Alzheimer’s: A Team-Based Approach to Health Care
Susan Medhurst
Grand Canyon University: HCA 515
10/5/2013

Unfortunately, there is no single form of identifying test that can tell you if you have Alzheimer’s or if you are just forgetful. For those patients dealing with other illnesses like thyroid problems, depression and other health problems, memory loss is a very common side effect to their illness, which makes identifying Alzheimer’s even more difficult (Alzheimer’s association, 2013). This disease often goes unnoticed until the patient has reached a moderate to advanced stage because of the commonality of the indicators in early stages such as forgetfulness of where you put your car keys (Alzheimer’s association, 2013). Currently over five-million American’s have Alzheimer’s. This number will begin to increase as the baby boomers age and life expectancy is extended. The risk of getting Alzheimer’s only increases as we age with number of people doubling every 5-year interval beyond the age of 65 (Alzheimer’s association, 2013).
Case Study
Eaton, a 72 year old male patient, was found roaming downtown Denver with no recollection of how he got there. Paramedics brought him to the hospital for evaluation. The patient presents with progressive memory loss, confusion, agitation, and doesn’t know his last name. Identification in his wallet helped the hospital staff contact his wife. Upon the wife’s arrival, the patient seemed distant and unable to identify his wife Ethel. After multiple tests, the Care Team gave a Diagnosis of Moderate stage of Alzheimer’s (Diagnosis of Alzheimer's, 2013). Care Team Approach
An initial evaluation left the ER physician with a diagnosis “undetermined”. She ordered a CBC blood draw (Complete Blood Count) to rule out the possibility of other causes for loss of memory and confusion. The physician also performed a clinical exam and evaluation of the patients’ medical and family history. The family history, as explained by Ethel, proved to be non-determinant due to the patient being adopted (Determinants, n.d). The nurse on duty took the patients’ vitals and drew blood for the CBC.
A Psychologist was called in to perform a set of bedside mental exams and a Mini-mental state exam (MMSE) to confirm mental status. This psychologist referred the patient to a local neurologist for further examination.
The Neurologist was contacted and completed a neuropsychological test to further evaluate the patients’ state of mind. Genetic profiling was recommended to determine the stage of the patients’ illness as it was clearly Alzheimer’s. However, it was unclear without further testing, as to how advanced this case has affected this patients brain activity. A CT scan and CSF test were ordered to further investigate the best possible care for this patient based on the stage of the disease.
There is a diagnostic care team member who has performed the physicians’ order of a CT scan and a specialist completing the Cerebrospinal fluid protein spinal tap (to determine CSF)(Understanding Alzheimer's, 2013).
A social worker case manager has been assigned and recognizes the patient presents with good hygiene and his clothing is in good condition. She suspects that the patients’ spouse is managing primary care for the patients’ bathing, clothing and overall home care. Through a series of interviews with family members, the social worker learns that the patient regularly distresses family members with agitation and repetition of stories. Ethel describes the patient as easily aggregated with the occasional mini act of violence (throwing dishes, books). The wife is a 67 year old high functioning wife with 25 plus years of RN experience. She will act as the patients’ primary home caregiver. Psychologist and the social worker have recommended ongoing support for the patient and caregiver (spouse) to assist with positive reinforcement and response tactics. Recommend close family members be involved in bi-monthly AD meetings to ensure overall success as disease progresses.
Health Indicators and Determinants
Access to care: Patient lives within 15 miles of the Denver Neurological Alzheimer specialist. The spousal structure maintains VA insurance and Medicare. Long term care is expected and therefore, would require possible supplemental insurance. Resources have been given to wife to research further. VA and Medicare may cover all areas of need. Insurance needs are unclear at this time.
Healthy behaviors: Care Team recommends that this patient continue his exercise regimen of walking 2-3 miles a day. His dietary needs should be met through an increase in fresh vegetables and lean meat (Determinants, n.d).
Social: The patient and his wife of 54 years, have reared 4 children that live within 25 miles of the couple. Family structure is sound and spousal support is intact. Care may become more difficult as patient progresses therefore the Social Worker has offered additional resources to help the family structure deal with this disease and their beloved father/husband. The patient and his wife have no religious affiliation. Patient was raised Catholic and spouse was raised Baptist but neither have a desire to practice or involve a religious dogma.
Biology and Genetics: This patient has no ‘genetic’ family history because his biological father and mother are unknown. This patient was adopted non-open adoption and has no known true biological relative (Determinants, n.d).
Individual behavior: While this patient quit smoking 27 years ago, his wife continues smoking in the home which lends to a badly polluted environment for this patient. The Care Team (CT) has recommend that the spouse either quit smoking or, at a minimum, smoke outside of the home to decrease patient exposure (Determinants, n.d). Smoking has been proven to decrease immunity and the goal with this patient is to increase immunity.
A Team Approach
A comprehensive team approach will be critical to this patients’ ability to maintain a comfortable lengthy life (Ham et. al, 2012). This patient will require different levels of care from the hospital, rehab center, neurosurgical specialist, PCP and home care medical team (Ham et. al, 2012). As this patient ages, his Primary Care Provider (PCP) will own testing for other chronic illnesses that effect this patients treatment. PCP will look for common geriatric disease such as Diabetes, CPOE, heart issues, stroke indicators and monitor for Fall Risk (Alzheimer’s association, 2013).
Each area also offers a layer of complexity to treatment. It is crucial that effective communication between these team members be effectively executed. The non-team based approach can introduce cause for error by missing critical key components to treatment and often miss things like depression, prior alcoholism, vascular disease and other key factors. The team understands that this disease cannot be cured, only treated to ensure they can reduce further disability, relieve suffering, prevent further complications while offering an improved quality of life (Edwards & Langley, 2007).
Funding Treatment
Each of the above treatment team members have different goals and objectives regarding the care of this patient. However, the overall goal of the team is to offer the best possible patient care based on the patients’ available resources. Insurance companies save from this team based model by ensuring a reduction in duplicative services (CMS, 2010). Programs like the ACA state a benefit in cost savings with key provisions which will save $29 billion over a 10 years period (CMS, 2010). This program offers “key provisions that will promote broader integration and coordination of care that enable physicians and nurses to spend more time with their patients and reduce duplicative services. These models will improve health care delivery by promoting team-based care, developing new models of care delivery, and supporting improved provider performance with continuous feedback on meeting specific performance objectives” (CMS, 2010).
Everyone Wins
Many hospital organizations are reviewing patient satisfaction scores, cost savings measures, and reduction in litigation through excellent patient care. In addition, other possible benefits of an effective medical care team includes; increased quality of care for the patient, improved employee satisfaction and overall lower stress levels for the care team members (Edwards, 2007). In Hickmans “Best practice interventions to improve…”, he describes a study of nursing methodologies that focus on patient care and help us to better understand how mismanaged teams can fail in a patient setting (Hickman et al., 2007). “Many nursing issues impact on the quality of care the older person can expect to receive. These include nurses’ attitudes and lack of expertise in the acute care of older patients and a failure to tailor management to the needs of individual patients” (Hickman et al., p.2, 2007). This type of failure and mismanagement of talent leads to increased healthcare expenses. As Edwards explains, good communication and clear policy are key elements to positively influencing teamwork (Edwards, 2007).

References:
Alzheimer’s Association, (2013). Diagnosis of Alzheimer's Disease and Dementia. Retrieved from http://www.alz.org/alzheimers_disease_diagnosis.asp
CMS Office of the Actuary, (2010). Affordable Care Act Update: Implementing Medicare Cost Savings. Retrieved from http://www.cms.gov/apps/docs/aca-update-implementing-medicare-costs-savings.pdf
Determinants of Health. (n.d.). Retrieved from http://www.healthypeople.gov/2020/about/DOHAbout.aspx
Edwards, A., & Langley, A. (2007). Understanding how general practices addressed the Quality and Outcomes Framework of the 2003 General Medical Services contract in the UK: a qualitative study of the effects on quality and team working of different approaches used. Quality In Primary Care, 15(5), 265-275. Permalink http://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=27015224&site=eds-live&scope=site
Ham, Richard J., Sloane, Philip D., Warshaw, Gregg A., Bernard , Marie A. MD, Flaherty , 2012. Primary Care Geriatrics: A Case-Based Approach. Elsevier Health Sciences
Hickman, L., Newton, P., Halcomb, E., Chang, E., & Davidson, P. (2007). Best practice interventions to improve the management of older people in acute care settings: a literature review. Journal Of Advanced Nursing, 60(2), 113-126. doi:10.1111/j.1365-2648.2007.04417.x Permalink http://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009676400&site=eds-live&scope=site
Pauly, M. V. (2011). Patient Protection and Affordable Care Act Cost-Containment Choices: The Case for Incentive-Based Approaches. Journal Of Health Politics, Policy & Law, 36(3), 591-596. doi:10.1215/03616878-1271315. Permalink http://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=62558477&site=eds-live&scope=site