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Assessment-Preliminary Care Coordination Plan

Assessment-Preliminary Care Coordination Plan

Cognitive impairment refers to a decline in cognitive abilities, including thinking, reasoning, memory, perception, and language skills, that interferes with an individual’s daily functioning (Owens et al., 2020). It is frequently linked to illnesses including Alzheimer’s disease, dementia, traumatic brain injury, and other neurological problems. It can range in severity from mild to severe. This impairment can impact a person’s capacity to communicate, make decisions, carry out everyday duties, and maintain independence. Cognitive impairment emphasizes the need for care, support, and appropriate solutions because it can cause difficulties with social relationships, employment, and general quality of life.

With the growing prevalence of conditions like Alzheimer’s disease and dementia, this plan endeavors to fill the void left by budget cuts, empowering nurses and the community to navigate these challenges effectively. Through evidence-based analysis and collaborative strategies, this initiative aims to provide comprehensive support, education, and access to resources for individuals facing cognitive decline and their caregivers. Embracing a dynamic approach, this plan seeks to lay a robust foundation for a more informed, resilient, and compassionate community in managing cognitive impairment.

Best Practices for Managing Cognitive Impairment in Aging and Elder Care

Cognitive impairment, specifically Alzheimer’s disease or dementia, poses significant challenges in aging and elder care within our community. It’s imperative to approach this concern comprehensively, integrating evidence-based practices to ensure those affected’s well-being and quality of life. Understanding the complex nature of cognitive decline is crucial. While there’s no definitive cure, interventions can significantly impact the progression and management of symptoms. Firstly, fostering a supportive environment is pivotal. Owens et al. (2020) highlight that this involves creating dementia-friendly spaces, offering memory aids, and implementing safety measures to prevent accidents. Moreover, educating caregivers and family members plays a crucial role. Guiding communication techniques, strategies to manage behavioral changes, and stress reduction methods help enhance the overall caregiving experience (Owens et al., 2020). Support groups and counseling services offer emotional support and practical advice, contributing significantly to the holistic care approach.

Medical management is another critical aspect. Collaborating with healthcare providers for regular evaluations, medication management, and timely interventions ensures optimal treatment (Owens et al., 2020). Engaging in cognitive exercises and maintaining a healthy lifestyle through proper nutrition and physical activity have shown promise in slowing cognitive decline.

However, uncertainties persist in the efficacy of certain interventions and the exact mechanisms behind cognitive impairment. The suggested care plan will remain dynamic, continuously integrating new research findings and evolving best practices. A multi-disciplinary team approach is necessary to ensure the success of this preliminary care coordination plan. Owens et al. (2020) underscore that this involves collaboration with physicians, psychologists, social workers, occupational therapists, and community resources to provide a comprehensive support system for affected individuals and their families.

Specific Goals for Addressing Cognitive Impairment in Aging and Elder Care

Enhanced Caregiver Support and Education

Research by Ismail et al. (2020) indicates that it is crucial to establish educational programs for caregivers and family members to train at least 80% of primary caregivers within the community within the next year. Additionally, remember to measure success by conducting assessments and surveys to evaluate knowledge retention and skill application.

Improved Access to Resources

Another goal is to Increase access to community resources by collaborating with local organizations and institutions, ensuring that 90% of individuals with cognitive impairment and their families are aware of available support services within six months (Ismail et al., 2020). Tracking progress through attendance records and feedback from users of these services is important.

Enhanced Safety Measures

To implement safety protocols in 100% of care facilities within the community to prevent accidents related to cognitive impairment within the next three months. Regular audits and incident reports will assess the effectiveness of these measures.

Regular Health Assessments

Nevertheless, to ensure that 70% of individuals with cognitive impairment receive regular health assessments and follow-ups by healthcare professionals within the next year. Tracing this is done through medical records and appointment logs (Ismail et al., 2020). Also, engagement in cognitive exercises and healthy activities can be encouraged by organizing workshops and events, aiming for a 20% increase in participation within six months. Evaluation will be based on attendance records and pre-and-post-participation assessments.

Collaborative Care Approach

Establishing interdisciplinary meetings involving healthcare providers, social workers, and community resources to discuss quarterly and update care plans for at least 90% of individuals with cognitive impairment is also necessary (Ismail et al., 2020). Attendance records and the implementation of revised care plans will measure success.

Community Resources for Effective Cognitive Impairment Care in Aging and Elder Care

Alzheimer’s Association

This resource provides support groups, educational workshops, and a 24/7 helpline. Their programs empower caregivers and individuals with cognitive impairment, fostering understanding and enhancing coping strategies. Studies by Owens et al. (2020) highlight the positive impact of Alzheimer’s Association programs on caregiver stress reduction and improved patient outcomes.

Eldercare Locator

Run by the U.S. Administration on Aging, this service connects seniors and caregivers with local resources such as adult daycares, legal assistance, and transportation services. Evidence by Cravello et al. (2021) suggests that access to community-based services like these enhances the quality of life for seniors and caregivers, aiding in managing cognitive impairment.

Local Senior Centers

These centers offer a variety of programs, including social activities, exercise classes, and informational seminars. Studies by Cravello et al. (2021) indicate that social engagement and mental stimulation provided by these centers can help slow cognitive decline and improve overall well-being.

Memory Care Facilities

These specialized care facilities provide a secure and supportive environment for individuals with cognitive impairment. Research by Owens et al. (2020) underscores the positive impact of tailored environments and trained staff on the quality of life and management of symptoms in dementia patients.

Area Agencies on Aging (AAA)

AAA provides information and access to meal delivery, in-home care, and caregiver support. Evidence by Cravello et al. (2021) supports the effectiveness of AAA programs in reducing caregiver burden and enhancing the ability to care for older adults at home.

Dementia-Friendly Programs

According to Cravello et al. (2021), communities with initiatives aimed at creating dementia-friendly environments, including training for businesses and community members, have shown positive outcomes in reducing stigma and enhancing inclusion for those with cognitive impairment.


This preliminary care coordination plan outlines an approach to addressing the complexities of cognitive impairment in aging and elder care. Integrating evidence-based strategies, fostering collaboration, and leveraging diverse community resources aims to enhance the quality of life for individuals with cognitive impairment and their caregivers. Recognizing the complex nature of this health concern, the plan remains adaptable, continually evolving to incorporate new findings and innovative practices. Through education, support networks, and accessible services, this approach endeavors to create a more supportive and informed community poised to effectively manage and support those affected by cognitive impairment.


Cravello, L., Martini, E., Viti, N., Campanello, C., Assogna, F., & Perotta, D. (2021). Effectiveness of a family support intervention on caregiving burden in a family of elderly patients with cognitive decline after the COVID-19 lockdown. Frontiers in psychiatry12, 590104.

Ismail, Z., Black, S. E., Camicioli, R., Chertkow, H., Herrmann, N., Laforce Jr, R., … & CCCDTD5 participants. (2020). Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia. Alzheimer’s & Dementia16(8), 1182-1195.

Owens, D. K., Davidson, K. W., Krist, A. H., Barry, M. J., Cabana, M., Caughey, A. B., … & US Preventive Services Task Force. (2020). Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. Jama323(8), 757-763.


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Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Assessment-Preliminary Care Coordination Plan

Assessment-Preliminary Care Coordination Plan

Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts, and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
Allow plenty of time to plan your chosen healthcare concern.
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

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