Table 3.

Nursing care coordination activities across cases.

	V1SAGES AND PRICARE	QUEBEC ALZHEIMER PLAN
Segmentation: Care coordinators play an essential role in both programs for the identification of eligible patients with complex health and social care needs	Identify patients who could benefit from the CM intervention:	Identify patients who could benefit from a cognitive evaluation:
	Case managers: Use their clinical judgement to complement objective data from EHR or administrative databases related to frequent use of care services Use validated clinical assessment tools (the INTERMED-Self-Assessment Questionnaire) to assess complex health needs Consult patient EHR and clinical record from the hospital (if available) Understand the reason for frequent ED visits and for hospitalizations Identify the patient’s physical and/or mental illnesses Identify social challenges such as insecure housing or employment, poverty, violence, substance use disorders. Document the health and social services previously provided to the patient, as well as the names, roles and contact information of professionals currently involved with the patient or who may eventually be called upon to participate in the care of the patient. Confirm whether the patient’s current situation requires a CM intervention (to be discussed with the family physician and key healthcare providers)	Patient navigators: Recognize a clinical situation or memory complaints reported by patients or caregivers that should trigger an evaluation Pay particular attention to high-risk patients Ask questions related to their memories or use the Mini-COG assessment tool (a 3-minute instrument that can increase detection of cognitive impairment in older adults). High-risk patients are: – aged 65 years old and over with one or more risk factors: CVA, TIC, recent delirium, old age depression, and Parkinson’s – aged 75 years old and over who need to renew their driving licence
Coordination:	Assess comprehensive patient and family needs and goals:	Assess cognitive and functional status:
	Assessment (and follow-up) could be performed during home visits if necessary. Case managers: Validate the information collected from the medical records with the patient Complete and specify the assessment that was initiated in the identification phase Assess and identify the patient’s personal needs, goals, priorities and preferences for future services and resources. Inform the patient that they have the right to appoint an advocate that may be someone other than a family member Involve the family and caregivers, with the patient’s consent Establish a final list of care professionals that will be invited to examine the patient’s situation (healthcare and social services professionals, managers or representatives of community organizations) Seek the patient’s consent to communicate with potential care professionals throughout the intervention Ensure that the patient understands and agrees to the creation of an individualized service plan	With the patient’s consent, an initial assessment is performed in the presence of a caregiver. Patient navigators: Assess previous medical history and family history, current social support, psychosocial context, etc. Evaluate the history of the memory complaint that triggered the visit Use validated assessment tools: – MMSE (Mini Mental State Examination-Folstein) – MoCA (Montreal Cognitive Assessment) – GDS-15 or GDS-5 (Geriatric Depression Scale) Assess the functional status, specifically the ADL and IADL Question caregivers about their perceptions of danger and the strategies to be implemented if they had to be away from home and leave the person alone Run blood tests or CT scans (if a collective prescription is used) Refer to the “Clinical process aimed at treating behavioural and psychological symptoms of dementia” in case of relevant symptoms Transfer information to the GP
	Develop an individualized service plan (ISP):	Develop a nursing therapeutic plan (NTP):
	Prepare the patient for an ISP meeting: Explain what an ISP meeting is, the role they will have to play and the importance of sharing their wishes and preferences during the meeting Seek the patient’s consent to invite relevant health and social care providers and caregivers to the meeting Use simple and clear language and be open to the patient’s views as a partner Plan the ISP meeting: Review the list of care professionals and relevant providers who will be invited to the ISP meeting Communicate directly with the targeted care professionals to request their involvement Ensure that the involvement of care professionals is clear Establish a detailed agenda for the meeting Communicate with the patient to reconfirm consent regarding the professionals who will participate in the meeting Lead the ISP meeting: Invite the care team to collaboratively examine the patient’s situation, needs and preferences prior to the patient’s arrival Develop the ISP with the patient and their advocate upon their arrival: Consider their needs and prioritize what they want to address Establish the preferred methods of communication and strategies for exchanging information with the group Write up the ISP in plain language Validate that the patient understands and agrees to it Transmit the ISP to the patient and care professionals	The nursing therapeutic plan (NTP) records the nursing plan and instructions for clinical monitoring and care, and reports on the evolution of the patient’s priority problems and needs. Patient navigators share their NTP with other healthcare professionals.
	Follow-up:	Follow-up:
	Establish with the patient their preferred method for reaching the case manager Follow up regularly with the patient’s primary care providers, ensuring active engagement Review the ISP at least once every 3 months Verify if the patient’s goals have been attained Reassess the situation with the patient and adjust the ISP as necessary (if the patient desires a change, or if a care professional identifies any issue) Monitor the current medications and changes (introduction of a new molecule, resuming medication, etc.)	Once the diagnosis has been established and announced by the GP (in the presence of the RN when possible), patient navigators: Re-explain the diagnosis to the patient and caregivers if needed Provide the patient and caregiver with their contact information and inform them of their availability Educate the patient and caregiver about the disease and actions to be put in place to manage the behavioural and psychological symptoms of dementia Discuss the diagnosis and treatment plan with the patient and caregivers Assess the patient and caregiver’s psychological state and needs Provide the patient and caregiver with information on the following: the need for a driving assessment medication risk assessment financial risk assessment
		Provide counselling on difficulties that arise in daily life as well as moments of discouragement with the person and their loved ones Provide counselling on medico-legal aspects Use collective prescriptions to monitor medications Write and update a therapeutic nursing plan to ensure personalized clinical follow-up Two weeks later (then four to six weeks later): Verify patient and caregiver’s understanding of the situation, the situation itself and the treatment plan In case of medication intake: check side effects, adherence, tolerance, weaning if needed Six months later: Repeat the cognitive and functional evaluation Reassess the patient’s and caregiver’s psychological state and needs Reassess side effects, adherence, tolerance to medications, and manage medications following a collective prescription Reassess the need for home care services Refer the patient and caregivers to relevant resources if needed Ask about the patient’s driving ability and inform the GP Schedule a follow-up in six months
	Coordinate care and services:	Coordinate care and services:
	In addition to activities included in the planning, development and follow-up of the ISP, case managers: Establish with the patient their preferred method for reaching relevant services Establish contact with the services or resources identified in the ISP Provide a personalized reference for the patient Explain the case Inform care professionals of past and potential challenges facing the patient Make all necessary external links to appropriate services (community organizations, home care services, specialized clinics, other clinics, and services) Support the patient in navigating the various services provided	Inform the patient and caregiver about available resources Refer to Alzheimer Society Refer patient and caregiver to services available from the local community service centre Communicate with the community pharmacist to facilitate the medication delivery process Call the local community service centre to schedule a short respite stay if necessary Refer to other relevant resources Follow up on referrals
Engagement:	Provide educational self-management support for patients and families:	Provide educational self-management support for patients and families:
	This component is considered an ongoing and transversal process to be performed as needed throughout the intervention. Case managers: Develop a trusting patient-provider relationship in order to positively influence patient’s motivation and engagement in self-care Use motivational interviewing principles and strategies to engage the patient Support the patient to set realistic goals through a “SMART” action plan Support the development of skills related to psychological well-being (anxiety management and assertiveness strategies)	This component aims to maintain patient autonomy for the longest possible time and slow the progression of the AD: Provide education and explanation about AD, the treatment plan, and how to handle behavioural and psychological symptoms of dementia Consider alternatives to driving based on the person’s abilities and reality. Discuss the expected outcomes of the treatment and possible side effects Explain the importance of getting legal and financial affairs in order as soon as possible Provide counselling on medico-legal aspects: power of attorney, protective supervision, etc.
	Support the development of the patient’s ability to monitor, take appropriate actions and know when and how to seek professional help Help the patient prepare for meetings with the various care professionals Ensure the patient is empowered to communicate their goals and to receive the desired care Coach the patient on how to effectively communicate with their relatives: Help the patient establish expectations Help ensure a successful care partnership Provide follow-up/support meetings Organize group self-management support led by lay leaders who suffer from a chronic disease
	Develop a relational continuity of care:	Develop a relational continuity of care:
	This is the same resource person who follows the patient and knows their file Serve as the patient’s main contact Advocate for the patient Maintain a relationship of trust (as stated earlier) and enhance the patient’s sense of security Negotiate the services and defend the rights and interests of the patient Adopt a calm, confident, sensitive, friendly, empathic and supportive attitude	Establish a partnership and a relationship of trust with the patient and their caregivers. Provide their direct contact details so the patient or their caregiver can contact the patient navigator if necessary Discuss the diagnosis and the treatment plan
Success measures	Case managers are not involved in data collection	Patient navigators collect data including processes and performance indicators.

Key sources (in addition to interviews with experts): MSSS,2019 [52]; MSSS, 2014 [53]; Danish et al., 2020 ([31]; Nicol-Clavet, 2017 [54].

Legend: ADL: activities of daily living; CM: Case manager; CVA: Cerebral vascular accident; ED: Emergency department; EHR: Electronic health record; GP: General practitioner also known as family physician; IADL: instrumental activities of daily living; MSSS: Ministry of Health and Social Services; TIA: Transient ischemic attack.