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Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

A care coordination plan is essential when serving a specific patient population. It enables the proper planning of activities (U.S Department of HHS, n.d.). Furthermore, all stakeholders involved in healthcare service delivery get to access relevant information. Accordingly, holistic care services that address the needs of the specific patient population are available (Birtwell & Dubrow-Marshall, 2018). This paper discusses a preliminary care coordination plan for Alzheimer’s disease.

The Health Concern and the Associated Best Practices

According to Mok et al. (2020), Alzheimer’s disease (AD) is a neurodegenerative disorder that impairs cognitive and behavioral function. This impairment leads to disruptions in the normal social functioning of the person (Birtwell & Dubrow-Marshall, 2018). The disease is progressive and can transform from mild to moderate and then into a severe form of the disease (Mok et al., 2020). Data indicates that approximately 5.8 million Americans were diagnosed with AD in 2020 (CDC, n.d). Additionally, the incidence of the disease will triple by 2060 (CDC, n.d). AD is prevalent in people aged 65 years and more (CDC, n.d). The risk factors for the disease include age and family history (CDC, n.d). Furthermore, studies are ongoing to determine whether environmental factors play a role in AD development.

Alzheimer’s disease is characterized by diverse signs and symptoms. The mild form presents with memory loss, getting confused about familiar places, and experiencing difficulties with handling financial aspects such as settling bills (Weller & Budson, 2018). The moderate form presents further memory deterioration, disturbance in thought and logical reasoning, difficulties recognizing close allies and family members, and anterograde amnesia (Weller & Budson, 2018). The severe form presents with absolute dependence on family members and caregivers. During this stage, mobility is lost, and most patients succumb to co-morbidities such as aspiration pneumonia (Weller & Budson, 2018).

Various practices can be implemented to promote health improvement for patients with AD. These practices should address the patient’s physical, psychosocial, and cultural needs. Progressive dementia affects the patient’s motor activity (Weller & Budson, 2018). This varies from the inability to eat and drink to absolute loss of mobility. Patients with AD should engage in periodic physical activity. Studies have linked adequate cardiorespiratory activity to higher hippocampal capacity (Sharma et al., 2018). This can significantly alter brain atrophy caused by AD. Physical activity should be specifically tailored for each patient. Patients who have lost mobility should be fed and cleaned regularly, including proper mouth care (Sharma et al., 2018). Tube feeding is useful for those who have lost the ability to chew (Sharma et al., 2018).

Psychosocial interventions are important for people with AD. In this context, useful techniques include occupational therapy, cognitive stimulation and training, reminiscence, and music therapy (Birtwell & Dubrow-Marshall, 2018). Additionally, social support programs and educational forums are useful. Cognitive stimulation enhances the patient’s cognition (Birtwell & Dubrow-Marshall, 2018). Reminiscence helps to create good memories and improves the patient’s emotional status. Techniques such as music and aromatherapy have helped minimize behavioral manifestations (Birtwell & Dubrow-Marshall, 2018). Support programs are useful for patients, families, and caregivers. They enable them to share their experiences and provide relevant help (Birtwell & Dubrow-Marshall, 2018).

Furthermore, cultural needs are relevant for patients’ health improvement with AD. Culture refers to a person’s way of life (U.S. Department of HHS, n.d.). Patients have unique beliefs and customs. They are most likely to seek care from culturally sensitive healthcare facilities (U.S. Department of HHS, n.d.). Healthcare providers and other stakeholders should research and be aware of various cultural traditions of specific ethnic groups with AD (U.S Department of HHS, n.d.). They should actively reach the patients via community contacts who understand their beliefs. Culturally sensitive practitioners and institutions are most likely to be contacted by people with AD (U.S Department of HHS, n.d.). This improves access to care and ensures the well-being of the patients.

Specific Goals to Address the Health Care Problem

Three major goals can be formulated to address AD. The first specific goal is to optimize the efficiency and quality of care (U.S Department of HHS, n.d.). This entails the provision of high-quality healthcare services to patients with AD. Different techniques can be used to achieve this. Firstly, adequate training should be provided to the healthcare workforce and other family caregivers (U.S Department of HHS, n.d.). They should understand the importance of timely diagnosis and initiation of treatment. Secondly, they should understand the importance of cultural sensitivity and awareness in their practice (U.S Department of HHS, n.d.). Additionally, standardized, high-quality, and evidence-based guidelines for the care of patients with AD should be established (U.S Department of HHS, n.d.). This will embrace uniformity in the provision of high-quality healthcare services.

The second goal is to prevent and treat AD effectively within the next decade. This can be achieved by allocating resources toward comprehensive research in evidence-based preventive measures against AD (U.S Department of HHS, n.d.). The research should be well-coordinated among various stakeholders in the public and private sectors. The findings should be incorporated into medical practice as soon as they are proven to be effective. Currently, preventive measures include lifestyle modifications such as avoiding binge drinking. Evidence-based findings will complement the current practices and achieve better outcomes.

The third goal is the expansion of support programs for patients with AD and their families. This involves availing pertinent resources to address their current and future needs and upholding their safety and overall well-being (U.S Department of HHS, n.d.). This can be achieved by enforcing culturally sensitive services through training of healthcare providers and other caregivers (U.S Department of HHS, n.d.). Additionally, programs that help families plan for their current and future needs, including proper housing, should be adopted. The safety and dignity of patients with AD should be guaranteed by the active involvement of Adult Protective Services (U.S Department of HHS, n.d.).

Community Resources for a Safe and Effective Continuum of Care

The Alzheimer’s Association ensures a safe and effective continuum of care for people with AD. In Minnesota, their offices are located in Minneapolis, Duluth, Rochester, and St. Cloud (Alzheimer’s Association, n.d.). This association is actively providing perpetual programs that focus on training and the development of the community about AD. They provide adequate information concerning caring for people with AD. The association achieves this by embracing cultural inclusivity and awareness (Alzheimer’s Association, n.d.). By so doing, a better quality of care is provided to patients with AD. Furthermore, cultural inclusivity has increased the acceptability and participation in the classes and training programs of the Alzheimer’s Association.

Conclusion

Alzheimer’s disease (AD) is a neurodegenerative disorder that impairs cognitive and behavioral function. A care coordination plan that addresses the cultural, physical, and psychosocial needs of patients with AD is important. Accordingly, the Alzheimer’s Association is committed to providing a safe and effective continuum of care for patients with AD. The association has achieved this by embracing cultural sensitivity and awareness.

References

Alzheimer’s Association. (n.d.). Minnesota-North Dakota Chapter. https://www.alz.org/mnnd

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

Mok, V. C. T., Pendlebury, S., Wong, A., Alladi, S., Au, L., Bath, P. M., Biessels, G. J., Chen, C., Cordonnier, C., Dichgans, M., Dominguez, J., Gorelick, P. B., Kim, S. Y., Kwok, T., Greenberg, S. M., Jia, J., Kalaria, R., Kivipelto, M., Naegandran, K., … Scheltens, P. (2020). Tackling Challenges in Care of Alzheimer’s Disease and other Dementias Amid the COVID-19 Pandemic, Now and in the Future. Alzheimer’s and Dementia, 16(11), 1571–1581. https://doi.org/10.1002/alz.12143

Sharma, S., Mueller, C., Stewart, R., Veronese, N., Vancampfort, D., Koyanagi, A., Lamb, S. E., Perera, G., & Stubbs, B. (2018). Predictors of Falls and Fractures Leading to Hospitalization in People With Dementia: A Representative Cohort Study. Journal of the American Medical Directors Association, 19(7), 607–612. https://doi.org/10.1016/j.jamda.2018.03.009

Weller, J., & Budson, A. (2018). Current Understanding of Alzheimer’s Disease Diagnosis and Treatment. F1000Research, 7(0), 1–9. https://doi.org/10.12688/f1000research.14506.1

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

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Question 


Hello, this is my first assignment for my next course: Coordinating patient-centered care for my BSN program. Please follow all instructions for full points.

Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

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

Introduction

NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular 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.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Preparation

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 health care concern.
Note: Remember that you can submit all, or a portion of, your draft 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 this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan
Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
Stroke.
Heart disease (high blood pressure, stroke, or heart failure).
Home safety.
Pulmonary disease (COPD or fibrotic lung disease).
Orthopedic concerns (hip replacement or knee replacement).
Cognitive impairment (Alzheimer’s disease or dementia).
Pain management.
Mental health.
Trauma.
Identify available community resources for a safe and effective continuum of care.
Document Format and Length
Your preliminary plan should be an APA scholarly paper, 3-4 pages in length.
Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
In your paper include possible community resources that can be used.
Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence
Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements
The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

Analyze your selected health concern and the associated best practices for health improvement.
Cite supporting evidence for best practices.
Consider underlying assumptions and points of uncertainty in your analysis.
Describe specific goals that should be established to address the health care problem.
Identify available community resources for a safe and effective continuum of care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
Write with a specific purpose with your patient in mind.
Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
Additional Requirements
Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

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.
Analyze a health concern and the associated best practices for health improvement.
Competency 2: Collaborate with patients and family to achieve desired outcomes.
Describe specific goals that should be established to address a selected health care problem.
Competency 3: Create a satisfying patient experience.
Identify available community resources for a safe and effective continuum of care.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format. I have also attached the rubric.

 

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