Capella 4050 Assessment 4

Assessment 4 – Final Care Coordination Plan

Name:

Capella University

School of Nursing and Health Sciences, Capella University

FPX-NURS 4050: Coordinating Patient-Centered Care

Prof. Name:

Date

Final Care Coordination Plan

In this Final care coordination plan, the initial care coordination plan from Assessment 1 will be assessed using best practices discovered in scholarly sources. This plan will concentrate on the chosen healthcare issue – Alzheimer’s disease (AD) – and emphasize the development of patient-focused health interventions, taking into account ethical considerations, recognizing health policy consequences, outlining priorities for care coordinators, and aligning the plan with Healthy People 2030 objectives.

Patient-centered Health Interventions and Timelines for Alzheimer’s Disease

Early Detection and Diagnosis

The first healthcare issue related to Alzheimer’s disease (AD) is early detection and diagnosis. A patient-centered intervention for this issue involves implementing routine cognitive assessments for individuals aged 65 and older or those with a family history of AD within the community. The timeline for this intervention is to initiate assessments within six months and continue them annually (Bandini et al., 2022). To include community resources, collaboration with local primary care providers and memory clinics is essential, as they can offer cognitive assessments and referrals to specialists when necessary (Disler et al., 2022).

Enhancing the Quality of Life for AD Patients and Caregivers

The second healthcare issue is enhancing the quality of life for AD patients and caregivers. Targeted intervention for this issue is to develop and implement support and educational programs within the community for patients and caregivers. The timeline for establishing these programs is within one year, with annual evaluations to assess their effectiveness (Gostin et al., 2020). To incorporate community resources, partnerships with local Alzheimer’s associations, healthcare providers, and community organizations will be formed. These partnerships will help create and deliver support groups, workshops, and respite care services to cater to the needs of AD patients and caregivers (Banner et al., 2019).

Fostering Community Engagement and Awareness

The third healthcare issue is fostering community engagement and awareness. An intervention to address this issue involves organizing community awareness campaigns and events to educate the public about Alzheimer’s disease, its risk factors, and available resources. The timeline for launching the campaign is within six months, with annual events and ongoing awareness efforts thereafter (Dams-O’Connor et al., 2023). To involve community resources, collaborations with local organizations, schools, and media outlets are necessary. These collaborations will help disseminate information, promote community events, and create volunteer opportunities for individuals to support those affected by Alzheimer’s disease (Quiñones et al., 2023).

Consider Ethical Decisions in Designing Patient-centered Health Interventions

Ethical considerations play a crucial role in designing patient-centered health interventions. When implementing routine cognitive assessments, potential ethical concerns include patient privacy, informed consent, and potential stigmatization (Luk et al., 2021). According to literature, informed consent is vital in cognitive assessments, as patients must be aware of the purpose, potential risks, and benefits of the assessment. Furthermore, healthcare providers should be prepared to address potential stigmatization by educating patients and families about Alzheimer’s disease and emphasizing the importance of early detection and intervention (Reiss et al., 2022).

Capella 4050 Assessment 4

Allocation of resources for support and educational programs must be balanced with other community health needs, ensuring fairness and equitable distribution of resources. The literature suggests that resource allocation should be guided by principles of justice, efficiency, and community engagement to promote equitable access to healthcare services (Creary, 2021). Allocating resources to Alzheimer’s support and educational programs can be justified by the increasing prevalence of the disease and the substantial impact on patients, caregivers, and the healthcare system (Gostin et al., 2020).

Health Policy Implications for the Coordination and Continuum of Care

Expansion of Medicare Coverage for Cognitive Assessments

The expansion of Medicare coverage for cognitive assessments, as stipulated in the “National Alzheimer’s Project Act (NAPA)”, has significant implications for the coordination and continuum of care for Alzheimer’s disease patients. This policy provision enables greater access to early detection and diagnosis by reducing financial barriers for those seeking cognitive assessments. As a result, patients can receive timely interventions and care planning, leading to better management of the disease and improved health outcomes. This policy also highlights the importance of interdisciplinary collaboration between primary care providers, specialists, and care coordinators to ensure a seamless transition of care (Langbaum et al., 2022).

Increased funding for Alzheimer’s research

The Alzheimer’s Disease Research Summit Recommendations, which advocate for increased funding for Alzheimer’s research, are crucial for advancing the understanding of the disease, improving diagnostic tools, and developing more effective treatments. This policy provision supports the coordination and continuum of care by enhancing evidence-based practices and informing care strategies. As new discoveries are made, care coordinators can incorporate emerging knowledge into their interventions, ensuring that patients receive the most up-to-date and effective care (Crowe et al., 2020).

Promotion of care models emphasizing care coordination and support services

The “Patient Protection” and “Affordable Care Act (ACA)” encourages the adoption of care models emphasizing care coordination and support services for patients and caregivers, which are vital for improving the quality of care for individuals with Alzheimer’s disease (Olivari et al., 2020). These policies, such as the creation of “Accountable Care Organizations (ACOs)” and “Patient-Centered Medical Homes (PCMHs)”, encourage the integration of healthcare services, community resources, and support systems, leading to better management of the disease and enhanced patient and caregiver satisfaction. The adoption of such models fosters a more patient-centered approach, addressing the unique needs of Alzheimer’s patients and their caregivers while ensuring continuity of care across various healthcare settings (Chen et al., 2022).

Priorities and Evidence-Based Changes in Care Coordination

Ensuring individual needs and preferences are considered

A care coordinator would prioritize addressing the unique needs and preferences of the patient and family members. This may involve adjusting the care plan to accommodate specific cultural or personal beliefs, communication preferences, and lifestyle considerations. Tailoring the care plan to the individual patient enhances patient satisfaction and adherence to the plan, ultimately improving health outcomes (Atri, 2019).

Providing culturally competent care

Culturally competent care is essential for addressing the diverse needs of patients and their families. A care coordinator would emphasize the importance of understanding and respecting the cultural background, beliefs, and values of the patient and their family. This may involve incorporating culturally appropriate interventions, language services, or educational materials into the care plan, ensuring that the care provided is respectful and inclusive (Antón-Solanas et al., 2022).

Promoting patient and caregiver engagement in decision-making

A care coordinator would prioritize involving the patient and their caregivers in the decision-making process to ensure the care plan is patient-centered and meets their unique needs. This may involve providing opportunities for open communication, shared decision-making, and regular feedback on the plan’s progress. Engaging patients and caregivers in the decision-making process fosters a sense of ownership and collaboration, contributing to better adherence and outcomes (Mele et al., 2021).

Emphasizing the importance of early detection and intervention

The care coordinator would stress the significance of early detection and intervention in managing Alzheimer’s disease. This may involve educating the patient and their family members about the importance of regular cognitive assessments, potential warning signs, and available interventions. By emphasizing the benefits of early detection and intervention, the care plan can be adapted and modified to ensure timely and effective care (Reiss et al., 2022).

Align Learning Sessions with Best Practices and Healthy People 2030

When evaluating the learning session content, it is crucial to consult the literature on best practices for Alzheimer’s disease patients and caregivers, such as cognitive stimulation therapy and individualized care plans. Aligning the teaching sessions with Healthy People 2030 objectives involves integrating goals like increasing the proportion of older adults receiving cognitive assessments, reducing caregiver burden, and promoting community-based support services. To achieve this, learning sessions should emphasize early detection, intervention, and ongoing support for Alzheimer’s disease patients and their caregivers (Hittle et al., 2023).

Capella 4050 Assessment 4

Necessary revisions to the learning sessions include updating the content with the latest research findings, tailoring sessions to meet diverse needs by considering factors like cultural background and cognitive abilities and stressing the importance of early detection and intervention (Pronk & Stiefel, 2020). By incorporating these revisions, the care coordination plan will not only align with national health goals but also contribute to improved health outcomes for individuals with Alzheimer’s disease and their caregivers.

Conclusion

This evaluation highlights the significance of creating patient-focused health interventions that tackle particular healthcare concerns while taking into account ethical choices and applicable health policies. By setting priorities and implementing evidence-based modifications to the care coordination plan, care coordinators can enhance the care quality for patients and their loved ones. Furthermore, aligning educational sessions with best practices and Healthy People 2030 goals guarantees that interventions stay current and efficient in addressing healthcare difficulties. Ultimately, this all-encompassing method to care coordination leads to improved health outcomes, increased well-being, and better quality of life for individuals and communities impacted by health problems such as Alzheimer’s disease.

References

Antón-Solanas, I., Rodríguez-Roca, B., Vanceulebroeck, V., Kömürcü, N., Kalkan, I., Tambo-Lizalde, E., Huércanos-Esparza, I., Casa Nova, A., Hamam-Alcober, N., Coelho, M., Coelho, T., Van Gils, Y., Öz, S. D., Kavala, A., & Subirón-Valera, A. B. (2022). Qualified nurses’ perceptions of cultural competence and experiences of caring for culturally diverse patients: A qualitative study in four european countries. Nursing Reports, 12(2), 348–364. https://doi.org/10.3390/nursrep12020034 

Atri, A. (2019). Current and future treatments in Alzheimer’s disease. Seminars in Neurology, 39(02), 227–240. https://doi.org/10.1055/s-0039-1678581 

Banner, D., Bains, M., Carroll, S., Kandola, D. K., Rolfe, D. E., Wong, C., & Graham, I. D. (2019). Patient and public engagement in integrated knowledge translation research: Are we there yet? Research Involvement and Engagement, 5(1). https://doi.org/10.1186/s40900-019-0139-1

Bandini, J. I., Schulson, L. B., Ahluwalia, S. C., Harrison, J., Chen, E. K., Lai, J. S., & Edelen, M. (2022). Patient, family caregiver, and provider perceptions on self-assessment screening for cognitive impairment in primary care: Findings from a qualitative study. Gerontology and Geriatric Medicine, 8, 233372142211314. https://doi.org/10.1177/23337214221131403

Chen, J., Buchongo, P., Spencer, M. R. T., & Reynolds, C. F. (2022). An HIT-supported care coordination framework for reducing structural racism and discrimination for patients with ADRD. The American Journal of Geriatric Psychiatry, 30(11), 1171–1179. https://doi.org/10.1016/j.jagp.2022.04.010

Creary, M. S. (2021). Bounded justice and the limits of health equity. Journal of Law, Medicine & Ethics, 49(2), 241–256. https://doi.org/10.1017/jme.2021.34

Crowe, C., Collie, C., Johnson, C., & Wiltsey Stirman, S. (2020). An intervention mapping process to increase evidence-based psychotherapy within a complex healthcare system. American Psychologist, 75(8), 1116–1129. https://doi.org/10.1037/amp0000631

Dams-O’Connor, K., Awwad, H. O., Hoffman, S., Pugh, M. J., Johnson, V. E., Keene, C. D., McGavern, L., Mukherjee, P., Opanashuk, L., Umoh, N., Sopko, G., & Zetterberg, H. (2023). Alzheimer’s disease-related dementias summit 2022: national research priorities for the investigation of post-traumatic brain injury Alzheimer’s disease and related dementias. Journal of Neurotrauma. https://doi.org/10.1089/neu.2022.0514

Disler, R., Pascoe, A., Anderson, H., Piejko, E., Asaid, A., & Disler, P. (2022). A new model for general practice-led, regional, community-based, memory clinics. BMC Primary Care, 23(1). https://doi.org/10.1186/s12875-022-01829-1

Gostin, L. O., Friedman, E. A., & Wetter, S. A. (2020). Responding to Covid‐19: How to navigate a public health emergency legally and ethically. Hastings Center Report, 50(2), 8–12. https://doi.org/10.1002/hast.1090

Hittle, B. M., Hils, J., Fendinger, S. L., & Wong, I. S. (2023). A scoping review of sleep education and training for nurses. International Journal of Nursing Studies, 142, 104468. https://doi.org/10.1016/j.ijnurstu.2023.104468 

Langbaum, J. B., Zissimopoulos, J., Au, R., Bose, N., Edgar, C. J., Ehrenberg, E., Fillit, H., Hill, C. V., Hughes, L., Irizarry, M., Kremen, S., Lakdawalla, D., Lynn, N., Malzbender, K.,

Maruyama, T., Massett, H. A., Patel, D., Peneva, D., Reiman, E. M., . . . Aisen, P. S. (2022). Recommendations to address key recruitment challenges of Alzheimer’s disease clinical trials. Alzheimer’s & Dementia, 19(2), 696–707. https://doi.org/10.1002/alz.12737

Luk, J. W., Pruitt, L. D., Smolenski, D. J., Tucker, J., Workman, D. E., & Belsher, B. E. (2021). From everyday life predictions to suicide prevention: Clinical and ethical considerations in suicide predictive analytic tools. Journal of Clinical Psychology, 78(2), 137–148. https://doi.org/10.1002/jclp.23202

Mele, C., Marzullo, M., Di Bernardo, I., Russo-Spena, T., Massi, R., La Salandra, A., & Cialabrini, S. (2021). A smart tech lever to augment caregivers’ touch and foster vulnerable patient engagement and well-being. Journal of Service Theory and Practice, 32(1), 52–74. https://doi.org/10.1108/jstp-12-2020-0292

Pronk, N. P., & Stiefel, M. C. (2020). Leveraging the rest of society: aligning healthy people 2030, well-being in the nation, and other national health indicators with workplace health and well-being. American Journal of Health Promotion, 34(4), 461–465. https://doi.org/10.1177/0890117120915113f 

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. https://doi.org/10.1080/07317115.2023.2197895

Reiss, A. B., de Levante Raphael, D., Chin, N. A., & Sinha, V. (2022). The physician’s Alzheimer’s disease management guide: Early detection and diagnosis of cognitive impairment, Alzheimer’s disease and related dementia. AIMS Public Health, 9(4), 661–689. https://doi.org/10.3934/publichealth.2022047