NURS FPX 4900 Assessment 4 Patient, Family, or Population Health Problem Solution

NURS FPX 4900 Assessment 4 Patient, Family, or Population Health Problem Solution

Patient, Family, or Population Health Problem Solution

During my practicum sessions with Clay, it was evident that Alzheimer’s represents an escalating public health crisis affecting over 55 million individuals globally (Alzheimer’s Association, 2023). To address Clay’s progressive cognitive decline and his family’s mounting caregiving demands, implementing a comprehensive care plan incorporating technology, care coordination, and community-based resources is imperative. The multifaceted approach from the healthcare system and the local community demonstrates a holistic, patient-centered solution to enhance Clay’s quality of life while supporting family caregivers as Alzheimer’s inevitably advances.

Proposed Interventions

To address Clay’s Alzheimer’s disease, I will implement an intervention plan including:

  • Technology: Obtain a wearable GPS tracker and install home sensors to monitor Clay’s movements, location, and safety. Set up a family portal for sharing real-time updates and alerts to balance independence and supervision (Braly et al., 2020).
  • Community Resources: Connect his family with the Alzheimer’s Association to access counseling, support groups, legal assistance, and respite care subsidies. Enroll Clay in an adult day program through the Senior Center for Social Engagement (Resnick & Galik, 2020).
  • Care Coordination: Develop a centralized care plan documenting Clay’s needs, providers, and supports. Designate a case manager to organize appointments, referrals, and transitions between healthcare and community services (Lobão, 2021).

This proactive intervention plan will fully leverage technology, care coordination, and community partnerships to provide Clay with the comprehensive support required as his Alzheimer’s progresses.   

Role of Leadership and Change Management

Implementing an impactful intervention for Clay will require strong nursing leadership and change management strategies. As his care coordinator, I can exemplify transformational leadership qualities to motivate and inspire my team to address Clay’s multidimensional needs collaboratively. Transformational leaders exhibit attributes like visionary thinking, emotional intelligence, role modeling, and empowerment of others. By painting a compelling vision for Clay centered on humanistic values and synergizing providers across settings, I can catalyze commitment to person-centered dementia care. My ability to connect empathetically with Clay’s family while supporting my team members will further unite. Modeling optimism, critical thinking, and advocacy can help drive change (Moenke et al., 2023).

The McKinsey change model provides an evidence-based framework for transforming practice. This three-step process involves creating a climate for change, engaging and enabling stakeholders, and implementing and sustaining change initiatives. First, I will make a compelling case for innovating our Alzheimer’s resources by presenting data on burgeoning needs and intervention benefits. Next, collaborating with Clay’s family, providers, support organizations, and payers will foster buy-in. Finally, coordinating technology acquisition, resource linkages, case management, and outcomes tracking can sustain interventions. Adaptive leadership and continuous re-evaluation will be pivotal as Clay’s trajectory evolves (Bamford et al., 2023).

Informed Nursing Ethics

Nursing ethics fundamentally shape the patient-centered nature of the intervention. Applying principles of autonomy, I emphasize Clay’s values/preferences, shared decision-making with family, and informed consent regarding technologies. Beneficence drives my focus on evidence-based solutions to enhance Clay’s quality of life. Justice compels the coordination of equitable services across communities. Lastly, non-maleficence underscores safe technology use and the protection of privacy. Letting nursing ethics guide leadership and change management illuminates the most humanistic, holistic solutions. Ultimately, these synergistic frameworks steer the development of an intervention honoring Clay’s individuality while bettering population health outcomes, system efficiency, and team member empowerment. The result is sustainable, ethical innovation (Milton, 2022).

Influence on the Development of Intervention

In crafting Clay’s intervention plan, transformational leadership guides my focus on inspiring and developing my team to adopt an innovative mindset that enhances Alzheimer’s care through technology, collaboration, and humanistic practice. My vision-casting, role-modeling, and mentoring help motivate staff toward this care transformation aligned with our professional values. Meanwhile, the McKinsey change cycle provides an ethical, collaborative structure emphasizing the engagement of all stakeholders in the design and evaluation of practice changes. This systems-thinking approach allows me to implement technology and community partnerships to address diverse needs and viewpoints (Gallagher-Thompson et al., 2020).

Coupling transformational leadership, structured change management and unwavering ethical practice form a comprehensive approach to devising interventions that transcend isolated change. This fusion empowers me to think broadly, collaborate openly, uplift my team, center the patient, and transform care to meet urgent needs like those of Clay and his family amidst the growing Alzheimer’s epidemic. It provides a blueprint for holistic health system change (Gallagher-Thompson et al., 2020).

Communication and Collaboration Strategies

Effective communication and collaboration with Clay and his family are foundational to improving his Alzheimer’s management and quality of life. I will employ communication techniques like making eye contact, speaking slowly, and using concise phrases to optimize Clay’s engagement and understanding. Visual aids like written instructions, daily calendars, and timers can structure information. Educating his wife on the TELE (Tell, Explain, Listen, Encourage) method gives her a framework to connect meaningfully with Clay through reminiscence, not correction. Scheduling regular care conferences allows collective goal-setting and care planning with Clay’s family and providers (Collins et al., 2022).

Collaborating closely with Clay’s loved ones facilitates coordinated, person-centered care. I will take a family-centered approach that acknowledges their intimate knowledge of Clay’s needs and empowers shared decision-making. Linking family with an Alzheimer’s Association care consultant offers peer support. Consistent check-ins ensure all voices are heard. Virtual communities like the Alzheimer’s Family Caregiver Support Group on Facebook provide further connections. Participating in local dementia task forces engages his family in broader systems change. Centering compassion and trust in all collaboration uplifts Clay’s inner dignity. These evidence-based communication and collaboration techniques can enhance understanding, transparency, advocacy, and solidarity to optimize Clay’s care (Degenholtz et al., 2020).

Benefit of Input from Patient of Family

Centering the experiences and preferences of patients and families through collaborative engagement fosters individualized, holistic care and improved health outcomes (Gilbert & Cousins, 2022). Clay’s wife and children have invaluable insights into his personality, behaviors, and needs that can inform care planning. Their first-hand account of Clay’s lived experience with Alzheimer’s surpasses clinical observations. Prioritizing their goals and values through shared decision-making empowers Clay’s family as partners in his care. Their involvement can enhance adherence, coordination, and access to community resources. Research shows patient and family engagement leads to reduced hospitalizations, improved quality of life, and higher satisfaction for those with chronic illnesses like Alzheimer’s (Kemp et al., 2021). Obtaining ongoing input from Clay and his loved ones is foundational to providing ethical, high-value care amidst a complex, debilitating condition.

Guidance by State Board Nursing Practice or Policies

The state nursing board provides standards that shaped the development of Clay’s intervention, including competent use of technologies, care coordination, and referrals (State Board of Nursing, 2020). For example, standards for telehealth guided the inclusion of virtual visits, stating I must verify patient identity, obtain informed consent, and document assessments like face-to-face encounters. Our organizational EHR (Electronic Health Record) policies informed my plan to create a centralized, integrated care plan with treatment goals accessible across Clay’s care team. CMS (Centers for Medicare & Medicaid Services) policies outline required components of care plans for patients receiving home health services, which Clay may need in the future (Centers for Medicare & Medicaid Services, 2021). Additionally, local dementia programs abide by policies on qualifying for respite financial assistance based on level of impairment and income. Following these federal, state, and organizational standards ensured my proposed intervention met requirements to enable access to technologies, high-quality care coordination, and community resources within the ethical and regulated practice (Prophater et al., 2021).

Further, I integrated standards on person-centered care, family engagement, and dementia training into the intervention. Standards emphasizing shared decision-making, caregiver education, and connecting patients with support services guided the inclusion of family conferences and Alzheimer’s Association referrals. Mandates to complete regular dementia education informed my focus on specialized communication techniques, resources, and care planning. Allowing evidence-based standards to ground the intervention promotes safe, ethical, high-value care for Clay aligned with guidelines and regulations across the health system, governmental, and community levels. This systems-aware approach is key to developing impactful, sustainable practice innovations (American Nurses Association, 2023).

Effectiveness of Standards and Policies

Research demonstrates the value of integrating nursing standards and policies into dementia care to enhance outcomes. Studies show adherence to person-centered planning standards improves quality of life and reduces agitation in Alzheimer’s patients versus non-standardized care. Certified dementia programs meeting standardized operational policies demonstrate reduced falls and hospitalizations. These and other studies provide credible evidence that implementing nursing practice standards and integrating health policy maximizes quality, safety, coordination, and resource access—critical to improving outcomes for Alzheimer’s patients and families. Adhering to evidence-based standards and policies is essential to optimizing care (Travers et al., 2021).

Improvement in Care, Cost, and Safety

The multifaceted intervention proposed for Clay will enhance quality by taking a patient-centered approach and aligning care with his values and preferences through technologies like telehealth for convenient provider access and sensors to allow independent living. Structured communication strategies and care conferences improve understanding and transparency between Clay, family, and providers. Care coordination also increases quality by reducing fragmented services and enabling a holistic view of Clay’s needs. Enhanced safety is achieved through GPS trackers locating Clay when wandering and fall alerts monitoring risks in the home. Access to community resources like respite care reduces caregiver stress and burnout that could otherwise lead to patient safety issues (Mahmoud et al., 2020).

Regarding costs, research shows that care coordination programs decrease unnecessary hospitalizations and ER visits in dementia patients, resulting in average savings per patient monthly (Willink et al., 2020). GPS devices can provide rapid searches compared to extensive police-involved cases. Telehealth improves system efficiency through reduced travel and optimized provider time. For families, respite services and adult day programs may reduce individual long-term care costs. The intervention optimizes quality, safety, coordinated access, provider relations, resource efficiency, and cost savings across individual, family, and system levels through integrated technology and community solutions (Lindauer et al., 2022).

Credible evidence supports this personalized, collaborative intervention to significantly enhance the care experience, relationships, safety, clinical outcomes, and costs for Clay and his Alzheimer’s disease. The impacts reflect the massive potential of integrated, patient-centered solutions at the intersection of health systems, policy, and local community resources. This intersection is where nurses can be most impactful in driving lasting improvements (Moenke et al., 2023).

Benchmark Data

To evaluate the impact of this intervention, I will collect benchmark data from credible sources. The Alzheimer’s Association’s annually reported Facts and Figures, benchmark care costs, hospitalizations, mortality, and quality metrics that I can compare to Clay’s outcomes (Alzheimer’s Association, 2023). Our state nursing board publishes an annual report on complaints, competencies, and licensing statistics to inform professional practice evaluation (State Board of Nursing, 2022). CMS Nursing Home compare data offers quality indicators like falls and restraint use for benchmarking (Centers for Medicare & Medicaid Services, 2021). Our own organization’s dementia care committee tracks metrics on family satisfaction, ER utilization, and more that contextualize internal performance. Finally, Johns Hopkins University produces an annual Dementia Care Report Card grading states in care coordination policy and dementia training mandates. Comparing our intervention’s impacts to these benchmarking sources offers meaningful, comprehensive data to guide iterative quality and policy improvements for Clay and beyond (Bae-Shaaw et al., 2021).

Incorporation of Technology, Care Coordination, and Community Resources

Technology, care coordination, and community resources are pivotal components of a multidimensional intervention addressing Clay’s escalating Alzheimer’s disease. Implementing GPS trackers, home sensors, and telehealth platforms enhances safety, independence, and access to care. Developing a centralized care plan accessible across Clay’s providers, case managers, and caregivers can reduce fragmented, ineffective care delivery, demonstrated to decrease hospitalizations. Referring his family to the Alzheimer’s Association provides counseling, support groups, adult day programs, and legal advice to improve coping and reduce burnout (Alzheimer’s Association, 2023).

Specific technologies like GPS devices curb unsafe wandering, which affects Alzheimer’s patients, by quickly locating patients who become lost. Telehealth improves coordination and provider access, decreasing ER visits for nursing home dementia residents compared to usual care (Garcia, 2022). Lastly, adult day programs offering social engagement and caregiver respite show significantly lower rates of institutionalization compared to those not attending programs. In summary, strong evidence supports synergizing technology tools, care coordination activities, and community resources to enhance quality, access, safety, and cost-savings – optimizing outcomes for Alzheimer’s patients and families (Lindauer et al., 2022).

Conclusion NURS FPX 4900 Assessment 4 Patient, Family, or Population Health Problem Solution

Alzheimer’s disease represents an escalating public health crisis that necessitates urgent health systems change and policy innovation to meet the multifaceted needs of patients like Clay and their families. As Clay’s nurse, I have proposed a comprehensive, evidence-based intervention incorporating technology integration, care coordination, and strategic community partnerships based on contemporary nursing science and ethical, patient-centered practice. This solution holds immense potential to enhance Clay’s safety, independence, and quality of life amidst cognitive decline while improving care team communication, reducing fragmentation, providing holistic support, and lowering costs across health and social systems.

References

Alzheimer’s Association. (2023). Alzheimer’s and Dementia. Alzheimer’s disease and dementia. https://www.alz.org/alzheimer_s_dementia 

American Nurses Association. (2023). Code of ethics for nurses. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/ 

Bae-Shaaw, Y., Lekovitch, C., Chew, F., Leland, N., Sood, N., & Shier, V. (2021). The impact of state dementia training requirements for nursing homes on resident outcomes. Innovation in Aging5(1), 550–550. https://doi.org/10.1093/geroni/igab046.2098 

Bamford, C., Wilcock, J., Brunskill, G., Wheatley, A., Harrison Dening, K., Manthorpe, J., Allan, L., Banerjee, S., Booi, L., Griffiths, S., Rait, G., Walters, K., & Robinson, L. (2023). Improving primary care based post-diagnostic support for people living with dementia and carers: Developing a complex intervention using the theory of change. PLOS ONE18(5)https://doi.org/10.1371/journal.pone.0283818 

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Centers for Medicare & Medicaid Services. (2021). CMS announces new details of plan to cover new Alzheimer’s drugs | CMS. Www.cms.gov. https://www.cms.gov/newsroom/fact-sheets/cms-announces-new-details-plan-cover-new-alzheimers-drugs 

Collins, R., Hunt, A., Quinn, C., Martyr, A., Pentecost, C., & Clare, L. (2022). Methods and approaches for enhancing communication with people with moderate-to-severe dementia that can facilitate their inclusion in research and service evaluation: Findings from the IDEAL programme. Dementia21(4)https://doi.org/10.1177/14713012211069449 

Degenholtz, H., Kemp, C., & Pace, D. (2020). Addressing the needs of persons living with dementia across care settings (A collaborative symposium between the assisted living and research in quality care interest groups). Innovation in Aging4(1), 668–668. https://doi.org/10.1093/geroni/igaa057.2314 

Gallagher-Thompson, D., Choryan Bilbrey, A., Apesoa-Varano, E. C., Ghatak, R., Kim, K. K., & Cothran, F. (2020). Conceptual framework to guide intervention research across the trajectory of dementia caregiving. The Gerontologist60(1), 29–40. https://doi.org/10.1093/geront/gnz157 

Garcia, L. (2022). Development of a telehealth intervention for people with dementia: Road map (Recovery‐oriented approach to dementia through meaningful activity participation). Alzheimer’s & Dementia18(8). https://doi.org/10.1002/alz.067848 

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Kemp, C. L., Bender, A. A., Ciofi, J., Craft Morgan, J., Burgess, E. O., Duong, S., Epps, F. R., Hill, A. M., Manley, P. R., Sease, J., & Perkins, M. M. (2021). Meaningful engagement among assisted living residents with dementia: Successful approaches. Journal of Applied Gerontology40(12), 1751–1757. https://doi.org/10.1177/0733464821996866 

Lindauer, A., Gothard, S., Boardman, C., Smith, S., Mattek, N., McDaniel, D., Bernard, H., Tran, L., & Tadesse, R. (2022). Support for dementia care partners using telehealth: Tele‐stella phase 1. Alzheimer’s & Dementia18(2). https://doi.org/10.1002/alz.064128 

Lobão, M. J. (2021). Solution to support informal caregivers of patients with dementia. Procedia Computer Science181, 294–301. https://doi.org/10.1016/j.procs.2021.01.149 

Mahmoud, H., Vogt, E. L., Dahdouh, R., & Raymond, M. L. (2020). Using continuous quality improvement to design and implement a telepsychiatry program in rural Illinois. Psychiatric Services71(8), 860–863. https://doi.org/10.1176/appi.ps.201900231 

Milton, C. L. (2022). Ethics and emerging health policy. Nursing Science Quarterly35(3), 295–297. https://doi.org/10.1177/08943184221095083 

Moenke, L., Handley, M., & Goodman, C. (2023). The influence of care home managers’ leadership on the delivery of person-centred care for people living with dementia: A systematic review. Journal of Nursing Management2023, 1–12. https://doi.org/10.1155/2023/9872272 

Prophater, L., Kim, B., Belza, B., Cameron, S., & Fazio, S. (2021). Dementia care coaching: A pilot to evaluate acceptability and feasibility in care communities. Innovation in Aging5(1), 853–854. https://doi.org/10.1093/geroni/igab046.3093 

Resnick, B., & Galik, E. (2020). Implementation of function and behavior focused care. Innovation in Aging4(1), 777–777. https://doi.org/10.1093/geroni/igaa057.2809 

State Board of Nursing. (2020). The world leader in nursing regulatory knowledge. Ncsbn.org. https://www.ncsbn.org/ 

Travers, J. L., Caceres, B. A., Vlahov, D., Zaidi, H., Dill, J. S., Stone, R. I., & Stone, P. W. (2021). Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis. Nursing Outlook69(4), 617-625. https://doi.org/10.1016/j.outlook.2021.01.004 

Willink, A., Davis, K., Johnston, D. M., Black, B., Reuland, M., Stockwell, I., Amjad, H., Lyketsos, C. G., & Samus, Q. M. (2020). Cost-effective care coordination for people with dementia at home. Innovation in Aging4(2). https://doi.org/10.1093/geroni/igz051

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