NURS FPX4050 Care Coordination Plan Paper
For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1(ATTACHED) using best practices found in the literature.
Preparation
In this assessment, you will evaluate AND BUILD ON the preliminary care coordination plan you developed in Assessment 1 (ATTACHED) using best practices found in the literature.
To prepare for your assessment, you will research the literature on your selected health care 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 upon EBP and discuss how the plan includes elements of Healthy People 2020.
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 title page and reference list.
**GRADING REQUIREMENTS**
1. Designs patient-centered health interventions and timelines for a selected health care problem that includes community resources.
-Address three health care issues.
-Design an intervention for each health issue.
-Identify three community resources for each health intervention.
2. Considers insightful ethical decisions in designing patient-centered health interventions. These decisions are supported by the literature.
-Consider the practical effects of specific decisions.
-Include the ethical questions that generate uncertainty about the decisions you have made.
3. Identifies relevant health policy implications for the coordination and continuum of care, based on precise and accurate interpretations of relevant policy provisions. Makes valid, insightful inferences.
-Cite specific health policy provisions.
4. 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.
5.Uses 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 2020 document. Clearly explains the need for any revisions.
-Use the literature on evaluation as guide to compare learning session content with best practices.
-Align teaching sessions to the Healthy People 2020 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; contains few errors in grammar/punctuation, word choice, and spelling
Caring for Alzheimer’s Patient
Care coordination refers to the deliberate organization of resources and activities to ensure that a patient’s needs are met. A patient with a health condition has various types of needs including physiological, psychological, and social needs. Holistic patient care involves caring for all these needs to ensure the best outcomes out of patient care efforts. Community-dwelling patients with Alzheimer’s disease require attention from home caregivers and other caregivers who work together to enhance the functional capacity of the patient. Care coordination for such patients is essential to meet their diverse needs. This paper presents a preliminary care coordination plan for a patient with Alzheimer’s disease to enhance health status and improve their functional capacity.
The Health Concern
Alzheimer’s disease is a progressive and irreversible mental health disorder. Primarily, this disorder destroys memory and the individual’s thinking and social skills. Eventually, the affected person loses the ability to perform even simple tasks (CDC, 2018). This disease is the most common cause of dementia among older adults and it mainly sets in after the age of 60. The main challenge presented by Alzheimer’s disease is a person’s working memory whereby they lose the ability to coordinate activities of daily living, lose memory of their environment and people they are familiar to, and cannot perform simple tasks on their own. As such, a person with Alzheimer’s disease requires assistance in activities of daily living due to memory loss.
The health concern affects many older adults in the United States and causes many deaths. Aging is the most known factor for increasing the risk of Alzheimer’s. It is estimated that 5.5 million Americans 65 years old and above have Alzheimer’s although studies have shown that the condition is underreported (CDC, 2018). Early onset Alzheimer’s manifesting as early as in the thirties has also been observed although at lower rates than that affecting older adults. Studies show that if the current population trends continue, the population affected by Alzheimer’s will continue to increase in the country. A community-dwelling person with Alzheimer’s disease requires effective care coordination to promote their functioning and health outcomes.
Best Practices
Research on caring for people with Alzheimer’s disease is extensive and most of the research focuses on how to increase functionality of this patient population. One category of best practices is to reduce frustrations that people with Alzheimer’s disease may face. The most common symptom of the condition is deterioration of memory and gradual loss of social and functional skills. To make it easy for such a person to function, the caregiver must create a schedule and tasks that are easy to follow and remember (Douglas & McDonald, 2016). For instance, providing simple instructions and engaging the patient as much as possible are crucial approaches to ensuring that the patient functions at their optimal level. Similarly, monitoring patient movements and activities to avoid wandering is a crucial approach to maintaining optimal health and functionality.
Moreover, when dealing with a patient with Alzheimer’s disease, it is crucial to focus on enhancing the patient’s environment’s safety. Alzheimer’s disease impairs problem-solving skills and judgment, making the patient more susceptible to injury (Douglas & McDonald, 2016). It thus becomes necessary for caregivers to reduce risks that the patient may face and enhance their functional capacity. For instance, caregivers must beware of risks of falls such as scatter rugs and clatter. In addition to Alzheimer’s disease, the patient’s old age may also increase risk of falls and other injuries hence it is crucial to reduce those risks.
Goals for Care Coordination
Patient care goals depend on the physical, psychological, and cultural factors associated with the health concern. The physical needs of the patient mostly include verbal communication and performing activities of daily living. The goal of care to address verbal communication is to establish an effective means of speech and understanding communication or an alternative method of communicating with the caregiver (Jennings et al., 2017). Diminished speech abilities reduce efficacy of care hence the need to establish the most convenient communication. Moreover, the goal for activities of daily living is that the patient will maintain optimum activities of daily living including ambulating, feeding, bathing, and toilet use.
Furthermore, psychological needs for a person with Alzheimer’s disease include social isolation and disturbed thought processes. Social isolation may occur due to limitations of social interaction with other members of community. The care goal for this need, therefore, is for the patient to maintain effective social interaction and relations as per the limits of disease progress (Jennings et al., 2017). As for disturbed thought process, the patient’s behavioral problems should be identified and controlled. The cultural needs of a patient with Alzheimer’s disease include aspects such as care for people of racial minorities. The caregiver should strive to maintain optimum cultural competency when caring for patients with Alzheimer’s disease. Overall, the patient has numerous physical, psychological, and cultural needs requiring effective care coordination and caregiving.
Community Resources
Effective continuum of care is needed for effective coordination and management of care for people with Alzheimer’s disease. The Alzheimer’s Association is a crucial community resource that provides information to patient caregivers and offers advice and consultations to patients as well (Alzheimer’s Association, n.d.). This resource can be useful in gathering information and using it for care. Another community resource is peer support groups which can address the psychological effects of having the condition or caring for a person with the condition. Other than support groups, respite care can aid caregivers who are distressed by the duties and tasks of caring for Alzheimer’s patients. Homes for the elderly also provide assistance with activities of daily living and could help patient maintaining physical mobility. These community resources are crucial for care coordination.
Conclusion
Alzheimer’s disease is a health condition requiring effective care coordination to maintain functionality of the patient and enhance their lifestyle. This condition mostly affects older adults and is related to aging. Health concerns include thought processes and cognitive functioning of the patient, activities of daily living, and risk of injury. Home caregivers can get assistance from professionals in caring for the patient and may also access professional information on the condition through Alzheimer’s Association. Caring for an Alzheimer’s patient aims to maintain the best quality of life while mitigating any adverse effects of the health condition.
References
Alzheimer’s Association. (n.d.). Programs and support. https://www.alz.org/help-support/i-have-alz/programs-support
Centers for Disease Control and Prevention. (2018). US burden of Alzheimer’s disease, related dementias to double by 2060. CDC Newsroom. https://www.cdc.gov/media/releases/2018/p0920-alzheimers-burden-double-2060.html
Douglas, N. F., & McDonald, K. (2016). Interprofessional care in the management of Alzheimer’s dementia: Leaving our silos. Perspectives of the ASHA Special Interest Groups, 1(2), 129-137.
Jennings, L. A., Palimaru, A., Corona, M. G., Cagigas, X. E., Ramirez, K. D., Zhao, T., … & Reuben, D. B. (2017). Patient and caregiver goals for dementia care. Quality of Life Research, 26(3), 685-693. https://doi.org/10.1007/s11136-016-1471-7
NURSFPX4050 Care Coordination Plan
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