Assessment 1: Triple Aim Outcome Measures
Name
Capella University
NURS-FPX6612: Health Care Models Used in Care Coordination
Instructor Name
July, 2024
Slide 2
Triple Aim Outcome Measures
Hello, I am _________, and today I will present information about the Institute for Healthcare Improvement’s triple as a new case manager at a small rural hospital, Sacred Heart. I aim to discuss how current and potential models of healthcare assist in adopting this framework, the roles of governmental regulations, and the concept of using outcome measurements in care coordination to deliver the triple aim within a population. We will identify how this framework of solving population health problems, patient care experiences, and genetic outcomes of efficient costs can be sorted out. We will then discuss how current and future healthcare models will comply with these goals.
Slide 3
Experience of Care/Patient Satisfaction
The triple aim enhances the patients’ experience by severalfold since it incorporates patient-centered care and care coordination. Implementing such conceptual models as the proposed patient-centered medical home (PCMH) will cause high patient satisfaction as they receive enhanced, personalized, and accessible care from the providers (Fønss et al., 2021). Interpersonal skills and, specifically, patient engagement are the most important components contributing to trust and collaboration between patients and the healthcare staff (Ginting et al., 2022). An approach that is focused on the physical well-being of the patient is not only capable of addressing a patient’s needs but also of supporting a framework in a health facility. This implies that patient satisfaction has a direct positive relationship with his or her health since likely attitudes and impressions that a patient posts towards the health facility that he or she attends will always adhere to the doctors’ advice and even engage in positive health behaviors such as practicing regular checkups.
Slide 4
Improving Population or Community Health
Actions with the triple aim to prioritize improving population health entail shifting from the system where the patient has to get sick before they are attended to where they are asked how to prevent sicknesses (Limbers et al., 2020). These viewpoints imply that, when undertaking and implementing community-based public health initiatives, it is important to ensure the latter prioritizes care for the determinants above, thereby enabling the healthcare systems to systematically reduce the variations of more and less healthy citizens within communities. Through transitional care and patient self-management, people are assisted to be more independent in managing their care and, in the long run, achieve better management of chronic diseases touching on hospitalization (Douthit et al., 2022). These activities boost the health standards of well-being and reduction of diseases, hence improving the health of the residents at the regional, state, and national levels. Community health improvement is also related to cooperation with such organizations to create detailed health plans (Elsener et al., 2023).
Slide 5
Decreasing Per Capita Costs
On the aspect of cost, the triple aim strives to contain cost and eliminate wastage in utilizing resources within health services (Alderwick et al., 2021). High-value areas are easily observable with data analytics and health informatics, where cost savings can be made for high-quality care (Mao et al., 2023). Government initiatives such as the value-based payment tradition compel the providers of health facilities to concentrate on the facilitation of health per output rather than focusing on services rendered (Amon et al., 2022). The models of care coordination have been extended to the following: guided care and integrated care pathways are tools that make efficiency high but low on repeatability. Acclaimed for cutting down per capita costs, it is also useful for adopting strategies that better match funds with appropriate uses, mostly on the side of the patient and the whole health system.
Slide 6
Rationale and Philosophy of Healthcare Models
Modern and future concepts of healthcare provision are focused on patient-oriented, effective, and evidence-based approaches (Metusela et al., 2020). Therefore, models like the PCMH stress patient-centered, accessible, integrated, and coordinated care. This approach also helps to enrich the continuity of the services offered to patients, boosts the quality of care delivered, and reduces expenses (Rammohan et al., 2023). Transitional care models deal with provisions of care before a patient is discharged from a hospital and after getting discharged to prevent readmission and adverse effects (Samal et al., 2021). Multidisciplinary teams deliver chronic disease care at the community level within the guided care model to emulate the Chronic Care Model. Altogether, these philosophies promote the triple aim because they help to create conditions under which care is anticipatory, tailored to the individual patient, and efficient.
Slide 7
Evolution and Impact on Healthcare Quality
Healthcare models have become more diverse and complex, incorporating specialization and community services. Moreover, they have consolidated strong post-discharge services ranging from home visitations to telehealth. Accountable care organizations are strategic organizational structures that coordinate providers’ incentives for improving the quality of services while simultaneously containing costs. Research by Samal et al. (2021) has proven that such models improve healthcare quality in the following aspects. For example, research by Mao et al. (2023) discovered that PCMHs cut down the emergency department utilization and admissions rate. A study by Fønss et al. (2021) identified research evidence that pointed out that readmission was lowered by 20 percent by transitional care interventions pointing out the need for proper post-discharge support systems. Research by Samal et al. (2021) established that managing long-term illnesses had been enhanced through the involvement of ACOs, which has positively impacted the patient and costs. These models contribute to quality healthcare by coordinating care, raising preventive service use, and cultivating a quality improvement mindset.
Slide 8
Data Gathering and Evaluation in Healthcare Models
Healthcare models such as PCMH transitional care and ACO are supposed to contain ways to gather and evaluate evidence-based data. These models emphasize integration and constant assessment that facilitates the accumulation of elaborate information on patients’ conditions and any other person interacting with them. For instance, the PCMHs use the EHR system to supervise the concern and the results concerning the interaction to ensure the appropriateness and accessibility of the info. A study by Elsener et al. (2023) demonstrated that transitional care models employ house calls and telehealth methods to capture new data following a patient’s discharge. According to research by Amon et al. (2022), ACOs rely on data networks to assess activity indicators, while patient outcomes enable decision-making. The fixed method of data collection and analysis helps medical professionals comprehend the current ideal models and methods for improving the existing processes and raising general standards of the healthcare industry.
Slide 9
Evidence-Based Data in Care Coordination
Healthcare management in nursing depends on data-driven evidence to reduce discrepancies in care delivery coordination through clinical decisions and better patient outcomes. For instance, a study conducted by Rammohan et al. (2023) revealed that care coordination protocols to reduce readmissions were made by 15%. Research by Douthit et al. (2022) identified the same effect of merging real-time data analytics into nursing practices, where the percentage of early interventions and patient surveillance increased by 20%. Additionally, research findings by Tyler et al. (2023) highlighted that evidence-based protocols in transitional care practices enhanced patient satisfaction and reduced adverse consequences.
Slide 10
Governmental Initiatives and Outcome Measures
The components that can be applied in population-based reimbursement include governmental regulation/ outcome measures because they support the triple aim’s goals in care delivery. The Affordable Care Act proposed frameworks like accountable care organizations that compel care providers to seek improvement in the quality of health care while at the same time reducing the costs (Tyler et al., 2023). The Centre for Medicare and Medicaid has encouraged value-based purchasing programs, especially where payments reflect service quality. Furthermore, a merit-based incentive payment system facilitates reporting and improvement of measures for healthcare involving practitioners (Rammohan et al., 2023). Such initiatives offer confidence that the care coordination processes are meant to direct the national quality benchmarks that have been actualized, hence patient care improvement and effective use of available resources regarding health care services.
Slide 11
Process Improvement Recommendations
Adopting the patient-focused medical home (PCMH) framework is advised to enhance the care coordination at Sacred Heart Hospital. This approach also highlights the importance of comprehensive care, aligning more closely with the triple aim of enhancing the quality of patient satisfaction while reducing expenses. Electronic health records will assist the working care team to freely pass info and the right data to other parts of the care team. Moreover, telehealth services may positively affect the given demographic concerning the number of hospitalizations since it will also imply the availability of preventive care (Mao et al., 2023). They will advance the infrastructural organization of medical services, as well as take into account the applicant’s interests.
Slide 12
Addressing Stakeholder Questions and Concerns
Stakeholders might ask why the costs of implementing these improvements are high and where the investing resources are getting to (Ginting et al., 2022). Focusing on such factors as the mere reports and records of complete efficaciousness of such approaches, which has brought evidence of overall savings for the longer term and enhancement of patient health, will be useful for proving the point. Another typical issue might be staff compliance with the changes and implementation of new technologies and processes (Limbers et al., 2020). To avert this, the need for practical, comprehensive training programs and follow-up support should be provided to make the transition easier. Stakeholders may be concerned about keeping the patients engaged during telehealth (Fønss et al., 2021). To positively influence telehealth service stakeholders, instead of focusing on potential issues or negative outcomes, it is necessary to present research showing that patients are satisfied with these services and receive improved health outcomes in rural areas.
Slide 13
NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Conclusion
Applying the triple aim at Sacred Heart Hospital can increase patient satisfaction and engagement, advance public health, and decrease the overall revenue price. This can be done by utilizing models such as the PCMH and Implementing technology such as the EHRs and telehealth, in line with the governmental regulatory framework of health. This approach will help address stakeholders’ concerns by presenting evidential outcomes and sufficient training for constant and long-term effective work. These strategies will increase healthcare system efficiency, effectiveness, and, most importantly, the focus on the patient’s needs and the general public’s well-being.
NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures References
Alderwick, H., Hutchings, A., & Briggs, A. (2021). The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: A systematic review of reviews. BMC Public Health, 21(753). https://doi.org/10.1186/s12889-021-10630-1
Amon, C., King, J., Colclasure, J., Hodge, K., & DuBard, C. A. (2022). Leveraging accountable care organization infrastructure for rapid pandemic response in independent primary care practices. Healthcare, 10(2), 100623. https://doi.org/10.1016/j.hjdsi.2022.100623
Douthit, B. J., Walden, R. L., Cato, K., Coviak, C. P., Cruz, C., D’Agostino, F., Forbes, T., Gao, G., Kapetanovic, T. A., Lee, M. A., Pruinelli, L., Schultz, M. A., Wieben, A., & Jeffery, A. D. (2022). Data science trends relevant to nursing practice: A rapid review of the 2020 literature. Applied Clinical Informatics, 13(1), 161–179. https://doi.org/10.1055/s-0041-1742218
Elsener, M., Santana, R. C., Sege, J., Harmon, P., & Jafri, F. N. (2023). Telehealth-based transitional care management program to improve access to care. BMJ Open Quality, 12(4), e002495. https://doi.org/10.1136/bmjoq-2023-002495
Fønss, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1), e040057. https://doi.org/10.1136/bmjopen-2020-040057
Ginting, M. L., Wong, C. H., Lim, Z. Z. B., Choo, R. W. M., Carlsen, S. C. H., Sum, G., & Vrijhoef, H. J. M. (2022). A patient-centered medical home care model for community-dwelling older adults in Singapore: A mixed-method study on patient’s care experience. International Journal of Environmental Research and Public Health, 19(8), 4778. https://doi.org/10.3390/ijerph19084778
Limbers, C. A., Gutierrez, A., & Cohen, L. A. (2020). The patient-centered medical home: Mental health and parenting stress in mothers of children with autism. Journal of Primary Care & Community Health, 11, 2150132720936067. https://doi.org/10.1177/2150132720936067
Mao, W., Shalaby, R., & Agyapong, V. I. O. (2023). Interventions to reduce repeat presentations to hospital emergency departments for mental health concerns: A scoping review of the literature. Healthcare, 11(8), 1161. https://doi.org/10.3390/healthcare11081161
Metusela, C., Usherwood, T., & Lawson, K. (2020). Patient-centered medical home (PCMH) transitions in western Sydney, Australia: A qualitative study. BMC Health Services Research, 20, 285. https://doi.org/10.1186/s12913-020-05123-7
Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S., Anand, P., & Mustacchia, P. (2023). The path to sustainable healthcare: Implementing care transition teams to mitigate hospital readmissions and improve patient outcomes. Cureus, 15(5), e39022. https://doi.org/10.7759/cureus.39022
Samal, L., Fu, H. N., Camara, D. S., Wang, J., Bierman, A. S., & Dorr, D. A. (2021). Health information technology to improve care for people with multiple chronic conditions. Health Services Research, 56 (1), 1006–1036. https://doi.org/10.1111/1475-6773.13860
Tyler, N., Hodkinson, A., Planner, C., Angelakis, I., Keyworth, C., Hall, A., Jones, P. P., Wright, O. G., Keers, R., Blakeman, T., & Panagioti, M. (2023). Transitional care interventions from hospital to community to reduce health care use and improve patient outcomes: A systematic review and network meta-analysis. JAMA Network Open, 6(11), e2344825. https://doi.org/10.1001/jamanetworkopen.2023.44825
