Assessment 4: Final Care Coordination Plan FPX 4050

Final Care Coordination Plan

 Alzheimer’s disease (AD) is the selected health care problem for care coordination since patients with AD require medical care from various health professionals. Persons with AD heavily rely on others and are the highest healthcare consumers secondary to their reduced cognitive function and capacity to carry out activities of daily living (ADLs) independently.

Care coordination for persons with AD focuses on addressing their multidisciplinary needs, enhancing their health outcomes, delay admission to nursing homes, and reducing healthcare costs associated with repeated services from the various health providers (Chen et al., 2020). The purpose of this paper is to design patient-centered health interventions for the final care coordination plan and discuss ethical decisions and priorities that should be considered in developing the plan.

Patient-Centered Health Interventions and Timelines for Care Delivered

The care coordination plan will involve providing patient-centered care consultation for AD patients. Every AD patient in the care coordination program will be assigned a care coordinator within two weeks of establishing the program. In the first two weeks, the care coordinator will interview the patient and their caregiver either at the clinic or home setting. The interview will focus on obtaining information on the patient’s physical and cognitive functioning, social support system, financial status, living status, and the home environment (Hughes et al., 2017). The care coordinator will use the Cognitive Impairment Screening tool to assess the degree of cognitive impairment. The coordinator will also use the Functional Activities Questionnaire to measure the patient’s ability to carry out instrumental daily living activities (IADL).

The care coordinator will convey the interview results to the interdisciplinary health team within a week after the interview. The interdisciplinary team will collaboratively develop a care plan within a week, based on the patient’s stage of disease, health needs, and goals. The care coordinator is responsible for ensuring that the plan is implemented, monitoring the patient for changes in condition, and assessing medication management needs (Hughes et al., 2017). Besides, the coordinator will provide care directly, arrange referrals to providers, and conduct ongoing monitoring for the patient.

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The care coordinator will determine the frequency of patient visits based on the identified health needs. However, every patient will receive a visit from either a community health worker or registered nurse once monthly. In every patient visit, the health provider will offer health education to the patient and caregiver on health promotion practices and train caregiving skills (Hughes et al., 2017). The health provider will also educate and encourage the patient to utilize available community resources for AD services, such as adult day care centers, education programs, and support groups. For instance, the care coordinator can refer the patient and caregiver to available community resources such as respite care, support groups, caregiver education and training programs, and caregiver coaching services.

Ethical Decision in Designing Patient-Centered Health Interventions

Patient-centered care interventions should be driven by the ethical principles of autonomy, beneficence, nonmaleficence, and justice. Hansson and Fröding (2020) argue that the principles of beneficence and nonmaleficence have vital roles in guaranteeing the quality and safety of care interventions. Consequently, a patient should only be provided medically beneficial interventions based on the best available evidence (Hansson & Fröding, 2020). Particularly, interventions that are known to have significant harmful effects should not be provided, and the provider is responsible for not harming the patient.

The care coordinator should involve the patient and the caregiver in making decisions regarding healthcare interventions to incorporate their preferences, cultural values, and lifestyle. According to Hansson and Fröding (2020), shared decision-making should entail: Involving both the provider and patient in the treatment decision-making process; the provider and patient sharing information; the provider and patient taking action to engage in the decision-making process by communicating treatment preferences; and the provider and patient agreeing on the interventions to implement. It is crucial in healthcare ethics that the available resources are allocated as per a patient’s needs to promote justice.

Overuse of the scarce medical and caregiving resources in care coordination can decrease or delay access to these resources for the people who need them the most (Hansson & Fröding, 2020). A system of ethical decision-making can be anticipated to offer resourceful patients more opportunities to increase their healthcare resources share.

Relevant Health Policy Implications for the Coordination and Continuum of Care

The Affordable Care Act (ACA) intends to improve care coordination across the health system’s settings. Besides, multiple ACA sections comprise new care coordination programs relevant to geriatric care coordinators (Kominski, Nonzee & Sorensen, 2017). The policymakers aimed to better integrate patient care, designed services, and measurement tools. The ACA has care coordination provisions under Medicare and Medicaid, which seek to improve care coordination by aligning incentives for quality care and moving towards better-integrated care. 

The Community-Based Care Transitions Program (CCTP) is a provision under Medicare, which evaluates paradigms for improving care transitions from a hospital to other health care settings (Kominski et al., 2017). The program intends to lower readmission rates of elderly patients and their Medicare costs by improving coordination and care continuum. Health Homes for Chronic Conditions is also a provision under Medicaid. It allows states to create a Health Home that coordinates care for persons with multiple chronic illnesses or adverse mental conditions (Kominski et al., 2017). Implementation of this provision can significantly improve the coordination and continuum of care for AD patients. 

Priorities That a Care Coordinator Would Establish When Discussing the Plan with a Patient and Family Member

Priorities that should be established when developing the care plan with the patient and family member include meeting the patients’ needs and preferences. Therefore, the client’s needs and preferences should be well known and communicated to the interdisciplinary team to guide the delivery of safe, appropriate, and effective care (Nadash, Silverstein & Porell, 2019). For instance, the care coordinator should establish priorities such as meeting an AD patient’s cognitive, physical, social, and financial needs. The care coordinator should also prioritize improving the patient’s health outcomes and life quality (Nadash et al., 2019). Consequently, every intervention discussed with the patient should improve their health outcomes, either by delaying disease progress or preventing comorbidities. For instance, the AD patient coordinator should establish a priority of slowing deterioration of cognitive and physical functioning and enhancing their quality of life. 

One of the care coordinator’s roles is to monitor and follow-up with the patient, including responding to changes in patients’ needs. Changes to the care plan may be needed if the goals are not achieved within the set timeline. However, the change interventions should be based on evidence-based practice to promote the desired patient (Chen et al., 2020). A change of interventions may be required if the patient does not positively respond to the initial plan and if the interventions have adverse effects on them. Financial challenges may also warrant a change to ensure the care provided is affordable to the patient, but the new interventions should be supported by evidence-based practice. 

Aligning Teaching Sessions to the Healthy People 2020 Document

Best practices and evidence-based practice should guide patient education activity content. The care coordinator should assess if the best practices are feasible based on the patient’s physical, cognitive, and financial capabilities. Teaching lessons can be aligned to the Healthy People 2020 document by identifying an objective that one wishes to attain using health education. The provider can select the health education content from the interventions and resources section to guide them in providing evidence-based patient education (HHS, 2015). For instance, when providing patient education to an AD patient, the care coordinator can identify an objective for health education from the topic, Dementias, Including Alzheimer’s Disease (HHS, 2015). The coordinator can select the objective of reducing the proportion of preventable hospitalizations in adults aged 65 years and older with diagnosed Alzheimer’s disease and other dementias. Based on this objective, the coordinator can identify education interventions that can lower hospitalizations in this population. 


Patient-centered care interventions for AD will include assigning a care coordinator and conducting a comprehensive patient assessment. A care plan will then be developed by an interdisciplinary team based on its needs. The care coordinator will be tasked with providing patient education, arranging referrals, referring the patient to community resources, and monitoring the patient for changes. Ethical principles that should be considered in designing the interventions include beneficence, nonmaleficence, autonomy, and justice. The interventions should not harm the patient and should be guided by the best evidence. Priorities that should be established for the care coordination plan include meeting the patient’s needs and preferences, improving health outcomes and the quality of life. However, the care plan can be changed if the desired outcomes are not achieved or if the patient requests alternatives due to financial challenges.   

Assessment 4: Final Care Coordination Plan FPX 4050 References

Chen, B., Cheng, X., Streetman-Loy, B., Hudson, M. F., Jindal, D., & Hair, N. (2020). Effect of care coordination on patients with Alzheimer’s disease and their caregivers. The American Journal of Managed Care26(11), e369-e375.
Hansson, S. O., & Fröding, B. (2020). Ethical conflicts in patient-centered care. Clinical Ethics, 1477750920962356.
Hughes, S., Lepore, M. M., Wiener, J. M., & Gould, E. (2017). Research on Care Coordination for People with Dementia and Family Caregivers.
Kominski, G. F., Nonzee, N. J., & Sorensen, A. (2017). The Affordable Care Act’s Impacts on Access to Insurance and Health Care for Low-Income Populations. Annual review of public health38, 489–505.
Nadash, P., Silverstein, N. M., & Porell, F. (2019). The Dementia Care Coordination Program: Engaging Health Systems in Caregiver Supports. Dementia18(4), 1273-1285.
US Department of Health and Human Services. (2015). Healthy people 2020. Dementias, including Alzheimer’s disease.

Evaluation of the Patient:

Let’s quickly assess our client and her needs before we present our care coordination strategy. Our client is Ms. D. Smith, a 26-year-old woman with cerebral palsy who also needs a trachea due to her condition. Her mother, Ms. V. Wyatt, lives with them and takes care of her. Following a relapse of her Lupus diagnosis, Ms. Wyatt is now improving in her health. As a result, she needed additional help from family members and home health nurses to provide Ms. Smith with care until she can once again operate independently. Ms. Smith has not been given the necessary treatment throughout this time, which has led to episodes of tracheal decannulation, skin breakdown, and two recent falls from her bed and wheelchair (Adams et al., 2019).

Health-Related Issues That May Be Included:

Case management has requested the assistance of trusted family members and homecare specialists in order to create an effective treatment plan for Ms. Smith. It was determined that (a) the care of her trachea, (b) the instruction of her staff to prevent falls, and (c) the maintenance of the integrity of her skin were areas of concern for her health and safety. It has been agreed that Ms. Smith’s care will undergo another evaluation on October 15, 2019, to see whether any changes to her current course of treatment are necessary to ensure her continuing health and security. This choice was made as a result of the choice to conduct the evaluation, which has been made. It will be crucial for Ms. Wyatt to perform one of the two tasks flawlessly. 1. Verify that Ms. Smith has enough family support to ensure her ongoing safety and care until Ms. Wyatt has healed fully (Radder et al., 2020).

It appears that Ms. Wyatt will be able to recover to the point where she can resume her duties as Ms. Smith’s full-time carer. If neither of these two possibilities becomes available within the next month and a half, Ms. Smith will be transferred to a facility that provides temporary relief for a shorter period of time. Because she won’t be able to have a home of her own for some time, she will have to remain in foster care for the foreseeable future. Homecare services will be offered inside the home on a round-the-clock basis, seven days a week, in order to assist with care and to educate family members who are prepared to take on the obligations of caregiving. As a direct result of this, Ms. Wyatt will take part in both physical treatment and occupational therapy in an effort to speed up her own rehabilitation. In addition to this, she will participate in training to improve the ways in which care is provided to patients in light of the difficulties in healthcare that were discussed before (Radder et al., 2019).

Ethics-related factors to take into account:

Notwithstanding the fact that we are approaching Ms. Smith’s needs from the perspective of client-centered care, we still have a duty to consider ethical nursing care obligations. It is our responsibility as a nurse to ensure that the patient receives the care that is in their best interests. To guarantee that Ms. Smith continues to have the same level of physical and mental wellness that she has had her whole life—that is, staying at home with her family—we adhere to industry standards and act in her best interests. She will maintain the same degree of physical and mental health that she has in the future thanks to this. Not only are we being held accountable for our own behavior, but also that of the carer who assisted our consumer (s). Last but not least, it is our responsibility to do business in a way that does not in any way, shape, or form harm our customers, whether or not such harm was intended.

A Discussion of the Continuum of Care and Coordination and Its Health Policy Consequences

The coordination of care is governed by a number of laws that have been put in place by the government. When it was first enacted into law, the Patient Protection and Affordable Care Act (ACA) has been the subject of numerous viewpoints. The law’s requirement that people in the US have health insurance led directly to an improvement in access to medical care. In addition, more people are employed to coordinate the patient’s medical treatment as a result of an increase in the number of patients who requested this particular service. The majority of Americans also have access to Medicare, a health insurance program that has been in place in the country since the 1940s, which gives them the chance to apply for insurance coverage that satisfies their needs. Coverage for senior citizens in the United States was established in 1965 under the leadership of John F. Kennedy, who was the President at the time. The policy emphasizes care coordination methods to address the trend of increasing patient populations who need this therapy. This is due to an increase in the number of patients who need this therapy.

The Patient’s health problems include:

The patient was found to have the chronic obstructive pulmonary disorder (COPD), a type of lung disease that causes the airways to get blocked as a result of smoking. The illness is accompanied by a multitude of symptoms, the most common of which are coughing up mucus and wheezing. Those who have been diagnosed with COPD have a significantly increased chance of contracting a number of other illnesses, including coronary heart disease, lung cancer, and a wide range of other ailments. Because of this, it is crucial to managing the situation appropriately. The patient struggles to effectively use the necessary self-management abilities during this period (Cartier et al., 2020). The patient, for instance, is not as well-informed as they ought to be on the significance of taking all recommended medications, like ciprofloxacin and prednisolone, exactly as instructed. Less instruction is also given to the patient on how to control the various chest compressions required for reoxygenating the lungs, as well as how to handle the dry coughing that occurs during the procedure. Second, the patient is less informed about the techniques that can be used to enhance breathing based on their current condition. This is problematic because the patient’s general health depends on breathing improvement. The patient finds this difficult because one of their main worries is improving their breathing. Last but not least, the patient is not immune to influenza, which is known to exacerbate the symptoms of COPD. The vaccination has not been received by the patient. The likelihood of the existing condition getting worse has not been decreased as a result of the person’s failure to receive the immunization, which is cause for concern (Bahr & Weiss, 2019).

About the Coordination of Care’s Priorities

The following is a list of the priorities that should be taken into account while planning care coordination. In order to gain a deeper grasp of the patient’s viewpoints, values, and desires, the nurse and doctor must stay in constant communication with one another as well as with the patient and the patient’s family. Critical stages in the procedure include assessment and ongoing patient and family education about the course of the disease. After it is accomplished, it might be possible to implement coordinating services and a number of other disciplines. Even after being discharged from hospitals or other care facilities, such as nursing homes or rehabilitation facilities, where they had been residing, patients continue to receive medical treatment. In order to enhance the patient’s outcomes, it is vitally important to keep evaluating the patient. This can be done through follow-ups and the use of the appropriate therapies to achieve patient-specific objectives. There is a demand that access is granted to Jane Doe’s home. The healthcare team’s role is to figure out how she can get the proper diet, exercise, transportation, medications, and resources, as well as how to manage her weight. Coupled with having the means to support one’s own lifestyle and medical care,


Adams, S., Stinson, J., Moore, C., Beatty, M., Desai, A., Radmand, A., … & Orkin, J. (2019). 16 Assessing the requirements for a patient-facing virtual platform to enhance care coordination for children with medical complexity. Paediatrics & Child Health24(Supplement_2), e7-e7.

Bahr, S. J., & Weiss, M. E. (2019). Clarifying model for continuity of care: A concept analysis. International journal of nursing practice25(2), e12704.

Cartier, Y., Fichtenberg, C., & Gottlieb, L. M. (2020). Implementing Community Resource Referral Technology: Facilitators And Barriers Described By Early Adopters: A review of new technology platforms to facilitate referrals from health care organizations to social service organizations. Health Affairs39(4), 662-669.

Radder, D. L., Nonnekes, J., Van Nimwegen, M., Eggers, C., Abbruzzese, G., Alves, G., … & Bloem, B. R. (2020). Recommendations for the organization of multidisciplinary clinical care teams in Parkinson’s disease. Journal of Parkinson’s disease10(3), 1087-1098.

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.


NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.


In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.


Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

  • Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.
Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

  • Design patient-centered health interventions and timelines for a selected health care problem.
    • Address three health care issues.
    • Design an intervention for each health issue.
    • Identify three community resources for each health intervention.
  • Consider ethical decisions in designing patient-centered health interventions.
    • Consider the practical effects of specific decisions.
    • Include the ethical questions that generate uncertainty about the decisions you have made.
  • Identify relevant health policy implications for the coordination and continuum of care.
    • Cite specific health policy provisions.
  • Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
    • Clearly explain the need for changes to the plan.
  • Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
    • Use the literature on evaluation as guide to compare learning session content with best practices.
    • Align teaching sessions to the Healthy People 2030 document.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 1: Adapt care based on patient-centered and person-focused factors.
    • Design patient-centered health interventions and timelines for a selected health care problem.
  • Competency 2: Collaborate with patients and family to achieve desired outcomes.
    • Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
  • Competency 3: Create a satisfying patient experience.
    • Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
  • Competency 4: Defend decisions based on the code of ethics for nursing.
    • Consider ethical decisions in designing patient-centered health interventions.
  • Competency 5: Explain how health care policies affect patient-centered care.
    • Identify relevant health policy implications for the coordination and continuum of care.
  • Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
    • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
    • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.


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