Dementia Care plan and Care Coordination


       This study explores the short- and long-term care needs of a patient who was admitted to the hospital with pneumonia, worsening symptoms of dementia and has six other comorbidities. The short-term needs focus on how the hospital will manage the presenting condition and the comorbidities. The long-term goals deal with simple ways quality of life can be improved once discharged into a nursing home or community care services. The aim, in this case, is to formulate care plans, that are based on the current and perceived needs of the patient in relation to disease progression. This care plan will be done in collaboration with other health care professionals. It is also important that this care plan is not rigid and can change based on the clinical and functional status of the patient (Sørensen et al., 2020). The care plan aims to manage the patient’s condition holistically. Holistic care is care that considers the physical, emotional, social, economic and spiritual needs of the patient. (Ventegodt et al., 2016).  The paper also looks at the important role care coordinators have in ensuring that there are no gaps in access to care services while the patient is in hospital, home or nursing home. The role of the care coordinator, in this case, is to bring together professionals from other disciplines to work out a care plan that benefits the family and the patient (Wayne Zachary et al., 2016). Successful care coordination requires four main elements, these include; easy access to a range of health care services, effective care planning transitions and good communication. Also, a focus on the total health care needs of the patient and clear, simple information that the patient/carer can understand (Catalyst, 2018).

Care Needs

       The immediate care needs prior to the patient being discharged to either the care home or the community, is to develop a care plan for medication administration. The care plan should include some of the reasons for refusal of medication and the strategies for administration. It is common to hear from caregivers about the challenges they face when administering medication to people with worsening dementia symptoms. When confronted with refusal of care on any the challenging behaviours it is important to remember that these behaviours are sometimes their way of communicating. The first step to managing this process is to provide a calm environment.  Sometimes, people with dementia refuse medication in response to feeling rushed, afraid and often confused as to what they are supposed to do. In some cases, refusal of medication can be in response to the feeling of loss of control, which can in turn trigger anger and agitation (Backhouse et al., 2020). But often, refusal to take medication can be attributed to the pills being too big to swallow, or the medication leaves and unpleasant taste in the mouth. After performing a swallowing assessment, consultation with the physician and pharmacist will be needed to prescribe medications that are crushable (Curyto et al., 2017).

        Since the patient does not have the cognitive ability to advocate for themselves, the care plan will be done in partnership with the family. The care plan will aim to manage the patient’s comorbidities holistically. Behavioural and Psychological Symptoms of Dementia (BPSD) represent a diverse group of non-cognitive symptoms that happen in people with dementia. BPSD represent a major component of the dementia syndrome irrespective of the type. These symptoms include; agitation, anxiety, apathy, irritability, depression and disruption in sleep. The severity of these symptoms is dependent on the patient and stage of dementia (Wang et al., 2020). In this case the family have reported that, patient has become unpredictable and refusing care, suggesting that the patient is in moderate to severe stages of dementia. This indicates that the patient will need constant behavioural management. BPSD symptoms are as clinically important as cognitive symptoms as they strongly relate to the degree of functional decline (Janus et al., 2017). The assessment of these symptoms requires a thorough examination to collect specific and detailed information about the clinical history, the patient’s   experiences and objective behaviours (Wang et al., 2020).

       Although the patient may be impacted by dementia in their communication and social skills. It is important to have an individual assessment with the patient first and when possible, it is desirable that the patient is encouraged to speak their concerns in an open dialogue. In this case information from a family member or caregiver is essential in order to cluster these symptoms and then come up with both pharmacological and non-pharmacological interventions. Another issue that is known to contribute to behavioural issues is lack of sleep (Gibson & Gander, 2019) . Night-time sleep can be encouraged by increasing daytime activities and discouraging daytime napping. While in hospital it is important to document all interactions nurses and allied health care have with the patient. This helps with the behavioural management plan if discharged to either nursing home or into community care. Also, this can be used as part of the education package for the family (Shenker & Singh, 2017).

         Thirdly, elderly patients with congestive heart failure may have more atypical presentations, this is especially the case for the more frail or cognitive impaired patients. This may be due to cognitive deficits, sedentary lifestyle or exercise limitations and other comorbidities. These factors may contribute to the late onset of symptoms and complicate the presentation of fatigue, dyspnoea and lethargy (Sano & Majima, 2018). Infections like pneumonia, renal disease with fluid overload, anaemia and hypertension tend to make the symptoms worse. Studies indicate that elderly people with heart failure are more likely to present with symptoms of decreased cardiac output, such as fatigue, weakness, dizziness and a change in mental status (Liguori et al., 2018). Moreover, the development of peripheral oedema in patients with heart failure can be attributed to excessive fluids. Therefore, fluid regulation remains one of the most important ways of managing congestive heart failure. Regulating the fluid intake while the patient is in hospital is easy, the trouble is once they are discharged. If discharged to the care home, it is standard protocol for nursing homes to do monthly weights. In this case weekly weights and fluid restriction are indicated, to improve the overall breathing quality. If the patient is discharged home to the husband, education would need to be arranged on the importance of monitoring the patient’s fluid intake and have strategies in place for the patient to take the medication for fluid regulation (Miller, 2016).

Role of care Coordinator

      Based on the Maslow’s Hierarchy of Needs, care coordination will aim to deal first with the physiological needs and then the safety issues upon discharge (Oved, 2017). The role of the care coordinator, in this case, is to bring together professionals from other disciplines and to facilitate an easy platform for communication while in hospital or the community. Typically, an individual with a chronic illness will be under the care of more than one doctor, it is the job then of the care coordinator to make sure that the scope of practice and the roles between professionals are clearly defined. For example, a patient cannot have more than one primary care physician prescribing or making daily clinical decision, this prevents polypharmacy and confusion on who to call in case of an emergency (Keine et al., 2019). And it is standard practice for that all referral to other physicians such as consultants are done by the primary physician. Furthermore, the role of a care coordinator is to compile a discharge care plans. The discharge care plan in this case, must have behavioural/pain management strategies, mobility and dietary care plan and a list of community support groups. For example, Silver Chain in Western Australia offers a range of community care services for people with varying levels of acuity. Also, Dementia Support Australia (DSA) offers support on how to manage dementia symptoms non pharmacologically. Prior to discharge, the role of the coordinator is to organise these services, have a care plans and all contacts needed for community or long-term care. 

Care Plan   

Immediate care Needs

Personal GoalsPlanningImplementationEvaluationOutcomes
The patient will take the medication on time.   Swallowing assessment from speech pathologist. Consultation with the doctor and pharmacists.Crash or crushable medications. And mix with jam or yoghurt. Nurses and personal care workers to administer medication as chartedThe patient Is able to take medication without fighting when disguised in yoghurt.After three days of establishing a routine medication administration, typically during mealtimes the patients was able to take medication.
To manage the congestive heart failureConsultation with dietician on diet that is low in in salt. And diet to maintain a healthy BMI.Daily record of the fluid balance chart and weight recording. Consultation with the doctor on the for-fluid restrictionThe patient’s weight will be stable.The patient does not have peripheral oedema. And does not have respiratory infections general quality of life is improved.

Long term needs

Personal GoalsPlanningImplementationsEvaluationsOutcomes
The patient will be trained in how to use the prescribed mobility aid.Mobility assessment and care plan will be done by the physiotherapistDaily remainder and education to use mobility aidThe patient will use the mobility aid at least 70% of the time prior to discharge.After weeks of reorientation explanation and assurance the patient can use the prescribed mobility aid.
Extreme behaviours will be minimisedBehavioural management chart, and documentation consultation with the family on the patient’s personality, like and dislikes. Documentation of positive and negative interactions.Have specific ways written up on how challenging behaviours such as aggression and irritability will be addressed. Have set routine, for example, meal and sleep times and increase daytime activities.Challenging behaviours have been minimised prior to discharge.Monthly report of challenging behaviours has been minimised.
The patient will maintain a healthy BMIMonthly weights will be done. And Mini nutritional assessment will be done. For example, measure the calf circumference.Yearly review of care plans or when there is a change in patient condition.After months of monitoring food, a and fluid intake, a health BMI was achieved.Incidence of fluid overload where reduced.
The patient will feel supported with her personal hygieneHave a continence assessment and toileting assessment from the continence nurseHave a commode or shower chair in the toilet. Toilet rails and call bell at home. Have a toileting schedule in place.Incontinence episodes diminishedOverall skin integrity improved. Incontinence episodes will be reduced due toileting schedule

National Strategic Framework for Chronic Conditions

      This care plan meets the current management priorities in the national strategic framework for chronic illness because it firstly moves away from managing dementia specifically but aims to treat the patient holistically. It supports a stronger emphasis on coordinated care across the health system. In this case, it utilises the expertise of the speech pathologist, physicians, physiotherapist, occupational therapists and personal care workers. The aim is to provide continuity of care whether in a long-term care home or community care. It does this by having easy access to information, education, and support for the patient and the families. For example, the use of discharge summaries, access to Dementia Support Australia for advice on the non-pharmacological intervention of behavioural issues. For health care professionals it is through the use of progress notes so that all care workers are kept up to date with the changes to the patient care and condition.  (Health, 2019).

The Wagner Chronic care Disease Model

         The Wagner chronic care disease model identifies six essential elements of a care system that encourages chronic disease management. This model puts the patient at the centre of the decision-making process, the hope is that through intra-professional and interprofessional partnership better health outcomes can be achieved.   These elements are the community, the health care system, self-management support, delivery system designs and clinical information systems  (Health, 2019).  This care plan aims to deal with the chronic illness irrespective of the health care setting, it also focuses on partnerships with a community organisation to develop interventions that fill the gaps in needed health care services. This care plan also fulfils the self-management principle, by utilising the use of effective self-management strategies for both the family and the patient. It does this by helping the patient set simple achievable goals and ways they can be achieved. To promote independence and empowerment for the patient, it is important to educate all direct and allied care workers to only help a resident with tasks they cannot do themselves. For example, if the patient can still feed themselves, then allow them to eat for themselves until they are not able to (Baptista et al., 2016).


            The professionals responsible for organising referrals is dependent on the hierarchy of competency and the scope of practice. The job of a care coordinator in this case is to set appointments for when these professionals will see the patients.  At a micro-level, while the patient is in hospital it is the responsibility of the nurse in charge of care to make sure that these referrals are done and sent to the people involved in care.  Hand over and case conferences, in this case, provides a good opportunity for the care coordinator to follow up with all health care workers about the general progress of all the patients and to make sure there are no gaps in care delivery. The ideal platform for these referrals to be delivered is through email, and then follow- up phone calls to set the dates for appointments. It is the job of the care coordinator to educate the client why they need the referrals and consultations from other professionals.  Changes to the patient must be done in writing either by sending a letter to the primary care provider or via email.  The appendix has a list of all the referrals done during the care planning.


Backhouse, T., Dudzinski, E., Killett, A., & Mioshi, E. (2020). Strategies and interventions to reduce or manage refusals in personal care in dementia: A systematic review. International Journal of Nursing Studies, 109.

Baptista, D. R., Wiens, A., Pontarolo, R., Regis, L., Reis, W. C. T., & Correr, C. J. (2016). The chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic Syndrome, 8.

Catalyst, N. (2018). What Is Care Coordination? NEJM Catalyst.

Curyto, K. J., McCurry, S. M., Luci, K., Karlin, B. E., Teri, L., & Karel, M. J. (2017). Managing Challenging Behaviors of Dementia in Veterans. Journal of Gerontological Nursing, 43(2), 33–43.

Gibson, R. H., & Gander, P. H. (2019). Monitoring the sleep patterns of people with dementia and their family carers in the community. Australasian Journal on Ageing, 38(1), 47–51.

Health, A. G. D. of. (2019, August 22). National Strategic Framework for Chronic Conditions [Text]. Australian Government Department of Health; Australian Government Department of Health.

Janus, S. I. M., Reinders, G. H., van Manen, J. G., Zuidema, S. U., & IJzerman, M. J. (2017). Psychotropic Drug-Related Fall Incidents in Nursing Home Residents Living in the Eastern Part of The Netherlands. Drugs in R&D, 17(2), 321–328.

Keine, D., Zelek, M., Walker, J. Q., & Sabbagh, M. N. (2019). Polypharmacy in an Elderly Population: Enhancing Medication Management Through the Use of Clinical Decision Support Software Platforms. Neurology and Therapy, 8(1), 79–94.

Liguori, I., Russo, G., Curcio, F., Sasso, G., Della-Morte, D., Gargiulo, G., Pirozzi, F., Cacciatore, F., Bonaduce, D., Abete, P., & Testa, G. (2018). Depression and chronic heart failure in the elderly: An intriguing relationship. Journal of Geriatric Cardiology : JGC, 15(6), 451–459.

Miller, W. L. (2016). Fluid Volume Overload and Congestion in Heart Failure. Circulation: Heart Failure.

Oved, O. (2017). Rethinking the Place of Love Needs in Maslow’s Hierarchy of Needs. Society, 54(6), 537–538.

Sano, M., & Majima, T. (2018). Self-management of congestive heart failure among elderly men in Japan. International Journal of Nursing Practice, 24(S1), e12653.

Shenker, J. I., & Singh, G. (2017). Sleep and Dementia. Missouri Medicine, 114(4), 311–315.

Sørensen, M. ( 1 ), Groven, K. s. ( 2 ), Gjelsvik, B. ( 3 ), Almendingen, K. ( 4 ), & Garnweidner-Holme, L. ( 4 ). (2020). The roles of healthcare professionals in diabetes care: A qualitative study in Norwegian general practice. Scandinavian Journal of Primary Health Care.

Ventegodt, S., Kandel, I., Ervin, D. A., & Merrick, J. (2016). Concepts of Holistic Care. In I. L. Rubin, J. Merrick, D. E. Greydanus, & D. R. Patel (Eds.), Health Care for People with Intellectual and Developmental Disabilities across the Lifespan (pp. 1935–1941). Springer International Publishing.

Wang, G., Gong, H., Albayrak, A., van der Cammen, T. J. M., & Kortuem, G. (2020). Personalising Management of Behavioural and Psychological Symptoms of Dementia in Nursing Homes: Exploring the Synergy of Quantitative and Qualitative Data. BioMed Research International, 1–16.

Wayne Zachary, Russell Charles Maulitz, & Drew A. Zachary. (2016). What Causes Care Coordination Problems? A Case for Microanalysis. EGEMs, 4(3).

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