Preliminary Care Coordination Plan
Care coordination is concerned with the deliberate alignment and integration of patient care activities. It is characterized by the sufficient sharing of relevant information among all the personnel involved in the treatment of a patient. This approach in nursing is purposed to realize safer and more effective patient care. The achievement of high-quality and high-value healthcare relies on the critical consideration of the patient’s needs and preferences. Some of the crucial care coordination activities include monitoring and follow-ups, aligning resources with patient needs, assessment of patient needs and goals, and involving community resources. A care coordination plan can effectively work to adequately serve the needs of an elderly individual with cognitive impairment concerns such as dementia.
Dementia results from damaged nerve cells and their corrupt linkage to the brain. Individuals living with the condition often experience diminishing memory, difficulty in language comprehension, and insufficient problem-solving skills (Mayo Clinic, 2019). These symptoms substantively affect the day-to-day functioning of patients. The management of dementia is extremely complex, especially since the condition does not have any particular cure. Therefore, proper coordination ought to exist from the diagnostic assessment throughout primary care. The involvement of community management is also crucial in the dementia management of older adults.
Patient-centered care is crucial for efficient dementia management. This approach to care relies on the creation of interpersonal relationships between caregivers and individuals living with dementia. Recognition, respect, and trust are key components that facilitate the establishment of patient-centered care (Fazio, Pace, Flinner, & Kallmyer, 2018). Further, various elements emerge as integral to the provision of proper care to dementia patients. These include comfort, attachment, inclusion, occupation, and identity. Persons living with dementia need a feel of comfort during their condition. Moreover, when in a strange hospital environment, it is important that they feel a sense of attachment. The inclusion element calls for the involvement of patients and close family in their care and life (Fazio et al., 2018). Lastly, individuals with dementia must have an identity. It is the role of caregivers to ensure that the sense of continuity with the past in individuals with dementia is achieved.
The simple provision of care based on the routines created for staff convenience is not adequate for the efficient care of dementia patients. Dementia care’s best practice necessitates for the critical evaluation of programs and communication strategies in implementing essential support. Furthermore, they must conform to the priorities for the patient’s health. One of the priorities to care is to improve the quality of life of individuals (Parker, Hickman, Phillips, & Ferguson, 2020). Therefore, co-management structures may be put in place to facilitate this aspect, especially when patients are on home-based care (Jennings et al., 2017). Sufficient communication between nurses and caregivers works to ensure that the treatment provided to people living with dementia is appropriate.
Moreover, it is a health priority for individuals to maintain a healthy diet. People with dementia are at risk of forgetting to take meals or water. Furthermore, a decreased appetite that accompanies medication may result in poor dietary choices. This puts individuals highly susceptible to weight loss, irritability, and disorientation (Logan, 2016). Hence, coordination is crucial in ensuring that people living with the condition eat sufficient nutritious foods and drink adequate fluids. Maintaining a healthy diet assists in the prevention of the onset of other illnesses that may result in a diminishing quality of life.
The maintenance of proper hygiene is another crucial priority for health in patients. Individuals living with dementia might find it difficult to remember keeping themselves clean. Hence, in the provision of care, individuals may be assisted with essential hygiene activities, including bathing, toileting, brushing teeth, and regular cloth change (Logan, 2016). It is essential to create working plans that outline proper approaches toward ensuring the maintenance of patients’ personal hygiene. Factors such as safety during bathing must be highly considered to prevent the occurrences of accidents that might inflict harm to patients.
In care coordination, teamwork is an essential factor. Nurses, physicians, caregivers, and family members are involved in the wellness of individuals living with dementia. Working as a team among the various care management participants would provide a proper platform for fruitful coordination (Logan, 2016). Partners in Dementia Care is an example of a model that relies on teamwork. The approach to care is characterized by the partnership involving Veterans Affairs Medical Centers and local Alzheimer’s Association chapters (Hughes, Lepore, Wiener, & Gould, 2017). This model is focused on assisting individuals with dementia and their caregivers to access medical and social services. The team members may share activities to ensure the timely and consistent delivery of care to patients.
Furthermore, care management is a vital approach to care coordination. This is substantively aided by health information technology. Electronic information systems’ availability helps in fast communication among all participants in a patient’s care cycle. Information systems assist in the centralization of information regarding a patient (AHRQ, 2018). Therefore, this technological aspect functions as a vital piece in the coordination of care of individuals living with dementia. Participants in care can share and access appropriate information that is relevant to the presentation of care to patients.
The efficient provision of quality healthcare is often dependent on the availability of necessary resources. Various resources exist in the community for the provision of care for individuals living with dementia. The National Institute of Aging Alzheimer’s and Related Dementias Education and Referral (ADEAR) Center provides a crucial resource for support and advice. The center is always available to provide information regarding diagnosis, treatment, caregiver needs, patient needs, and long-term care (NIH, 2019).
Moreover, adult day care services are available in the community as a resource for helping individuals living with dementia. The service offers care in a safe environment with the assistance of staff who are well trained to look after people with dementia. The daycare services provide families with a break from care to pursue other activities (NIH, 2019). Moreover, dealing with patients and catering for their needs may result in stress. The community has well-established counseling centers that help in guiding healthcare and social work professionals to deal with overwhelming situations. These resources are crucial components of care coordination for older adults living with dementia and other related cognitive issues.