Category: NURS-FPX6612

NURS FPX 6612 Assessment 4 Cost Savings Analysis Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Cost Savings Analysis Care coordination refers to collaborating among various healthcare professionals to organize and implement patient care activities and sharing information to provide safe and effective patient-centered care. It is a crucial component of healthcare management that aims to ensure that patients receive appropriate care at the right time and in the right setting (CMS, n.d.). This assessment presents a cost-savings analysis for Miami Valley Hospital, where I work as a senior care coordinator. This report aims to identify the impact of care coordination using Health Information Technology (HIT) on augmenting cost effectiveness, improving patient outcomes, and enhancing the collection of evidence-based data to improve healthcare quality for the community.  Care Coordination and Cost-Effectiveness Health Information Technology (HIT) is vital in enhancing care coordination. Effective implementation of HIT can lead to coordinated sharing of patient information, leading to safe and effective patient care. Effective patient care may result in significant cost savings within the healthcare system. The underlying assumptions of this analysis include the belief that care coordination is essential to improve patient outcomes, streamline transitions, and elevate the use of resources to reduce complications, prevent unnecessary healthcare expenses, and enhance overall cost-effectiveness. Prevention of hospital readmissions, optimized resource utilization, and effective management of chronic diseases are some of the mechanisms that result in cost-effectiveness due to coordinated care. Healthcare providers collaborating and ensuring a smooth transition of care from the hospital to other settings, such as home or rehabilitation facilities, prevent unnecessary hospital readmissions, ultimately contributing to cost-effectiveness for the organization. According to the literature, preventing single readmission of patients with Medicare results in financial gains of $10,000 – $58,000 as per the Hospital Readmission Reduction Program  (HRRP). Moreover, preventing hospital readmission rates helps an organization save $170 million annually (Yakusheva & Hoffman, 2020).  NURS FPX 6612 Assessment 4 Cost Savings Analysis Furthermore, care coordination enhances resource utilization efficiency within the healthcare system. Through the effective sharing of information using HIT, healthcare providers can make informed decisions about allocating resources for medical tests, imaging studies, and specialist consultations. This results in value-based delivery of healthcare services, avoiding unnecessary duplication of tests and amenities, and leads to cost savings for the organization and patients (Williams et al., 2019). Lastly, chronic diseases often require ongoing and coordinated care. 85% of healthcare costs are invested in the management of chronic diseases. Thus, coordinated care is essential to prevent disease exacerbations, complications, and recurrent hospitalizations, which are the primary reasons for these elevated costs (Holman, 2020). This proactive approach improves the health and well-being of individuals with chronic diseases, resulting in patient cost savings. Overall, care coordination plays a vital role in balancing quality care and cost savings within the healthcare system. Care Coordination and Positive Health Outcomes Health consumerism is the active participation of patients in their healthcare journey. Patient engagement is one of the crucial components of care coordination. Care coordination using HIT tools such as Electronic Health Records (EHRs) and patient portals allows patients to access their health information, empowering them to make healthcare decisions and manage their health effectively. The concept of patient-centeredness elaborates on the cause-and-effect relationship between care coordination and health consumerism. Coordinated care between provider and patients through regular communication, ongoing monitoring, and tailoring patient care plans according to their needs and preferences encourages them to be informed consumers, actively participating in discussions about their treatment options, medications, and lifestyle choices with healthcare providers (Albertson et al., 2022). By informing patients about their healthcare journeys and fostering a collaborative relationship between healthcare providers and patients, care coordination supports shared decision-making, promoting improved health consumerism.  Coordinated care through HIT aids preventive care and early intervention, leading to positive health outcomes. With access to personalized health data, individuals are better positioned to adopt preventive measures and make lifestyle changes that positively impact their well-being (Choi & Powers, 2023). Moreover, collaboration among healthcare providers, facilitated by HIT, provides a holistic understanding of patients’ healthcare needs, enabling timely interventions and reducing the chances of complications. Furthermore, HIT-driven care coordination leads to continuity of care, ensuring a smooth healthcare experience for patients across different settings. This continuity of care augments patient experience, resulting in positive health outcomes and promoting a more holistic and coordinated approach to healthcare practices (Cha, 2023). Care Coordination and Enhanced Evidence-based Data Patient-Centered Medical Homes (PCMH) is an emerging healthcare model focusing on holistic, coordinated, patient-centered care. It involves a collaborative approach to improve patient outcomes through enhanced communication, patient engagement, and continuous quality improvement (De Marchis et al., 2019). Care coordination can enhance the collection of evidence-based data and quality of care using the PCMH model in several ways.  Care coordination through PCMH involves the integration of EHRs to optimize healthcare processes and improve quality. This EHR integration improves the data collection by providing a holistic view of the patient’s health. Moreover, a coordinated and evidence-based data collection approach enables healthcare providers to make evidence-based decisions and tailor care plans to individual needs, improving the quality of care (Jubril, 2019).  The PCMH model emphasizes effective communication and collaboration among healthcare providers. This improved communication ensures immediate sharing of relevant patient health information, facilitating the collection of timely and accurate evidence-based data, ultimately encouraging evidence-based decisions, well-coordinated care, and improved healthcare quality.  NURS FPX 6612 Assessment 4 Cost Savings Analysis Practice changes, performance measures, and benchmarking under the umbrella of PCMH aids in assessing and comparing the quality of care provided. This involves systematic data collection to measure performance against established standards. This evidence-based data collected through care coordination helps the organization to identify areas for improvement and healthcare practices with evidence-based standards to enhance the quality of care (Quigley et al., 2021).  Care coordination enhances the collection of evidence-based data for analytics and modeling, supported by the PCMH model, to identify disease patterns, predict health risks among the population, and tailor

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Patient Discharge Care Planning Patient discharge care planning is a crucial aspect of ensuring continuity of care and preventing hospital readmissions. This assessment is based on Marta Rodriguez, a college freshman who was involved in a car accident in Nevada. She was initially treated at a shock trauma center for four weeks, undergoing multiple surgeries and receiving antibiotic treatment for a systemic infection. Marta recently relocated from New Mexico to Nevada for her studies and has student health insurance coverage. One of the primary considerations in Marta’s care planning is her language preference. Spanish is her native language, while English is her second language. As a senior care coordinator overseeing her case, it is essential to evaluate the key issues that the interprofessional team must address to develop an effective discharge plan. A well-coordinated discharge plan will integrate Health Information Technology (HIT) to facilitate care continuity, data reporting mechanisms to enhance clinical efficiency, and patient-reported health information to improve overall health outcomes. This interprofessional approach will be presented in a team meeting to ensure Marta receives comprehensive and patient-centered post-discharge care. Longitudinal Patient Care Plan HIT plays a vital role in ensuring a smooth transition from hospital care to home-based or outpatient care. Digital tools and telehealth services can enhance patient monitoring, support virtual follow-ups, and promote patient engagement in their recovery process (Abraham et al., 2022). For Marta, Electronic Health Records (EHR) with multilingual support will be crucial in maintaining a detailed and accessible medical history, including her surgeries, medication regimens, and infection treatments. By leveraging real-time data sharing, healthcare professionals can collaborate effectively to make informed decisions about her post-discharge care (Khoong et al., 2020). To enhance Marta’s recovery, the interprofessional team will implement remote monitoring and telehealth platforms to track her medication adherence, schedule virtual follow-ups, and monitor vital signs. Predictive analytics tools and Clinical Decision Support Systems (CDSS) will be employed to assess Marta’s risk factors, such as infection recurrence or post-operative complications, ensuring early interventions when necessary (Somsiri et al., 2020). These technologies will minimize the risk of hospital readmission and support a seamless care transition. Implications of HIT in Care Planning The integration of HIT elements into Marta’s care plan will contribute to a patient-centered approach that enhances care coordination and reduces readmission risks. With access to real-time data, the interprofessional team can promptly address emerging health concerns while engaging Marta in her care process (Srinivasan et al., 2020). The use of EHR and CDSS will further improve communication among healthcare providers, fostering collaboration to ensure Marta’s post-discharge care is well-structured. Additionally, HIT tools support a longitudinal approach to patient care, allowing for proactive interventions and personalized care planning. By leveraging patient data effectively, healthcare professionals can enhance Marta’s recovery outcomes and empower her to take an active role in managing her health (Somsiri et al., 2020). HIT ensures that patient information remains accessible and up to date, reducing the likelihood of treatment errors and enhancing care efficiency. Table Format Representation Key Area Implementation in Marta’s Care Expected Outcomes Longitudinal Patient Care Plan Utilizing EHR with multilingual capabilities to document Marta’s medical history and treatment plans (Khoong et al., 2020). Implementing telehealth platforms for virtual follow-ups and remote monitoring (Abraham et al., 2022). Ensures continuity of care, reduces hospital readmission risks, and allows real-time updates for healthcare providers. Implications of HIT in Care Planning Integrating predictive analytics and CDSS to assess risk factors and enhance decision-making (Somsiri et al., 2020). Using real-time data sharing for collaborative care coordination (Srinivasan et al., 2020). Enhances patient-centered care, improves provider collaboration, and supports proactive health management. Patient Data and Reporting Analyzing Marta’s medication adherence and follow-up attendance for personalized interventions (Kumar et al., 2022). Using reported health data to tailor culturally competent care strategies (Real et al., 2020). Improves clinical efficiency, facilitates timely interventions, and enhances patient satisfaction and engagement. References Abraham, J., Meng, A., Tripathy, S., Kitsiou, S., & Kannampallil, T. (2022). Effect of Health Information Technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: A systematic review. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocac013 Khoong, E. C., Rivadeneira, N. A., Hiatt, R. A., & Sarkar, U. (2020). The use of technology for communicating with clinicians or seeking health information in a multilingual urban cohort: Cross-Sectional survey. Journal of Medical Internet Research, 22(4), e16951. https://doi.org/10.2196/16951 Kumar, S., Qiu, L., Sen, A., & Sinha, A. P. (2022). Putting analytics into action in care coordination research: Emerging issues and potential solutions. Production and Operations Management, 31(6). https://doi.org/10.1111/poms.13771 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Real, K., Bell, S., Williams, M. V., Latham, B., Talari, P., & Li, J. (2020). Patient perceptions and real-time observations of bedside rounding team communication: The Interprofessional Teamwork Innovation Model (ITIM). The Joint Commission Journal on Quality and Patient Safety, 46(7). https://doi.org/10.1016/j.jcjq.2020.04.005 Somsiri, V., Asdornwised, U., O’Connor, M., Suwanugsorn, S., & Chansatitporn, N. (2020). Effects of a transitional telehealth program on functional status, rehospitalization, and satisfaction with care in Thai patients with heart failure. Home Health Care Management & Practice, 108482232096940. https://doi.org/10.1177/1084822320969400 Srinivasan, M., Jayant, P., Zulman, D., Thadaney, I., Samuel, M., Robert, S., Lance, D. M., Ian, N., Artandi, M., & Sharp, C. (2020). Enhancing patient engagement during virtual care: A conceptual model and rapid implementation at an academic medical center. NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0262 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

NURS FPX 6612 Assessment 2 Quality Improvement Proposal Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Quality Improvement Proposal The Medicare and Medicaid Services define ACOs as organizations that deliver high-quality care treatments voluntarily to Medicare patients through effective care coordination (Millwee, 2020). The Sacred Heart Hospital (SHH) under Vila Health seeks to acquire the status of an Accountable Care Organization (ACO).  Assuming the duty of a case manager at SHH, a quality improvement proposal will be recommended to better include quality metrics by expanding the hospital’s HIT with a broad focus on Electronic Health Records (EHRs). Ways to Expand Hospital’s HIT to Include Quality Metrics The EHR system of SHH is outdated and requires appropriate updates to provide a better range of quality metrics on mammograms and colonoscopies. There are several ways by which the EHR system of SHH can be improved by adding extra features such as social work tabs, which will integrate patient health data and keep track of visits with patients. Additionally, the quality metrics relevant to patient care goals will be integrated within EHR (Aerts et al., 2021). These quality metrics will be rates of preventive screenings such as mammograms and colonoscopies, medication errors, patient satisfaction, and quality of care. The SHH will collaborate with public health departments and other clinics to gather data on patients not receiving recommended diagnostic tests, including mammograms and colonoscopies (Dawson et al., 2021).  By utilizing population health data, it will be easier for SHH to identify trends and barriers to care that people encounter during routine diagnostic tests. This data will be analyzed to pinpoint specific patient populations, such as women seeing gynecologists needing targeted interventions (Eckelman et al., 2020). These problems can be solved by implementing care coordination strategies such as leveraging the EHR to identify at-risk patients, practicing reminders and alerts for providers to engage with at-risk patients, and promoting care coordination to achieve higher rates of patients undergoing preventive screenings. This approach will also help track the health information from the community to make necessary improvements based on the gathered data (Watterson et al., 2020). NURS FPX 6612 Assessment 2 Quality Improvement Proposal Several issues can arise during expanding HIT within the organization: The organization requires adequate finances to implement practical ways to enhance EHR features and improve interoperability, including quality metrics. Due to a limited budget, the organization must meet financial requirements such as vendor selection and upgrading EHR systems (Gill et al., 2020). The healthcare organization is vulnerable to inconsistent standardized data, which hinders evaluating the accuracy of gathered data on quality metrics. The organization is also prone to face resistance to changes that are thought to be implemented within EHR and practice clinically. This resistance to change from staff can impact the effectiveness of including quality metrics without making them adequately used (Cho et al., 2021). These issues can be rationally solved by following strategies: Collaborating with other healthcare organizations for funds can improve SHH’s financial capacity. Introduce the standardized data protocols to maximize accuracy in evaluating aggregated data on quality metrics. Educate the healthcare staff on the benefits of using newly upgraded EHR in patient care quality and how it can facilitate timely care treatments (Cho et al., 2021). NURS FPX 6612 Assessment 2 Quality Improvement Proposal Expanding the HIT in the context of upgrading EHRs at SHH integrates the vital roles of informatics in nursing care in the form of nurse informaticists. The nurse informaticist specializes in care coordination through the effective use of HIT, facilitates care planning, and streamlines communication among healthcare staff. Moreover, the nurse informaticist conducts training and educational programs on promoting care coordination by using informatics tools (Gill et al., 2020). The training sessions are tailored to address specific workflows and use cases relevant to nursing care coordination. Similarly, informatics initiatives such as upgraded EHR use in hospitals foster a culture of continuous improvement as the nurses continue to solicit EHR feedback and apply it in initiatives (Eckelman et al., 2020). Using HIT and informatics tools within healthcare systems, including SHH, quality metrics can be better incorporated and utilized to improve patient care. Information Gathering in Healthcare Healthcare systems use patient health information to assess quality metrics and trends in delivering high-quality care and analyze the lagging areas. The primary focus of information gathering in healthcare settings like SHH is to obtain comprehensive data about patients, processes, outcomes, and organizational performance. This information is the foundation for evidence-based decision-making and the development of managerial practices to enhance patient care and operational efficiency (Hathaliya & Tanwar, 2020).  EHRs can be practical tools to gather information about patients’ clinical health data and evaluate treatment performed and achieved outcomes. For example, the information displayed on EHR, including patient demographics, medical history, lab results, medication lists, and treatment plans, can be. Use by clinicians to make well-informed and mindful decisions about patient care (Eckelman et al., 2020).  The organization can also gather data on quality metrics and performance indicators to assess the effectiveness of healthcare facilities. For example, medication errors display the need to include interventions that promote safe medication administration (Lv & Qiao, 2020). Information gathering in the organization also encompasses operational data such as staffing levels and resource utilization. These data help healthcare organizations identify opportunities to improve the quality of care and overall organizational performance (Lv & Qiao, 2020). NURS FPX 6612 Assessment 2 Quality Improvement Proposal   At SHH, healthcare organizations can gather information on these aspects and inquire about patient health data through EHR and personal interviews. One such example from SHH includes communicating with a patient named Caroline McGlade, combatting breast cancer, and describing her lack of knowledge in conducting mammograms and preventive care. The information provided shows a lagging factor behind preventive care at SHH due to financial constraints and need for more education about preventative care (Ye, 2021). Using this information, tailored strategies can be developed and implemented to promote preventive care, essential for SHH to

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 Introduction Hello everyone, my name is ——. As a case manager, I aim to present how the Triple Aim—improving population health, reducing costs, and enhancing the quality of care—can be effectively implemented at Sacred Heart Hospital (SHH). This initiative requires collaboration between hospital leaders and healthcare workers. Additionally, the presentation will explore governmental regulatory programs and outcome measures that contribute to a coordinated care approach, ensuring SHH successfully achieves the Triple Aim. Purpose The primary goal of this presentation is to educate hospital leadership and clinical teams about optimizing the coordinated care process to achieve the Triple Aim in Barnes County Community, where SHH is located. This will be accomplished through patient self-management models, care coordination initiatives, governmental regulations, and measurable outcome strategies. The success of care coordination in achieving the Triple Aim relies on interdisciplinary collaboration among healthcare professionals. Triple Aim and Its Contribution to Healthcare Organizations Experience of Care/Patient Satisfaction Enhancing patient experience at SHH requires a comprehensive approach that prioritizes patient-centered care and effective communication between healthcare providers and patients (Kwame & Petrucka, 2021). Additionally, identifying population needs, such as increasing health literacy, expanding insurance coverage, reducing wait times, and ensuring consistent follow-up care, will enhance patient satisfaction and foster trust between patients and providers. Improving Population or Community Health SHH can improve population health in Barnes County by implementing preventive care programs and health education initiatives. These efforts will help integrate preventive measures into patients’ lifestyles, ultimately enhancing overall health (Yamada & Arai, 2020). Additionally, addressing social determinants such as transportation challenges and low health literacy will increase access to care. Collaborations with other healthcare entities will further enhance resource-sharing and improve health outcomes. Decreasing Per Capita Costs Reducing per capita healthcare costs at SHH requires a balance between cost-effectiveness and quality care. Implementing cost-efficient care models and leveraging technology can optimize healthcare delivery. Furthermore, partnerships with governmental agencies and healthcare organizations will improve financial sustainability, minimize hospital readmission rates, and enhance the hospital’s ability to provide high-quality care within a financially responsible framework (Fichtenberg et al., 2020). Analyzing the Relationship Between Health Models and the Triple Aim Patient Self-Management Model (PSMM) The Patient Self-Management Model (PSMM) focuses on empowering individuals to actively manage their health. By providing patients with knowledge and tools, they can make informed decisions, leading to better health outcomes (Fu et al., 2020). This approach has shifted from a paternalistic model to a collaborative, patient-centered strategy, encouraging autonomy and accountability in managing chronic conditions. PSMM enhances healthcare quality by: Increasing adherence to treatment plans, leading to better outcomes (Lonc et al., 2020). Encouraging preventive care and early intervention, reducing complications. Improving patient satisfaction by fostering collaboration between providers and patients (Du et al., 2019). Care Coordination Model (CCM) The Care Coordination Model (CCM) ensures that healthcare services are seamlessly integrated across various providers and settings. This model emphasizes the importance of communication and collaboration in delivering comprehensive, patient-centered care (Karam et al., 2021). Over time, technological advancements have enhanced interdisciplinary coordination, leading to improved healthcare efficiency. CCM improves healthcare quality by: Reducing fragmented care through streamlined communication among providers (Bloem et al., 2020). Enhancing patient safety by minimizing medical errors (Carayon et al., 2020). Facilitating continuity of care, particularly for chronic disease management (Facchinetti et al., 2020). Both models contribute to the Triple Aim by enhancing patient outcomes, improving care quality, and reducing costs. Structure of Selected Health Care Models Healthcare Model Structure and Components Impact on Triple Aim Patient Self-Management Model (PSMM) Focuses on patient-centered care, self-monitoring, digital health tools, and education Enhances patient autonomy, reduces costs, and improves health outcomes (Solomon & Rudin, 2020). Care Coordination Model (CCM) Integrates care across settings, utilizes electronic health records (EHRs), and enhances interdisciplinary collaboration Reduces hospital readmissions, improves efficiency, and ensures continuous patient care (Awad et al., 2021). Evidence-Based Data in Coordinated Care Enhancing Decision-Making and Communication Evidence-based data plays a crucial role in refining coordinated care by supporting informed decision-making and improving communication among healthcare teams. By analyzing research findings and clinical guidelines, nurses and providers can implement best practices to enhance patient outcomes (Belita et al., 2020). Additionally, streamlined communication through interprofessional collaboration facilitates the development of tailored treatment plans (Hoffmann et al., 2023). Governmental Regulatory Initiatives and Outcome Measures Several regulatory initiatives support the achievement of the Triple Aim: Initiative Description Outcome Measures Health Information Exchange (HIE) Facilitates electronic sharing of patient data across providers Reduces duplicate tests, improves medication reconciliation, and enhances care continuity (Zhuang et al., 2020). Medicare Shared Savings Program (MSSP) Encourages accountable care organizations (ACOs) to coordinate care and lower costs Increases cost savings and enhances patient satisfaction (McWilliams et al., 2020). Meaningful Use Program Incentivizes the adoption of EHRs for better data exchange and care coordination Improves interoperability, enhances patient engagement, and reduces medical errors (Mohammadzadeh et al., 2021). By adopting these regulatory measures, SHH can enhance coordinated care and optimize patient outcomes. Process Improvement Recommendations for Stakeholders Stakeholders Challenges and Concerns Recommended Solutions Healthcare Providers Concerns over initial investment and workflow disruptions Implement pilot programs for gradual adaptation and minimize disruptions. Hospital Administration Concerns regarding workforce adaptability to automation Conduct comprehensive training programs for a smooth transition. Interdisciplinary Teams Need for enhanced communication Develop structured communication protocols for cross-departmental collaboration (Karam et al., 2021). Conclusion To achieve the Triple Aim, SHH must prioritize care coordination through the integration of healthcare models such as PSMM and CCM. These models enhance patient outcomes, reduce costs, and improve overall community health. Through collaboration with healthcare leaders, administrators, and external partners, SHH can successfully implement these strategies to deliver high-quality, cost-effective care to Barnes County Community. I encourage stakeholders to consider these recommendations to ensure sustainable improvements in healthcare delivery. Thank you. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures