Assessing the Problem – Technology, Care Coordination, and Community Resources Considerations

Assessing the Problem – Technology, Care Coordination, and Community Resources Considerations

Members of the interdisciplinary team should collaborate effectively to manage Alzheimer’s disease. This paper discusses the use of health technology in Alzheimer’s disease (AD) management. It also discusses care coordination and identifies community resources for people with AD. Furthermore, it describes policies and procedures and nursing ethics involved in the management of AD.

Part One

Impact of Health Care Technology

Optimal care and management of Alzheimer’s disease benefit significantly from healthcare technology. In this context, relevant technologies include telehealth and electronic medical records. Various types of telehealth technology have proved useful to patients with AD. To begin with, mobile health can be leveraged to optimize the management of AD. According to De Marchi et al. (2021), mobile health enhances care delivery by enhancing adherence to care plans and offering an avenue for education. Mobile health features such as reminder messages and alerts help to increase medication adherence (De Marchi et al., 2021). Healthcare practitioners leverage mobile health to send text and audio messages that aim to improve adherence to care plans and address any concerns. Alternatively, Sauer (2019) reports that prerecorded audio messages can be leveraged to alert patients and their caregivers to administer or take medication.

Secondly, De Marchi et al. (2021) report that remote patient monitoring facilitates patient follow-ups and provides an opportunity for prompt care delivery. In this regard, patients with AD use wearables and sensors that monitor their vitals and allow them to upload and email their vitals to the interdisciplinary team for review. Consequently, this facilitates perpetual patient monitoring and eliminates the necessity for in-person visits. Additionally, De Marchi et al. (2021) report that sensors enable caretakers and medical professionals to keep track of patients’ other behaviors, like sleep and exercise.

Thirdly, De Marchi et al. (2021) report that video conferencing allows healthcare practitioners to intervene promptly. Audio and video conferencing makes real-time communication between AD patients and families and healthcare practitioners easier (De Marchi et al., 2021). As a result, video conferencing allows patients to conduct specialty consultations virtually. For example, a patient’s clinician can use videoconferencing to personalize the treatment plan based on input from remote patient monitoring (De Marchi et al., 2021). Videoconferencing can also benefit patients with AD by allowing their healthcare providers to track the recommended lifestyle modification practices.

Electronic medical records (EMR) are another type of technology that impacts the management of AD. Electronic medical records allow healthcare practitioners to optimize workflow and formulate evidence-based care plans (Sutton et al., 2020). For instance, Sutton et al. (2020) report that clinical decision support systems in EMR systems are noteworthy because they are crucial to accurate diagnosis and the creation of treatment plans. According to Sutton et al. (2020), EMR systems also reduce the likelihood of medical errors by eliminating legibility errors to allow accurate information sharing among the interdisciplinary team. Therefore, EMR systems improve the quality of care by optimizing the decision-making process and improving clinical workflow.

Butzner and Cuffee (2021) identify some disadvantages of telehealth technology. To begin with, patients found in rural areas are likely to experience poor connectivity and limited broadband access. This limits access to healthcare services by the general population. Also, Butzner and Cuffee (2021) report that telehealth promotes patient visits to unknown healthcare providers. This may impede the creation of a therapeutic relationship and hinder the treatment process.

The evidence is harmonious with the technology that has been embraced at my place workplace. We leverage electronic medical record systems to improve the clinical decision-making process, minimize medical errors and optimize workflow. Also, we leverage telehealth technology to manage chronic illnesses like Alzheimer’s disease. To improve adherence to the treatment regimen, we employ mobile health features such as alarms and reminders. Additionally, we utilize video conferencing to accord patients’ concerns real-time feedback. Wearable technology is available to provide ongoing remote patient monitoring.

Potential Barriers and Costs

Numerous variables make telehealth less effective. Drees (2020) reports that a lack of digital literacy among medical professionals, patients, caregivers, and patients’ families makes telehealth less acceptable. Sessions focused on enhancing participants’ digital knowledge and abilities can be used to solve this problem. According to Drees (2020), the other barrier is the lack of accessible, high-quality connectivity. This makes it difficult for patients and healthcare professionals to communicate via telehealth technology. Drees (2020) reports that the lack of multistate licensure makes it difficult for patients and healthcare practitioners from other states to connect. Drees (2020) also notes that patients’ preferences for in-person sessions are another barrier. Preferences for in-person sessions impede the acceptability and use of telehealth technology.

Care Coordination and Community Resources

Care coordination can be used to manage AD. It entails the distribution of patient care roles among members of the interdisciplinary team and patients (CMS.gov, n.d.). In the context of AD, the interdisciplinary team involved in care coordination accomplishes tasks such as patient assessment, formulation of care plans, communication, implementing care plans, monitoring and modifying care plans, and evaluating health outcomes. Care coordination is beneficial because it facilitates collaboration and promotes the delivery of efficient healthcare services. Nursing staff, physicians, pharmacists, nutritionists, and laboratory technicians are examples of stakeholders who coordinate care for AD patients. To begin with, nurses facilitate the safe administration of drugs (Schmutz et al., 2019). Additionally, nurses create individualized and holistic care plans for AD patients. They work in concert with the interdisciplinary team to provide individualized education based on the severity of the patient’s AD. As stated by Schmutz et al. (2019), physicians should leverage clinical decision support systems to create comprehensive treatment plans. Further, pharmacists are key stakeholders involved in patient education and counseling. They educate patients about the appropriate use of medications, the importance of adherence to the treatment plan, and the potential adverse effects. In addition, pharmacists enforce the rational use of medications. Moreover, laboratory technicians perform tests and report findings to enable physicians to develop evidence-based treatment plans. Lastly, nutritionists provide pertinent information about dietary modifications for patients with AD. This evidence is harmonious with the practices observed in my clinical practice. Kurpas et al. (2021) report opposing views by indicating that patients’ lack of trust and limited understanding of the role of the interdisciplinary team impedes care coordination.

The Alzheimer’s Association is an example of a community resource that provides a range of community-friendly programs. It provides face-to-face support groups and lectures (ALZ.org, n.d.). These resources allow patients and their families to cope with the disease effectively. Support groups provide an opportunity for communication, sharing experiences with the disease, and exploring the best strategies for managing the disease (ALZ.org, n.d.). Also, educational sessions equip patients and their families with relevant information about AD. By so doing, they gain a better understanding of the disease and, hence better control of AD.

Barriers to Care Coordination and Use of Community Resources

Numerous factors influence effective care coordination and accessibility to community resources. Examples of these factors include organizational culture, availability and allocation of resources, and organizational policies (Vargas et al., 2020). Adequate allocation of human and financial resources averts the possibility of shortages of healthcare providers. These shortages hinder care coordination by making medical staff more susceptible to stress, burnout, and medical errors (Vargas et al., 2020). Additionally, sufficient financial and human resources facilitate the activities of local community resources. By so doing, patients with AD access quality services from community resources. An organization that embraces a culture of collectivism and cultural congruence promotes care coordination. This culture advocates for interdisciplinary collaborations and nondiscriminatory practices toward patients and other healthcare practitioners. Also, care coordination is hampered by a lack of established operational policies and procedures (Vargas et al., 2020). The absence of policies and standard operating procedures is an enabler for role ambiguity, confusion, and ineffective delegation of tasks.

State Board Nursing Practice Standards, Organizational or Governmental Policies

An example of a federal policy that guides the usage of healthcare technology is the Health Insurance Portability and Accountability Act (HIPAA). Edemekong et al. (2022) report that HIPAA establishes rules for safeguarding personal health information (PHI) transmitted electronically. All covered entities are obligated to safeguard the privacy and confidentiality of PHI. Access to PHI should be restricted to authorized persons only. According to Edemekong et al. (2022), violation of this Act’s requirements can result in both criminal and civil fines. This Act will direct my activities when dealing with Alzheimer’s patients. I will respect and protect their privacy and confidentiality. In addition, I will ensure that their PHI is secure and not accessible to unauthorized individuals. I will only avail this information in the situations authorized by the Act.

Moreover, the standards of the American Nurses Association (ANA) influence care coordination for patients with AD. According to MO.gov (n.d.), ANA develops practice standards, professional performance recommendations, and specialized practice guidelines. ANA’s standards support the preservation of the nursing process, comprehensive care, individualized and holistic care, and scientific research. In addition, it promotes the use of standard treatment recommendations and ongoing medical education to develop a skilled nursing workforce (MO.gov, n.d.). As such, the ANA’s provisions will direct my profession. For example, to attain patient-centeredness, I will employ the nursing process. In addition, I will work in concert with the interdisciplinary team to deliver high-quality care.

The National Alzheimer’s Project Act (NAPA) and ANA’s standards of practice have an impact on the scope of nursing practice. ANA’s standards of practice mandate that nurses conduct research and incorporate evidence-based practice into their daily work (MO.gov, n.d.). Nurses should also exhibit strong cooperation abilities and collaborate with the interdisciplinary team to improve care delivery. Nurses must also complete routine training activities and exhibit sufficient professional proficiency. The NAPA states that nurses should be dedicated to the successful care and prevention of AD. To enhance the management of the disease, they should work with patients and their families. They should also improve AD data collecting, reporting, processing, and distribution while educating the general public.

My interaction with AD patients will be centered around nursing ethics. To uphold autonomy, I will acknowledge the importance of patients and their families in the treatment process. I will ensure that patients and their families choose the components of their treatment plans. Also, I will protect patients with diminished autonomy. I will only administer therapy after obtaining patient or family consent. Next, to uphold beneficence and non-maleficence, I will take the initiative to avert potential harm to the patient. For example, I will ensure that the potential merits of the care plans outweigh the risks. I will accomplish this by obtaining a thorough medical, family, and social history. In addition, I will explore and implement evidence-based strategies that improve patient outcomes. Finally, I will avoid discriminatory practices and prejudices toward patients and their families to uphold fairness. I will allow all patients to benefit from the best treatment programs aimed at improving outcomes and achieving better patient safety.

Part Two

I interacted with my aunt, a sixty-nine-year-old African-American female diagnosed with AD three years ago. I spent six hours with the patient and her spouse. During this interaction, I learned that the patient was not adherent to her treatment plan. Non-adherence was attributed to forgetfulness by the patient and her spouse. They stated that during their prior visit to the clinic, they had been taught the need to comply with the treatment plan. At the end of our conversation, we agreed to use mobile technology such as reminders, alarms, and videoconferencing to optimize patient care. The biggest impediment to our interaction was limited digital literacy. I leveraged therapeutic communication to create a rapport and address this shortcoming. My plan to address AD did not change. We agreed that the patient should adhere to the treatment plan to minimize hospitalizations and lower healthcare costs.

I used online sources such as PubMed and Google Scholar to find peer-reviewed literature. I also looked up information on credible organizational websites and used the CRAAP model to evaluate the credibility and reliability of articles.

References

ALZ.org. (n.d.). Programs and Support. https://www.alz.org/help-support/i-have-alz/programs-support#:~:text=Call%20the%20Alzheimer's%20Association%2024,crisis%20assistance%3B%20and%20emotional%20support.

Butzner, M., & Cuffee, Y. (2021). Telehealth interventions and outcomes across rural communities in the United States: narrative review. Journal of medical Internet research, 23(8), e29575. https://doi.org/10.2196/29575

CMS.gov. (n.d.). Why Care Coordination is Important. https://innovation.cms.gov/key-concept/care-coordination

De Marchi, F., Contaldi, E., Magistrelli, L., Cantello, R., Comi, C., & Mazzini, L. (2021). Telehealth in neurodegenerative diseases: Opportunities and challenges for patients and physicians. Brain Sciences, 11(2), 1–20. https://doi.org/10.3390/brainsci11020237

Drees, J. (2020). 9 Barriers for Patients Accessing Telehealth. https://www.beckershospitalreview.com/telehealth/9-barriers-for-patients-accessing- telehealth.html

Edemekong, F. P., Annamaraju, P., & Hayde, J. M. (2022). Health Insurance Portability and Accountability Act. https://www.ncbi.nlm.nih.gov/books/NBK500019/

Kurpas, D., Stefanicka-Wojtas, D., Shpakou, A., Halata, D., Mohos, A., Skarbaliene, A., … Tkachenko, V. (2021). The Advantages and Disadvantages of Integrated Care Implementation in Central and Eastern Europe – Perspective from 9 CEE Countries. International Journal of Integrated Care, 21(S2), 14.DOI: https://doi.org/10.5334/ijic.5632

MO.gov. (n.d.). Standards of Nursing Practice. https://health.mo.gov/living/lpha/phnursing/standards.php.

Schmutz, J. B., Meier, L. L., & Manser, T. (2019). How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: A systematic review and meta-analysis. BMJ Open, 9(9), 1–16. https://doi.org/10.1136/bmjopen-2018-028280

Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. Npj Digital Medicine, 3(1), 1–10. https://doi.org/10.1038/s41746-020-0221-y

Vargas, I., Eguiguren, P., Mogollón-Pérez, A. S., Bertolotto, F., Samico, I., López, J., De Paepe, P., & Vázquez, M. L. (2020). Understanding the factors influencing the implementation of participatory interventions to improve care coordination. An analytical framework based on an evaluation in Latin America. Health Policy and Planning, 35(8), 962–972. https://doi.org/10.1093/heapol/czaa066

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In a 5-7 page written assessment, determine how healthcare technology, coordination of care, and community resources can be applied to address the patient, family, or population problem you’ve defined. In addition, plan to spend approximately 2 direct practicum hours exploring these aspects of the problem with the patient, family, or group you’ve chosen to work with and, if desired, consulting with the subject matter and industry experts. Document the time spent (your practicum hours) with these individuals or groups in the Capella Academic Portal Volunteer Experience Form. Report on your experiences during the second 2 hours of your practicum.

Introduction
As a baccalaureate-prepared nurse, you’ll be positioned to maximize the use of technology to achieve positive patient outcomes and improve organizational effectiveness. Providing holistic coordination of patient care across the entire healthcare continuum and leveraging community resource services can lead to both positive patient outcomes and organizational improvements.

Preparation
In this assessment, you’ll determine how healthcare technology, coordination of care, and community resources can be applied to address the health problem you’ve defined. Plan to spend at least 2 direct practicum hours working with the same patient, family, or group. During this time, you may also choose to consult with subject matter and industry experts.

To prepare for the assessment:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete and how it will be assessed.
Conduct sufficient research of the scholarly and professional literature to inform your assessment and meet scholarly expectations for supporting evidence.
Review the Practicum Focus Sheet: Assessment 3 [PDF], which provides guidance for conducting this portion of your practicum.
Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.

Instructions
Complete this assessment in two parts.

Part 1
Determine how healthcare technology, the coordination of care, and the use of community resources can be applied to address the patient, family, or population problem you’ve defined. Plan to spend at least 2 practicum hours exploring these aspects of the problem with the patient, family, or group. During this time, you may also consult with subject matter and industry experts of your choice. Document the time spent (your practicum hours) with these individuals or groups in the Capella Academic Portal Volunteer Experience Form. Use the Practicum Focus Sheet: Assessment 3 [PDF] provided for this assessment to guide your work and interpersonal interactions.

Part 2
Report on your experiences during the second 2 hours of your practicum.

Who did you meet with?
What did you learn from them?
Comment on the evidence-based practice (EBP) documents or websites you reviewed.
What did you learn from that review?
Share the process and experience of exploring the effect of the problem on the quality of care, patient safety, and costs to the system and individual.
Did your plan to address the problem change based upon your experiences?
What surprised you, or was of particular interest to you, and why?
Capella Academic Portal
Update the total number of hours on the NURS-FPX4900 Volunteer Experience Form in the Capella Academic Portal.

The BSN Capstone Course (NURS-FPX4900 ) requires the completion and documentation of nine (9) practicum hours. All hours must be recorded in the Capella Academic Portal. Please review the BSN Practicum Campus page for more information and instructions on how to log your hours.

Requirements
The assessment requirements, outlined below, correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, note the additional requirements for document format and length and for supporting evidence.

Analyze the impact of healthcare technology on the patient, family, or population problem.
Cite evidence from the literature that addresses the advantages and disadvantages of specific technologies, including research studies that present opposing views.
Determine whether the evidence is consistent with the technology use you see in your nursing practice.
Identify potential barriers and costs associated with the use of specific technologies and how those technologies are applied within the context of this problem.
Explain how care coordination and the utilization of community resources can be used to address the patient, family, or population problem.
Cite evidence from the literature that addresses the benefits of care coordination and the utilization of community resources, including research studies that present opposing views.
Determine whether the evidence is consistent with how you see care coordination and community resources used in your nursing practice.
Identify barriers to the use of care coordination and community resources in the context of this problem.
Analyze state board nursing practice standards and/or organizational or governmental policies associated with health care technology, care coordination, and community resources and document the practicum hours spent with these individuals or groups in the Capella Academic Portal Volunteer Experience Form.
Explain how these standards or policies will guide your actions in applying technology, care coordination, and community resources to address care quality, patient safety, and costs to the system and individual.
Describe the effects of local, state, and federal policies or legislation on your nursing scope of practice, within the context of technology, care coordination, and community resources.
Explain how nursing ethics will inform your approach to addressing the problem through the use of applied technology, care coordination, and community resources.
Document the time spent (your practicum hours) with these individuals or groups in the Capella Academic Portal Volunteer Experience Form.
Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
Apply APA style and formatting to scholarly writing.
Additional Requirements
Format: Format your paper using APA style. APA Style Paper Tutorial [DOCX] is provided to help you in writing and formatting your paper. Be sure to include:
A title page and reference page. An abstract is not required.
Appropriate section headings.
Length: Your paper should be approximately 5–7 pages in length, not including the reference page.
Supporting evidence: Cite at least five sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format.
Proofreading: Proofread your paper, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on its substance.
Competencies Measured