Background Information on Alzheimer’s Disease Care Coordination Plan
Alzheimer’s disease (AD) is a brain and degenerative disease that often begins during the twenties or more before symptoms manifest, with alterations in the brain inconspicuous to the individual impacted. The disease affects more than five million Americans (Samus et al., 2017). Symptoms begin to manifest after years of brain alterations and include language difficulties, memory loss, thinking capacity problems, and inability to execute daily living activities (Silva et al., 2019). Therefore, Alzheimer’s disease patients greatly rely on their caregivers for their daily upkeep and extensively utilize long-term services and supports (LTSS) and medical care. Most nursing home residents have AD or dementia diagnosis. Consequently, Alzheimer’s disease places a significant burden on the impacted persons and their caregivers.
Given the anticipated growing elderly population and Alzheimer’s disease high incidence among older Americans, the number of impacted persons is expected to keep soaring. This increase is likely to soar the demand for Medicare and Medicaid care. Consequently, persons with Alzheimer’s disease often require care from multiple providers, including psychiatrists, home health care workers, geriatricians, and nurse aides. However, this care is often delivered in a disjointed and uncoordinated manner. Therefore, care coordination can help address Alzheimer’s disease patients’ multidisciplinary needs, including supporting informal caregivers (Samus et al., 2017). Thus, improving health outcomes for all individuals involved in the care process. Additionally, it can decrease Medicare and Medicaid spending by abolishing needless care and promoting care services that maintain the wellbeing of both parties. Besides, in Alzheimer’s disease, a care coordinator is usually allocated to an informal caregiver and is responsible for directing services for the Alzheimer’s disease patient, offering supportive services to their caregivers, and coordinating LTSS or medical care utilization.
This paper aims to explore literature and apply evidence-based information to support teaching, learning, and communicating best practices required for care coordination for individuals with Alzheimer’s disease.
Patient-Centered Health Interventions for Alzheimer’s Disease
Effective disease and symptoms management choices are present, and practice recommendations endorse the incorporation and harmonized utilization of evidence-based methodologies to optimize care outcomes. Optimal Alzheimer’s disease care focuses on detecting and addressing patients’ multidimensional needs, including managing multimorbidity, behavioral and cognitive symptoms, and medical advancement accelerator management (Samus et al., 2017). Additionally, it includes modifying the patient’s living environment and offering social and caring services for patients in daily living. Besides, optimal care also requires addressing caregiver needs, including Alzheimer’s disease care-connected skills education and training, communication skills and coping approaches training, providing available community support systems information, problem-solving skills, and respite care.
Care coordination models tailored explicitly to Alzheimer’s disease (AD) represent a potentially vital tool to promote care and facilitate enhanced coordination, value, and quality of care. According to Samus et al. (2017), existing evidence demonstrates that Alzheimer’s disease-aligned care management is helpful to individuals with AD and their caregivers. Consequently, AD promising models highlight the need to concentrate on the patient and caregiver dyad, personalized care planning, structured needs assessments, continuous surveillance and adjustments of care plans, community-based organizations and health care provider referrals, linkages, and caregiver training, support, and problem-solving skills.
Therefore, to provide patient-centered health Interventions to AD patients in the community, I will apply the Maximizing Independence at the Home model (MIND at Home). The model strongly underscores the home as the center of AD care coordination. Its comprehensive needs assessment focuses on individuals with AD and their family caregivers connected to need-based intervention procedures and care approaches resulting from evidence-based research and best practices. Additionally, the model utilizes trained non-licensed community workforces as primary care coordinators and emphasizes person-centered outcomes, such as the patient residing at home for as long as possible. The model aligns with the ACA, the National Alzheimer’s Project Act, a policy requiring the creation of a National Plan for AD, and facilitates innovation and partnership across federal initiatives to enhance the course of AD.
There are several paramount health issues to consider in providing patient-centered interventions for AD in care coordination. Firstly, AD patients and their informal caregivers. The care coordination team and MIND at Home delivery process are executed by an interdisciplinary team that exploits and consolidates the experience and knowledge of nurses, occupational therapists, physicians, and non-clinical community workforces (Samus et al., 2017). Non-clinical community staff (NCS) act as the frontline interventionists and are coached, endlessly supported, and guided by the clinical team. NCS can serve roughly 40 to 50 dyads caseload (AD patient and their family caregiver). The nurse and NCS conduct the initial in-home needs assessment, after which they collaborate on the designing of the initial care plan.
After that, NCS conduct ensuing household appointment with the AD patient and their caregiver to examine needs assessment outcomes, utilize the family’s input to prioritize needs, offer specified educational resources, and arrive at a concurred individualized care plan. The patient and their family caregiver are then given a care plan and executed. The frequency and kind of coordinator engagement with the AD patient and their caregiver is individualized and determined by the care plan, family choice and need level. NCS intends to make visit every thirty days, at a minimum. When specified, MIND care team personnel and NCS take direct responsibility for facilitating follow-up via the suggested care approaches, including pricing medical services and equipment, reminders of visits, attending nursing home rehabilitation assemblies or outpatient visits, helping with program service applications, offering learning resources, and designing behavioral management procedures.
Secondly, personalized need-based care planning and uniform MIND service provision. This involves a written care plan given to the patient primary care provider and family that prioritizes their needs (Samus et al., 2017). Chief care strategies are implemented according to standardized protocols, and there is AD education for the patient and their family caregiver. Additionally, there is linkage and referrals to community-based resources such as the Alzheimer’s Association Dementia Care Coordination Program, the Knight Family Dementia Care Coordination (DCC) program, and nursing homes. These community resources equip the patient family caregiver with advanced skills training, problem-solving techniques, and care strategies to care for the AD patient effectively. Hence, serve as a caregiver resource binder. Additionally, they provide emotional support, needs assessment, symptom screening, and referrals to occupational therapists for specialized protocols. Thirdly, surveillance and adjustment of the patient care plan. NCS direct follow-up every thirty days, and quality reviews are conducted by the clinical supervisor every 60 days. Consequently, weekly care team rounds address challenging cases and track Dementia Care Management System (DCMS) encounters.
Ethical Decisions in Designing Patient-Centered Health Interventions
Healthcare providers are expected to make ethical decisions that incorporate ethical principles in routine patient care. This is also true in the multifaceted and ethically challenging field of dementia care. An important principle to always remember in caring for AD patients is that while these patients may no longer be capable of expressing their own will, they are still equally valued people throughout their disease, irrespective of their mental state. The commonly applied ethical principles in AD care include autonomy and wellbeing, justice, and beneficence. Firstly, allowing AD people to partake in decision-making is vital to promoting dignity, self-determination, and integrity. Hence, observing autonomy is perceived as crucial for person-centered AD care. Therefore, AD patients’ respect for autonomy requires that family caregivers assist them in expressing their critical interests and values. This can be challenging since AD patients may lack the capacity to execute their choices (Strom & Engedal, 2020). Additionally, caring for AD people residing at home can raise ethical dilemmas on balancing autonomy with patient safety and wellbeing.
Secondly, the overall goal of designing an AD care plan is to promote individuals’ wellbeing. Consequently, healthcare providers should safeguard the individual and ensure that decisions are in the patient’s best interest. However, based on the principle of beneficence, it is hard to know what is best for a patient. Thirdly, healthcare resources are ever-limited (Strom & Engedal, 2020). Hence, health providers are often required to resolve the distribution of limited care resources between different patient groups. Therefore, a challenge arises on how to offer everyone the same level of care based on the justice principle while at the same time considering a person’s individual needs. Hence, a question arises whether it is ethically correct to deny a patient care when health personnel is attending to a higher priority patient.
Health Policy Implications
The National Alzheimer’s Project Act (NAPA) enables the advancement of efforts to help mitigate Alzheimer’s disease and associated dementias (AD/ADRD). This policy requires the implementation of a National Plan for AD/ADRD with public-private Advisory Council input on AD research, services, and care (NIA, 2022). Consequently, the Advisory Council suggests to HHS urgent measures to enlarge, coordinate, and integrate initiatives to enhance the health outcomes of AD people and lessen the condition financial burden on the patients’ families and the society. Consequently, several provisions of the Patient Protection and Affordable Care Act have impacted care for people living with Alzheimer’s disease and their caregivers. Firstly, the Medicare and the health care reform law established a new Medicare benefit to offer Annual Wellness appointments for Medicare beneficiaries, including the detection and preventive services for cognitive impairment. Consequently, under Home and community-based services, states offering Home and community-based services to persons qualified for nursing home care will receive increased federal Medicaid payments. On the other hand, the CLASS Act helps individuals unable to accomplish daily living functional activities, pays for nonmedical services, and supports them in continuing living in their homes and communities.
Care Coordinator Priorities When Discussing the Care Plan with a Patient and Family Member
A Care Coordinator can engage patients and families by providing disease-associated education and information, connecting families to medical and nonmedical resources and services, mobilizing and arranging an informal care system, and providing coaching and emotional support. The intervention protocol requires care needs assessment, creating care goals, establishing action steps, and monitoring continuous action steps. Besides, all components must utilize a patient-centric approach, with care coordinators advising and mentoring to empower patients and their families to manage their care. Consequently, an issue of importance is the consideration of the multidimensional assessment of AD patients and their family caregivers. Additionally, the care coordinators should facilitate dyads development of interventional goals that align with consumer-driven philosophy. This means that intervention goals match patients’ and their caregivers’ priorities. Furthermore, scheduling monitoring visits timeframes should be based on care goals and the magnitude of support needed.
Care Coordination Evaluation
Care coordination and caregiver support are the core strategies to address the increasing public health challenge of caring for people with Alzheimer’s disease (Chen, 2020). Consequently, Samus et al. (2017) posit that care coordination can help address Alzheimer’s patients’ multidisciplinary needs, including providing support to informal caregivers. Besides, effective disease and symptom management require incorporating and coordinating the utilization of evidence-based methodologies to maximize care outcomes’ effectiveness. On the other hand, the Healthy People 2030 Alzheimer’s Disease core goals relate to enhancing the health and wellbeing of individuals with AD and associated dementias. The Healthy People 2030 core objectives framework aligns with learning session content AD best practices since it highlights the importance of having baseline data, assessing health impact, and applying evidence-based research to address patients’ goals associated with function, health, and quality of life. Additionally, healthy People 2030 acknowledges the role played by early diagnosis and provision of supportive services to enhance care outcomes. Therefore, efforts to facilitate early diagnosis, promote AD awareness and support services, and lessen preventable hospitalizations in people with cognitive deterioration symptoms can help enhance health outcomes in people with dementia.
Conclusion
Individuals with Alzheimer’s disease often require care from multiple providers, but in most cases, this care is often in a disjointed and uncoordinated manner. Therefore, care coordination can help address the multidisciplinary needs of these individuals and their caregivers to enhance overall health outcomes. Consequently, it will also decrease Medicare and Medicaid spending by abolishing needless care and supporting improved services. Besides, community-based resources such as the Alzheimer’s Association Dementia Care Coordination Program provide various resources to assist patients and caregivers live better lives. Caregivers referred to the program obtain care consultation services and individualized care planning.
References
Chen, B. (2020). Effect of care coordination on patients with Alzheimer disease and their caregivers. The American Journal of Managed Care, 26(11), e369-e374. https://doi.org/10.37765/ajmc.2020.88532
NIA, N. (2022). NIA and the National Plan to Address Alzheimer’s Disease. National Institute on Aging. Retrieved 7 May 2022, from https://www.nia.nih.gov/about/nia-and-national-plan-address-alzheimers-disease.
Samus, Q., Davis, K., Willink, A., Black, B., Reuland, M., & Leoutsakos, J. et al. (2017). Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus—Study protocol. International Journal of Care Coordination, 20(4), 123-134. https://doi.org/10.1177/2053434517744071
Silva, M., Loures, C., Alves, L., de Souza, L., Borges, K., & Carvalho, M. (2019). Alzheimer’s disease: risk factors and potentially protective measures. Journal Of Biomedical Science, 26(1). https://doi.org/10.1186/s12929-019-0524-y
Strom, B., & Engedal, K. (2020). Ethical aspects in dementia care – The use of psychosocial interventions. Nursing Ethics, 28(3), 435-443. https://doi.org/10.1177/0969733020952121
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