The state nursing board provides standards that shaped the development of Clay’s intervention, including competent use of technologies, care coordination, and referrals (State Board of Nursing, 2020). For example, standards for telehealth guided the inclusion of virtual visits, stating I must verify patient identity, obtain informed consent, and document assessments like face-to-face encounters. Our organizational EHR (Electronic Health Record) policies informed my plan to create a centralized, integrated care plan with treatment goals accessible across Clay’s care team. CMS (Centers for Medicare & Medicaid Services) policies outline required components of care plans for patients receiving home health services, which Clay may need in the future (Centers for Medicare & Medicaid Services, 2021). Additionally, local dementia programs abide by policies on qualifying for respite financial assistance based on level of impairment and income. Following these federal, state, and organizational standards ensured my proposed intervention met requirements to enable access to technologies, high-quality care coordination, and community resources within the ethical and regulated practice (Prophater et al., 2021).
Further, I integrated standards on person-centered care, family engagement, and dementia training into the intervention. Standards emphasizing shared decision-making, caregiver education, and connecting patients with support services guided the inclusion of family conferences and Alzheimer’s Association referrals. Mandates to complete regular dementia education informed my focus on specialized communication techniques, resources, and care planning. Allowing evidence-based standards to ground the intervention promotes safe, ethical, high-value care for Clay aligned with guidelines and regulations across the health system, governmental, and community levels. This systems-aware approach is key to developing impactful, sustainable practice innovations (American Nurses Association, 2023).
Research demonstrates the value of integrating nursing standards and policies into dementia care to enhance outcomes. Studies show adherence to person-centered planning standards improves quality of life and reduces agitation in Alzheimer’s patients versus non-standardized care. Certified dementia programs meeting standardized operational policies demonstrate reduced falls and hospitalizations. These and other studies provide credible evidence that implementing nursing practice standards and integrating health policy maximizes quality, safety, coordination, and resource access—critical to improving outcomes for Alzheimer’s patients and families. Adhering to evidence-based standards and policies is essential to optimizing care (Travers et al., 2021).
The multifaceted intervention proposed for Clay will enhance quality by taking a patient-centered approach and aligning care with his values and preferences through technologies like telehealth for convenient provider access and sensors to allow independent living. Structured communication strategies and care conferences improve understanding and transparency between Clay, family, and providers. Care coordination also increases quality by reducing fragmented services and enabling a holistic view of Clay’s needs. Enhanced safety is achieved through GPS trackers locating Clay when wandering and fall alerts monitoring risks in the home. Access to community resources like respite care reduces caregiver stress and burnout that could otherwise lead to patient safety issues (Mahmoud et al., 2020).
Regarding costs, research shows that care coordination programs decrease unnecessary hospitalizations and ER visits in dementia patients, resulting in average savings per patient monthly (Willink et al., 2020). GPS devices can provide rapid searches compared to extensive police-involved cases. Telehealth improves system efficiency through reduced travel and optimized provider time. For families, respite services and adult day programs may reduce individual long-term care costs. The intervention optimizes quality, safety, coordinated access, provider relations, resource efficiency, and cost savings across individual, family, and system levels through integrated technology and community solutions (Lindauer et al., 2022).
Credible evidence supports this personalized, collaborative intervention to significantly enhance the care experience, relationships, safety, clinical outcomes, and costs for Clay and his Alzheimer’s disease. The impacts reflect the massive potential of integrated, patient-centered solutions at the intersection of health systems, policy, and local community resources. This intersection is where nurses can be most impactful in
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