Assessing the Problem: Technology, Care Coordination, and Community Resources Considerations

Use of Care Coordination and Community Resources

As Clay’s Alzheimer’s progresses, robust care coordination will prove essential to navigate his complex health, psychosocial, and daily living needs. Thoughtfully designed care coordination strategies can optimize outcomes by enhancing the delivery and continuity of health services, providing education and support to families, and linking patients with community resources (Isaacs, 2021). For example, I will develop a comprehensive care plan outlining Clay’s medical needs, living arrangements, caregiver support, and legal/financial planning. A case manager can help Clay’s family implement and update the plan as his needs evolve. We will also connect his family with local Alzheimer’s associations that offer 24/7 helplines, support groups, and respite care subsidies to reduce caregiver stress. Connecting Clay with the Alzheimer’s Association’s ALZConnected online community would provide an accessible way to obtain peer support and exchange practical advice with others in the early stages of dementia (ALZConnected, 2023). Signing Clay up for the Alzheimer’s Association’s early-stage social engagement programs at the local chapter would give him structured activity with others experiencing mild Alzheimer’s symptoms (Alzheimer’s Association, 2022). These targeted care coordination steps integrate formal healthcare services and community-based resources to provide Clay with person-centered, team-based care (Banerjee & Argáez, 2021).

For the growing population of Alzheimer’s patients like Clay, care coordination programs and community partnerships are critical components of the care continuum. Initiatives to integrate health systems, long-term care facilities, caregiver supports, and social services can break down silos that lead to fragmented, ineffective care. Policy changes to fund care coordination programs for dementia patients have shown reduced hospitalizations, lowered costs, and improved family caregiver outcomes (McGurin et al., 2022). Community partnerships allow overburdened healthcare institutions to tap into local senior centers, places of worship, charities, and government agencies to provide social enrichment and practical support. By mobilizing the healthcare team and outside resources through a shared care plan, nurses can make care delivery more holistic, proactive, and patient-centered. This systems-based approach represents a pivotal strategy to address the multifaceted impacts of Alzheimer’s disease on patients, families, and populations (McGurin et al., 2022).

Benefits

Robust research demonstrates how implementing care coordination strategies and community partnerships improves outcomes in Alzheimer’s patients. A meta-analysis found that care coordination programs reduced emergency department visits and hospitalizations in dementia patients versus standard fragmented care (Chen, 2021). Another review showed that care coordination helped decrease behavioral symptoms in Alzheimer’s patients while improving caregiver stress and quality of life (Chen et al., 2021). Partnering with local senior centers, nonprofits, places of worship, and government agencies can provide Alzheimer’s families with crucial respite care, counseling, adult day programs, and legal assistance often not addressed within the formal healthcare system (CDC, 2020). However, barriers like costs, transportation, stigma, and mistrust in communities of color persist. Still, evidence supports care coordination and community partnerships as impactful strategies to address the multifaceted needs of Alzheimer’s patients and caregivers holistically, culturally-competently.

Consistency with Nursing Practice

In my nursing practice, I routinely coordinate care to connect Alzheimer’s patients with diverse services across settings. Our team develops comprehensive care plans outlining the patient’s medical, psychosocial, and daily living needs while designating care providers, case managers, and family members involved in the patient’s care. We frequently refer families to local Alzheimer’s Association chapters, which offer 24-hour help hotlines, support groups, respite subsidies, and legal/financial planning (Alzheimer’s Association, 2022). Our providers make warm handoffs to adult day programs run through senior centers and places of worship to give caregivers reprieve and patients social engagement. Home health agencies supply aides for bathing assistance and give nurses eyes in the home. However, barriers exist regarding the availability of specialists like neurologists and geriatric psychiatrists who manage Alzheimer’s complexities. Still, mindful care coordination and community partnerships allow me to practice patient-c