Care Coordination Plan for a Patient with Alzheimer’s Disease

Final Care Coordination Plan
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Final Care Coordination Plan
Introduction
Alzheimer’s disease is a disease that affects millions of people in the world. In the US alone, Alzheimer’s Association (2022) indicates that 6.5 million people aged 65 and above are living with the condition. Further, the projections paint a grim future for the American population indicating that by 2050, 12.7 million people aged 65 and older will be living with Alzheimer’s disease. What is more, as a condition that is known to have no cure (OASH, 2022), the statistics above present a worrying trend that will greatly impact the healthcare sector. However, though the future appears grim, OASH (2022) advises that the focus must be on helping to enhance the quality of life for those diagnosed with the condition. After diagnosis, focusing efforts on measures that can help improve the quality of life of the diagnosed patient can help enhance their health outcomes. However, to successfully manage the condition, there is a need to employ a coordinated or combined effort. Often, patients with Alzheimer’s disease seek and need care and help from different professionals, including nursing aides, psychiatrists, geriatricians, and physicians (Office of the Assistant Secretary for Planning and Evaluation, 2013). Also, these patients need the help and care of their family and their community. However, if all these efforts are uncoordinated and less information is shared, the chances are high that the patient will end up receiving retrogressive instead of progressive care. Therefore, there is a need to develop a coordinated plan to help enhance the quality of life of a patient. Provided herein is a comprehensive care coordination plan for a patient who has Alzheimer’s disease.
Identification of Groups
Several groups of people are highly likely to be involved in caring for a patient with Alzheimer’s disease. The first group entails the patient’s family. For any patient, the family presents a crucial group of people who can help doctors and nurses care for a patient. Babaei and Abolhasani (2020) note that a patient’s family is the first resource that a patient has because of the support system they offer. The researchers add that the presence of a supportive family helps offer patients a positive outlook and psychological support. Therefore, as a group charged with or involved in caring for a patient with Alzheimer’s disease, the family is one of the most crucial groups.
The second group entails the nursing aides and home health care workers. This second group closely follows the family as a key component in helping enhance the quality of life of a patient with Alzheimer’s disease. Though their role is not as celebrated, nurse aides and home health care workers play a major role in the lives of patients living with Alzheimer’s disease. One of the things they do is create an environment conducive to enhancing a patient’s quality of life. Rahman, Anjum, and Sahakian (2019) note that home healthcare workers help reduce healthcare services’ utilization because of their support for Alzheimer’s patients. The implication of the above is that cost of healthcare is reduced, and patients get to focus on managing the condition. However, the researchers quickly pointed out that there is a need for ample training for home healthcare workers.
The third group entails physicians or geriatricians. This group is just as important as the other two. However, their role is not as involving as the other groups, even though they are the ones with all the knowledge needed to manage AD. One thing that this group does is help patients learn various coping strategies and how these can help them manage their condition better. For Alzheimer’s disease, the goal is management and enhanced quality of life, therefore, even for physicians, their task is geared towards helping patients learn how to live with the condition. Further, physicians and geriatricians are also key in helping patients deal with their psychological and emotional states. Here, geriatric psychologists and psychiatrists play crucial roles.
Identification of Patient Needs/Needs Assessment
As earlier indicated, it is crucial for the groups involved to consider a coordinated plan to help ensure that the larger goal of enhancing the quality of life for the patient is achieved. However, for this to be attained at an optimal level, the needs of the patient must be identified first. These needs can be group-specific, which means that some of them can only be catered to by one of the groups identified above. For AD patients their needs are categorized into three. These include:
Psychosocial needs – these needs mainly encapsulate the patient’s mental, behavioral, and spiritual needs. The family and the nurse aides or the home healthcare workers often cater to these needs.
Cultural needs – these needs entail the patient’s beliefs, language, ethnic background, values, and traditional practices. These needs come from the innate need to belong, provided for by one’s family and the community. For physicians, nurse aides, and home health care workers, it is crucial to align or stay acquainted with a patient’s cultural needs else these can become an impediment to care. Clark et al. (2018) note that there is a need for medical professionals to be mindful of cultural views and interpretations harbored by different people concerning AD, and how these can impact care. Without a deep knowledge of these beliefs, medical professionals will likely face many challenges in their pursuit to ensure improved quality of life for patients. Therefore, in as much as these needs are best-taken care of by one’s family and community, staying acquainted with them as a medical professional makes it possible to offer care from an informed point of view.
Physical needs – these needs mainly entail the daily needs of a patient. These can entail movement, rest, stability, and even exercise. While they may seem simple and easy to deliver, these needs call for patient supervision and daily care.
Best Practices and Crucial Care Coordination Elements
This section will outline some of the best practices while also discussing some crucial care coordination elements and how these gel to form an excellent care coordination plan for patients living with AD. Every element or practice in a care coordination plan ought to work in alignment with others. There ought to be a pattern or flow of events that paves the way for the next practice or element to help ensure the condition is well managed. Below are elements that also form part of AD’s coordinated care plan with enhanced healthcare for the patient assured.
Early diagnosis
Early diagnosis is a best practice and an element of the coordinated care plan. According to Rasmussen and Langerman (2019), early diagnosis is a critical practice that can help ensure that eventual dementia that AD exposes patients to is delayed. As per the researchers, it is possible to make plans for the condition and mitigate the risk factors that predispose patients to the heightened progression of dementia. Therefore, it is a crucial step that aids patients to not only live longer but also manage the disease better.
Aside from the above, it is crucial to consider early diagnosis within the lens of the coordinated care plan for AD. One fact ...