Final Care Coordination Plan for Alzheimers disease (AD)

Final Care Coordination Plan for Alzheimers disease (AD)

Alzheimer’s disease (AD) is the most common form of dementia. It accounts for up to 67% of all dementia cases presenting in later adulthood. It is the sixth leading cause of death in the U.S., responsible for over 120,000 deaths in 2019. Due to its high care needs and complexities in its presentation, managing the disease fetches high costs. Comprehensive AD care utilizing coordinative approaches has been lauded for its effectiveness in the comprehensive management of AD and other forms of dementia. This paper outlines patient-centered health interventions used in coordinating care for AD patients, ethical decisions in designing these approaches, relevant policies in coordinating AD care, and the priorities in care coordination. Our assignment help will hone your writing prowess for papers that will awe your professors.

Patient-Centered Health Interventions and Timelines for AD

Patient-centered approaches in dementia care are warranted in the comprehensive management of AD. This approach promotes purposeful living for patients with Alzheimer’s disease, establishes relationship-based services to promote a sense of self among these patients, and preserves their dignity. Several issues are, however, apparent in the comprehensive management of AD and other forms of dementia. Aggressive pharmacotherapy for symptomatic management and to slow the progression of the disease, progressive support of these patients in their activities of daily living to enhance their quality of life, and early detection and diagnosis are some of the issues in the comprehensive management of this disease.

Pharmacotherapy in AD

Aggressive pharmacotherapy is often warranted in AD to lessen the severity of symptoms and slow the progression of the disease. Due to the progressive and chronic nature of the disease, specific issues in pharmacotherapy, such as non-adherence to medications, are sometimes present. This has mainly been attributable to the disease process as well as to poor access to these medications (Marulappa et al., 2022). Non-adherence to pharmacotherapy has been implicated in serious health implications, with hospitalizations and disease exacerbations likely to occur. This highlights the need to adhere to pharmacotherapy.

Interventions to Optimize Pharmacotherapy

Several interventions can be utilized to optimize medication use among patients with dementia. Tailoring medication regimens to the individual patient habits, prescribing as few medications as effectively possible, and coordinating patients dosing schedules with their other caregivers may enhance their medication adherence, thereby optimizing pharmacotherapy on these patients. Frequent monitoring and contact with patients with these conditions may also enhance their drug-taking behaviors. This enables caregivers to take a more active role in ensuring that these patients take their medications are recommended.

Community Resources

Several community resources are available to help patients with AD and other forms of dementia in optimizing their treatment processes. The eldercare locator is a valuable resource that provides information on other community resources that provide Alzheimer’s support, such as nursing homes. Home healthcare care services can help patients optimize their treatment plans. This organization consists of skilled caregivers who can coordinate care services for Alzheimer’s under home-based care and assist in medication taking. Geriatric care managers are also valuable in this respect.

Progressive Support in Activities of Daily Living (ADL)

AD and other forms of dementia are usually accompanied by a growing need for support in ADLs, such as bathing and toileting. The patients’ immediate caregivers bear the burden of addressing these needs. However, as cognitive and functional impairment, characteristic of dementia, increases, caregivers are often confronted with increasing care practices to meet these patients’ needs. This, in most cases, is overwhelming to them (Lindeza et al., 2020). Supporting these patients in their ADLs is, however, important as it not only dignifies them but also ensures that they lead a quality life

Interventions

Patients’ referral to instructions of care such as nursing homes remains an effective intervention for ensuring they get the necessary support in their ADLs. This is particularly beneficial where there is a perceived lack of commitment to caring and offering support from other caregivers in home-based settings. Enhancing caregivers’ knowledge of best practices in supporting Alzheimer’s in their ADLs is also necessary. This will enable them to maintain accountability in supporting these patients in their ADLs. Such practices as appropriate dressing, paying attention to their toileting habits, and providing positive reinforcement to preserve their dignity may be helpful in this regard.

Community Resources

The National Alzheimer’s and Related Dementia Education and Referral Center is an example of a community resource that helps patients with these illnesses in their treatment. This organization offers information on various aspects of the disease, including caregivers’ needs, and can thus be valuable to caregivers supporting patients with dementia. Meal services are another essential community resource that brings meals to patients at home and can help address their nutritional needs. Respite services are another valuable community resource that provides short-term care for patients with AD at home. They can be used to augment other caregivers’ roles in the patients.

Early Detection and Diagnosis of AD

Findings on AD diagnosis reveal a disconnect in the number of people with the disease and those with a positive diagnosis of the disease. Close to half of older adults with the disease are yet to have a formal diagnosis of the disease. Early detection and diagnosis of the disease enable individuals to begin therapy early and have been implicated in high-quality life (Rasmussen & Langerman, 2019). This underpins the need for community screening to identify persons at risk for the disease.

Interventions

Intensifying community screening programs for AD is one of the interventions for promoting early detection of the disease. These screening programs can be implemented at the primary level of care or through community outreach campaigns. Diagnostic recommendations should be made to all patients suspected of cognitive decline functionalities. Non-physician recommendations on diagnostics should also be encouraged to increase the number of patients seeking diagnostic measures for the disease.

Community Resources

The Alzheimer’s Association, the National Alzheimer’s and Related Dementia Education and Referral Center, and Alzheimer.gov are valuable community resources in AD management. These organizations provide information on the disease, including diagnostic features of the disease. They can be leveraged to help identify at-risk groups and make diagnostic recommendations. They also guide the management of the disease.

Ethical Decisions in Designing Patient-Centered Health Interventions

Comprehensive management of AD and other forms of dementia presents a balance between respecting patients’ autonomy and promoting their welfare while recognizing and acknowledging their disease process. These diseases present significant cognitive decline and diminish the capabilities of these patients to make informed decisions concerning their health. This may present ethical challenges in designing therapeutic plans for these patients. Ethical decision-making utilizes ethical principles in addressing these ethical challenges that may present during the care processes (Varkey, 2020). The ethical provisions of beneficence, autonomy, nonmaleficence, and justice are valuable in this regard, as they help clinicians in their clinical decision-making processes.

While the principle of autonomy requires that clinicians allow their patients to make independent decisions on their health, beneficence requires them to promote the welfare of their patients. This may be challenging in dementia care, especially when patients present with profound cognitive impairment and reduced capacity to make informed decisions. A delicate balance between respecting patients’ autonomy and doing what is deemed clinically good may present in this case. An ethical question that may generate uncertainty in this instance is whether or not the clinician should allow the patients to make important decisions about their health. This notwithstanding, the primary mandate of clinicians is to ensure no harm befalls their patients and that their welfare is promoted.

Relevant Health Policy Implications for the Coordination and Continuum of Care

Several healthcare policies influence the coordination and continuum of care for patients with AD. The value-based systems under the Medicare program are an example of healthcare policy with implications on the coordination and continuum of care. The Health Readmission Reduction Program under the Medicare value-based system implores healthcare organizations to improve their communications and care coordinative processes to foster better engagements between patients, patient’s families, and caregivers to lower avoidable hospital readmission (Teisberg et al., 2020). This policy, in this respect, optimizes clinical approaches to patients and ensures that best practices in care coordination are employed.

Priorities that a Care Coordinator would Establish when Discussing the Plan with a Patient and Family Member

When discussing evidence-based therapeutic plans with a patient and their family, priorities include communicating the need for the change and its impact on their well-being. In comprehensive care for AD, the need for changes in therapeutic plans is often to improve patient experiences and their clinical outcomes. This can be attained by revising the therapeutic plans to either add or substitute medications, enhance self-management practices, and educate patients on aspects of their disease. These have an overall impact of lessening symptom severity. The impact of the change is often evident in the improved quality of life of these patients.

Comparison of Learning Session Content with Best Practices

Literature provisions on the management of Alzheimer’s and other forms of dementia are in concert with literature provisions on best practices in AD management. Both reinforce the significance of patient-centered approaches in the comprehensive management of AD as well as the importance of early detection of the disease. Both recommend community screening approaches and enhanced recommendations by caregivers to encourage diagnostics tests on persons suspected of having these diseases. These provisions are also aligned with the provisions of the Healthy People 2030 on dementia. The Healthy People 2030 document outlines the management goals of the disease. It aims to improve the health and quality of life for all patients with dementia by increasing the proportion of adults diagnosed with the disease and reducing preventable hospitalizations. The Healthy People 2030 details specific interventions for specific groups. These provisions can be used to revise the learning session’s contents to include the objective outlined under the Healthy People goals.

Conclusion

AD remains a health concern in the U.S. Its progressive and chronic nature and complex manifestation make it challenging to manage. Coordinative approaches maintain effectiveness in the comprehensive management of the disease. Several issues may, however, become apparent when managing this disease. Optimal pharmacotherapy, early detection, and diagnosis of AD are some healthcare issues that healthcare systems are still dealing with. Leveraging community resources to help manage these illnesses may provide a reprieve in managing these diseases. Ethical and policy concerns also arise when coordinating care for AD patients. Policies such as Medicare apply when managing AD and other forms of dementia.

References

Lindeza, P., Rodrigues, M., Costa, J., Guerreiro, M., & Rosa, M. M. (2020). Impact of dementia on informal care: A systematic review of family caregivers’ perceptions. BMJ Supportive & Palliative Care. https://doi.org/10.1136/bmjspcare-2020-002242

Marulappa, N., Anderson, N. N., Bethell, J., Bourbonnais, A., Kelly, F., McMurray, J., Rogers, H. L., Vedel, I., & Gagliardi, A. R. (2022). How to implement person-centered care and support for dementia in outpatient and home/community settings: Scoping review. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07875-w

Rasmussen, J., & Langerman, H. (2019). Alzheimer’s disease – why we need an early diagnosis. Degenerative Neurological and Neuromuscular Disease, Volume 9, 123–130. https://doi.org/10.2147/dnnd.s228939

Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and implementing value-based health care. Academic Medicine, 95(5), 682–685. https://doi.org/10.1097/acm.0000000000003122

Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

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Assessment 4 Instructions: Final Care Coordination Plan
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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 healthcare 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 healthcare 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 on EBP and discuss how the plan includes elements of Healthy People 2030.

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 a 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 healthcare 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 a 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; contain 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 healthcare problem.
Competency 2: Collaborate with patients and families 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 healthcare 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.