Care coordination refers to the delivery of specialized healthcare services in a synchronized and collaborative way to hasten recovery. The primary goals of this evidence-based strategy are to optimize healthcare outcomes by integrating relevant services and minimize healthcare expenditures by eradicating expendable tests and procedures (Catalyst, 2018). Patients with long-term illnesses benefit more from coordinated services as these conditions are disruptive, alter personal identities, and impact social relations considerably (Hannigan, Simpson, Coffey, Barlow, & Jonas, 2018). Successful care coordination encompasses four distinct aspects: effective communication and care plan transitions between healthcare workers, patient-centeredness, easy access to a wide array of clinical services, and clear and straightforward information the client comprehends (Catalyst, 2018). Dementia is a chronic disease that instigates tremendous cognitive decline involving memory and other domains such as spatial processing, abstract thinking, executive functioning, and language (Emmady & Till, 2022). This condition requires tremendous attention as it affects approximately 47 million people globally and poses a substantial healthcare burden in the United States. A comprehensive final care coordination plan on dementia will shed significant light on relevant patient-centered action, ethical factors, health policies, and overall evidence-based measures.
Patient-Centered Health Interventions and Timelines
Client-based services are one of the primary care coordination aims. When caring for the chronically ill such as those diagnosed with dementia, multidisciplinary teams should focus on specific client needs to ensure high-quality and safe services. Dementia patients necessitate holistic services guided by evidence-based protocols as their cognitive decline exponentially affects daily functioning. The mortality risk is exceptionally high in cases where Alzheimer’s disease is the primary instigator (Emmady & Till, 2022). Therefore, health professionals working in care coordination teams should solely provide need-based interventions to mitigate exacerbated outcomes and optimize the quality of life of these individuals. Offering patient-oriented services involves identifying specific healthcare issues, designing specific therapy strategies for each concern, and pinpointing community resources to facilitate the treatment process within specific timelines (one year for this case).
Three Healthcare Issues
The patient under evaluation is a 65-year-old Caucasian male diagnosed with dementia about one year ago. He lives alone in Brooklyn, New York City (NYC), because his children live in other states because of work. Until recently, he has been taking good care of himself and complying adequately with his treatment regimen and other lifestyle modifications with constant monitoring from nurses, physicians, and social workers working in a nearby healthcare facility. However, his clinical concerns are currently declining memory, noticed by his neighbors as he often wanders around the residence with no recollection of his house, inability to cater to his activities of daily living evidenced by poor grooming and inadequate nutrition, and a depressed mood where he voices suicidal ideations. Highlighting healthcare issues informs client-centered treatment.
An Intervention for Each Health Issue
Health professionals must initiate patient-oriented treatment guided by specific client needs at all times. After a comprehensive evaluation of the client’s symptoms, it is prudent to note that the 65-year-old man under assessment is experiencing considerable cognitive decline affecting his memory and holistic well-being as his health is spiraling. The three health concerns include memory loss, depressive symptoms, and inability to perform daily activities of living. Thus, for his altered cognitive decline evidenced by memory loss and reduced executive functioning, clinicians should re-prescribe dementia medications such as cholinesterase inhibitors such as galantamine, donepezil, or rivastigmine to boost cognitive abilities (Emmady & Tadi, 2022). Moreover, his depressive symptoms could benefit from antidepressants such as selective serotonin reuptake inhibitors (SSRIs), supportive care, social stimulation, and memory training (Emmady & Tadi, 2022). The last measure would be finding a caregiver to provide physical and social support for the patient to minimize his risk, as living alone with such symptoms may worsen clinical prognoses. Thus, implementing these specific measures would optimize clinical outcomes tremendously.
Community Resources for Each Intervention
Community resources are highly invaluable when managing chronic conditions such as dementia. They provide safe spaces and social support boosting recovery rates. Therefore, assisting the 65-year-old male to access various health resources will enhance their clinical prognoses and provide a robust morale system encouraging compliance and lifestyle modification. The NYC resources for dementia patients include Alzheimer’s and Aging Resource Center of Brooklyn Inc, Alzheimer’s Foundation of America, and the Institute for Community Living Inc. These platforms offer comprehensive therapy with specialized health professionals guiding patients through regimen adherence, depression management, and caregiving opportunities minimizing harm. Thus, exposing the 65-year-old dementia client to these resources will enhance their clinical outcomes considerably.
Ethical Decisions in Designing Patient-Centered Interventions
Ethics is the driving force behind any evidence-based measure guided by patient-centered notions. The American nursing association (ANA) created a code of ethics to guide nurses in making feasible solutions during professional practice (Haddad & Geiger, 2022). Four ethical guidelines should be the benchmark of high-quality and safe nursing practice, including beneficence, non-maleficence, autonomy, and justice. Care coordination is an extensive process requiring shared decision-making concerning clinical interventions to ensure optimal benefit to the client while boosting their autonomy, as chronic disease management is a long-term process. Thus, the ANA code of ethics should be the guide to achieving high-quality patient outcomes related to dementia. These protocols advocate for respect for dignity, advocacy for client rights or safety, professionalism, accountability, competence, collective effort, and meaningful incorporation of current policies or practice guidelines (Haddad & Geiger, 2022). Practical ethical decision-making for the 65-year-old male diagnosed with severe dementia will be beneficial as it will guide the care coordination team in prioritizing clinical needs and selecting measures such as safer drug options and meaningful social support groups. Using ethical principles to guide clinical decision-making and prioritize patient needs ensures maximum benefit.
Health professionals should highlight ethical questions creating uncertainties concerning decisions made regarding dementia treatment. Identifying these precarious sentiments may inform double-checking and in-depth interdisciplinary discussions to determine the best options for the client. Such ethical inquiries include:
- How safe are the pharmacotherapeutic regimens for the patient?
- What are the challenges of declining cognitive abilities for a nearly geriatric client?
- What implications does dementia pose to patient safety?
- How effectively can health professionals manage coexisting illnesses such as depression without harming dementia patients further?
Health Policy Implications on Care Coordination
Heath policies play a significant role in fostering care coordination for the chronically ill. These guidelines inform evidence-based and value-oriented care boosting the patient experience during treatment. Health policies such as the health insurance portability and accountability act (HIPAA) streamline care coordination by facilitating seamless patient information transfer among the involved clinicians through safe pathways (Qin, 2019). Thus, the interdisciplinary team can share patient data during various transitions without compromising privacy, confidentiality, and security to ensure care continuity across all continuums. HIPAA guidelines are imperative during care coordination as they facilitate effective communication and shared decision-making for holistic and evidence-based client management.
The affordable care act (ACA) also has various provisions for care coordination for patients with preexisting conditions and complex medical needs. According to Kuo, McAlister, Rossignol, Turchi, and Stille (2018), the ACA act reinforces and incentivizes care coordination services for clients with increased medical complexities. Moreover, this legislation encourages primary care provision to boost collaborative and integrated services for affected client groups (Kuo et al., 2018). Thus, ACA has beneficial implications for chronically ill clients such as those battling dementia, as it supports holistic and high-quality service delivery aligned with specific patient needs.
Care Coordinator Priorities with Patients and Family Members
Care coordination is a rigorous process requiring collaborative effort and recovery-focused objectives to optimize the clinical experience of the chronically ill. Thus, with this in mind, prioritizing interventions is the most appropriate way to lessen the load on this cumbersome process and ensure the incorporation of holistic measures addressing the patient’s physiological, psychological, socioeconomic, cultural, and spiritual needs. The client, in this case, is a 65-year-old Caucasian male battling severe cognitive decline secondary to dementia. The first priority should be patient empowerment and family involvement. The 65-year-old lives alone and requires familial and clinical support to support prompt recovery and mitigated harm. Thus, engaging the patient’s family and encouraging them to offer caregiving services to their loved ones would improve the care provision process. Another priority would be to enhance compliance with the prescribed pharmacotherapeutic and non-medication measures. Emmady and Tadi (2022) suggest using dementia drugs to reduce cognitive decline, antidepressants, memory training, and other forms of social support. The care coordination team should reinforce optimal adherence to the regimen to hasten recovery (Amjad et al., 2018). Therefore, deciphering care prerequisites during collaborative action fosters evidence-based intervention.
Other priorities during care coordination for dementia patients include open communication, healthcare affordability, cultural competence, ethical guidance, and treatment safety. Making evidence-based changes to the care coordination plan based on the highlighted concepts will boost the intervention’s efficacy in addressing client needs. Effective knowledge transfer between health professionals and the patient is imperative for cooperation and collaboration. Cultural competence also streamlines caregiver and patient interaction while minimizing discomfort and stereotypical ideations (Clark et al., 2018). Moreover, ethical considerations will help professionals prioritize client safety during treatment by addressing risks such as polypharmacy and adverse drug events (Hanigan et al., 2018). Another vital point to consider during dementia management is the affordability of related services. Care coordination for chronic conditions needs numerous interventions, which may be costly for patients and their families (Amjad et al., 2018). Thus, a comprehensive evaluation of care coordination needs and patients’ holistic wellness allows clinicians to prioritize services and deliver the highest quality of care.
Literature and Healthy People 2030
Literary sources and the Healthy people 2030 document reinforce the need for evidence-based and patient-centered interventions during dementia management. These objectives align with my learning session content which supports best practices during care coordination and overall management of chronic conditions. Healthy people 2030 (n.d.) strives to enhance the prognoses and quality of life for individuals diagnosed with dementia, especially Alzheimer’s. This document’s findings resonate with Emmady and Tadi (2022)’s findings that Alzheimer’s is the leading instigator of dementia and the fifth typical mortality case among U.S. adults. Moreover, over six million battle this chronic condition in the United States, necessitating collaborative and evidence-based action to optimize wellness by reducing associated symptoms. Care coordination and collaborative strategies should focus on supportive care while addressing these populations’ primary symptom of cognitive decline; memory loss. The healthy people 2030 document advocates for measures that enhance health and boost the life quality among dementia patients.
The healthy people 2030 guidelines reinforce best practices to minimize preventable hospitalizations among dementia patients. Coordinated care models in primary care settings mitigate hospitalization risk among these individuals by providing high-quality and supportive interventions to ensure enhanced clinical outcomes (Healthy People 2030, n.d.). Health professionals should emphasize care coordination among interdisciplinary teams guided by evidence-based protocols to facilitate high-quality and safe interventions for dementia patients. Thus, the healthy people 2030 document is a practical pathway to holistic and patient-oriented dementia management.
Conclusion
A final care coordination plan for chronically ill dementia patients should encompass policy provision, ethical guidelines, patient-centered interventions, and insights from the healthy people 2030 publication. Dementia is a chronic progressive disorder with detrimental implications for cognitive functions. It instigates considerable memory loss and reduces language abilities, abstract thinking, and executive functioning. Therefore, care coordination is the appropriate evidence-based approach to address the health ramifications triggered by dementia. This collaborative effort relies on patient-centered interventions guided by recommended treatment regimens and supportive action. Ethical guidelines, primarily beneficence and policies such as HIPAA and the ACA legislation, also streamline the implementation of coordinated services for the chronically ill. The healthy people 2030 publication also offers current treatment provisions for dementia. Thus, a comprehensive care coordination program should align with client needs and best practices for optimal outcomes and positive patient experience.
References
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Catalyst, N. E. J. M. (2018). What is care coordination? NEJM Catalyst, 4(1). Doi: 10.1056/CAT.18.0291
Clark, J. L., Phoenix, S., Bilbrey, A. C., McManis, T., Escal, K. A., Arulanantham, R., … & Ghatak, R. (2018). Cultural competency in dementia care: An African American case study. Clinical Gerontologist, 41(3), 255–260. Doi: 10.1080/07317115.2017.1420725
Emmady, P. D., & Tadi, P. (2022). Dementia. In StatPearls [Internet]. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557444/
Haddad, L. M., & Geiger, R. A. (2022). Nursing ethical considerations. StatPearls Publishing. Retrieved from https://europepmc.org/article/nbk/nbk526054
Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: Findings from a cross-national mental health systems study. International Journal of Integrated Care, 18(3). Doi: 10.5334/ijic.3978
Healthy People 2030 (n.d.). Dementias. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives/dementias
Kuo, D. Z., McAllister, J. W., Rossignol, L., Turchi, R. M., & Stille, C. J. (2018). Care coordination for children with medical complexity: Whose care is it, anyway? Pediatrics, 141(Supplement_3), S224-S232. Doi:10.1542/peds.2017-1284G
Qin, F. (2019). The debilitating scope of care coordination under HIPAA. NCL Rev., 98, 1395. Retrieved from https://heinonline.org/HOL/LandingPage?handle=hein.journals/nclr98&div=53&id=&page=
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