NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Name

Capella university

NURS-FPX 6612 Health Care Models Used in Care Coordination

Prof. Name

Date

Triple Aim Outcome Measures

Hello everyone, my name is —–.  As a case manager, I would present how the triple aim of improving population health, reducing cost, and enhancing the quality of care can be implemented with the help of hospital leaders and other healthcare workers at Sacred Heart Hospital (SHH). Moreover, the presentation will delve into governmental regulatory programs and outcome measures that will promote the coordinated care process to attain the triple aim of SHH. 

Purpose

This presentation has the significant objective of raising awareness among hospital leadership and clinical leadership about how the coordinated care process can be improved to attain the triple aim within the population of Barnes County Community, where SHH is located. This will be done by utilizing patient self-management and care coordination models, governmental regulatory initiatives, and outcome measures. Care coordination is necessary for achieving the triple aim and requires collaborative efforts of interdisciplinary healthcare organization teams.

Triple Aim and its Contribution to Healthcare Organization

The Triple Aim focuses on three key principles: improving the patient experience of care, decreasing the per capita cost of healthcare, and improving the health of populations,. In Sacred Heart Hospital, the application of Triple Aim can yield significant benefits in the following ways:

Experience of Care/ Patient Satisfaction

Enhancing the patient experience of care at SHH involves a multifaceted approach aimed at improving overall satisfaction. This can be done by implementing patient-centered care strategies and emphasizing open and effective communication between healthcare providers and patients (Kwame & Petrucka, 2021). Additionally, the comprehension of the population’s needs, such as increasing health literacy and the need for health insurance, reducing wait times, and facilitating follow-up care for patients. These efforts will result in increased patient satisfaction scores and the cultivation of trust between healthcare professionals and patients. 

Improving Population or Community Health

Sacred Heart Hospital can improve the population health of Barnes County Community by implementing preventive care programs and health education to ensure patients integrate preventive measures into their lives and improve overall health (Yamada & Arai, 2020). Moreover, it addresses social determinants of health, such as lack of transportation and poor health literacy level, and time-sensitive chores, such as farming. The hospital can collaborate with other healthcare entities to enable resource-sharing and facilitate anticipated outcomes such as decreased preventable diseases and increased awareness and participation in health-promoting activities. 

Decreasing Per Capita Costs

Efforts to decrease per capita costs at SHH involve carefully balancing cost-efficiency and quality care. The hospital must implement cost-effective care models and leverage technology to optimize healthcare delivery processes. Moreover, partnerships and collaborations with governmental or healthcare organizations can contribute to financial stability and facilitate care treatments to reduce hospital readmission rates and enhance the ability of the hospitals to provide quality care within a financially responsible framework (Fichtenberg et al., 2020).

By implementing the proposed strategies, SHH can achieve the triple aim tailored to address the demands of the community’s natives and hospital resources. 

Analyzing the Relationship Between the Health Model and Triple Aim

To analyze the relationship between health models and how they support the triple aim, I have chosen two particular health models: the Patient Self-Management Model and the Care Coordination Model.

Patient Self-Management Model (PSSM)

The rationale of the Patient Self-Management Model (PSSM) lies in empowering individuals to participate actively in their healthcare. This model is built on the philosophy that patients can make informed decisions about their health when equipped with adequate knowledge and tools. This leads to better patient health outcomes and improved well-being (Fu et al., 2020). This model has been revolutionized from a paternalistic approach to a collaborative, patient-centered paradigm. Over time, healthcare professionals have recognized the significance of involving patients in decision-making, creating a sense of autonomy and accountability. This has led to patient-centered care and potentially increases the chances of adherence to treatment plan rates and better health outcomes (Fu et al., 2020). 

The PSSM enhances healthcare quality in three ways: improved adherence and outcomes, preventive care and early intervention, and enhanced patient satisfaction. Patients actively engaged in self-management tend to adhere more effectively to treatment plans, improving health outcomes. Additionally, increased responsibility fosters a sense of ownership, leading to better medication adherence and lifestyle modifications (Lonc et al., 2020). Similarly, empowering patients to self-manage often involves education on preventive measures and early recognition of potential issues.

This proactive approach can contribute to the prevention of complications and early detection of health concerns. The healthcare quality of patients is improved with a better quality of life (Du et al., 2019). This model also impacts patient satisfaction by promoting a collaborative and participatory healthcare experience. Patients educated on self-management of their health condition and provided with patient-centered care plans show increased satisfaction levels, enhancing trust in healthcare and building a positive relationship with healthcare providers (Lonc et al., 2020).

Care Coordination Model (CCM)

The care coordination model ensures seamless and well-coordinated healthcare services across various healthcare providers and settings. This model recognizes that effective communication and collaboration among the healthcare workforce are essential for delivering comprehensive, patient-centered care. The evolution of this model has seen a progression from fragmented care delivery to a more integrated and interconnected system. Additionally, it has been facilitated by technological advancements with a growing emphasis on interdisciplinary collaboration (Karam et al., 2021). 

CCM can enhance healthcare quality by reducing fragmentation and duplication, enhancing patient safety, and promoting continuity of care. Care coordination addresses the issue of fragmented care by streamlining communication and information sharing among healthcare providers (Bloem et al., 2020). Moreover, it reduces the duplication of tests and procedures due to inadequate communication and collaboration, which leads to cost savings and improved efficiency. Coordinated care also reduces the likelihood of medical and treatment errors and enhances patient safety (Carayon et al., 2020).

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

This model ensures that healthcare providers have access to comprehensive patient information with technological strategies such as Electronic Health Records or patient portals (Chelladurai & Pandian, 2021). This strategy minimizes the risk of adverse events and cultivates a safer care environment. Furthermore, care coordination promotes a seamless transition of care across different healthcare organizations. This continuity is crucial for patients with chronic conditions or complex health needs to manage chronic diseases better and improve overall healthcare quality (Facchinetti et al., 2020). 

Analyzing these evidence-based assertions to enhance the quality of care, it is clear that both these models improve patient health outcomes and quality of care, reducing healthcare costs and improving the community’s overall health. Hence, both these models support the Triple Aim of improving care and the community’s health while reducing healthcare costs.

Structure of Selected Health Care Models

The PSMM and CCM structure contributes to gathering and evaluating the quality of evidence-based data to enhance healthcare quality. The patient self-management model emphasizes using a patient-centered care approach within the healthcare setup to encourage individuals to actively participate in managing their condition. This approach involves systematic data collection through patient-reported outcomes, lifestyle choices, and self-monitoring activities (Solomon & Rudin, 2020). Additionally, integrating digital health technologies such as mobile phones and wearables is inherent to this model.

These technologies and modalities provide a structured framework for continuous data collection and allow real-time monitoring and analysis of patient-generated health data. Technology integration ensures data consistency and accuracy, enabling healthcare providers to draw reliable conclusions (Awad et al., 2021). This structured data collection contributes to evidence-based insights into the efficacy of patient management interventions. 

Similarly, the care coordination model is structured to create interconnected healthcare systems, fostering seamless communication and information exchange among interprofessional healthcare teams. This cross-linked association ensures that relevant data is accessible across the care continuum (Awad et al., 2021). Moreover, the CCM emphasizes using EHRs to facilitate coordination and collaboration, allowing healthcare providers to draw patient data from comprehensive health records in EHRs (Du et al., 2019). Furthermore, this model integrates performance metrics and quality indicators to assess care coordination effectiveness. These structured measures provide a systematic approach to evaluating the quality of care delivered across different hospital care points. This leads to understanding the success of care coordination and identifying areas for improvement (Javed et al., 2020).

Evidence-Based Data Shaping Coordinated Care Procedure

Evidence-based data plays a crucial role in honing the care coordination procedure in nursing by providing a foundation for informed decision-making and enhancing communication among healthcare providers. This ultimately leads to improved patient health outcomes and quality of care. As nurses access and analyze evidence-based data for care coordination, they can make decisions grounded in the best available evidence. This contributes to developing care plans and interventions tailored to patients’ needs.

Furthermore, nurses can integrate research findings and clinical guidelines into their decision-making and deliver evidence-based care treatments (Belita et al., 2020). This reduces the likelihood of making medication and treatment errors and enhances safety with better patient outcomes. Similarly, evidence-based data facilitates effective communication as healthcare professionals share relevant patient information, treatment plans, and outcomes in interprofessional team meetings. This leads to articulating treatment plans based on particular patient scenarios and cases and promotes crafting tailored treatment plans through a collaborative and cohesive approach to patient care (Hoffmann et al., 2023).

Governmental Regulatory Initiatives and Outcome Measures

Several governmental regulatory initiatives aim to enhance the care coordination process and achieve the Triple Aim of boosting patient outcomes, ameliorating patient experience, and diminishing healthcare expenses. One of these governmental initiatives is the Health Information Exchange (HIE) initiatives, which promote the seamless sharing of patient health information across healthcare providers and settings. These programs encourage the electronic exchange of patient health data to support coordinated, continuous care. The outcome measures of this initiative will include reduced duplicate testing, improved medication reconciliation rates, and enhanced continuum of care (Zhuang et al., 2020).

By coordinated care through technology use, data sharing becomes efficient, minimizing unnecessary repetitions, leading to cost savings and improved utilization. Similarly, by tracking the accuracy of medication reconciliation during care transition, the safety of patients is enhanced, and the continuum of care is ameliorated. Another Medicare Shared Savings Program (MSSP) promotes accountable care organizations (ACOs) to coordinate care and reduce healthcare costs. This program was developed by the Centers for Medicare and Medicaid Services (CMS) to enable ACOs to enhance savings achieved through improved care quality and cost-effectiveness. The outcome measures of this program are cost savings and enhanced patient satisfaction scores (McWilliams et al., 2020).

With the help of cost-savings through strategic planning by ACO, quality of care is enhanced as optimal resources are allocated by reducing costs, contributing to the Triple Aim. The Meaningful Use Program incentivizes healthcare providers to practice and efficiently use Electronic Health Records to boost patient care coordination, data exchange, and overall healthcare quality. This results in improved interoperability through easier exchange of patient data, increased patient engagement by providing access to patients for enhanced collaboration, and reduced medical and treatment errors (Mohammadzadeh et al., 2021). SHH can adopt these governmental initiatives and outcome measures to achieve the Triple Aim.

Process Improvement Recommendations to Stakeholders

Our healthcare organization, SHH, can improve the care coordination process to achieve Trip Aim outcomes for Barnes County Community with the help of the collaborative effort of healthcare providers, leadership authorities, and hospital administration. These stakeholders express concerns about initial investment and potential workflow disruptions. Additionally, questions may arise regarding the adaptability of the workforce to automate processes. To address these concerns, prioritize pilot-phase implementation to minimize disruptions and allow teams to adapt gradually.

Moreover, it is also recommended that comprehensive training programs be integrated to ensure a smooth transition and build workforce capacity. Additionally, stakeholders must establish continuous quality improvement initiatives to ensure the long-term efficiency of the care coordination process. Lastly, I recommend developing enhanced communication protocols for ameliorating collaboration among cross-departmental team members. This will ensure streamlining the communication without disrupting existing processes with open dialogue and refined communication strategies (Karam et al., 2021). 

Conclusion

To conclude, SHH must prioritize care coordination and achieve the Triple Aim by integrating healthcare models such as PSMM and CCM. The collaborative efforts of healthcare leaders, administrators, and outside partnerships can achieve this aim and promote enhanced quality of care with better patient outcomes for Barnes Community County. I urge the relevant stakeholders to consider these suggestions to fulfill the Triple Aim of boosting patient care and experience, facilitating the community’s health, and decreasing healthcare costs. Thank you.

References

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Belita, E., Squires, J. E., Yost, J., Ganann, R., Burnett, T., & Dobbins, M. (2020). Measures of evidence-informed decision-making competence attributes: A psychometric systematic review. BMC Nursing19(1). https://doi.org/10.1186/s12912-020-00436-8 

Bloem, B. R., Henderson, E. J., Dorsey, E. R., Okun, M. S., Okubadejo, N., Chan, P., Andrejack, J., Darweesh, S. K. L., & Munneke, M. (2020). Integrated and patient-centred management of parkinson’s disease: A network model for reshaping chronic neurological care. The Lancet Neurology19(7), 623–634. https://doi.org/10.1016/S1474-4422(20)30064-8 

Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020). SEIPS 3.0: Human-centered design of the patient journey for patient safety. Applied Ergonomics84(84), 103033. https://doi.org/10.1016/j.apergo.2019.103033 

Chelladurai, U., & Pandian, S. (2021). A novel blockchain based electronic health record automation system for healthcare. Journal of Ambient Intelligence and Humanized Computinghttps://doi.org/10.1007/s12652-021-03163-3 

Du, S., Liu, W., Cai, S., Hu, Y., & Dong, J. (2019). The efficacy of e-health in the self-management of chronic low back pain:A meta analysis. International Journal of Nursing Studies, 103507. https://doi.org/10.1016/j.ijnurstu.2019.103507 

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Facchinetti, G., D’Angelo, D., Piredda, M., Petitti, T., Matarese, M., Oliveti, A., & De Marinis, M. G. (2020). Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis. International Journal of Nursing Studies101, 103396. https://doi.org/10.1016/j.ijnurstu.2019.103396 

Fichtenberg, C., Delva, J., Minyard, K., & Gottlieb, L. M. (2020). Health and human services integration: Generating sustained health and equity improvements. Health Affairs39(4), 567–573. https://doi.org/10.1377/hlthaff.2019.01594 

Fu, W., Liu, Q., Qiu, X., Liu, S., & Xu, J. (2020). Evaluation of the effect of self-management model in diabetic patients in community under the guidance of general practitioners. Chinese Journal of Health Management, 431–436. https://pesquisa.bvsalud.org/portal/resource/pt/wpr-869261 

Hoffmann, T., Bennett, S., & Mar, C. D. (2023). Evidence-based practice across the health professions. In Google Books. Elsevier Health Sciences. https://books.google.com/books?hl=en&lr=&id=BbbREAAAQBAJ&oi=fnd&pg=PP1&dq=evidence-based+data+and+informed+decision+making+in+healthcare&ots=YwEpeVeZ7R&sig=gjLV8pNjZBysDztQObgdjgTX6yg 

Javed, A. R., Sarwar, M. U., Beg, M. O., Asim, M., Baker, T., & Tawfik, H. (2020). A collaborative healthcare framework for shared healthcare plan with ambient intelligence. Human-Centric Computing and Information Sciences10(1). https://doi.org/10.1186/s13673-020-00245-7 

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care21(1), 1–21. https://doi.org/10.5334/ijic.5518 

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing20(158), 1–10. https://doi.org/10.1186/s12912-021-00684-2 

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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Mohammadzadeh , N., Saeedi, S., & Rezayi, S. (2021). A review of the process of meaningful use program and its challenges in the electronic health record roadmap. Journal of Health and Biomedical Informatics8(1), 117–127. http://jhbmi.ir/article-1-540-en.html 

Solomon, D. H., & Rudin, R. S. (2020). Digital health technologies: Opportunities and challenges in rheumatology. Nature Reviews Rheumatology16(9), 525–535. https://doi.org/10.1038/s41584-020-0461-x 

Yamada, M., & Arai, H. (2020). Long-term care system in japan. Annals of Geriatric Medicine and Research24(3), 174–180. https://doi.org/10.4235/agmr.20.0037 

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