric**
| | | | | |
| — | — | — | — | — |
| **Criteria** | **Meets Expectations** | **Partially Meets Expectations** | **Does Not Meet Expectations** | **Criterion Score** |
| Introduction: Gap | 18 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap | 13.5 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe a specific gap in the delivery of healthcare to a specific population | Score of Introduction: Gap,<br>/ 18 |
| Introduction: History | 18 points<br>Briefly describes the history of this gap in access to healthcare | 13.5 points<br>Describes the history of this gap in access to healthcare, but description is verbose or contains inaccuracies | 0 points<br>Does not describe the history of this gap in access to healthcare | Score of Introduction: History,<br>/ 18 |
| Introduction: Socioeconomic Background | 18 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare | 13.5 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare, but explanation is cursory or illogical | 0 points<br>Does not explain the socioeconomic background has on a population’s access to healthcare | Score of Introduction: Socioeconomic Background,<br>/ 18 |
| Introduction: Affect | 18 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | 13.5 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | Score of Introduction: Affect,<br>/ 18 |
| Introduction: Implications | 18 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | 13.5 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed, but predictions are unrealistic or unrelated | 0 points<br>Does not predict any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | Score of Introduction: Implications,<br>/ 18 |
| Clear Communication | 5 points<br>Consistently and effectively communicates in an organized way to a specific audience | 3.75 points<br>Shows progress toward meeting expectations, but communication is inconsistent or ineffective in a way that negatively impacts understanding | 0 points<br>Shows no evidence of consistent, effective, or organized communication | Score of Clear Communication,<br>/ 5 |
| Citations and Attributions | 5 points<br>Uses citations for ideas requiring attribution, with consistent minor errors | 3.75 points<br>Uses citations for ideas requiring attribution, with major errors | 0 points<br>Does not use citations for ideas requiring attribution | Score of Citations and Attributions,<br>/ 5 |
Total
Score of HCM 340 Milestone One Rubric,
/ 100
**Overall Score**
**Meets Expectations**
76 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Partially Meets Expectations**
1 point minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Does Not Meet Expectations**
0 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
| | |
| — | — |
| | |
Bottom of Form
## image1.gif
**## HCM340ModuleTwoAnnotatedBibliographyTemplate4.docx**
[Note: To complete this template, replace the bracketed text with your own content. This is a working document that will be used throughout the term. Remember, this paper is to be written in your own words, do not copy and paste information from the internet.
**Only one resource is required for each section of the Module Two assignment, but additional resources may be needed for full credit in the final project.** **Remove this note and all others in the template before you submit your assignment**.]
## HCM 340 Annotated Bibliography
[Your First and Last Name]
[Course Number and Name]
[Your Instructor’s Name]
[Date Assignment Is Due]
## Annotated Bibliography
**I: Describe a specific gap in the delivery of healthcare. Include the specific population affected by the gap**.
I. [Title of Resource.]
a. [Give the APA formatted reference.] Examples of APA Formatting:
a.
**Print Book General Format**:
i. Author, A. A. (Date).
_Title of book_. Source.
b.
**Webpage General Format**:
i. Author, A. A. (date).
_Title of webpage/document_. Website. https://www.someaddress.com/full/url
c.
**Journal Article With a DOI General Format:**
i. Author, A. A., & Author, B. B. (Date). Title of article.
_Title of Journal_,
_Volume_(Issue), page numbers. DOI
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**II. Briefly describe the history of this gap in access to healthcare. Has this been an issue historically, or is it a modern issue?**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**III. Explain the impact that the socioeconomic background of the population has on their access to healthcare.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**IV: Describe how the healthcare delivered to the population is affected by the gap in access.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**V: Predict any potential implications if this gap in a is not addressed.**
I. [Title of Resource.]
a. [Give the APA formatted reference.]
b. [Summarize the content of the source.]
c. [Why is this resource relevant to your chosen topic?]
**## MilestoneOne.docx**
2
**HCM 340 Milestone One**
Danitza Fernandez-Andes
Southern New Hampshire University
Health Care Delivery System
Dr.Dalona Griffin
May 24, 2026
**HCM 340 Milestone One**
**Introduction**
This paper examines a gap in quality related to care coordination for individuals with chronic illnesses. It will describe the specific gap and the affected population, briefly outline the history of the issue, explain the impact of socioeconomic background, describe how the gap affects healthcare delivery, and predict potential implications if the gap is not addressed. Care coordination fragmentation remains a persistent quality issue in U.S. healthcare, particularly for adults managing multiple chronic conditions.
**Gap**
A major gap in the delivery of healthcare exists in the fragmentation of care coordination for individuals with chronic illnesses. This gap primarily affects adults with multiple chronic conditions (MCC), such as diabetes, heart disease, and arthritis (Joo, 2023). Fragmented care occurs when patients receive services from multiple providers with poor communication and a lack of integrated care planning, resulting in disjointed treatment. This leads to poorer patient outcomes compared to well-coordinated care. Adults with chronic illnesses are particularly vulnerable because their conditions require ongoing management across specialties, yet the healthcare system often fails to provide seamless coordination (Joo, 2023).
**History**
The gap in care coordination for people with chronic illnesses is a longstanding structural issue rather than a recent development. The U.S. healthcare system was originally designed to address acute, short-term conditions. Over decades of policy reforms, this misalignment has persisted despite various attempts at improvement (Bierman et al., 2021). The Agency for Healthcare Research and Quality (AHRQ) has recognized these ongoing failures in caring for individuals with multiple chronic conditions, highlighting that the problem has deep roots in the historical structure of care delivery (Bierman et al., 2021).
**Socioeconomic Background**
Socioeconomic background significantly impacts access to coordinated care for individuals with chronic illnesses. Low-income and safety-net populations face additional barriers such as low health literacy, transportation difficulties, language barriers, and limited access to specialists. These challenges make care coordination even more difficult and worsen health outcomes (Nguyen et al., 2021). Lower socioeconomic status often means reliance on under-resourced safety-net systems, where structural inequities compound the effects of fragmented care. Individuals with higher socioeconomic resources are better able to navigate the system or access supplementary support (Nguyen et al., 2021).
**Affected**
The gap in care coordination negatively affects the healthcare delivered to individuals with chronic illnesses. Fragmentation is associated with higher rates of emergency department visits, avoidable hospitalizations, uncontrolled symptoms, medication errors, increased diagnostic testing, and diminished patient functioning (Joo, 2023; McMenamin et al., 2023). Without effective coordination, patients experience duplicated efforts, gaps in communication among providers, and suboptimal management of their conditions. Models that emphasize team-based and nurse practitioner-led coordinated care have shown better outcomes, underscoring the current deficiencies in standard delivery (McMenamin et al., 2023).
**Implications**
If this gap in care coordination is not addressed, several serious implications are likely. Patients will continue to face fragmented, duplicated, and burdensome healthcare experiences, leading to preventable adverse events, increased caregiver fatigue, and escalating healthcare costs (Watson et al., 2024). Broader effects may include higher overall system strain, reduced quality of life for those with chronic illnesses, and continued inefficiencies. Without systemic changes toward person-centered and coordinated care planning, these issues will persist and potentially worsen as the population with multiple chronic conditions grows (Watson et al., 2024).
**References**
Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda.
_Health Services Research, 56_(1), 973–979.
[https://doi.org/10.1111/1475-6773.13863](https://doi.org/10.1111/1475-6773.13863)
Joo, J. Y. (2023). Fragmented care and chronic illness patient outcomes: A systematic review.
_Nursing Open, 10_(6), 3460–3473.
[https://doi.org/10.1002/nop2.1607](https://doi.org/10.1002/nop2.1607)
McMenamin, A., Turi, E., Schlak, A. E., & Poghosyan, L. (2023). A systematic review of outcomes related to nurse practitioner-delivered primary care for multiple chronic conditions.
_Medical Care Research and Review, 80_(6), 563–581.
[https://doi.org/10.1177/10775587231186720](https://doi.org/10.1177/10775587231186720)
Nguyen, K. H., Fields, J. D., Cemballi, A. G., Desai, R., Gopalan, A., Cruz, T., Shah, A., Akom, A., Brown, W., Sarkar, U., & Lyles, C. R. (2021). The role of community-based organizations in improving chronic care for safety-net populations.
_The Journal of the American Board of Family Medicine, 34_(4), 698–708.
[https://doi.org/10.3122/jabfm.2021.04.200591](https://doi.org/10.3122/jabfm.2021.04.200591)
Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Carney, M. T., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-centered care planning for people living with or at risk for multiple chronic conditions.
_JAMA Network Open, 7_(10), Article e2439851.
[https://doi.org/10.1001/jamanetworkopen.2024.39851](https://doi.org/10.1001/jamanetworkopen.2024.39851)
a.
**## FinalProjectMilestoneOne.docx**
Final Project Milestone One: Topic Selection
[**Listen**](https://app.readspeaker.com/cgi-bin/rsent?customerid=9568&url=https%3A%2F%2Flearn.snhu.edu%2Fd2l%2Flms%2Fdropbox%2Fuser%2Ffolder_submit_files.d2l&lang=en_us&readid=d2l_read_element_1)
Top of Form
| | |
| — | — |
| Hide Assignment Information |
| Turnitin™ | |
| This assignment will be submitted to Turnitin™. |
| Instructions | |
| | | |
| — | — |
| | Possible Points: <br>**60**<br>For this assignment, select a topic from the list provided in the Milestone One Guidelines and Rubric document. Explain why the chosen topic represents a gap in healthcare. Analyze the specific population impacted by the issue.<br>Submit your assignment here. Use the Milestone One Template to complete this assignment. Make sure you’ve included all the required elements by reviewing the <br>[guidelines and rubric](https://learn.snhu.edu/d2l/common/dialogs/quickLink/quickLink.d2l?ou=2262862&type=content&rcode=snhu-3033437). | |
| | |
| |
Hide Rubrics
**Rubric Name: HCM 340 Milestone One Rubric**
| | | | | |
| — | — | — | — | — |
| **Criteria** | **Meets Expectations** | **Partially Meets Expectations** | **Does Not Meet Expectations** | **Criterion Score** |
| Introduction: Gap | 18 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap | 13.5 points<br>Describes a specific gap in the delivery of healthcare, including the specific population affected by the gap, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe a specific gap in the delivery of healthcare to a specific population | Score of Introduction: Gap,<br>/ 18 |
| Introduction: History | 18 points<br>Briefly describes the history of this gap in access to healthcare | 13.5 points<br>Describes the history of this gap in access to healthcare, but description is verbose or contains inaccuracies | 0 points<br>Does not describe the history of this gap in access to healthcare | Score of Introduction: History,<br>/ 18 |
| Introduction: Socioeconomic Background | 18 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare | 13.5 points<br>Explains the impact socioeconomic background has on a population’s access to healthcare, but explanation is cursory or illogical | 0 points<br>Does not explain the socioeconomic background has on a population’s access to healthcare | Score of Introduction: Socioeconomic Background,<br>/ 18 |
| Introduction: Affect | 18 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | 13.5 points<br>Describes how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care, but the description is cursory or contains inaccuracies | 0 points<br>Does not describe how the healthcare delivered to the population is affected by the gap in access to quality, equity, or efficiency of care | Score of Introduction: Affect,<br>/ 18 |
| Introduction: Implications | 18 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | 13.5 points<br>Predicts any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed, but predictions are unrealistic or unrelated | 0 points<br>Does not predict any potential implications if this gap in access to quality, equity, or efficiency of care is not addressed | Score of Introduction: Implications,<br>/ 18 |
| Clear Communication | 5 points<br>Consistently and effectively communicates in an organized way to a specific audience | 3.75 points<br>Shows progress toward meeting expectations, but communication is inconsistent or ineffective in a way that negatively impacts understanding | 0 points<br>Shows no evidence of consistent, effective, or organized communication | Score of Clear Communication,<br>/ 5 |
| Citations and Attributions | 5 points<br>Uses citations for ideas requiring attribution, with consistent minor errors | 3.75 points<br>Uses citations for ideas requiring attribution, with major errors | 0 points<br>Does not use citations for ideas requiring attribution | Score of Citations and Attributions,<br>/ 5 |
Total
Score of HCM 340 Milestone One Rubric,
/ 100
**Overall Score**
**Meets Expectations**
76 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Partially Meets Expectations**
1 point minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
**Does Not Meet Expectations**
0 points minimum
Instructors should not modify this row (it will automate from the scores above). This score represents the average evaluation across all rubric criteria.
| | |
| — | — |
| | |
Bottom of Form
## image1.gif