Begin by identifying a patient from your clinicals who has a chronic health condition such as diabetes, COPD, hypertension, mental health diagnosis, and post stroke care. Discuss all aspects of healthcare coordination with the chosen diagnosis. Your paper should include the following information: 
Description of the patient’s health issues, diagnoses, and treatment plan.
Description of the interdisciplinary team that will participate in this care.
Can the CCCR model be used in managing this patient’s care? How so? If not, can you name another model to help in managing this patient’s care?  

What is the cost of managing this disease? Are there resources available for the patient and family to help with costs and other factors such as commute and etc?
What is your role as the APRN in this team?
As the APRN, how can you evaluate if the care management is successful?
As the APRN, how can you evaluate if this patient needs a higher level of care?
Are there any barriers or challenges that you foresee for this patient? How can you overcome these barriers?