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NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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    NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

    Student Name

    Capella University

    NURS-FPX 6612 Health Care Models Used in Care Coordination

    Prof. Name


    Triple Aim Outcome Measures

    Greetings, I’m __________, assuming the role of a case manager at Sacred Heart, a rural hospital, for this presentation. The objective remains guiding hospital members on achieving care coordination through the Triple Aim process.


    This presentation aims to enlighten Sacred Heart Hospital’s leadership on the care coordination process, aligning their practices with Triple Aim objectives for the rural population. Additionally, it seeks to enhance understanding of supporting models for Triple Aim, facilitating a comparative analysis using two chosen models: the Patient-Centered Medical Home (PCMH) and Transitional Care.

    Triple Aim

    The Triple Aim focuses on improving healthcare quality services, including a better patient experience, healthier populations, and lower healthcare costs. Efficient care coordination is pivotal for achieving these objectives. The subsequent sections will detail how the Triple Aim contributes to community health, enhances patient care experience, and reduces healthcare costs.

    Patient Experience of Care

    The primary Triple Aim objective is enhancing the patient experience, achievable through means like reducing waiting times, improving communication, and involving patients in treatment plans. Patient satisfaction impacts adherence to treatment, engagement in care, and overall health outcomes. Improving patient experience leads to better health outcomes, fostering compliance with treatment plans, attendance at follow-up appointments, and issue reporting.

    Enhancing Community or Population Health

    The Triple Aim improves community health by recognizing and addressing health needs, emphasizing the role of care coordination. Identifying high-risk patients and ensuring they receive appropriate care is critical. Collaboration with community partners to address social determinants of health and execute preventive measures is essential.

    Reducing Per Capita Costs

    Triple Aim aims to reduce per capita healthcare costs by enhancing care quality. Care coordination contributes by reducing hospital stays, unnecessary procedures, and tests, and preventing readmissions. Collaboration with community partners to address social determinants of health can further reduce chronic disease management costs.

    In conclusion, achieving Triple Aim objectives requires healthcare providers to enhance patient experience, community health, and minimize healthcare costs. Effective care coordination plays a crucial role in achieving these goals.

    Analyzing the Relationship Between Health Models and Triple Aim

    The Patient-Centered Medical Home (PCMH) and Transitional Care models have gained prominence for their potential to align with Triple Aim objectives. PCMH emphasizes comprehensive, coordinated, and patient-centered care, evolving to incorporate technology and improve patient outcomes. Transitional Care supports patients during transitions, employing a team-based approach and integrating technology for communication.

    Both models enhance healthcare quality, reducing hospital readmissions and improving patient satisfaction. PCMH has improved chronic disease management, while Transitional Care has reduced hospital readmissions, improved patient outcomes, and reduced healthcare costs.

    In summary, the PCMH and Transitional Care models have the potential to improve patient outcomes, enhance care coordination, and reduce healthcare costs while aligning with Triple Aim objectives.

    Structure of Healthcare Models

    PCMH and Transitional Care models aim to enhance patient care quality and better health outcomes. They employ strategies such as using electronic health records (EHRs), evidence-based guidelines, interdisciplinary teams, and evidence-based interventions.

    PCMH emphasizes a team-based approach and relies on EHRs for real-time data access. Transitional Care focuses on evidence-based interventions during care transitions, using a transitional care team for coordination.

    The structure of these models emphasizes the use of EHRs, evidence-based guidelines, interdisciplinary teams, and evidence-based interventions to ensure patients receive appropriate care.

    Evidence-based Data Shaping the Care Coordination Process

    Care coordination in nursing relies significantly on data based on scientific evidence. This data helps identify gaps, areas for improvement, and patient needs such as chronic conditions, medication adherence, and social determinants of health.

    Effective care coordination utilizes evidence-based data to inform care plans, identify barriers to care, and design interventions tailored to each patient. This approach promotes continuity of care, reduces the risk of medical errors, and improves patient outcomes.

    In conclusion, empirical research enhances care coordination in nursing, leading to more effective interventions, improved patient outcomes, and better continuity of care.

    Governmental Regulatory Initiatives

    To achieve the Triple Aim, Sacred Heart Hospital can modernize its care coordination process by incorporating regulatory initiatives and outcome measures from the government. The Medicare Shared Savings Program (MSSP) incentivizes care coordination, improving quality, and reducing costs.

    Another initiative, the Hospital Readmissions Reduction Program (HRRP), aims to reduce readmissions by penalizing hospitals with higher-than-expected rates. Effective care coordination can reduce readmissions, contributing to the Triple Aim.

    Additionally, outcome measures like patient satisfaction and healthcare utilization can be employed to monitor and improve the care coordination process continuously.

    Process Improvement Recommendations to Stakeholders

    To achieve Triple Aim outcomes, Sacred Heart Hospital must improve its care coordination process. Stakeholders, including the administration, healthcare providers, patients, caregivers, and Vila Health representatives, need to understand the necessity of this update and how it aligns with Triple Aim objectives.

    Stakeholders will likely inquire about resource requirements and the impact on their work. Responding to these concerns, SHH should explain that the update requires minimal additional resources and is essential for improving patient outcomes. Assuring stakeholders about the reasonable timeline and providing adequate support will address concerns and ensure efficient implementation.


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    Fønss Rasmussen, 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.

    Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207–213.

    NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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    NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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