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Final Care Coordination Plan: Alzheimer’s Disease Facts

Care coordination serves as an essential practice in patient-centered care, targeting patients’ needs, preferences, and values and ensuring access to care and holistic treatment. In this key, a care coordination plan (CCP) entails the proper arrangement of patient care activities and tight collaboration between respective stakeholders to promote efficient and safe care. Thus, this paper aims at delivering patient-centered health interventions and timelines for Alzheimer’s disease (AD) and considering ethical decisions and particular health policy implications. The paper will also define the priorities of a care coordinator when discussing the plan with a patient and family members.

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Health Interventions and Timelines

Mr. G. is a 72-year-old man with a nine-year anamnesis of Alzheimer’s disease, who additionally suffers from Stage 1 hypertension, with systolic pressure frequently over 145 mm Hg, and recurrent insomnia incidents. Although AD is an incurable neurodegenerative disorder, the severity of its symptoms can be considerably mitigated. For instance, in The Johns Hopkins Hospital, primarily in the department “Neurology and Neurosurgery,” the patient can find many high-qualified and experienced medical professionals directly dealing with the illness.

In this regard, physicians can offer both pharmacological and non-pharmacological therapies. The best pharmacological treatment include drugs approved by the US Food and Drug Administration (FDA), such as donepezil, rivastigmine, memantine, galantamine, and memantine with donepezil (Alzheimer’s Association, 2020). The timeline for therapy by memantine with donepezil, for instance, can take one month. For persistent therapeutic effect, a doctor can recommend supportive therapy. Transcranial magnetic stimulation (TMS), computerized cognitive training (CCT), music therapy, and moderate physical activity (PA) belong to useful psychosocial interventions. The study by Liang et al. (2018) confirmed that PA and CCT showed significant betterment in the conditions of patients with AD. The treatment of TMS or CCT can last several months and should be prescript at intervals, at least 2 times a year.

Treating hypertension principally depends on the proper prescription of drugs. These medications typically include angiotensin-converting enzyme (ACE) inhibitors, thiazide diuretics, Angiotensin II receptor blockers (ARBs), and Calcium channel blockers (CCB) (Mayo Clinic Staff, 2018). Nonetheless, taking such medicines should be under the doctor’s watchful supervision and after undergoing particular tests. Their use can proceed 2-5 weeks on average under the attending doctor’s close observation. Mayo Clinic can deliver thorough hypertension diagnosis and treatment in the Nephrology and Hypertension department.

The best interventions for insomnia can involve both pharmacological and non-pharmacological therapies. Physicians can prescribe eszopiclone, ramelteon, zaleplon, or zolpidem, which can be offered only for a few weeks because of various side effects and the addiction risk (Mayo Clinic Staff, 2016). The most efficient treatment is cognitive behavioral therapy for insomnia (CBT-I), comprising light therapy, relaxation techniques, sleep hygiene, and stimulus control therapy (Mayo Clinic Staff, 2016). The patient can always employ these methods without any adverse consequences. It is worth noting that the patient can receive the treatment of insomnia in The Johns Hopkins Hospital, namely, in Psychiatry and Behavioral Sciences and Neurology departments.

Ethical Decisions

In the medical environment, ethical imperatives assume utter significance because the realization of healthcare programs and trust in the providers directly hinge on them. When developing health interventions, the principal ethical decision is beneficence, namely, the absence of malignity or intentional harm. Specifically, benevolence requires physicians to prefer medical practices that foster clients’ best interests and well-being (DeCamp et al., 2018). For example, some doctors deliberately prescribe medications that can lead to persistent addiction if taken inappropriately, which is categorically prohibited.

The next critical ethical principle is respect for patients’ preferences, needs, and values. This decision means acknowledging patients’ personalities, engaging them in the decision-making process, and treating them with dignity. Furthermore, it also necessitates healthcare providers to deliver a clear, evidence-based presentation of interventions’ advantages and hazards to patients to ensure an informed care choice. This, altogether, provides reducing personnel-related errors and promotes patients’ recovery or alleviation of disease’s course. The final ethical principle is equity and justice towards all persons regardless of their racial, social, and sex affiliations. This moral tenet is responsible for an equitable distribution of healthcare resources, including medications, workforce, or vaccines, among the entire population. Besides, medical providers should give top priority to patients in a difficult and emergency state because this facilitates early diagnosis and selecting appropriate treatment.

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Health Policy Implications

The basic act aiding people with AD and other forms of dementia, as well as their caregivers, is the Patient Protection and Affordable Care Act (ACA), signed by President Obama in 2010. Medicare, a federal health insurance program for people aged more than 65, reimburses the fees of inpatient care and some doctors’ medical services for individuals suffering from AD (“Medicare,” n.d.). Medicare also covers care provided in inpatient hospice or other nursing facilities for persons with AD determined to be near death. Besides, the program pays for care planning services, allowing the patients and their caregivers to be familiar with various treatments and other services available in their community. The Medicare supplement is Medigap covering deductibles and copayments stipulated in Medicare. Moreover, Medicaid, the American state healthcare plan for the needy, can embrace the whole or part of long-term home care services if individuals meet eligibility requirements (“Medicaid,” n.d.). These requirements concern patients’ monthly income, property, investments, savings, medical expenses, and even family members.

Priorities for the Plan

When deliberating the plan with patients and their family members, care coordinators should establish four central priorities: accountability, patient support, relationships and agreements, and connectivity. The functional changes based on these priorities foster enhancing the coordination of care. Accountability implies designing a specific tracking system and identifying a primary care clinic accountable for care coordination. The ground for selecting a primary care clinic is that fragmented care is often connected with delays and other unexpected care problems. Moreover, it is a significant irritant to clients because of superfluous, often duplicated, services, which also disturbs primary care practitioners’ workflow. In addition, along with this action, developing a QI plan with definite objectives and measurements is necessary. A tracking system should be implemented to manage referrals such as specialist consults, hospitalizations, etcetera.

Patient support entails the organization of a professional team to assist patients and their caregivers during referrals and transitions. In particular, the priority requires hiring staff to coordinate care referrals and train them in patient-centered communication directed at motivation and problem-solving. A referral coordinator should also be responsible for patients’ clinical, insurance, and logistical needs and remove their barriers to referrals or transitions. Relationship priority aims at developing and setting agreements with perspective specialist groups, hospitals, and community agencies. The CC plan should also take into account medical providers that deliver services on substance abuse, nutrition, behavioral health, financial and caregiver assistance, social work, and others. Agreements should be designed based on collective goals and the best intentions for the patients’ care. Connectivity is associated with building an information transfer system containing shared EHR and standardized information transferring process.

The Literature on Evaluation

Over recent two decades, scholars have performed numerous profound studies on evaluating CC plans in different states. Most of them have revealed a conducive influence of such programs on staffs’ performance and patients’ outcomes and satisfaction. For instance, a study by Hoyer et al. (2018) inferred that CC interventions tend to diminish the 30-day readmission rates and highlighted the importance of timely interventions for patients in remote locations. Moreover, a systematic review by Conway et al. (2019) found that CC plans were frequently linked to improved patient and health service results, especially when nurses actively interact with patients. Such evaluative literature is particularly beneficial since it determines the effectiveness of CC programs and new practical approaches and facilitates detecting problematic zones needing thorough consideration.

Healthy People 2020 was taken by the Department of Health and Human Services in 2010 to arrange prophylactic efforts and spur national health promotion. Following the document, a CC plan should pursue four objectives: promoting longer lives, combating healthcare disparities, shaping a favorable public environment, and enhancing life quality (“Healthy People 2020,” 2010). Specifically, the first aim suggests raising life expectancy and reducing preventable diseases, disabilities, injuries, and premature deaths, while the second encompasses averting ethnic, sex, and socioeconomic inequity. Regarding the third goal, the plan should create an environment with favorable socioeconomic determinants and observe main healthcare federal policies. The last purpose is directed at improving physical and psychological well-being.

In conclusion, the paper has designed a CC plan for the patient with Alzheimer’s disease, hypertension, insomnia, and patient-centered health interventions, considering ethical decisions and policy provisions. For AD, doctors can advise health improvement methods, including drugs, CCT, TMS, aerobic exercises, and music therapy. While designing health intervention, the central ethical principles are beneficence, respect for patients’ preferences and values, and equity and justice. The main policy provisions are primarily determined by the Patient Protection and Affordable Care Act, especially Medicare and Medicaid. The substantial reliable literature demonstrated the beneficial effect of CC programs on patients’ outcomes and healthcare providers’ performance.


Alzheimer’s Association. (2020). 2020 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 16(3), 391–460. Web.

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Conway, A., O’Donnell, C., & Yates, P. (2019). The effectiveness of the nurse care coordinator role on patient-reported and health service outcomes: A systematic review. Evaluation & the health Professions, 42(3), 263-296. Web.

DeCamp, M., Pomerantz, D., Cotts, K., Dzeng, E., Farber, N., Lehmann, L., Reynolds, P. P., Sulmasy, L. S. & Tilburt, J. (2018). Ethical issues in the design and implementation of population health programs. Journal of General Internal Medicine, 33(3), 370-375. Web.

Healthy People 2020. (2010). The US Department of Health and Human Services. Web.

Liang, J.-H., Xu, Y., Lin, L., Jia, R.-X., Zhang, H.-B., & Hang, L. (2018). Comparison of multiple interventions for older adults with Alzheimer’s disease or mild cognitive impairment: A PRISMA-compliant network meta-analysis. Medicine (Baltimore), 97(20), e10744. Web.

Mayo Clinic Staff. (2018). High blood pressure (hypertension): Diagnosis & treatment. Mayo Clinic.

Mayo Clinic Staff. (2016). Insomnia: Diagnosis & treatment. Mayo Clinic.

Medicaid. (n.d.). The Alzheimer’s Association. Retrieved January 13, 2020, from

Medicare. (n.d.). The Alzheimer’s Association. Retrieved January 13, 2020, from

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