Final Care Coordination Plan

Final Care Coordination Plan

According to the U.S Department of HHS (n.d.), a care coordination plan enables the stakeholders involved in patient care to organize patient activities systematically and achieve effective and safe patient care. Open communication and information sharing are enablers of a successful care coordination plan. Patients and their families should be engaged in the treatment process to ensure culturally sensitive holistic care is provided (Birtwell & Dubrow-Marshall, 2018). This paper develops a care coordination plan for patients with Alzheimer’s disease.

Patient-Centered Health Interventions and Timelines

Alzheimer’s disease (AD) is associated with various healthcare issues. The three healthcare issues associated with AD are physical, cultural, and psychosocial issues. AD is associated with a disturbance in the motor activity of the patient (Oki et al., 2021). This can be manifested as an absolute or partial loss of mobility. To address this problem, patients with AD should embrace physical exercise. Both aerobic and muscle-strengthening exercises are beneficial. Examples of aerobic exercise are yoga, cycling, and brisk walking (Oki et al., 2021). Aerobic exercises are associated with a higher hippocampal volume in patients with AD (Oki et al., 2021). This is a representation of minimal brain atrophy hence a better prognosis (Oki et al., 2021).

According to Oki et al. (2021), muscle-strengthening exercises include weight lifting, push-ups, and chin-ups. Muscle-strengthening exercises improve balance and postural mobility (Oki et al., 2021). Timeline: three weekly sessions of aerobic exercise and two weekly sessions of muscle-strengthening exercise for six months. The community resources that support physical activity are Minnesota Pedestrian Laws, Minnesota Walks, Let’s Go for a Walk, and gyms such as Northeast Fitness (Minnesota Department of Health, 2021).

Psychosocial problems for people with AD include depression, agitation, and apathy. Various interventions can be used to address this problem: occupational therapy, cognitive stimulation, reminiscence, social support programs, and music therapy (Birtwell & Dubrow-Marshall, 2018). Reminiscence facilitates the creation of good memories and achieves a better emotional status. Music and aromatherapy help curb behavioral manifestations such as depression and apathy (Birtwell & Dubrow-Marshall, 2018). Cognitive stimulation therapy improves memory and thought for patients with mild and moderate manifestations of AD (Birtwell & Dubrow-Marshall, 2018). Timeline: Twice weekly, sessions of occupational therapy, cognitive stimulation, reminiscence, music therapy, and monthly social support programs for six months. The community resources that support psychosocial interventions are Adult Rehabilitative Mental Health Services, Assertive Community Treatment, and Targeted Case Management (Department of Human Services, n.d.).

Cultural problems associated with AD include the lack of culturally sensitive healthcare services. Patients have unique cultural beliefs, which may impede proper access to care. Cultural insensitive healthcare facilities are likely to be avoided by the patient (U.S Department of HHS, n.d.). Healthcare facilities that embrace cultural sensitivity are most likely to be chosen by patients. The intervention involves all stakeholders who should research and embrace the cultural traditions of patients with AD visiting the hospital (U.S Department of HHS, n.d.). This can be achieved using community contacts who understand patients’ beliefs. Culturally sensitive increases access to healthcare services by people with AD and enable early initiation of treatment plans that better patient outcomes (U.S Department of HHS, n.d.). The community resources that support culturally sensitive interventions include Minnesota Health Care Programs, Adult mental health, and the Alzheimer’s Association (Department of Human Services, n.d.).

Ethical Decisions in Designing Patient-Centered Health Interventions

Ethical decision-making is important when designing patient-centered health interventions. Ethical aspects that can have practical effects include autonomy, justice, beneficence, and non-maleficence (DeCamp et al., 2018). Autonomy enables the patients to be key stakeholders in selecting their treatment plans and other interventions (DeCamp et al., 2018). The patient-centered intervention should reflect the patient’s choice. An example from this context is when a specific psychosocial intervention is required for a patient. The options include occupational therapy, cognitive stimulation, reminiscence, social support programs, and music therapy (Birtwell & Dubrow-Marshall, 2018). Patient autonomy requires healthcare providers and clinicians to explain each intervention and state their merits and any demerit. After that, patients and their families should be involved in the discussion to select the best strategy. The ethical question is, “Does the healthcare intervention protect and respect the patient’s choice?”

According to DeCamp et al. (2018), beneficence requires healthcare workers to engage in actions that benefit the patient, whereas non-maleficence advocates for actions that do not harm patients. Accordingly, the outcomes of a health care intervention address all of the patient’s needs and cause no injurious effect. An example in this context is selecting the appropriate physical exercise for patients with AD. The intensity of physical exercise should be individualized. The result should be improving balance, postural mobility, and slow brain atrophy (Oki et al., 2021). Ethical question: “Does the healthcare intervention serve the best interest of the patient?”

According to DeCamp et al. (2018), justice directs healthcare workers to uphold equality when dealing with patients. The benefits and shortcomings of a healthcare intervention should be distributed equally among all patients. This can be accomplished by ensuring similar techniques and dedication is applied to patients receiving the same intervention (DeCamp et al., 2018). It is worth noting that justice is applicable when patients have similar needs. Differing needs can warrant individualized treatment. Ethical question: “Are the merits and shortcomings of the healthcare interventions shared equally among all patients?”

Health Policy Implications for the Coordination and Continuum of Care

The National Alzheimer’s Project Act is an example of a policy that affects the coordination and continuum of care for patients with AD. This is underpinned in the provisions of this Act. It focuses on the prevention and effective management of AD by 2025 (U.S. Department of Health and Human Services, 2021). This is accomplished by engaging in research to establish evidence-based practices that provide optimal treatment outcomes for patients with AD. The other provision is to enhance the quality and efficiency of care provided to patients with AD. To accomplish this, a health workforce with pertinent skills is required (U.S. Department of Health and Human Services, 2021). Adequate training helps to equip healthcare providers with adequate knowledge and skills. By so doing, timely diagnosis, patient education, and best care guideline are used to manage patients.

The third provision of the Act advocates for support programs for patients with AD and their families. This is accomplished by providing culturally sensitive patient education and support materials (U.S. Department of Health and Human Services, 2021). Additionally, patients and families are helped to identify and plan for their future needs. The other provision is public education and engagement. The general public should be educated about AD, its manifestations, and caring for patients with AD (U.S. Department of Health and Human Services, 2021). This is accomplished via collaborating with the local and the global community. By so doing, there is a continuum of care for patients with AD.

Priorities when Discussing the Plan with Patients and their Families

The care coordinator should prioritize various aspects when discussing the care plan with a patient and family member. The first aspect relevant for AD patients is the severity of the disease: mild, moderate, or severe (Lazzari et al., 2021). Mild and moderate AD is associated with a better prognosis than the severe form of the disease. Mild and moderate forms can benefit from aerobic exercise, which slows down brain atrophy and improves cognition. The severe form of AD can benefit from psychosocial approaches such as occupational therapy, reminiscence, social support programs, and music therapy (Birtwell & Dubrow-Marshall, 2018). All AD forms should be managed using FDA-approved medications such as donepezil, rivastigmine, memantine, and galantamine (Fish et al., 2019).

The second aspect is access to care. Regardless of the stage of AD, all patients should have adequate access to care (Lazzari et al., 2021). This can be fulfilled by determining the values and preferences of the patient. Access to care can be improved by providing culturally and linguistically sensitive services. Linguistically appropriate services can be achieved using translators. Culturally sensitive services can be achieved through research and community contacts (U.S Department of HHS, n.d.). The severe forms of AD can warrant patient admission. Holistic care services that address the needs of the patients should be provided. An example is providing antidepressants such as sertraline to AD patients suffering from depression (U.S Department of HHS, n.d.).

Comparing Learning Session Content with Best Practices

Literature on evaluation reveals that patient and family engagement is important when establishing healthcare interventions. This is harmonious with the principle of autonomy. Open communication is key to facilitating meaningful patient and family engagement. Additionally, in the context of AD, the care coordinator should prioritize aspects such as the severity of the disease and access to care. The severity of the disease helps determine the best physical or psychosocial interventions for use by the patient. Access to care can be enhanced by embracing culturally and linguistically sensitive services.

National Alzheimer’s Project Act has proposed best practices for people with AD. Healthcare providers should engage in the prevention and effective treatment of AD by engaging in research (U.S. Department of Health and Human Services, 2021). Quality and effective care should be availed through active patient and family engagement using a competent and skilled workforce (U.S. Department of Health and Human Services, 2021). Support programs that fulfill the holistic needs of patients with AD are also beneficial.

Furthermore, the teaching sessions should be consistent with provisions of the Healthy People 2030 document. The Healthy People 2030 proposes three major objectives for patients with AD. The first one is to increase the percentage of patients with AD who are aware of their diagnosis (Healthy People 2030, n.d.). The second objective is to minimize the percentage of avoidable hospitalizations in elderly patients with AD. The other one is to increase the percentage of elderly patients who have shared with healthcare providers the state of their cognitive decline (Healthy People 2030, n.d.). The teaching sessions should embrace the provisions of Healthy People 2030. Care coordinators should focus on patient and public awareness about AD. Timely diagnosis and initiation of interventions can help to reduce hospitalizations in the elderly population.

References

Birtwell, K., & Dubrow-Marshall, L. (2018). Psychological Support for People with Dementia: A Preliminary Study. Counselling and Psychotherapy Research, 18(1), 79–88. https://doi.org/10.1002/capr.12154

DeCamp, M., Pomerantz, D., Cotts, K., Dzeng, E., Farber, N., Lehmann, L., Reynolds, P. P., Sulmasy, L. S., & Tilburt, J. (2018). Ethical Issues in the Design and Implementation of Population Health Programs. Journal of General Internal Medicine, 33(3), 370–375. https://doi.org/10.1007/s11606-017-4234-4

Department of Human Services. (n.d.). Adult Mental Health Programs and Services. https://mn.gov/dhs/people-we-serve/seniors/health-care/mental-health/programs-services/

Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New Approaches for the Treatment of Alzheimer’s Disease. Bioorganic and Medicinal Chemistry Letters, 29(2), 125–133. https://doi.org/10.1016/j.bmcl.2018.11.034

Healthy People 2030. (n.d.). Alzheimer’s Disease. https://health.gov/healthypeople/search?query=alzheimer%27s%20disease&f%5B0%5D=content_type%3Ahealthy_people_objective

Lazzari, C., Kotera, Y., Green, P., & Rabottini, M. (2021). Social Network Analysis of Alzheimer’s Teams: A Clinical Review and Applications in Psychiatry to Explore Interprofessional Care. Current Alzheimer Research, 18(5), 380–398. https://doi.org/10.2174/1567205018666210701161449

Minnesota Department of Health. (2021). Physical Activity Resources – Minnesota Department of Health. Health.state.mn.us. Retrieved 1 June 2022, from https://www.health.state.mn.us/communities/physicalactivity/paresources.html.

Oki, M., Matsumoto, M., Yoshikawa, Y., Fukushima, M., Nagasawa, A., Takakura, T., & Suzuki, Y. (2021). Risk Factors for Falls in Patients with Alzheimer Disease: A Retrospective Study of Balance, Cognition, and Visuospatial Ability. Dementia and Geriatric Cognitive Disorders Extra, 11(1), 58–63. https://doi.org/10.1159/000514285

U.S Department of HHS. (n.d.). National Plan to Address Alzheimer's Disease. https://aspe.hhs.gov/national-plan-address-alzheimers-disease#:~:text=Goals%20as%20Building%20Blocks%20for%20Transformation, Achieving%20the%20vision&text=this%20National%20Plan%3A, Prevent%20and%20Effectively%20Treat%20Alzheimer's%20Disease%20by%202025, Enhance%20Public%20Awareness%20and%20Engagement

U.S. Department of Health and Human Services. (2021). National Plan to Address Alzheimer’s Disease: 2021 update. 1–70. http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Hello, this is the last assessment in which you will have to use assessment one, order number 45564, to complete the assignment.

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

Introduction

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessments.

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Note: Remember that you can submit all, or a portion of, your plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.

Instructions

Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.
Document Format and Length
Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5-7 pages in length, not including title page and reference list.

Supporting Evidence
Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Design patient-centered health interventions and timelines for a selected health care problem.
Address three health care issues.
Design an intervention for each health issue.
Identify three community resources for each health intervention.
Consider ethical decisions in designing patient-centered health interventions.
Consider the practical effects of specific decisions.
Include the ethical questions that generate uncertainty about the decisions you have made.
Identify relevant health policy implications for the coordination and continuum of care.
Cite specific health policy provisions.
Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
Clearly explain the need for changes to the plan.
Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
Use the literature on evaluation as guide to compare learning session content with best practices.
Align teaching sessions to the Healthy People 2030 document.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Additional Requirements
Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Adapt care based on patient-centered and person-focused factors.
Design patient-centered health interventions and timelines for a selected health care problem.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
Competency 3: Create a satisfying patient experience.
Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
Competency 4: Defend decisions based on the code of ethics for nursing.
Consider ethical decisions in designing patient-centered health interventions.
Competency 5: Explain how health care policies affect patient-centered care.
Identify relevant health policy implications for the coordination and continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.