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Capella 4050 Assessment 1

Capella 4050 Assessment 1

Assessment 1: Preliminary Care Coordination Plan


Capella University

School of Nursing and Health Sciences, Capella University

FPX-NURS 4060: Coordinating Patient-Centered Care

Prof. Name:


Preliminary Care Coordination Plan

The role of care coordination is crucial in managing patients within the community setting, especially in light of the recent budget cuts and relocation of the case management staff to the inpatient setting. As a staff nurse taking on this expanded role, it is essential to plan effectively to address the specific health concerns of community residents. One such health concern is cognitive impairment, particularly Alzheimer’s disease (AD), which is a progressive neurodegenerative disorder that affects cognitive functions, memory, and behavior. Capella 4050 Assessment 1. This assessment will analyze Alzheimer’s disease, identify best practices for health improvement, establish specific SMART goals to address the problem, and explore significant community resources for a safe and effective continuum of care while considering the physical, psychosocial, and cultural needs of the affected population.

Analysis of Health Concern and Best Practices for Health Improvement

Alzheimer’s disease (AD) is a prevalent health concern worldwide, affecting more than 50 million people globally. As a progressive neurodegenerative disorder, AD significantly impacts cognitive functions, memory, behavior, and the ability to perform daily activities. The burden of AD extends to patients, families, caregivers, and communities, resulting in substantial social, emotional, and economic challenges (Meyers et al., 2022). The best practices for health improvement in Alzheimer’s disease encompass three main areas of consideration: physical, psychosocial, and cultural. 

Physical Considerations

Patients with AD often experience physical difficulties, including mobility impairments, balance issues, and reduced motor skills. Effective management of these physical challenges involves providing individualized care plans that address specific needs, such as physical therapy, occupational therapy, and fall prevention strategies (de Oliveira Silva et al., 2019). Evidence from clinical trials and systematic reviews supports the use of tailored exercise programs to improve physical function and reduce the risk of falls in patients with AD (Mok et al., 2020).

Psychosocial Considerations

AD patients and their caregivers are at risk of experiencing various psychosocial issues, such as social isolation, caregiver burden, depression, and anxiety. Best practices for addressing these concerns include providing psychosocial support, counseling, and interventions tailored to the individual’s needs (Meyers et al., 2022). A meta-analysis demonstrated the effectiveness of non-pharmacological interventions, such as cognitive stimulation, reminiscence therapy, and psychoeducation, in improving the psychosocial well-being of patients with AD (Cammisuli et al., 2022). Furthermore, engaging patients in social activities and providing support groups for caregivers can help alleviate stress and promote overall well-being (Skov et al., 2021).

Cultural Considerations

Cultural factors play a significant role in the understanding and management of AD. It is essential to consider patients’ cultural backgrounds and beliefs when planning care and support services. Best practices for culturally sensitive care include incorporating cultural competence training for healthcare professionals, providing educational materials in multiple languages, and engaging with community-based organizations to facilitate culturally relevant support (Babulal et al., 2019). A study highlighted the positive impact of culturally tailored interventions on caregiver outcomes, including decreased depression and burden (Mok et al., 2020).

Capella 4050 Assessment 1

Despite the evidence supporting these best practices, there are still underlying assumptions and points of uncertainty in the analysis. These include the limited understanding of the underlying causes and mechanisms of AD, the lack of curative treatments, and the variability in the effectiveness of interventions depending on individual and cultural factors (Cammisuli et al., 2022).

Specific Goals for Addressing Alzheimer’s Disease

In addressing Alzheimer’s disease in the community setting, the following SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals are proposed:

Goal 1: Improve early detection and diagnosis rates

Ensuring that individuals at risk of developing Alzheimer’s disease receive timely interventions and support requires improving early detection and diagnosis rates. A SMART goal for this objective is to implement routine cognitive assessments for individuals aged 65 and older or with a family history of AD within the community. This goal aims to increase early detection and diagnosis rates by 20% within two years. To achieve this, healthcare professionals will be trained in administering cognitive assessments, and necessary resources will be provided for assessment implementation (Skov et al., 2021). Early detection and diagnosis enable timely interventions and support, improving the quality of life for patients and their families. The target is to achieve this within two years of implementing the routine cognitive assessments (Wong, 2020).

Goal 2: Enhance the quality of life for patients and caregivers

Addressing the needs of Alzheimer’s disease patients and their caregivers is crucial to improving their overall quality of life. A SMART goal for this objective is to develop and implement support and educational programs for AD patients and their caregivers within the community. The goal is to increase patient and caregiver satisfaction with care and support services by 25% within one year (Eikelboom et al., 2019). To achieve this, collaboration with local Alzheimer’s associations, healthcare providers, and community organizations is necessary to develop and deliver support and educational programs. Improved quality of life for patients and reduced caregiver burden contribute to better health outcomes and enhanced well-being. The target is to achieve this within one year of initiating the support and educational programs (Manson et al., 2020).

Goal 3: Foster community engagement and awareness on Alzheimer’s disease

Educating the public and raising awareness about Alzheimer’s disease is essential in promoting early detection, interventions, and social support for those affected. A SMART goal for this objective is to organize community awareness campaigns and events to educate the public about Alzheimer’s disease, risk factors, and available resources. The goal is to reach 50% of the community members with educational materials and information on Alzheimer’s disease within one year (Quiñones et al., 2023). To achieve this, partnerships with local organizations, schools, and media outlets are necessary to disseminate information and promote community events. Increased community awareness and engagement facilitate early detection, timely interventions, and social support for those affected by Alzheimer’s disease (Eikelboom et al., 2019). The target is to achieve this within one year of launching the community awareness campaigns and events.

Community Resources for a Safe and Effective Continuum of Care

A comprehensive and effective care coordination plan for Alzheimer’s disease in the community setting should incorporate various community resources, which have been shown to improve health outcomes and provide a safe continuum of care (Wang et al., 2019). One such resource is primary care providers, who play a critical role in assessing cognitive function, diagnosing Alzheimer’s disease, and initiating appropriate treatments. Their involvement in regular follow-ups and care coordination can significantly improve the quality of care for individuals with dementia (Manson et al., 2020). Memory clinics are another essential resource, as they specialize in providing multidisciplinary assessments, diagnosis, and management of cognitive disorders. Evidence suggests that these clinics can improve diagnostic accuracy, care coordination, and access to resources and support for patients and their families (Largent et al., 2023).

Capella 4050 Assessment 1

Home healthcare agencies that offer skilled nursing care, physical therapy, and occupational therapy can also be beneficial for patients with Alzheimer’s disease (Burgdorf et al., 2021). Research has shown that home healthcare can improve patient satisfaction, reduce caregiver burden, and enhance the quality of life for dementia patients. Adult day care centers provide structured programs, socialization, and supervision for patients with Alzheimer’s disease during daytime hours, which can have positive effects on their physical, cognitive, and emotional well-being (Wang et al., 2020).

Support groups play a vital role in facilitating emotional support and information exchange for both patients and caregivers. Studies have demonstrated that support groups can help reduce stress, improve coping skills, and enhance the quality of life for caregivers of individuals with Alzheimer’s disease (Manson et al., 2020). Respite care services offer temporary relief for caregivers by providing short-term care for patients with Alzheimer’s disease, which has been shown to reduce caregiver burden and improve overall well-being (Durán-Gómez et al., 2020).

Local chapters of the Alzheimer’s Association offer various resources, including educational materials, support groups, and advocacy efforts. These resources help raise awareness and improve access to services for patients and families affected by the disease (Kokorelias et al., 2020). Additionally, cultural and faith-based organizations can provide culturally-specific support and resources tailored to the unique needs of diverse communities, addressing cultural barriers to care and promoting a better understanding of Alzheimer’s disease within different cultural contexts (Bender et al., 2022).


In conclusion, effectively managing Alzheimer’s disease in the community setting necessitates a comprehensive care coordination plan that includes analyzing the health issue, identifying optimal practices for health enhancement, setting SMART objectives, and utilizing vital community resources. By incorporating these components, the care coordination plan can cater to the physical, psychosocial, and cultural requirements of Alzheimer’s patients, thereby improving overall community health. As a staff nurse assuming the care coordination role, staying knowledgeable, proactive, and flexible in response to the ever-changing healthcare environment and the particular needs of patients and their families is crucial.


Babulal, G. M., Quiroz, Y. T., Albensi, B. C., Arenaza-Urquijo, E., Astell, A. J., Babiloni, C., Bahar-Fuchs, A., Bell, J., Bowman, G. L., Brickman, A. M., Chételat, G., Ciro, C., Cohen, A. D., Dilworth-Anderson, P., Dodge, H. H., Dreux, S., Edland, S., Esbensen, A., Evered, L., & Ewers, M. (2019). Perspectives on ethnic and racial disparities in Alzheimer’s disease and related dementias: Update and areas of immediate need. Alzheimer’s & Dementia, 15(2), 292–312. 

Bender, A. A., McIntosh, R. L., Sudduth, S., Harris, M., Tuckey, K., Morgan, J. C., Jungerman, J. M., Cox, A., Moore, M. A., Ingram, B., Pier, E., Johnson, T. M., Loring, D. W., Hepburn, K., Medders, L., Levey, A. I., Lah, J. J., & Hales, C. M. (2022). The Georgia memory net: Implementation of a statewide program to diagnose and treat Alzheimer’s disease and related dementias. Journal of the American Geriatrics Society, 70(4), 1257–1267. 

Burgdorf, J. G., Amjad, H., & Bowles, K. H. (2021). Cognitive impairment associated with greater care intensity during home health care. Alzheimer’s & Dementia. 

Cammisuli, D. M., Cipriani, G., Giusti, E. M., & Castelnuovo, G. (2022). Effects of reminiscence therapy on cognition, depression and quality of life in elderly people with Alzheimer’s disease: A systematic review of randomized controlled trials. Journal of Clinical Medicine, 11(19), 5752. 

de Oliveira Silva, F., Ferreira, J. V., Plácido, J., Sant’Anna, P., Araújo, J., Marinho, V., Laks, J., & Camaz Deslandes, A. (2019). Three months of multimodal training contributes to mobility and executive function in elderly individuals with mild cognitive impairment, but not in those with Alzheimer’s disease: A randomized controlled trial. Maturitas, 126, 28–33. 

Durán-Gómez, N., Guerrero-Martín, J., Pérez-Civantos, D., López Jurado, C. F., Palomo-López, P., & Cáceres, M. C. (2020). Understanding resilience factors among caregivers of people with Alzheimer’s disease in spain. Psychology Research and Behavior Management, Volume 13, 1011–1025. 

Eikelboom, W. S., Singleton, E., van den Berg, E., Coesmans, M., Mattace Raso, F., van Bruchem, R. L., Goudzwaard, J. A., de Jong, F. J., Koopmanschap, M., den Heijer, T., Driesen, J. J. M., Vroegindeweij, L. J. H. M., Thomeer, E. C., Hoogers, S. E., Dijkstra, A. A., Zuidema, S. U., Pijnenburg, Y. A. L., Scheltens, P., van Swieten, J. C., & Ossenkoppele, R. (2019). Early recognition and treatment of neuropsychiatric symptoms to improve quality of life in early Alzheimer’s disease: Protocol of the BEAT-IT study. Alzheimer’s Research & Therapy, 11(1). 

Kokorelias, K. M., Gignac, M. A. M., Naglie, G., Rittenberg, N., MacKenzie, J., D’Souza, S., & Cameron, J. I. (2020). A grounded theory study to identify caregiving phases and support needs across the Alzheimer’s disease trajectory. Disability and Rehabilitation, 1–10. 

Largent, E. A., Grill, J., O’Brien, K., Wolk, D., Harkins, K., & Karlawish, J. (2023). Testing for alzheimer disease biomarkers and disclosing results across the disease continuum. Neurology 

Manson, A., Ciro, C., Williams, K. N., & Maliski, S. L. (2020). Identity and perceptions of quality of life in Alzheimer’s disease. Applied Nursing Research, 52, 151225. 

Meyers, E. A., Amouyel, P., Bovenkamp, D. E., Carrillo, M. C., De Buchy, G. D., Dumont, M., Fillit, H., Friedman, L., Henderson-Begg, G., Hort, J., Murtishaw, A., Oakley, R., Panchal, M., Rossi, S. L., Sancho, R. M., Thienpont, L., Weidner, W., & Snyder, H. M. (2022). Commentary: Global Alzheimer’s disease and Alzheimer’s disease related dementia research funding organizations support and engage the research community throughout the COVID-19 pandemic. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 18(5), 1067–1070. 

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., Kwok, T., Greenberg, S. M., Jia, J., Kalaria, R., Kivipelto, M., Naegandran, K., & Lam, L. C. W. (2020). Tackling challenges in care of Alzheimer’s disease and other dementias amid the COVID19 pandemic, now and in the future. Alzheimer’s & Dementia, 16(11). 

Quiñones, M. M., Silva, C., Ross, C., Sörensen, S., Serrano, R., Van Orden, K., & Heffner, K. (2023). Recruiting socially disconnected latinos caring for a person with alzheimer’s disease and related dementias during the COVID-19 pandemic: Lessons Learned. Clinical Gerontologist, 1–14. 

Skov, S. S., Nielsen, M. B. D., Krølner, R. F., Øksnebjerg, L., & Rønbøl Lauridsen, S. M. (2021). A multicomponent psychosocial intervention among people with early-stage dementia involving physical exercise, cognitive stimulation therapy, psychoeducation and counselling: Results from a mixed-methods study. Dementia, 147130122110406. 

Wang, H., Xie, H., Qu, Q., Chen, W., Sun, Y., Zhang, N., Liu, Y., Li, T., Chan, K. Y., Gauthier, S., & Yu, X. (2019). The continuum of care for dementia: Needs, resources and practice in China. Journal of Global Health, 9(2). 

Wang, J., Caprio, T. V., Simning, A., Shang, J., Conwell, Y., Yu, F., & Li, Y. (2020). Association between home health services and facility admission in older adults with and without alzheimer’s disease. Journal of the American Medical Directors Association, 21(5), 627-633.e9. 

Wong, W. (2020). Economic burden of Alzheimer disease and managed care considerations. The American Journal of Managed Care, 26(Suppl 8), S177–S183. 

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