NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures
Phillip October 6, 2023 No Comments

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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


My name is Albert S. Smith, and I will be assuming the role of a case manager at Sacred Heart, a rural hospital, for this presentation. The purpose of this presentation is to guide hospital members on achieving care coordination through the Triple Aim process.


The aim of this presentation is to enlighten the leadership of Sacred Heart Hospital regarding the care coordination process and align their practices with the Triple Aim objectives for the rural population. Additionally, this presentation seeks to enhance understanding of supporting models for Triple Aim and facilitate a comparative analysis. Two models have been chosen for this presentation: the Patient-Centered Medical Home (PCMH) and Transitional Care.

Triple Aim

The Triple Aim concept comprises objectives focused on enhancing healthcare quality services. These objectives encompass 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 elaborate on how the Triple Aim contributes to community health, enhances patient care experience, and reduces healthcare costs.

Patient Experience of Care

One of the primary objectives of the Triple Aim is to enhance the patient experience, achievable 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 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.

Enhancing Community or Population Health

The Triple Aim seeks to improve community health by recognizing and addressing their health needs. 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.

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 programs that promote preventive care can also decrease healthcare costs by addressing health issues before they become severe and costly to treat.

In conclusion, achieving Triple Aim objectives necessitates healthcare providers to enhance patient experience, community health, and minimize healthcare costs. Effective care 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 can achieve Triple Aim objectives and enhance patient care quality.

Analyzing the Relationship Between Health Models and Triple Aim

The Patient-Centered Medical Home (PCMH) and Transitional Care models have gained 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 healthcare costs.

The PCMH model emphasizes comprehensive, coordinated, and patient-centered care that is accessible, continuous, and team-based. It empowers patients to become active partners in their own 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).

On the other hand, Transitional Care is designed to support patients during transitions of care, 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 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.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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 evolves, these models are likely to be refined and adapted to meet the changing needs of patients and providers.

Structure of Healthcare Models

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 evidence-based data, aiding healthcare providers in making informed decisions to improve patient care quality.

The PCMH model emphasizes a team-based approach to healthcare, focusing on providing 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 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 the latest research and clinical evidence.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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 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 informed decisions regarding patient care.

The structure of these healthcare models emphasizes the use of electronic health records and 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.

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 as family members to ensure patients receive comprehensive and high-quality care.

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 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.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Nurses use this information to design interventions tailored to each patient’s unique needs and 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 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.

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 together to deliver the best possible care, care coordination helps improve patient care quality while reducing costs and improving efficiency.

Governmental Regulatory Initiatives

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 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, 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 coordinate care for patients, ensuring they receive appropriate care in a cost-effective manner. This will help to reduce the per capita cost of healthcare while improving patient outcomes, thereby contributing to the Triple Aim.

Another regulatory initiative applicable to Sacred Heart Hospital’s care coordination process is the Hospital Readmissions Reduction Program (HRRP), aiming 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.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

In addition to these regulatory initiatives, outcome measures such as patient satisfaction, clinical 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 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 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.

Process Improvement Recommendations to Stakeholders

Sacred Heart Hospital must improve its care coordination process to achieve Triple Aim 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 healthcare.


The stakeholders in this case include the hospital administration, healthcare providers, patients, caregivers, and representatives from Vila Health.

Anticipated Needs and Concerns of Stakeholder Group

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

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.

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.


Bravo, F., Levi, R., Perakis, G., & Romero, G. (2022). Care coordination for healthcare referrals under a shared‐savings program. Production and Operations Management.

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.

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 managed care, 24(5), 237-243.

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.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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.

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

Shahsavari, H., Zarei, M., & Aliheydari Mamaghani, J. (2019). Transitional care: Concept analysis using Rodgers’ evolutionary approach. International Journal of Nursing Studies, 99, 103387.