NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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Assessment 1: Triple Aim Outcome Measures
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Student Name
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Capella University
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Course Name
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Nov 8, 2023
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Triple Aim Outcome Measures
Introduction
I am Albert S. Smith, assuming the role of a case manager at Sacred Heart, a rural hospital, for
this presentation. The purpose is to guide hospital members in achieving care coordination
through the Triple Aim process.
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Purpose
This presentation aims to enlighten the leadership of Sacred Heart Hospital regarding the care
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coordination process and align their practices with the Triple Aim objectives for the rural
population. It also seeks to enhance understanding of supporting models for Triple Aim and
facilitate a comparative analysis. Two models have been chosen for this presentation: the
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Patient-Centered Medical Home (PCMH) and Transitional Care.
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Triple Aim
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The Triple Aim concept comprises objectives focused on enhancing healthcare quality services,
including a better patient experience, healthier populations, and lower healthcare costs. Efficient
care coordination plays a pivotal role in achieving these objectives. The following sections will
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elaborate on how the Triple Aim contributes to community health, enhances patient care
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experience, and reduces healthcare costs.
Patient Experience of Care

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One of the primary objectives of the Triple Aim is to enhance the patient experience, achievable
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through various means such as reducing waiting times, improving communication, and involving
patients in treatment plans. Patient satisfaction is vital as it impacts patient adherence to
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treatment, engagement in care, and overall health outcomes. Improving patient experience
leads to better health outcomes, as patients are more likely to comply with treatment plans,
attend follow-up appointments, and report any issues.
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Enhancing Community or Population Health

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The Triple Aim seeks to improve community health by recognizing and addressing health needs.
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Healthcare providers must assess population data and formulate plans to enhance health
outcomes. Care coordination is critical in this process, as care coordinators can identify high-risk
patients and ensure they receive appropriate care. Furthermore, collaboration with community
partners to address social determinants of health and execute preventive measures like
immunization and health screenings is essential.
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Reducing Per Capita Costs
The Triple Aim aims to reduce per capita healthcare costs by enhancing care quality and
minimizing waste. Efficient care coordination can contribute to cost savings by reducing hospital
stays, unnecessary procedures and tests, and preventing readmissions. Moreover, healthcare
providers can reduce chronic disease management costs by collaborating with community
partners and addressing social determinants of health. Population health management
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programs that promote preventive care can also decrease healthcare costs by addressing
health issues before they become severe and costly to treat.
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In conclusion, achieving Triple Aim objectives necessitates healthcare providers to enhance
patient experience, and community health, and minimize healthcare costs. Effective care
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coordination plays a critical role in achieving these goals, helping to identify high-risk patients,
minimize waste, and promote preventive care. Moreover, by assessing population data, working
with community partners, and implementing evidence-based strategies, healthcare providers
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can achieve Triple Aim objectives and enhance patient care quality.
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Analyzing the Relationship Between Health Models and Triple
Aim
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The Patient-Centered Medical Home (PCMH) and Transitional Care models have gained
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prominence due to their potential to improve patient outcomes and align with the Triple Aim
objectives, including enhancing patient experience, improving population health, and reducing
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healthcare costs.
The PCMH model emphasizes comprehensive, coordinated, and patient-centered care that is
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accessible, continuous, and team-based. It empowers patients to become active partners in

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their care while enhancing care coordination among healthcare providers. The model has
evolved to incorporate technology, patient engagement tools, and quality metrics, thereby
improving patient outcomes and reducing healthcare costs (Kaufman et al., 2018).
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On the other hand, Transitional Care is designed to support patients during transitions of care,
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such as from hospital to home or from one healthcare provider to another (Shahsavari et al.,
2019). Furthermore, the model employs a team-based approach that includes a care
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coordinator working with the patient and their family to ensure a smooth transition and follow-up
care. Technology like telehealth is integrated to enhance communication and improve care
coordination.
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These healthcare models enhance healthcare quality in several ways. For example, the PCMH
model has reduced hospital readmissions and emergency department visits and improved
chronic disease management (Ruediger et al., 2019). Additionally, it has enhanced patient and
provider satisfaction (Ruediger et al., 2019). Similarly, Transitional Care has been found to
reduce hospital readmissions, improve patient outcomes, reduce medication errors, enhance
patient satisfaction, and reduce healthcare costs (Fønss Rasmussen et al., 2021).In summary,
the PCMH and Transitional Care models possess the potential to improve patient outcomes,
enhance care coordination, and reduce healthcare costs. Moreover, they align with the Triple
Aim by focusing on patient-centered care and improving population health. As healthcare
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evolves, these models are likely to be refined and adapted to meet the changing needs of
patients and providers.
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Structure of Healthcare Models
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The Patient-Centered Medical Home (PCMH) and Transitional Care models are designed to
enhance the quality of care provided to patients while ensuring better health outcomes
(McNabney et al., 2022). These models employ various strategies to gather and evaluate
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evidence-based data, aiding healthcare providers in making informed decisions to improve
patient care quality.
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The PCMH model emphasizes a team-based approach to healthcare, focusing on providing
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comprehensive and coordinated care to patients. This model heavily relies on electronic health
records (EHRs) to gather and evaluate evidence-based data (McNabney et al., 2022). EHRs
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allow healthcare providers to access patient data in real-time, enabling more informed decisions
regarding patient care (M. & Chacko, 2021). Furthermore, the PCMH model emphasizes the use
of evidence-based guidelines to ensure patients receive the most appropriate care, based on
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the latest research and clinical evidence.

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On the other hand, the Transitional Care model is designed to provide continuity of care for
patients transitioning from one healthcare setting to another. It emphasizes using
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evidence-based interventions to ensure patients receive the most appropriate care during the
transition process. A key feature of this model is the transitional care team, responsible for
coordinating care during the transition process, relying on evidence-based data to make
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informed decisions regarding patient care.

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The structure of these healthcare models emphasizes the use of electronic health records and
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evidence-based guidelines to gather and evaluate data. They also rely on interdisciplinary
teams and evidence-based interventions to ensure patients receive the most appropriate care.
By utilizing these strategies, healthcare providers can enhance patient care quality while
ensuring better health outcomes.
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Evidence-based Data Shaping the Care Coordination Process
The nursing practice of care coordination is significantly influenced by data based on scientific
evidence. Utilizing data in care coordination helps identify gaps and areas that require
improvement, enabling healthcare providers to design more effective interventions. The care
coordination process involves collaboration and communication among healthcare providers,
patients as well and family members to ensure patients receive comprehensive and high-quality
care.
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Effective care coordination relies on evidence-based data to identify patient needs, such as
chronic conditions, medication adherence, and social determinants of health (Kangovi et al.,
2020). This data also helps to identify potential barriers to care, such as transportation or
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financial constraints, that may prevent patients from accessing necessary healthcare services.
Moreover, evidence-based data informs the development of care plans and pathways that
facilitate the delivery of coordinated care across different healthcare settings.
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Nurses use this information to design interventions tailored to each patient’s unique needs and
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preferences, ensuring they receive the right care at the right time. The use of evidence-based
data also improves patient outcomes by promoting continuity of care and reducing the risk of
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medical errors. By ensuring all healthcare providers have access to the same patient
information, care coordination reduces the likelihood of redundant tests, conflicting medications,
and other complications that may arise when patients receive care from multiple providers.
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In conclusion, care coordination in nursing can be improved with the help of empirical research.
By using this data, healthcare providers can design more effective interventions, improve patient
outcomes, and promote continuity of care. By ensuring that all healthcare team members work
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together to deliver the best possible care, care coordination helps improve patient care quality
while reducing costs and improving efficiency.
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Governmental Regulatory Initiatives

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To achieve the Triple Aim, Sacred Heart Hospital needs to modernize its care coordination
process, and incorporating regulatory initiatives and outcome measures from the government is
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one way to do this. One such regulatory initiative is the Medicare Shared Savings Program
(MSSP), a value-based payment model incentivizing healthcare providers to coordinate care,
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improve quality, and reduce healthcare costs (Bravo et al., 2022). Furthermore, by participating
in this program, Sacred Heart Hospital can collaborate with other healthcare providers to
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coordinate care for patients, ensuring they cost-effectively receive appropriate care. This will
help to reduce the per capita cost of healthcare while improving patient outcomes, thereby
contributing to the Triple Aim.
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Another regulatory initiative applicable to Sacred Heart Hospital’s care coordination process is
the Hospital Readmissions Reduction Program (HRRP), which aims to reduce hospital
readmissions by penalizing hospitals with higher-than-expected readmission rates. Effective
care coordination processes can reduce the likelihood of readmissions, enhancing patient
outcomes and reducing healthcare costs. This contributes to achieving the Triple Aim by
improving the care experience for patients, enhancing population health, and lowering the cost
of healthcare provision.
In addition to these regulatory initiatives, outcome measures such as patient satisfaction, clinical
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quality measures, and healthcare utilization can be employed to monitor the effectiveness of the
care coordination process at Sacred Heart Hospital. By tracking these measures, the hospital
can identify areas for improvement and adjust its care coordination processes accordingly. For
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example, if patient satisfaction scores are low, the hospital may need to improve communication
between care providers and patients or provide additional resources to support patients after
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discharge. Therefore, Sacred Heart Hospital can achieve the Triple Aim and provide
high-quality, cost-effective care to its patients by continuously monitoring and improving the care
coordination process.
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Process Improvement Recommendations to Stakeholders
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Sacred Heart Hospital must improve its care coordination process to achieve Triple Aim
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outcomes for the community. The existing care coordination process is inefficient and leads to
suboptimal patient experience, poor health outcomes, and increased per capita cost of
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healthcare.
Stakeholders
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The stakeholders in this case include the hospital administration, healthcare providers, patients,
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caregivers, and representatives from Vila Health.

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Anticipated Needs and Concerns of Stakeholder Group

The stakeholders will want to understand why updating the care coordination process is
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necessary and how it aligns with the Triple Aim objectives. They will also want to know the
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specific strategies SHH will employ to achieve the Triple Aim outcomes.
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Questions and Objections Likely to be Raised

The stakeholders might question the resources required to update the care coordination
process and how it will impact their work. They might also object to the timeline for implementing
these changes, citing that it is too short.
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Response to Questions and Objections
In response to questions about resources, SHH should explain that updating the care
coordination process requires minimal additional resources and is necessary to improve patient
outcomes. Moreover, to address concerns about the timeline, SHH should assure stakeholders
that the timeline is reasonable and that the hospital will provide adequate support to enable
everyone to make the necessary changes efficiently.
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References
Bravo, F., Levi, R., Perakis, G., & Romero, G. (2022). Care coordination for healthcare referrals
under a shared‐savings program. Production and Operations Management.
https://doi.org/10.1111/poms.13830
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
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review. BMJ Open, 11(1), e040057. https://doi.org/10.1136/bmjopen-2020-040057
Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based
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community health worker program addresses unmet social needs and generates a positive
return on investment. Health Affairs, 39(2), 207–213. https://doi.org/10.1377/hlthaff.2019.00981
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Kaufman, B. G., Spivack, B. S., Stearns, S. C., Song, P. H., O’Brien, E. C., & Kansagara, D.
(2018). Impact of patient-centered medical homes on healthcare utilization. American journal of
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managed care, 24(5), 237-243.
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M., S., & Chacko, A. M. (2021, January 1). 2 – Interoperability issues in EHR systems:
Research directions (K. C. Lee, S. S. Roy, P. Samui, & V. Kumar, Eds.). ScienceDirect;
Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128193143000021
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McNabney, M. K., Green, A. R., Burke, M., Le, S. T., Butler, D., Chun, A. K., Elliott, D. P., Fulton,
A. T., Hyer, K., Setters, B., & Shega, J. W. (2022). Complexities of care: Common components
of models of care in geriatrics. Journal of the American Geriatrics Society.
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https://doi.org/10.1111/jgs.17811
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Ruediger, M., Kupfer, M., & Leiby, B. E. (2019). Decreasing re-hospitalizations and emergency
department visits in persons with recent spinal cord injuries using a specialized medical home.
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The Journal of Spinal Cord Medicine, 44(2), 221–228.

https://doi.org/10.1080/10790268.2019.1671075
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Shahsavari, H., Zarei, M., & Aliheydari Mamaghani, J. (2019). Transitional care: Concept
analysis using Rodgers’ evolutionary approach. International Journal of Nursing Studies, 99,
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103387. https://doi.org/10.1016/j.ijnurstu.2019.103387
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Assessment 1: Triple Aim Outcome Measures

experience, and reduces healthcare costs.

Patient Experience of Care

Enhancing Community or Population Health

accessible, continuous, and team-based. It empowers patients to become active partners in

the latest research and clinical evidence.

informed decisions regarding patient care.

Governmental Regulatory Initiatives

caregivers, and representatives from Vila Health.

Anticipated Needs and Concerns of Stakeholder Group

Questions and Objections Likely to be Raised

The Journal of Spinal Cord Medicine, 44(2), 221–228.

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