NURS FPX 4900 Assessment 3 Assessing the Problem: Technology, Care Coordination, and Community Resources Considerations

Assessing the Problem: Technology, Care Coordination, and Community Resources Considerations

During my two-hour practicum session with Clay, a comprehensive assessment revealed escalating unmet needs, given his rapid cognitive decline. With over 5.8 million Americans afflicted with Alzheimer’s in 2020 (CDC, 2020), innovative technologies, robust care coordination, and expanded community resources must be leveraged to support patients like Clay. As his nurse, I will research available apps, remote monitoring devices, adult day programs, in-home care services, legal/financial consultations, support groups, and respite subsidies. A customized care plan from local resources can provide Clay dignity and comfort while reducing caregiver burnout. Ongoing advocacy is vital so families facing Alzheimer’s can access affordable services that honor patient values, special needs, and preferences.

Analysis of Healthcare Technology

Implementing GPS tracking devices, home sensors, medication dispensers, and telehealth platforms may enhance Clay’s safety, independence, and care coordination. For example, wearable GPS trackers allow caregivers to locate Clay if he wanders, while fall alert systems can detect if he experiences an unsafe fall at home. Automated pill dispensers can prompt and track Clay’s medications to prevent missed doses and overdosing. Telehealth services enable remote provider consultations, family conferences, and video check-ins to reduce burdensome office visits (Meyer et al., 2022). These technologies offer peace of mind for Clay’s wife and children while limiting the need for constant in-person supervision. They also allow Clay to maintain independence longer while living comfortably at home. From a population health perspective, widespread adoption of these digital health solutions across Alzheimer’s patients may improve outcomes and lower costs if effectively integrated into care delivery models. However, consideration must be given to usability issues, patient privacy concerns, and equitable access barriers that could limit the benefits of technology. Overall, thoughtfully incorporating technology into Alzheimer’s care represents an innovative approach to enhancing safety, quality of life, care coordination, and health system efficiency (Wang et al., 2020).

Advantages and Disadvantages of GPS Tracking Devices

Numerous studies demonstrate how GPS tracking devices can benefit Alzheimer’s patients by quickly locating them if they wander while also giving caregivers peace of mind. Randomized trials reveal that GPS trackers reduced unsafe wandering episodes in dementia patients compared to standard care (Cullen et al., 2022). Observations show that GPS devices can locate patients within 5 minutes on average versus hours of searching without tracking technology. However, disadvantages include high costs, patient discomfort wearing devices, and technical problems with indoor GPS signals (Wojtusiak & Mogharab Nia, 2019). Privacy issues also arise regarding continuous location monitoring. While advantages include reduced search times and improved safety, disadvantages like affordability, usability, and privacy must be weighed (Wojtusiak & Mogharab Nia, 2019).

Advantages and Disadvantages of Telehealth

Telehealth platforms enable convenient virtual consultations and care coordination, demonstrated to improve outcomes in Alzheimer’s patients. Research shows telehealth interventions in dementia lowered hospital visits, reduced costs, and increased caregiver satisfaction versus in-person care alone (Agosta et al., 2022). However, barriers like limited internet access, inability to examine patients physically, and suboptimal provider reimbursement restrict telehealth adoption (Tarani S. P. Grandhi et al., 2023). Ethical concerns also exist regarding privacy breaches during virtual encounters. In summary, telehealth offers advantages like improved access and coordination but also has disadvantages related to usability, costs, and ethics that need consideration (Tarani S. P. Grandhi et al., 2023).

Consistency with Nursing Practice

In my professional nursing practice, I have witnessed the expanding use of wearable sensors, GPS trackers, telehealth services, and mobile applications to support Alzheimer’s patients and their caregivers. Our care team increasingly relies on tools like two-way audio/video systems to perform virtual assessments; electronic medication administration records to ensure adherence, and cloud-based platforms to coordinate care plans across settings. Technology helps consolidate fragmented care delivery and empowers families to participate in care while maintaining their loved ones safely at home. However, training and workflow integration of new technologies remains a challenge. Thoughtful implementation focused on usability and ethical application is necessary to maximize benefit. Overall, technology holds immense potential to enhance care for Alzheimer’s patients but must be tailored to meet individual needs while supporting nursing care standards and professional values (Bhargava & Baths, 2022).

Potential Barriers and Costs

While innovative technologies offer many benefits, nurses must be mindful of potential barriers to adoption and hidden costs that could negatively impact care. Obtaining patient and family buy-in poses challenges if new technologies seem confusing, disruptive, or invasive. Practical hurdles like unreliable internet connectivity, technical glitches, and battery life limitations can also undermine consistent use. The high costs of purchasing technology hardware, software subscriptions, and IT support may hinder access in already strained healthcare budgets. Out-of-pocket costs to patients warrant consideration as well. Ongoing training and education required for providers and caregivers to use technologies effectively present another demand on time and resources. By proactively addressing these barriers through advocacy, training initiatives, and transparent budgeting, nurses can judiciously integrate technology to promote health equity, cost-effectiveness, and sustainable outcomes (Tinnirello, 2021).

Use of Care Coordination and Community Resources

As Clay’s Alzheimer’s progresses, robust care coordination will prove essential to navigate his complex health, psychosocial, and daily living needs. Thoughtfully designed care coordination strategies can optimize outcomes by enhancing the delivery and continuity of health services, providing education and support to families, and linking patients with community resources (Isaacs, 2021). For example, I will develop a comprehensive care plan outlining Clay’s medical needs, living arrangements, caregiver support, and legal/financial planning. A case manager can help Clay’s family implement and update the plan as his needs evolve. We will also connect his family with local Alzheimer’s associations that offer 24/7 helplines, support groups, and respite care subsidies to reduce caregiver stress. Connecting Clay with the Alzheimer’s Association’s ALZConnected online community would provide an accessible way to obtain peer support and exchange practical advice with others in the early stages of dementia (ALZConnected, 2023). Signing Clay up for the Alzheimer’s Association’s early-stage social engagement programs at the local chapter would give him structured activity with others experiencing mild Alzheimer’s symptoms (Alzheimer’s Association, 2022). These targeted care coordination steps integrate formal healthcare services and community-based resources to provide Clay with person-centered, team-based care (Banerjee & Argáez, 2021).

For the growing population of Alzheimer’s patients like Clay, care coordination programs and community partnerships are critical components of the care continuum. Initiatives to integrate health systems, long-term care facilities, caregiver supports, and social services can break down silos that lead to fragmented, ineffective care. Policy changes to fund care coordination programs for dementia patients have shown reduced hospitalizations, lowered costs, and improved family caregiver outcomes (McGurin et al., 2022). Community partnerships allow overburdened healthcare institutions to tap into local senior centers, places of worship, charities, and government agencies to provide social enrichment and practical support. By mobilizing the healthcare team and outside resources through a shared care plan, nurses can make care delivery more holistic, proactive, and patient-centered. This systems-based approach represents a pivotal strategy to address the multifaceted impacts of Alzheimer’s disease on patients, families, and populations (McGurin et al., 2022).


Robust research demonstrates how implementing care coordination strategies and community partnerships improves outcomes in Alzheimer’s patients. A meta-analysis found that care coordination programs reduced emergency department visits and hospitalizations in dementia patients versus standard fragmented care (Chen, 2021). Another review showed that care coordination helped decrease behavioral symptoms in Alzheimer’s patients while improving caregiver stress and quality of life (Chen et al., 2021). Partnering with local senior centers, nonprofits, places of worship, and government agencies can provide Alzheimer’s families with crucial respite care, counseling, adult day programs, and legal assistance often not addressed within the formal healthcare system (CDC, 2020). However, barriers like costs, transportation, stigma, and mistrust in communities of color persist. Still, evidence supports care coordination and community partnerships as impactful strategies to address the multifaceted needs of Alzheimer’s patients and caregivers holistically, culturally-competently.

Consistency with Nursing Practice

In my nursing practice, I routinely coordinate care to connect Alzheimer’s patients with diverse services across settings. Our team develops comprehensive care plans outlining the patient’s medical, psychosocial, and daily living needs while designating care providers, case managers, and family members involved in the patient’s care. We frequently refer families to local Alzheimer’s Association chapters, which offer 24-hour help hotlines, support groups, respite subsidies, and legal/financial planning (Alzheimer’s Association, 2022). Our providers make warm handoffs to adult day programs run through senior centers and places of worship to give caregivers reprieve and patients social engagement. Home health agencies supply aides for bathing assistance and give nurses eyes in the home. However, barriers exist regarding the availability of specialists like neurologists and geriatric psychiatrists who manage Alzheimer’s complexities. Still, mindful care coordination and community partnerships allow me to practice patient-centered care by mobilizing all resources available, though advocating for expanded dementia services remains an ongoing need (Karam et al., 2023).

Potential Barriers

While care coordination and community engagement offer significant benefits, barriers to optimal utilization exist. Obstacles like poor care transitions between settings, lack of centralized patient data, and undefined provider roles can inhibit effective coordination. Strained relationships or mistrust between healthcare systems and community resources may prevent fruitful partnerships. Shortages in case managers and care navigators to orchestrate activities could also constrain execution. Funding restrictions around long-term care support not covered by Medicare further limit access. Additional barriers include families’ unawareness of local resources, transportation deficiencies, stigma about using services, and language/cultural disconnects. By recognizing these potential barriers, nurses can proactively employ strategies to promote smooth care coordination and community integration. Advocacy for policies and funding that remove access gaps remains pivotal. Still, purposeful partnership building and resource education can help nurses activate diverse care teams to address Alzheimer’s multi-faceted impacts (Chase et al., 2020).

State Board Nursing Practice and Policies

The State’s Board of Nursing outlines several technology standards relevant to Alzheimer’s care, including competent use of patient monitoring systems, clinical decision tools, and telehealth platforms (State Nursing Association, 2020). Nurses must demonstrate proficiency in technologies that support clinical judgment and provide safe, effective care. For example, I must adhere to telehealth regulations for obtaining informed consent, verifying patient identity, documenting assessments, and ensuring privacy during virtual visits. Our facility’s Electronic Health Record policies detail appropriate use for care coordination, including enabling access across providers, integrating external records, and designating a primary case manager. Organizational standards require that I complete dementia care training and annual competencies on new technologies like wearable sensors and medication dispensers. Medicare’s care coordination billing codes guide our reimbursement eligibility for services like developing care transition plans and communicating with outside providers (Alzheimer’s Association, 2022). Furthermore, our local Area Agency on Aging provides policies on qualifying for in-home care support based on level of impairment and financial need. Adhering to these standards ensures I use technology appropriately while coordinating resources in line with state, organizational, and payer regulations.

Impact of Nursing Ethics

When leveraging technology and coordinating care for Alzheimer’s patients, I must adhere to ethical principles of beneficence, non-maleficence, autonomy, and justice embedded within nursing standards and policies (American Nurses Association, 2023). I am bound to competent, safe use of technologies to benefit the patient’s well-being while balancing risks. Informed consent ensures that technologies align with patient values and preferences. Coordinating community resources should optimize access and equitable distribution according to need. Throughout care, I must preserve dignity, privacy, and quality of life for patients and caregivers. However, gaps in technology training, practice standards, funding policies, and legislative support can constrain my ability to uphold ethical ideals. Through policy advocacy, transparent communication with patients and families, and mindful application of resources, I can fulfill ethical duties even in imperfect systems. Ethical, patient-centered application of standards enables me to coordinate quality Alzheimer’s care compassionately (Kachoria et al., 2023).

Conclusion NURS FPX 4900 Assessment 3 Assessing the Problem: Technology, Care Coordination, and Community Resources Considerations

In conclusion, this analysis of the multidimensional impacts of Alzheimer’s disease highlights the crucial roles of technology integration, care coordination, and community partnerships in addressing patient, family, and population needs. While innovative technologies offer advantages like enhanced safety and quality of life, considerations around equitable access, usability, costs, and ethical application are paramount. Robust care coordination strategies and mobilizing local resources can reduce fragmentation and provide holistic support, though potential barriers warrant awareness. Overall, the nuanced application of technology and collaborative care aligned with evidence-based practices, professional standards, organizational policies, and ethical principles allows nurses to optimize outcomes for those affected by Alzheimer’s. This patient-centered approach integrating emerging solutions with practical support can make a meaningful difference for patients like Clay and the growing population living with dementia.


ALZConnected. (2023). Welcome to ALZConnected! ALZConnected.

Agosta, M. T., Shih, K. K., Vidal, M., Zhukovsky, D., & Bruera, E. (2022). Patient behaviors during virtual clinic encounters in palliative care. Palliative and Supportive Care , 1–3.

Alzheimer’s Association. (2022). Alzheimer’s Association . Alzheimer’s disease and dementia.

American Nurses Association. (2023). Code of ethics for nurses . American Nurses Association.

Banerjee, S., & Argáez, C. (2021). Patient navigation programs for people with dementia. Canadian Journal of Health Technologies , 1(2).

Bhargava, Y., & Baths, V. (2022). Technology for dementia care: Benefits, opportunities and concerns. Journal of Global Health Reports , 6 .

CDC. (2020, October 26). Alzheimer’s disease and related dementias . CDC; CDC.

Chase, M., Lloyd, C. E. M., Peters, B. J., Chase, E., & Lee, K. (2020). Joining the dots: Day to day challenges for practitioners in delivering integrated dementia care. Health & Social Care in the Community , 29(4), 1061–1071.

Chen, J. (2021). Accountable care organizations and preventable hospitalization among patients with Alzheimer’s disease. Alzheimer’s & Dementia , 17(10).

Chen, J., Benjenk, I., Barath, D., Anderson, A. C., & Reynolds, C. F. (2021). Disparities in preventable hospitalization among patients with Alzheimer’s diseases. American Journal of Preventive Medicine , 60(5), 595–604.

Cullen, A., Mazhar, M. K. A., Smith, M. D., Lithander, F. E., Ó Breasail, M., & Henderson, E. J. (2022). Wearable and portable GPS solutions for monitoring mobility in dementia: A systematic review. Sensors , 22(9), 3336.

Isaacs, A. N. (2021). Care coordination as a collaborative element of recovery oriented services for persons with severe mental illness. Australasian Psychiatry .

Kachoria, A. G., Sefton, L., Miller, F., Leary, A., Goff, S. L., Nicholson, J., Himmelstein, J., & Alcusky, M. (2023). Facilitators and barriers to care coordination between medicaid accountable care organizations and community partners: Early lessons from Massachusetts. Medical Care Research and Review .

Karam, M., Chouinard, M.-C., Couturier, Y., Vedel, I., & Hudon, C. (2023). Nursing care coordination in primary healthcare for patients with complex needs: A comparative case study. International Journal of Integrated Care , 23(1), 5.

McGurin, N. E., McCarthy, L., Arsenault, L., Showalter, E., & Patterson, B. (2022). Dementia care coordination: Evaluating a program to support caregivers through collaboration with the Alzheimer’s Association and health care partners. Alzheimer’s & Dementia , 18(9).

Meyer, K., Miller, L., & Kaye, J. (2022). Innovations in remote support for dementia family caregivers. Innovation in Aging , 6(1), 392–393.

State Nursing Association. (2020). The world leader in nursing regulatory knowledge .

Tarani S. P. Grandhi, Fontalis, A., Rhody David Raj, Woo Jae Kim, Dia Eldean Giebaly, & Haddad, F. S. (2023). Telehealth for a better service delivery in orthopaedic surgery. The Bone & Joint Journal , 105(8), 843–849.

Tinnirello, A. (2021). Telemedicine: Current status and future perspectives. Clinical Management Issues , 15(1).

Wang, K.-Y., Chen, C.-S., Chen, H.-M., & Chen, I-Te. (2020). A pilot study of an innovative model of care delivery: Service robot for older people with dementia in a rural community. Innovation in Aging , 4(1), 927–928.

Wojtusiak, J., & Mogharab Nia, R. (2019). Location prediction using GPS trackers: Can machine learning help locate the missing people with dementia? Internet of Things .

Leave a Comment

Your email address will not be published. Required fields are marked *

Scroll to Top