Preliminary Care Coordination Plan-Alzheimer’s disease (AD)

Preliminary Care Coordination Plan-Alzheimer’s disease (AD)

Alzheimer’s disease (AD) remains a health concern among the elderly. It is the most common form of dementia, mainly affecting adults aged 65 and above. AD is a progressive neurodegenerative disorder with an insidious onset that results in significant impairment of cognitive and behavioral functionalities. Significant in this disease are memory loss and declines in comprehension, judgment, and language functionalities. AD is the sixth leading cause of death in the U.S., accounting for over 120,000 deaths in 2019 alone. Liang et al. (2021) report that while mortality rates of cardiovascular illnesses showed a downward trend in the last decade, the mortality rates of AD and other forms of dementia increased by 145%. Management of the disease also fetches considerable healthcare costs, with unpaid dementia caregiving currently valued at over 250 billion dollars. These grime statistics reveal the severity of AD and why it is a concern to healthcare systems in the country.

Best Practices for Health Improvement in AD

Patient-centered dementia care is the gold standard of dementia management. This approach addresses the specific needs of patients with AD and other forms of dementia. The major components of patient-centered dementia care include the preservation of human dignity even in incarceration, promoting purposeful living and holistic care, and establishing relationship-based services to support a sense of self (Marulappa et al., 2022). By preserving human dignity and meeting their needs, this approach improves the quality of life of these individuals.

Another best practice in improving patients’ health with AD is increasing the detection of cognitive decline among individuals and encouraging diagnostic evaluation for AD. Findings reveal that close to half of older adults living in the U.S. do not have a formal medical diagnosis for the disease (Rasmussen & Langerman, 2019). This is attributable to individuals not following up on recommendations by physicians to obtain a diagnostic evaluation and lack of or inadequate community screening for dementia. The best practice in dementia care is for physician and non-physician caregivers to help increase the detection of the disease by encouraging diagnostic evaluation of the disease (Rasmussen & Langerman, 2019). This can be done in primary, residential, and community settings. Early detection of cognitive decline enables prompt initiation of pharmacotherapy to slow the disease’s progression and improve these patients’ quality of life. This underscores the need for early detection.

Another best practice is to meet the psychosocial, informational, and educational needs of patients with AD and their families. This can be achieved through a family-centered care approach. Patients and their families should be equipped with information and education on the disease process and management interventions. This will enable them to participate in the caregiving process and prepare them mentally for the care requirements that this disease presents with. Vital information given to patients and families in AD management includes information on disease progression, stress management, management of AD behavioral and psychological manifestations, and the risk factors for the disease (Maslow & Fortinsky, 2018). Including family members in comprehensive disease management allows them to receive targeted information about the disease, enabling them to bridge care gaps that may be unfamiliar to non-contact healthcare providers.

An assumption made when doing this analysis is that all patients presenting with AD and other forms of dementia will cooperate with their caregivers in designing therapeutic plans targeted at improving their health. A point of uncertainty in this analysis is the cultural considerations for patients with AD and other forms of dementia. Cultural interpretations of the manifestations seen in AD differ and may influence an individual’s health-seeking behavior, commitment to therapy, and cooperation with healthcare providers. Effective management of the disease requires that the patients, patients’ families, and caregivers have a shared vision.

Specific Goals to be Established in Addressing AD

The overall goal of AD management is to improve the health and quality of life of persons living with AD. The first goal of AD management is to increase the number of older adults who know they have the disease. This can be achieved by encouraging diagnostic evaluations on at-risk groups at various levels of care. The second goal is to lower preventable hospitalizations among adults with the disease. This can be attained through early detection and aggressive management of the disease through comprehensive and patient-centered approaches. Another goal is to increase the proportion of adults with the disease who seek healthcare. Healthcare seeking among patients with AD is essential as it provides the groundwork for symptomatic management of the disease. Encouraging health seeking among Alzheimer’s can be attained by intensified community outreach programs and campaigns to educate communities on the benefits of health seeking.

Community Resources

Several community resources are available for a safe and effective continuum of care among patients with AD. The Alzheimer’s Association is a premier organization aimed at supporting and caring for patients with AD and other forms of dementia. The Alzheimer’s Foundation of America is another organization essential for patients with AD. This organization provides information on caring for patients with AD. Home healthcare services are another valuable community resource in AD management. Home healthcare aides consist of qualified care professionals who help people with their illnesses and injuries. These resources can be leveraged to optimize care processes for patients with AD.

AD remains a health concern in the U.S. This disease is common among older adults and has been implicated in significant morbidity. Best practices in managing AD include early detection and patient-centered management of the disease. These approaches result in improved clinical outcomes, underpinning their use. Community resources such as the Alzheimer’s Association are also vital in caring for patients with the disease.

 References

Liang, C.-S., Li, D.-J., Yang, F.-C., Tseng, P.-T., Carvalho, A. F., Stubbs, B., Thompson, T., Mueller, C., Shin, J. I., Radua, J., Stewart, R., Rajji, T. K., Tu, Y.-K., Chen, T.-Y., Yeh, T.-C., Tsai, C.-K., Yu, C.-L., Pan, C.-C., & Chu, C.-S. (2021). Mortality rates in Alzheimer’s disease and non-alzheimer’s Dementia: A systematic review and meta-analysis. The Lancet Healthy Longevity, 2(8). https://doi.org/10.1016/s2666-7568(21)00140-9

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

Maslow, K., & Fortinsky, R. H. (2018). Nonphysician care providers can help increase the detection of cognitive impairment and encourage diagnostic evaluation for dementia in the community and residential care settings. The Gerontologist, 58(suppl_1). https://doi.org/10.1093/geront/gnx171

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/Free Essay Example

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Assessment 1 Instructions: Preliminary Care Coordination Plan
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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 healthcare problem. Identify and list available community resources for a safe and effective continuum of care.

Preliminary Care Coordination Plan-Alzheimer’s disease (AD)

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 healthcare 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.

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 healthcare concern.
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, which 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 healthcare problem.
Identify available community resources for a safe and effective continuum of care.
Organize content so ideas flow logically with smooth transitions; contain 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 families to achieve desired outcomes.
Describe specific goals that should be established to address a selected healthcare 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; contain 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.

Resources: Care Coordination Fundamentals
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You may review the following:

Improving Chronic Illness Care. (n.d.). Care coordination: Background. http://www.improvingchroniccare.org/index.php?p=Background&s=350
This resource provides background information on care coordination. Think about how this information applies to your community and patients as you read the case study of Ms. G., which highlights the importance of care coordination.
McGee, B. T., & Breslin, S. E. (2020, May). The Affordable Care Act 10 years in What nursing leaders should know. Nurse Leader.
Cleveland, K. A., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses. The Online Journal of Issues in Nursing, 24(19). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-24-2019/No2-May-2019/Affordable-Care.html

Resources: Additional Resources for Further Exploration
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You may use the following optional resources to further explore topics related to the competencies.

Improving Chronic Illness Care. (n.d.). Care coordination: Family Care Network: Developing agreements between primary care and specialty groups. http://www.improvingchroniccare.org/index.php?p=Family_Care_Network&s=344
The Family Care Network case study highlights the importance of care coordination. Look for similarities with your own practice and community.
Improving Chronic Illness Care. (n.d.). Care coordination: San Francisco General Hospital: Connectivity through electronic referral. http://www.improvingchroniccare.org/index.php?p=San_Francisco_General_Hospital&s=347
The San Francisco General Hospital case study addresses how care coordination can change patient outcomes. This is a great resource as you think about care coordination in your community.