DISSCUSSION: NURS FPX 4050 Caring for Alzheimers Patient

DISSCUSSION: NURS FPX 4050 Caring for Alzheimers Patient

DISSCUSSION: NURS FPX 4050 Caring for Alzheimers Patient

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.


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NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project or clinical patient encounter is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a hypothetical individual in your community as you consider the hypothetical patient’s unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.


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.
    • Analyze a health concern and the associated best practices for health improvement.
  • Competency 2: Collaborate with patients and family to achieve desired outcomes.
    • Describe specific goals that should be established to address a selected health care problem.
  • Competency 3: Create a satisfying patient experience.
    • Identify available community resources for a safe and effective continuum of care.
  • Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
    • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
    • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.


Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting.

Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks.

As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

  • Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
  • Allow plenty of time to plan your chosen health care concern.

Note: Remember that you can submit all, or a portion of, your draft plan to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.


Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan

Complete the following:

  • Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
    • Stroke.
    • Heart disease (high blood pressure, stroke, or heart failure).
    • Home safety.
    • Pulmonary disease (COPD or fibrotic lung disease).
    • Orthopedic concerns (hip replacement or knee replacement).
    • Cognitive impairment (Alzheimer’s disease or dementia).
    • Pain management.
    • Mental health.
    • Trauma.
  • Identify available community resources for a safe and effective continuum of care.
Document Format and Length
  • Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.
    • Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
  • In your paper include possible community resources that can be used.
  • Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
    • Study the subtle differences between basic, proficient, and distinguished.
Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

  • Analyze your selected health concern and the associated best practices for health improvement.
    • Cite supporting evidence for best practices.
    • Consider underlying assumptions and points of uncertainty in your analysis.
  • Describe specific goals that should be established to address the health care problem.
  • Identify available community resources for a safe and effective continuum of care.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
    • Write with a specific purpose with your patient in mind.
    • Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.
Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Preliminary Care Coordination Plan Example Paper

Selected Health Concern

Mental health has become a global concern in recent years. Despite the increasing incidence of this illness, stakeholders have not given it the necessary attention. The National Institute of Mental Health (2022) reports that one in five adults in the United States lives with a mental illness, representing about 52.9 million people in 2020. These people are afflicted with incapacitating impairments that substantially impact their daily lives. As a result of this insurmountable, afflicted persons believe that their difficulties lack legitimacy because they are uncommon in contrast to other illnesses. Sufferers with apparent health impairments in their ability to accomplish numerous errands are treated with derision, whereas the general public views mental health patients as having irrelevant worries.


Despite the fact that mental health conditions and invulnerable health concerns may not be indicative of a successful life, success is frequently associated with the availability of community resources and treatment alternatives. In low-income countries, more than 75% of mental health patients go untreated, while 35 to 50 % of high-income patients do not seek medical care and go untreated (Qin & Hsieh, 2020). This trend has a negative impact on the fight against mental illness. Additionally, more than $280 billion are lost annually in the United States providing services and treating mental health issues (The White House, 2022). Furthermore, according to the National Alliance on Mental Illness (2021), major depressive episodes, anxiety disorders, posttraumatic stress disorder, and bipolar disorder are leading causes of hospitalization for adults. Consequently, mental health problems remain a global hazard.

In addition, these diseases influence numerous social and economic areas. Among other aspects of life, mental health illnesses affect a person’s schooling abilities, work chances, and ability to maintain healthy interpersonal relationships. Therefore, seeking medical care and utilizing available community services is essential to living a mentally healthy life. In this view, the purpose of this project is to focus on a community member with a mental health disorder. The study’s primary objective is to design a care coordination plan.

The case patient has a mental illness (a depressive episode). During the evaluations, it becomes apparent that his family and acquaintances are willing to care for him. However, their assistance is insufficient, and they fail to comprehend the patient’s financial constraints in meeting his family’s demands. In addition, the patient sets unrealistic ambitions to conserve most of his resources, leaving his family with inadequate financial assistance. He desires to spend as little as possible on his healthcare. The patient’s worries necessitate discussing with mental health care specialists and developing a treatment plan appropriate to the community’s existing resources.

Community Resources Available for Effective and safe Care Continuum

The patient can benefit from a variety of support services aimed to help patients achieve mental health. First, Mental Health America (MHA) is committed to promoting mental health wellness by providing early identification and interventions for people at risk, integrating support, care, and services, with the sole goal of mental wellness recovery. It provides an affiliate network of mental health organizations to influence public policy and ensure access to reasonable and effective care for the vast number of mental health patients in the United States. Operating in 42 states and with more than 200 affiliates, the MHA’s affiliate network is committed to providing assistance and advocacy to all individuals affected in all communities throughout the United States (Mental Health America (MHA), 2022).  The affiliates provide outstanding programs and services specifically designed to address the needs of an area. The case patient can access information, mental health care, and a rehabilitation program through the affiliate network of the Mental Health Association.

Other resources include Substance Abuse Treatment Facility Locator, which assists individuals in locating programs with affordable payment options and links to support institutions. In addition, the National Suicide Prevention Lifeline provides vital support to those with mental health by connecting them to a local crisis center where they can seek emergency care. There is a toll-free number for this service. Therefore, one can select the choice that best meets their needs from among these options. However, he needs assistance in recognizing the existence of such resources and gaining access to them.

The Care Coordination Plan

Given the delicate nature of mental health issues, it is crucial to utilize effective and evidence-based approaches supported by the best clinical expertise, evidence, and research to give the highest possible level of care. A suitable intervention must be effective, well-defined, consider the patient’s goals, and comply with society norms (Lyon & Bruns, 2019). In addition, it should not be prohibitively expensive and should be adaptable to changing demands from patients and the community. According to this point of view, the healthcare professional and the patient need to work together to establish health goals that both parties are comfortable with.

The patient identified for this case resides within New York City. We planned an interview in two weeks and identified several objectives. One of them is to identify individuals who can offer unconditional support. Since his family is reluctant to provide support, the patient is encouraged to engage in social activities to help him identify new persons who can offer invaluable support. Nevertheless, the relatives are also encouraged to adopt a more accepting and supportive attitude towards the patient. This would go a long way in enhancing the patient’s mental health and general well-being. Treating a patient in isolation from his family is doomed to fail. Therefore, incorporating the family members in the care coordination plan is vital.

Moreover, the patient is encouraged to value himself, avoid negative self-evaluation and criticism, and treat himself respectively. The patient should also be able to live without undue fear or guilt, work more productively and provide positive input to his family and community, establish more meaningful and healthy interpersonal relationships, accurately appraise reality, and attain a self-defined spiritual view. These goals are all realistic and achievable. After identifying them, the patient should gradually focus on how to achieve them. Whenever he encounters unprecedented or considerably weighing down challenges, the patient should seek the available support from resources and personnel. He should also adhere to any prescribed treatment and therapeutic activities. Lastly, the patient should adopt healthy coping mechanisms to stress to avoid relapses and further deterioration of his state.


Lyon, A. R., & Bruns, E. J. (2019). From Evidence to Impact: Joining Our Best School Mental Health Practices with Our Best Implementation Strategies. School Mental Health. https://doi.org/10.1007/s12310-018-09306-w

Mental Health America (MHA). (2022). About Mental Health America. Mental Health America. https://mhanational.org/about

National Alliance on Mental Illness. (2021). Mental health by the numbers. Nami.org; National Alliance on Mental Illness. https://www.nami.org/mhstats

National Institute of Mental Health. (2022, January). Mental Illness. https://www.nimh.nih.gov/health/statistics/mental-illness

Qin, X., & Hsieh, C.-R. (2020). Understanding and Addressing the Treatment Gap in Mental Healthcare: Economic Perspectives and Evidence From China. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 57, 004695802095056. https://doi.org/10.1177/0046958020950566

The White House. (2022, May 31). Reducing the Economic Burden of Unmet Mental Health Needs. The White House. https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs/