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Final Care Coordination Plan

NURS FPX 4050 Assessment 4


Capella University

Instructor’s Name

October 2023

In this assessment, we embark on an in-depth exploration of healthcare coordination and its pivotal role in delivering comprehensive care for individuals affected by cognitive impairment, with a particular focus on Alzheimer’s disease and dementia. Our aim is to address the multifaceted challenges inherent to these conditions and to develop a cohesive care plan that ensures the safety and effectiveness of care within a community setting.

 Our approach will involve a comprehensive analysis of practices, the formulation of specific, measurable, and realistic goals, and the identification of critical community resources. Through this assessment, we emphasize the importance of a holistic approach that encompasses medical, psychosocial, and community-based interventions, underscoring the significance of both evidence-based practice and the alignment of healthcare strategies with the objectives outlined in Healthy People 2030.

Patient-Centered Health Interventions & Timelines

Cognitive Stimulation Programs

Implement personalized cognitive stimulation programs that focus on improving and maintaining cognitive function, targeting areas such as memory, attention, and problem-solving skills. These programs should be tailored to each patient’s cognitive baseline, with regular assessments to track progress. Utilize evidence-based cognitive training techniques and technologies to enhance engagement and effectiveness (Gonzalez-Moreno et al., 2022).

Medication Management

Optimize medication regimens based on individual needs and response. Collaborate with healthcare providers to ensure that patients receive appropriate medications, such as cholinesterase inhibitors or NMDA receptor antagonists, and monitor their effects over time. Ensure that potential benefits and risks are thoroughly assessed and that medication adjustments are made as needed to manage symptoms and slow cognitive decline (Adeola et al., 2020).

Caregiver Support and Education

Offer caregiver education programs that cover essential topics related to dementia care, coping strategies, and self-care. These programs should be accessible and culturally sensitive, taking into account the diverse needs of caregivers. Regular check-ins with caregivers should be conducted to evaluate their needs and progress in providing care, offering emotional and practical support (Huong et al., 2022).

NURS FPX 4050 Assessment 4


Initiate personalized cognitive stimulation programs immediately upon diagnosis. Regular assessments should be conducted every three months to track progress and make necessary adjustments (Calatayud et al., 2022).

Medication regimens should be reviewed within one month of diagnosis and periodically thereafter (approximately every three to six months). Adjustments should be made based on patient response and clinical assessments (Calatayud et al., 2022).

Caregiver education programs should be available as soon as a diagnosis is made and continue on an ongoing basis. Regular check-ins with caregivers, at least every three months, are essential to evaluate their needs and provide support (Calatayud et al., 2022).

Ethical Decisions in Designing Patient-Centered Healthcare Interventions

The literature highlights the importance of several key ethical decisions in this context. Firstly, it underscores the ethical imperative of respecting patient autonomy. Patients with cognitive impairment may face challenges in expressing their preferences or providing informed consent, emphasizing the need for advanced care planning and the appointment of healthcare proxies (Chiong et al., 2021). Ethical decisions thus revolve around identifying and honoring the patients previously expressed wishes and preferences, even as their capacity to make decisions may diminish over time.

Secondly, the literature emphasizes the need to maintain a careful balance between beneficence and non-maleficence. While healthcare providers aim to promote the well-being of patients through interventions, they must also avoid harm and prioritize the patient’s safety and dignity. This balance is crucial when considering the use of pharmacological interventions in individuals with cognitive impairment. Ethical decisions should involve a comprehensive evaluation of the potential benefits and risks of medications and a transparent discussion with patients and their families to make informed choices (Chiong et al., 2021). Additionally, recognizing the heterogeneity of patient responses, healthcare providers should remain realistic about the expected outcomes, aligning their interventions with the best interests of the patient while minimizing harm.

Policy Implications for the Coordination and Continuum of Care

First, healthcare professionals must consider the policy implications regarding early diagnosis and intervention. Many healthcare systems have provisions that support early detection and intervention for cognitive impairment. These provisions emphasize the importance of timely assessments, such as cognitive screenings, and promote access to diagnostic tools and specialist consultations. Inferences drawn from these policy provisions underscore the ethical responsibility of healthcare providers to prioritize early detection and intervention, as it aligns with best practices for managing cognitive impairment (Hilsabeck et al., 2022). Timely diagnosis not only improves the quality of care and patient outcomes but also potentially reduces the long-term healthcare burden. Healthcare providers should collaborate closely with primary care physicians, specialists, and public health agencies to ensure that these provisions are effectively implemented.

Second, healthcare policies often contain measures aimed at ensuring equity in access to care. Precise interpretation of these provisions highlights the necessity of addressing healthcare disparities related to cognitive impairment. Disparities may exist based on race, ethnicity, socioeconomic status, and geographic location, affecting access to diagnostic services, specialized care, and community resources (Hilsabeck et al., 2022). Healthcare providers must, therefore, make valid inferences that inform their practice. They should work towards reducing these disparities by promoting outreach and education efforts targeted at underserved populations and collaborating with local community organizations to enhance access to care. In doing so, healthcare providers not only adhere to policy provisions but also foster a more equitable and patient-centered continuum of care for patients (Hilsabeck et al., 2022). These insights emphasize the ethical responsibility to ensure that care is accessible and equitable, aligning with best practices and the broader goals of improving population health.

Care Coordinator Priorities to Discuss the Plan

When a care coordinator engages in discussions with a patient and their family members, several critical priorities must be established, underpinned by evidence-based practice, to ensure a patient-centered and effective care plan. Firstly, a key priority is to comprehensively assess the specific needs, preferences, and goals of the patient and their family. Evidence-based practice emphasizes that personalized care is most effective in improving health outcomes (Welch et al., 2021). This individualized approach is essential when dealing with cognitive impairment, such as Alzheimer’s disease and dementia, where the progression and impact can vary widely among patients. Therefore, the care coordinator should conduct thorough assessments to understand the patient’s cognitive baseline, their current cognitive and functional abilities, and their specific challenges and goals.

Another high-priority aspect involves fostering effective communication between all stakeholders. Evidence-based practice highlights the importance of clear and open communication in care coordination (Welch et al., 2021). The care coordinator should ensure that there is a collaborative dialogue between the healthcare team, the patient, and their family members to discuss the care plan comprehensively. During these discussions, the care coordinator can gather insights into the patient’s values, preferences, and cultural background. Such insights are crucial for aligning the care plan with the patient’s individual needs (Welch et al., 2021). Clear communication fosters trust, ensures that everyone is on the same page, and encourages active engagement in the care process.

The need for changes to the care plan arises from the dynamic nature of cognitive impairment. Evidence-based practice highlights the importance of regularly reviewing and adjusting interventions as new research emerges and as the patient’s condition evolves. These changes can be necessitated by shifts in the patient’s cognitive and functional abilities or new evidence on the effectiveness of interventions. For example, if a particular cognitive training program has demonstrated better outcomes in recent studies, the care coordinator may need to adjust the plan to incorporate this updated approach. Similarly, if the patient’s needs change or their preferences evolve, the care plan must adapt to address these shifts. Evidence-based practice emphasizes the importance of staying current with research findings and best practices to provide the most effective and up-to-date care (Timmons et al., 2022). By prioritizing these considerations and incorporating evidence-based adjustments, the care coordinator can ensure that the care plan remains patient-centered, responsive, and aligned with the best available evidence to optimize the patient’s well-being and quality of life.

Need for Revisions

In the context of cognitive impairment education, clear objectives might involve improving the understanding of cognitive impairment, enhancing caregiving skills, or promoting empathy and communication with individuals affected by these conditions. By assessing the learning session content, one can compare the stated objectives with the evidence-based best practices (Baimakhanova et al., 2023). If discrepancies are identified, revisions may be necessary to ensure that the content aligns with these objectives. The literature highlights the need for learning objectives to be specific, measurable, achievable, relevant, and time-bound (SMART), which should guide the revisions to ensure that the objectives are attainable and effective.

The literature on evaluation underscores the significance of active learning strategies. Evidence shows that interactive and participatory approaches to learning are more effective in retaining knowledge and promoting meaningful engagement among learners (Baimakhanova et al., 2023). A comparison between the learning session content and best practices may reveal gaps in terms of interactivity and engagement. Revisions might be needed to incorporate more interactive elements, such as case studies, simulations, or group discussions, to enhance the learning experience and align it with evidence-based best practices.

Aligning teaching sessions with the principles of the Healthy People 2030 document is essential to ensure that healthcare education contributes to broader public health goals. By evaluating the learning session content against these principles, healthcare educators can identify the need for revisions if the content does not adequately address or align with the objectives of Healthy People 2030. For example, if the content lacks a focus on population health, health equity, or addressing healthcare disparities, revisions may be needed to incorporate these elements, thereby fostering a more comprehensive and socially responsible educational approach (Baimakhanova et al., 2023).


This assessment has shed light on the complexities of healthcare coordination in the context of cognitive impairment, specifically Alzheimer’s disease and dementia. By emphasizing best practices, setting specific and realistic goals, and harnessing the power of community resources, we have advanced a holistic approach to care within a community setting. While uncertainties and challenges persist, such as variations in individual responses and access disparities, a collaborative effort involving healthcare professionals, caregivers, and community support services is paramount. By integrating medical, psychosocial, and community-based interventions, we can enhance the quality of life for individuals and offer essential support to their families, thereby fostering a more robust and effective continuum of care.


Adeola, M., Fernandez, J., & Sherer, J. (2020). Medication management in older adults with dementia. Dementia and Chronic Disease, 39–51.

Baimakhanova, G. M., KALI, M., & I. ORYNBASAR. (2023). Improving the effectiveness of the educational process using interactive methods. JOURNAL “BULLETIN SKSPU,” 2(36).

Calatayud, E., Jiménez-Sánchez, C., Calvo, S., Brandín-de la Cruz, N., Herrero, P., & Gómez-Soria, I. (2022). Effectiveness of cognitive stimulation personalized by the preexisting cognitive level in older adults. Topics in Geriatric Rehabilitation, 38(1), 73–80.

Chiong, W., Tsou, A. Y., Simmons, Z., Bonnie, R. J., & Russell, J. A. (2021). Ethical considerations in dementia diagnosis and care. Neurology, 97(2), 80–89.

Gonzalez-Moreno, J., Satorres, E., Soria-Urios, G., & Meléndez, J. C. (2022). Cognitive stimulation program presented through new technologies in a group of people with moderate cognitive impairment. Journal of Alzheimer’s Disease, 88(2), 513–519.

Hilsabeck, R. C., Lacritz, L. H., Colvin, M. K., Espe‐Pfeifer, P., Sperling, S. A., Arnett, P. A., & Perry, W. (2022). Cognition is a critical vital sign for older adults: the need for early detection of cognitive impairment is now. Policy Insights from the Behavioral and Brain Sciences, 9(2), 188–195.

Huong, T. T. T., Tam, P. T. T., Luu, P. T., An, N. T. T., Liem, D. T., Truc, N. T. T., Thang, T. C., Weschke, S., Klein, O. A., & Kilimann, I. (2022). Dementia caregiver support program in vietnam: development, implementation and first results. Alzheimer’s & Dementia, 18(S8).

Timmons, S., Fox, S., Drennan, J., Guerin, S., & Kernohan, W. G. (2022). Palliative care for older people with dementia—we need a paradigm shift in our approach. Age and Ageing, 51(3).

Welch, M. L., Hodgson, J. L., Didericksen, K. W., Lamson, A. L., & Forbes, T. H. (2021). Family-centered primary care for older adults with cognitive impairment. Contemporary Family Therapy.

NURS FPX 4050 Assessment 4

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