Assessment 4: Final Care Coordination Plan
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Final Care Coordination Plan
Given the dynamics in health care delivery, it is now crucial to care for older people to attain their optimum quality of life. This assignment provides an initial care coordination plan alongside patient-centered health interventions and evidence from the literature. It is meant to address key health issues of the elderly, such as mobility impairment, cognitive dysfunction, and social isolation (Maresova et al., 2023). When integrated with the goals of Healthy People 2030, the plan will address some of the challenges faced by the aging population.
Patient-Centered Health Interventions for Elder Care
The initial care coordination plan for elder care has three primary health issues: impaired mobility, reduced cognition, and lack of social contact. All of these areas are essential for the preservation of the quality of life and the level of autonomy of elderly patients (Tornero-Quiñones et al., 2020). For these problems to be effectively handled, we support the following interventions linked to each action plan: integrated community resources.
Mobility Limitations
These mobility concerns are prevalent in elderly people. Thus, we present a structured physical therapy program for each patient. The intervention will be initiated at the beginning of the care plan within the first fourteen days of admission. During this time, the patient will undergo physical therapy two times a week, depending on the next month’s evaluation of the patient’s progress. Sources of support for this intervention are physical therapists who offer expert advice on exercises to be undertaken, as well as senior fitness classes offered in community centers that offer individual exercises (Fien et al., 2022). Moreover, transport services are provided to enable patients to transport themselves to these sessions without transport problems.
Cognitive Decline
Deterioration in cognitive functioning is widespread and severe in the elderly population; therefore, evaluation and post-treatment are necessary (Owens et al., 2020). The presented approach consists of monthly cognitive status assessments and weekly cognitive training. The screenings will be conducted with the assistance of senior centers in the community, which will make it easy for elderly people to come. The program receives supervision from neurologists or psychologists who are local healthcare providers. Also, telemedicine services will be provided online to monitor the patients and join in group therapy sessions for cognitive work (Park et al., 2022). The use of this approach is very ideal for people who experience transportation challenges.
Social Isolation
Social isolation is an important concern for the elderly. It affects the mental health and overall well-being of the elderly (Clair et al., 2021). To address this, the intervention is to schedule weekly group sessions and conduct daily virtual communications using technology. Local social clubs and groups will be used to incorporate different activities that will improve social interaction. Volunteer organizations will also provide companionship services where volunteers frequently call or visit the elderly. In addition, we will organize technology classes to guarantee that elderly people have the proper skills to use social media, video calls, and other means of communication to connect with family and friends. These interventions are designed to be interdependent, each supporting aspects of physical, cognitive, and social health, ensuring a comprehensive approach to elder care. Again, through specific timelines and community resources, the plan seeks to achieve not only the identified health concerns but also long-term modifications that enhance the quality of the elderly’s lives.
Ethical Considerations in Designing Patient-Centered Health Interventions
Ethical issues, therefore, remain central while designing patient-centered health interventions for elderly care, especially with regard to sensitive issues such as autonomy, privacy, and informed consent. The literature supports a balanced approach that respects elderly patients’ dignity while providing obligatory care. Firstly, the principle of informed consent appears to be an important ethical concern. Cognitive impairment can impair the decision-making capability of the elderly individual; interventions should also contain strategies for continuously evaluating and honoring the patients’ decisional capacities. A study by Moilanen et al. (2021) highlights the importance of caregivers and healthcare professionals being trained to recognize and support the autonomy of elderly patients. It points out that decision-making abilities may be compromised, but their autonomy should still be respected and upheld.
Secondly, elderly patients’ privacy should be safeguarded when communal and digital interventions are applied. Therefore, as interventions include a technological aspect such as telehealth and online cognitive exercises, data privacy cannot be overemphasized. Some of the ethical frameworks highlighted by Keshta and Odeh (2021) stress the need to protect data and provide information to patients about how their data will be used and shared. Lastly, ethical decisions must consider the balance between intervention and over-medicalization. The purpose is to improve the quality of life in patients and avoid unnecessary medical procedures or treatments. Patient-centered care should incorporate interventions that are consistent with the patient’s values and goals to make sure that the care plan is medically necessary as well as beneficial in multiple aspects of the patient’s life (Grover et al., 2022; Mapes et al., 2020). These ethical considerations outlined in the literature help to advance not only the clinical requirements of health interventions but also the ethical obligations required in the care of vulnerable populations.
Assessing the practical effects of specific decisions in elder care interventions includes the determination of the planned impacts and possible side effects. For instance, initiatives to increase the use of telehealth services improve access to care for the elderly, but this can result in feelings of isolation or frustration among elderly people who lack adequate technology skills (Park et al., 2022). This raises ethical questions about whether digital inclusion is worth potentially increasing feelings of isolation or inequity. Furthermore, interventions like physical therapy and cognitive screenings assume the patient’s willingness and capability to participate. This leads to uncertainties about patient autonomy and consent, particularly in individuals with changing cognitive abilities. Such situations call for constant reevaluation and modification of the care strategies because of the patients’ changing necessities and functions.
Health Policy Implications for the Coordination and Continuum of Care
The admission and continuity of care for elderly patients are closely related, and both are linked significantly to health policy considerations (Mapes et al., 2020; Mehanna, 2022). This is especially the case when the treatment involves some form of physical therapy, cognitive health check-ups, and practical social interaction therapy. Two key policy provisions directly influence the approach and effectiveness of these interventions:
The Affordable Care Act (ACA)
This provision mandates employers to allow reasonable break time and provide a space other than a restroom for feeding their child up to one year of age. Although this particular provision is aimed at nursing mothers, its extension to elder care is in the establishment of the policy of reasonable accommodation for health care needs in the workplace. This also points to the importance of policies addressing the elderly in the workplace, such as flexible work schedules to attend health interventions or caregiving (Dario & Spatz, 2023).
The Older Americans Act (OAA)
The OAA was reauthorized in 2020 and provides funding for many home and community-based services, which include meals, caregiver assistance, and preventive health services (Gallo & Wilber, 2020). This act is essential in providing funds for programs that help the elderly to live independently and, hence, provide the most immediate support to interventions that address social isolation and community resource utilization. The provisions of the act for health promotion as well as disease prevention suit the implementation of community based screening as well as educational interventions for chronic disease management or mobility impairment. These policies stress a structure that the practice of care requires for the elderly, something that calls for systemic support to afford continuous, intercessory care. They are aligned with a societal focus to promote health in the elderly, implying a policy model of healthcare that also addresses the question of how interventions will be incorporated into population- and community-based systems. This integration is central to the coherence and efficiency of health interventions targeting the elderly; it is therefore crucial that care plans include these policies in their strategies and plans.
Priorities for Care Coordination
When discussing a care coordination plan with a patient and family members, a care coordinator would prioritize clear communication and individualized interventions. Additionally, continuous evaluation is important to guarantee the plan remains responsive to the patient’s changing needs. These priorities are important for creating a supportive environment that promotes active participation from the patient and their family in managing health issues effectively.
Clear Communication
The first one is the assurance that all sections of the care plan are effectively communicated to the patient and their family. To this, the patient should be informed of the reasons for each intervention intended, the expected impact, and the adverse effects or complications likely to arise from the measures to be taken (Pietrzykowski & Smilowska, 2021). The other aspect of communication is expressing understandable goals and being optimistic with the patient, the family, and the practitioners.
Specified Interventions
It may be that after an initial general assessment and frequent review of feedback with the patient and the family, adjustments may need to be made to the above. These changes would seek to increase the relevance of the interventions for the patient’s condition, behaviors, and preferences (Collado-Mateo et al., 2021). For instance, if a patient feels that a physical therapy session is too demanding, some changes may be made to find a more suitable exercise regimen. This emphasis on evidence ensures that the interventions that have been implemented are grounded in the most recent research. In addition, they are designed to enhance the comfort and interest of the patient.
Ongoing Evaluation
Regular assessments of the patient’s progress are necessary. This continuous evaluation enables the care coordinator to make proper decisions about the change or addition of a care plan based on the patient’s health condition. For instance, if the assessment of cognitive functioning reveals deterioration, the intervention measures could be adjusted to the more increased level of care that is needed (Sanjuán et al., 2020). The care coordinator guarantees that by prioritizing these areas, the care plan is both individual and considerate. This approach helps meet the needs of the patient while also incorporating the information provided during the caring process. This approach is very patient-centered and guarantees that any change that is made to a patient’s plan of care is based on evidence-based practices (Skoumal et al., 2024).
Compare Learning Session Content with Best Practices
The literature used on evaluation as a guide, learning sessions for elderly care should be closely lined up with best practices. These best practices show active engagement, accessibility, and relevance to the target audience. These practices must also incorporate the goals and objectives presented in the Healthy People 2030 document. This document centers on improving health and well-being for all, including decreasing health disparities among older adults (Mitra et al., 2022).
Alignment with Best Practices
According to the literature, effective learning sessions for the elderly should incorporate interactive elements, use clear and simple language, and provide content that is directly applicable to the daily lives of participants (Goodall et al., 2020). This approach helps to guarantee that educational content is not only understood by the elderly. It also guarantees that the information is preserved and utilized in managing their health conditions.
Revisions Based on Healthy People 2030
Healthy People 2030 points out the importance of preventive health measures and chronic disease management for older adults (Mehanna, 2022). Learning sessions are lined up with these objectives; content might need to be revised to include more information on preventive screenings. Additionally, it should cover dietary recommendations and exercise routines that are suitable for older adults. This alignment guarantees that the sessions are not only educational but also contribute directly to the national health objectives. In particular, it centers on improving physical and mental health outcomes for the elderly.
Need for Revisions
The need for revisions in the learning content becomes clear when gaps are identified between current educational outcomes and the desired health outcomes outlined in Healthy People 2030 (Mehanna, 2022). For example, if initial sessions do not properly deal with the prevention of falls—a common issue among the elderly—additional content would be incorporated. This content would educate participants about fall prevention strategies, thereby lining up more closely with the Healthy People goals of reducing injury and improving quality of life among older adults.
Conclusion
The enhanced care coordination plan for elderly care is designed with due consideration to ethical considerations, practicality, and health policies. This plan serves as a framework for dealing with critical health issues among the elderly. The use of community resources, besides being aligned with the Healthy People 2030 framework, sets this plan on the right track for realizing better health outcomes and improved quality of life among older persons. This means that constant review and adjustment of this plan will ensure that it is relevant and relevant within the lives of this population. This preventive approach demonstrates our dedication to providing high-quality and sensitive care to the elderly.
References
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Collado-Mateo, D., Lavín-Pérez, A. M., Peñacoba, C., Del Coso, J., Leyton-Román, M., Luque-Casado, A., Gasque, P., Fernández-del-Olmo, M. Á., & Amado-Alonso, D. (2021). Key factors associated with adherence to physical exercise in patients with chronic diseases and older adults: An umbrella review. International Journal of Environmental Research and Public Health, 18(4). https://doi.org/10.3390/ijerph18042023
Dario, H., & Spatz, D. L. (2023). An integrative review of breastfeeding and homelessness. Nursing for Women’s Health. https://doi.org/10.1016/j.nwh.2023.06.002
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Maresova, P., Ondrej Krejcar, Raihan Maskuriy, Nor, Selamat, A., Zuzana Truhlářová, Horak, J., Miroslav Joukl, & Vítková, L. (2023). Challenges and opportunity in mobility among older adults – key determinant identification. BMC Geriatrics, 23(1). https://doi.org/10.1186/s12877-023-04106-7
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