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Care Coordination Plan: Alzheimer’s Disease


Care coordination (CC) is an integral component of patient-centered care that focuses on individuals’ values and needs, ensuring access to care, and delivering holistic treatment. In this regard, a CC plan implies the elaborated arrangement of patient care activities and active cooperation between respective participants to promote safe and efficient care. Thus, this paper aims to provide patient-centered health interventions and timelines for Alzheimer’s disease (AD), considering ethical decisions and citing specific health policy provisions. The paper will also offer priorities that a care coordinator should set while conversing the plan with patients and their families and relate learning session content to excellent practices.

Patient-Centered Health Interventions and Timelines

Mr. B. is a 73-year-old man with a 7-year history of Alzheimer’s disease, who also suffers from Stage 1 hypertension, with systolic pressure usually over 140 mm Hg, and recurrent moderate insomnia incidents. Alzheimer’s disease is an incurable neurodegenerative disorder primarily characterized by a progressive impairment of memory and other cognitive abilities. Nevertheless, physicians can recommend pharmacological and non-pharmacological therapies that slacken the disease’s development and severity. The best pharmacological approaches include drugs, such as donepezil, rivastigmine, memantine, galantamine, and memantine with donepezil (Alzheimer’s Association, 2020). Taking these medications periodically, the patient can feel a noticeable temporary improvement in cognitive capacity. The timeline for treatment, for instance, by memantine with donepezil can comprise one month. In case of persistent therapeutic effect, a doctor can recommend maintenance therapy.

The useful psychosocial interventions can consist of computerized cognitive training (CCT), transcranial magnetic stimulation (TMS) music therapy, and a combination of aerobic and non-aerobic exercises. The study by Liang et al. (2018) confirmed that PA and CCT showed considerable improvement in conditions of individuals with AD. The treatment of TMS or CCT can last several months and should be prescribed periodically, about 2-3 times a year. It is worth noting that non-pharmacological therapies may be more useful than pharmacological approaches. Concerning community resources, in Rochester, Minnesota, in Mayo Clinic, Alzheimer’s Association Caregiver Support Groups, and Support Group for Individuals with Dementia, people can find many high-qualified medical professionals who directly deal with AD.

Addressing hypertension mainly depends on the appropriate prescription of drugs. These medicines usually include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, Angiotensin II receptor blockers (ARBs), and Calcium channel blockers (CCB) (Mayo Clinic Staff, 2018). However, taking such medications should be under the doctor’s vigilant control and after undergoing particular tests. In addition, the use of these medicines can proceed typically for 2-5 weeks under the attending doctor’s close observation. Community resources in Rochester, Minnesota, include Mayo Clinic, particularly the Nephrology and Hypertension department, Community Health Service Inc., and Joseph Lobl, MD (Location: 5777 E Mayo Blvd Phoenix, AZ 85054).

The best interventions for insomnia can consist of both pharmacological and non-pharmacological therapies. Doctors can prescribe ramelteon, eszopiclone, zaleplon, or zolpidem, which can be offered for a few weeks because they have various side effects and can cause addiction (Mayo Clinic Staff, 2016). The much better treatment is cognitive behavioral therapy for insomnia (CBT-I), including relaxation techniques, sleep hygiene, stimulus control therapy, and light therapy (Mayo Clinic Staff, 2016). The patient can use these methods for their whole life without any adverse consequences. Mayo Clinic, Jagdeep Bijwadia, MD (Location: 640 Jackson St Saint Paul, MN 55101) and Michelle Devine, MD (Location: 5200 Harry Hines Blvd Dallas, TX 75235) can deliver advanced diagnosis and treatment of insomnia. It is also worth noting that regarding all three conditions, the attending doctor should adjust the patient’s lifestyle, which implies selecting physical exercises and a suitable diet.

Ethical Decisions

In inpatient care and treatment, ethical imperatives acquire principal importance since the implementation of healthcare programs and trust in the medical profession directly depend on them. The prime ethical decision while designing health intervention is beneficence, that is, the absence of deliberate harm or malignity. Specifically, benevolence means that physicians prefer medical practices that favor patients’ best interests and well-being (DeCamp et al., 2018). For instance, some doctors willfully prescribe drugs that can cause durable addiction if taken inappropriately, which is categorically forbidden.

The second essential ethical principle is respect for patients’ preferences, values, and needs. This decision assumes recognizing patients’ personalities, involving them in decision-making, and treating them with dignity and sensitivity to their privacy and cultural beliefs. Furthermore, it also requires healthcare providers to give a clear, evidence-based presentation of benefits and risks to patients to help them make informed care choices. Overall, this ensures reducing staff-related errors and facilitates patients’ recovery or relief of the disease’s course.

Finally, the third integral ethical decision is equity and justice towards all people irrespective of their racial, social, and sex affiliations. This principle plays a vital role in a fair distribution of medical resources, including workforce, medications, tests, or vaccines, among the whole population. For example, Hispanic and African Americans are almost twice as likely to develop AD than older whites, and one of the core reasons for this is the limited access to care for the former (Alzheimer’s Association, 2020). Besides, in this regard, healthcare providers should give the priority to patients in an acute and urgent positions. As a result, this promotes early diagnosis and selection of appropriate treatment.

Health Policy Provisions

The Patient Protection and Affordable Care Act (ACA), signed into law by President Obama in 2010, contains several provisions that help people suffering from AD and other forms of dementia, as well as caregivers. Medicare, a national health insurance program for adults aged over 65, covers inpatient care and some doctors’ fees, and other medical services for individuals with AD (“Medicare,” n.d.). Medicare Part D also pays for most prescription medicines. Additionally, the program covers 100 days of skilled nursing home care under particular circumstances, but long-term custodial nursing home care is not provided (“Medicare,” n.d.). Medicare also serves hospice care delivered in inpatient hospice or nursing facilities for persons determined to be near death by their doctors (“Medicare,” n.d.). The program pays for care planning services for people diagnosed with AD, allowing individuals and their caregivers to become familiar with various treatments, clinical tests, and other services available in the community.

Medigap coverage can supplement Medicare, which covers deductibles and copayments required by Medicare. Furthermore, Medicaid, the American state health care program for the needy, can cover all or part of long-term home care services. However, individuals should meet eligibility requirements, and nursing homes should accept Medicaid to receive this coverage (“Medicaid,” n.d.). In particular, these requirements concern patients’ monthly income, savings, investments, property, medical expenses, and family members.


While discussing the plan with a patient and family member, a care coordinator should establish four main priorities: patient support, accountability, relationships and agreements, and connectivity. Patient support implies organizing a specific team to help patients and their caregivers during referral and transition. Recent research states that intensive care management, labeled as CC, of a low number of high-risk patients by nurses or other health providers betters outcomes and diminishes costs (“Reducing Care Fragmentation,” n.d.). In particular, the priority requires hiring or training staff to coordinate care referrals and transitions and respond to patients’ clinical, logistical, and insurance needs and address their barriers to referrals or transitions. Special personnel facilitates the transition process and clinical workflow, which favorably reflects on patients’ experience.

Accountability primarily assumes designing a tracking system and determining a primary care clinic responsible for care coordination. The reasons for choosing a primary care clinic are that fragmented care is frequently associated with delays and other care problems. Moreover, it is the core source of an irritant to patients because of unnecessary, often duplicated, services, which also complicates primary care practitioners’ workflow. Besides, along with this action, there is a need to develop a QI plan with clear goals and measures reviewing progress towards them (“Reducing Care Fragmentation,” n.d.). A tracking system should be implemented to monitor and manage referrals or transitions such as hospitalizations, and specialist consults, among others.

Relationship priority means detecting and developing agreements with leading hospitals, specialist groups, and community agencies. The CC plan should also consider medical providers that deliver services regarding substance abuse, behavioral health, nutrition, social work, financial and caregiver assistance, and others (“Reducing Care Fragmentation,” n.d.). Such actions help people respond to their needs operatively and receive better care. Connectivity requires building and introducing an information transfer system that contains shared electronic health records or e-referrals and a standardized information flow process. This system can significantly simplify and accelerate work processes and improve medical service.

The Literature on Evaluation

Over recent decades, scientists have conducted much profound research on evaluating CC plans in different countries. Most of them have found a favorable effect of such programs on medical staffs’ performance and patients’ outcomes and satisfaction. For instance, an observational study by Hoyer et al. (2018) concluded that CC interventions reduced the 30-day readmission rates and emphasized the importance of the relevant interventions for difficult-to-reach patients. Moreover, a systematic review by Conway et al. (2019) revealed that CC plans were frequently associated with much better patient and health service outcomes, especially where nurses were engaged in active, in-person interactions with patients. Such evaluation literature is particularly beneficial since it facilitates identifying problematic areas needing thorough consideration, trends, and new practical approaches, as well as determines the effectiveness of CC programs. This, overall, considerably broadens the opportunity for further development in healthcare service, which results in improved patients outcomes.

Healthy People 2020 was adopted by the Department of Health and Human Services in 2010 to direct disease prevention efforts and national health promotion. According to the document, a CC plan should pursue these objectives: favoring longer lives, eliminating healthcare disparities, shaping a conducive social and physical environment, and promoting life quality (“Healthy People 2020,” 2010). The first aim suggests increasing healthy life expectancy and diminishing preventable diseases, injuries, disabilities, and premature deaths, while the second one targets obviating ethnic, gender, and socioeconomic inequity. Concerning the third goal, the plan should create an environment with favorable socioeconomic factors and follow federal healthcare policies. The last objective is directed at improving physical and mental well-being.

In summary, the paper has developed a CC plan for Alzheimer’s disease (AD), hypertension, insomnia, and respective patient-centered health interventions, considering ethical decisions and policy provisions. Specifically, for AD, doctors can recommend health improvement methods, including aerobic exercises, music therapy, CCT, TMS, and drugs. While designing health intervention, the principle ethical decision is beneficence, respect for patient’s preferences and values, and equity and justice. The critical policy provisions are mainly determined by the Patient Protection and Affordable Care Act, especially Medicare and Medicaid. The ample literature confirmed the beneficial effect of CC programs on patients’ outcomes and nurses’ performance.


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

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.

Hoyer, E. H., Brotman, D. J., Apfel, A., Leung, C., Boonyasai, R. T., Richardson, M., Lepley, D., & Deutschendorf, A. (2018). Improving outcomes after hospitalization: A prospective observational multicenter evaluation of care coordination strategies for reducing 30-day readmissions to Maryland hospitals. Journal of General Internal Medicine, 33(5), 621–627. 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, 97(20), e10744. Web.

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

Medicaid. (n.d.). The Alzheimer’s Association. Web.

Medicare. (n.d.). The Alzheimer’s Association. Web.

Reducing care fragmentation: A toolkit for coordinating care. (n.d.). Improving Chronic Illness Care. Web.

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StudyKraken. (2022, August 30). Care Coordination Plan: Alzheimer’s Disease.

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"Care Coordination Plan: Alzheimer’s Disease." StudyKraken, 30 Aug. 2022,

1. StudyKraken. "Care Coordination Plan: Alzheimer’s Disease." August 30, 2022.


StudyKraken. "Care Coordination Plan: Alzheimer’s Disease." August 30, 2022.


StudyKraken. 2022. "Care Coordination Plan: Alzheimer’s Disease." August 30, 2022.


StudyKraken. (2022) 'Care Coordination Plan: Alzheimer’s Disease'. 30 August.

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