Alzheimers Disease Care Coordination Plan

Alzheimers Disease Care Coordination Plan

The World Health Organization (2021) reports that dementia is the seventh leading cause of mortality in the world currently among older people. Dementia causes significant disability to the patient and dependency on the patient’s family. Alzheimer’s disease (AD) is the most common cause of dementia (U.S. Department of Health and Human Services, n.d.).

This progressive neurodegenerative disorder is predominantly characterized by cognitive, behavioral, and health decline among older patients. It is not just the AD patients that suffer from this illness. This disorder impacts their caregivers and families significantly, both emotionally and financially. In the United States, about 6 million people live with AD, and it is the sixth leading cause of mortality among adult Americans, according to the Alzheimer’s Association (2019).

AD is associated with cognitive decline, caregiver burden, and recurrent hospitalizations, among other major health issues. The purpose of this paper is to develop a patient-centered care plan for these three major health issues and develop a comprehensive care coordination plan.

Care Plan

Care for Cognitive Decline

The cognitive decline among AD patients is associated with memory deterioration and confusion that deter these patients from performing daily tasks requiring cognition. This can lead to agitation, anxiety, aggression, or even depression. Medications remain the mainstay intervention for delaying the progression of cognitive decline. Medications such as aducanumab, rivastigmine, galantamine, donepezil, and memantine are FDA-approved medications effective for various stages of Alzheimer’s dementia (Alzheimer’s Association, n.d.; Cummings, 2021). These medications do not cure AD and are guaranteed to work in every patient.

Therefore, patients, their caregivers, and family members must know that despite the adverse events posed by these medications, clinical outcomes may not be achieved, thus the need for treatment adjustment. Patient education must include explaining to the patients the need for compliance and ensuring awareness about adverse medication events such as dizziness and the risk of falls. The timelines for these interventions are nonspecific and appropriate for every encounter with the patients, their caregivers, or family members.

Specific interventions to improve cognitive function and slow progression of cognitive and functional decline include but are not limited to reminiscence about old memories or objects such as photos or videos, visiting friends, involving the patient in creative activities such as crafts, going to church, reading, solving puzzles, and engaging with household chores among other stimulating activities.

These interventions do not apply to all patients. Therefore, the nurse or the caregiver needs to understand which interventions the patient likes and can tolerate. The caregiver or the nurse also needs to understand that the timelines for these interventions vary and should only be applied to tolerable durations. Every minute of care for AD patients should be occupied by activity or rest. It is, therefore, upon the caregiver to balance these activities and provide guidance. Establishing a daily routine and writing a plan of activities is, therefore, necessary for the caregiver to track their care and understand the effectiveness of the interventions.

Community resources are available for care for cognitive decline. Some examples include libraries, memory cafes, and Caregiver Action Networks (CANs). Libraries located within the community can provide the caregiver with memory-stimulating items to develop a daily schedule for AD patients.

Memory cafes located throughout the United States provide can offer support directly to clients to the patients or caregivers to enable their coping with the disease, including scheduling activities. Caregiver Action Networks offer online support resources that offer help to patients or caregivers, including tips and strategies to deliver interventions or cope with the disease.

Prevention of Readmission and Long-term Care Emergency Admissions

Hospitalization for AD patients is common and can be devastating to the patient and their family members, both emotionally and financially. Preventable admission to long-term care facilities or hospitals is one of the key priorities in the healthy people 2030 objectives. Healthy people 2030 aims to reduce preventable readmissions among AD patients (U.S. Department of Health and Human Services, n.d.). In cases of unpreventable readmissions, the critical objective is to shorten the duration of the readmission.

Interventions to prevent these hospitalizations are caregiver education and community care coordination. Caregiver education should include individual and family counseling education and regular counselor support (Warrick et al., 2018). To achieve these, the nurse should coordinate among these caregivers and include them in weekly support group sessions where they will receive counseling education as well as social support.

Family-based counseling education aims at promoting coping with the disease and family psychoeducation. Day programs for AD patients can also prevent hospitalizations (Warrick et al., 2018). Scheduling weekly attendance to these out-of-home programs enables the patients to interact with other patients, thus social bonding, networking, and better coping.

Community resources include but are not limited to Dementia Friendly America (DFA), The Alzheimer’s Association’s 24/7 Helpline, primary care day clinics, and Dementia Support Groups. Dementia Support Groups such as ALZConnected and Caregiver Nation offer help to caregivers in specific situations and connect various caregivers for social support and decision-making (Alzheimer’s Association, 2019). The Alzheimer’s Association’s 24/7 Helpline also serves this purpose remotely through phone calls.

DFA supports caregivers and coordinates them. Primary care day program clinics coordinate care among caregivers or patients and prevent unnecessary hospitalizations (Dementia Friendly America, n.d.). The coordinative function of these local clinics and out-of-home programs saves the patients unnecessary visits for specialist care and can promote early detection of disease complications.

Care Plan for Reducing Caregiver Burden

Improving the health of AD patient caregivers can also mean facilitating improving the health of AD patients. Caregivers of AD patients commonly experience stress, and this burdens them and thus can reduce the quality of care they provide to the patients. In worse cases, caregiver stress can increase the risk of patient placement into long-term care facilities. Other complications associated with caregiver burden are caregiver depression and low self-esteem. Some feared outcomes of caregiver burden are poor mental health and medical outcomes on the caregiver.

Caregiver education, follow-up, and coordination are some of the interventions that can reduce care burdens. Sharing information and knowledge with caregivers on the best strategies to reduce the burden and improve patient outcomes to minimize frustration is important to enhance coordination. Coordination can also include the use of telehealth to follow up with caregivers, reassure them, offer education, and connect them to available community resources (Abramsohn et al., 2019).

Coordinating these community services is a recurring intervention. The nurse should conduct weekly coordination to assess and reduce caregiver stress to promote outcomes of community care. Care for dementia is a lifelong process, and coordination does not stop. The nurse should also ensure coordination for legal processes of care, such as processing advance directives and Physician Orders for Life-Sustaining Treatment (POLST) during terminal care.

Community resources for care coordination and reduction in caregiver burden are numerous. They include but are not limited to Dementia Friendly America, Adult Day Care Services, Respite Services, Geriatric Care Managers, Home Care Services, Hospice Services, Eldercare Locator, and Alzheimer’s Association. DFA is an online national network of various related organizations that support caregivers with counseling and coordination with other community resources (Dementia Friendly America, n.d.).

Adult Day Care Services, Respite Services, and Home Care Services provide short-term caregiving for AD patients, and this can save the caregiver some time to reduce stress from the burden. Hospice services offer long-term end-of-life care for AD patients (National Institute on Aging, 2019). Eldercare locators connect caregivers to available community resources and are useful for caregivers who need these resources.

Ethics Behind the Patient-Centered Care Plan

The above care plan for AD patients is aligned with the healthy people 2030 objective that aims to improve the quality of life for people living with dementia. A patient-centered approach will ensure that only appropriate and relevant interventions are implemented in every patient situation. Respect for the patient and their family culture and traditions is important in the implementation of this coordination plan. The first provision, according to the American Nurse Association Nursing Code of Ethics, requires that nurses respect the unique attributes of every patient.

The second provision requires that the nurse’s commitment should be to the patient and their family (Gaines, 2022). In the individual patient’s case, without the intervention of a caregiver, this code may be limited due to their cognitive limitation, and autonomy and ethical principle can be compromised. Their decision-making should be through the caregiver in severe stages of AD.

The eighth provision of the Code Of Ethics demands that nurses collaborate with other professionals for optimal safe care and to reduce health disparities (Gaines, 2022). This code is adhered to in this plan by coordinating with other professionals such as geriatric care managers, dementia specialists, physicians, and psychiatrist referrals. Communication and information sharing is crucial to implementing this care coordination plan. The nurse will need to communicate with caregivers to provide education, share care plans and goals, and provide alternative care options. Collaborating with the caregiver to access community resources will be the most important part of this plan.

Legal and Policy Considerations

In conjunction with various nongovernmental organizations, the federal government has made efforts to ensure early detection of AD and improve quality of life. Every ten years, the government sets healthy people goals that include quality of life improvement for dementia patients. In 2011, the federal government signed into law the National Alzheimer’s Project Act (NAPA) (National Institute on Aging, n.d.). This legislative act had various policy provisions, one of which was to improve the quality of life for AD patients through research acceleration and coordinated care plans. Care coordination has been the epitome of successful care for AD.

Coordination of care at national levels relies on successful care coordination at the state and local levels of care. Therefore, this coordinated care plan remains relevant to national policies and legal processes relating to Alzheimer’s disease at the national level. The utilization of community resources requires successful care coordination. The transition of care from hospital to the community and from care caregiver to managers of community resources such as adult day care services require accurate and secure information sharing.

Security of protected health information (PHI) remains essential, and the care plan will have to abide by the privacy and confidentiality rules according to the Health Insurance Portability and Accountability Act of 1996. To keep all stakeholders posted on the care of AD patients, important information needs to be shared among these stakeholders.

Priority Consideration for the Care Coordinator

Primary caregivers must individualize every plan for every patient while maintaining the basic principles and care goals. Slowing the progression of cognitive decline, minimizing preventable hospitalizations, and preventing caregiver stress are key goals that the care coordinator must consider for AD patient care coordination (Kumar et al., 2022). Patient and caregiver education is part of care coordination. The coordinator must consider making the patients and their caregivers aware of the care goals, adverse events, and prognosis in a professional manner so as not to impact their mental health.

When discussing the plans, the coordinator must consider explaining to the caregivers that these interventions may not work for all patients and that change from one intervention to the next will be crucial for optimal outcomes (Rosenthal & Burchum, 2020). In these times of change, the caregiver must collaborate with primary care providers and community resources managers. Adverse events and medication adverse effects are some of the major reasons for poor compliance, and the coordinator must always notify the caregiver and the patient of these complications.

Bets Practice for Alzheimer’s Disease

Providing the best possible quality of life to AD patients is still the best that care providers can do for AD patients. This includes providing the best patient-satisfying experiences. The literature used for the development of this care coordination plan includes both peer-reviewed and non-peer-reviewed but still credible sources. These literature items provide the best available intervention to provide care for AD. Every intervention presented has required the inclusion of caregivers and community resources.

This process of evidence-based practice has emphasized the role of good care coordination in the improvement of patient experience and quality of life among AD patients. The literature on evaluation has also emphasized the central role of care coordination among all stakeholders of AD patient care as the best practice. These practices compare well with the healthy people 2030 goals. Healthy people 2030 acknowledge that AD is still incurable, and the best that healthcare can do currently is to slow its progression and improve the quality of life for these patients (U.S. Department of Health and Human Services, n.d.).

Nursing care has a central role in the coordination process. Communication, collaboration, and connecting patients to the best community resources for the best patient experiences override the need for admission to long-term care facilities. Therefore, best practices require good care coordination.


Coordination of care for AD patients involves many stakeholders, thus requiring ethical, legal, and professional considerations. Three issues identified with AD are inevitable disease progression, caregiver burden, and preventable hospitalizations. Various interventions have been presented in the plan to manage these issues and coordinate care with community resources. Alzheimer’s policies at national and state levels still apply. Information sharing for coordination will adhere to HIPAA rules. Individualizing care plans and coordination will consider patient and prognostic factors for successful care outcomes.


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