NURS FPX 6612 Assessment 1

Assessment 1: Triple Aim Outcome Measures


Capella University

FPX6612: Health Care Models Used in Care Coordination

Instructor’s Name

February 2024

Triple Aim Outcome Measures

Slide 1: Hello, welcome to today’s presentation on enhancing care coordination processes to achieve the Triple Aim objectives within Sacred Heart Hospital (SHH).

Slide 2: As the presentation focuses on this critical topic, it’s imperative to acknowledge the evolving landscape of healthcare delivery, particularly in rural communities like ours, where unique challenges often intersect with the overarching goals. We’ll explore innovative strategies and models to foster seamless coordination, optimize resources, and ultimately elevate the quality of care provided to our community.


Slide3: The purpose is to outline strategies for enhancing care coordination processes to achieve the Triple Aim. The presentation focuses on Sacred Heart Hospital (SHH) as the chosen institution, situated in a rural community facing unique challenges in healthcare delivery. Two models selected for analysis and integration into the care coordination framework are the Patient-Centered Medical Home (PCMH) model and the Accountable Care Organization (ACO) model. 

Triple Aim

Slide 4: At a regional level, implementing the Triple Aim can lead to significant improvements in population health by addressing underlying social determinants of health, promoting preventive care initiatives, and increasing access to essential healthcare services (Kokko, 2022). By proactively managing chronic conditions, promoting healthy behaviors, and targeting high-risk populations, healthcare organizations can effectively reduce the burden of disease and improve overall community well-being.

Slide 5: Improving the patient care experience is another critical aspect of the Triple Aim, as it directly impacts individual health outcomes and satisfaction with healthcare services. By emphasizing patient-centered care models, fostering strong provider-patient relationships, and enhancing care coordination efforts, healthcare organizations can create a more personalized and supportive care environment (North et al., 2023). This approach not only enhances patient engagement and adherence to treatment plans but also fosters trust and communication between patients and providers, leading to better health outcomes and higher levels of patient satisfaction.

Slide 6: Furthermore, the Triple Aim framework aims to address the escalating costs of healthcare by implementing strategies that promote efficiency, reduce waste, and optimize resource utilization (Bardhan et al., 2020). At a state and national level, widespread adoption of the Triple Aim can lead to substantial cost savings, improved healthcare outcomes, and a more equitable distribution of resources, ultimately advancing the collective health and well-being of entire populations.

Analyze the Relationships Health Model and Triple Aim

Slide 7: Accountable Care Organizations (ACOs) represent a model that emphasizes care coordination, quality improvement, and cost containment. By bringing together healthcare providers across different specialties and settings, ACOs facilitate collaboration and communication, thereby promoting more holistic patient care. Through initiatives like preventive care, chronic disease management, and population health management, ACOs strive to improve health outcomes while minimizing unnecessary utilization of healthcare resources, aligning with the Triple Aim’s focus on cost-effective, patient-centered care (Cantiello, 2022).

Slide 8: Another emerging healthcare model that supports the Triple Aim is the Patient-Centered Medical Home (PCMH). PCMHs prioritize patient-centered care delivery by providing comprehensive, coordinated, and accessible healthcare services. By serving as a central point of coordination for patients’ medical needs, PCMHs enhance care continuity, reduce fragmentation, and promote proactive management of chronic conditions (Cantiello, 2022). Through initiatives like care management, care coordination, and patient engagement, PCMHs aim to improve patient satisfaction, health outcomes, and healthcare utilization efficiency, aligning closely with the Triple Aim’s objectives.

Structure of Health Care Models

Slide 9: ACOs are designed to integrate healthcare providers across various settings, including hospitals, primary care practices, specialists, and community organizations. This integrated structure enables ACOs to collect comprehensive patient data from multiple sources, facilitating a more thorough assessment of patient health status, healthcare utilization patterns, and outcomes (Lan et al., 2022). By centralizing data from diverse sources, ACOs can analyze trends to enhance care quality and patient outcomes.

Slide 10: Similarly, the structure of PCMHs fosters a team-based approach to healthcare delivery, with primary care providers serving as the central point of coordination for patient care. Within the PCMH model, care teams collaborate closely to collect and evaluate patient data, including medical history, diagnostic tests, and treatment outcomes. This collaborative structure enables PCMHs to conduct regular assessments of patient health status, monitor adherence to evidence-based guidelines, and adjust care plans as needed to optimize outcomes (Metusela et al., 2020). By emphasizing continuous quality improvement and patient engagement, PCMHs facilitate the systematic collection and analysis of data to drive evidence-based decision-making and enhance care delivery.

Slide 11: Electronic health records (EHRs), clinical decision support tools, and population health management platforms enable healthcare providers within these models to access real-time patient data, track performance metrics, and generate actionable insights. By leveraging HIT systems, ACOs and PCMHs can streamline data collection, ensure data accuracy and integrity, and facilitate data-driven quality improvement initiatives (Cantiello, 2022). 

Evidence-based Data Shaping Care Coordination Process

Slide 12: In the context of care coordination, evidence-based data guides nurses in assessing patient needs, developing individualized care plans, and implementing interventions aimed at achieving positive health outcomes. For example, when coordinating care for a patient with complex healthcare needs, nurses may utilize evidence-based guidelines and protocols to prioritize interventions, monitor progress, and ensure continuity of care across different healthcare settings. By leveraging evidence-based data, nurses can optimize the efficiency and effectiveness of the care coordination process, ultimately enhancing patient safety, satisfaction, and overall quality of care (Sarawad, 2023). Moreover, evidence-based data in nursing contributes to ongoing quality improvement initiatives and the advancement of nursing practice. Through the systematic collection, analysis, and utilization of data, nurses can identify trends, evaluate the effectiveness of interventions, and identify areas for enhancement in the care coordination process. By integrating feedback from outcomes data and patient experiences, nurses can refine care coordination strategies, implement best practices, and drive continuous improvement in care delivery (Sarawad, 2023). 

Governmental Regulatory Initiatives

Slide 13: Governmental regulatory initiatives often involve the implementation of policies, regulations, and standards aimed at improving healthcare quality, enhancing patient outcomes, and controlling costs. For example, the Affordable Care Act (ACA) in the United States incentivize healthcare providers to collaborate, coordinate care across different settings, and focus on preventive measures to improve population health while reducing unnecessary healthcare utilization and expenditures (Bravo et al., 2022).

Slide 14: Outcome measures serve as quantifiable indicators used to assess the effectiveness and impact of care coordination efforts in achieving the Triple Aim. These measures encompass various dimensions of healthcare quality, patient outcomes, and cost containment (Schmidt et al., 2020). Examples of outcome measures include patient satisfaction scores, readmission rates, mortality rates, healthcare-associated infection rates, length of hospital stay, and adherence to evidence-based guidelines. By monitoring these outcome measures, policymakers, healthcare organizations, and stakeholders can evaluate the performance of care coordination initiatives, identify areas for improvement, and track progress toward achieving population health goals and enhancing patient experiences.

Process Improvement Recommendations to Stakeholders

Slide 15: It’s imperative to prioritize the establishment of robust communication channels among healthcare providers, patients, and community resources. Clear and efficient communication ensures seamless coordination of care, minimizes errors, and fosters a patient-centric approach to healthcare delivery (Singer & Porta, 2022). Additionally, proactive identification and mitigation of barriers to care access are paramount in optimizing care coordination efforts. Recognizing the diverse needs of our patient population, we must address factors such as transportation limitations, financial constraints, and social determinants of health. By partnering with community organizations, leveraging telehealth services, and offering financial assistance programs, we can remove barriers to care and ensure equitable access to healthcare services for all individuals within our community (Singer & Porta, 2022). Moreover, ongoing education and outreach initiatives can navigate the healthcare system effectively.


Slide 16: By leveraging evidence-based practices and embracing collaborative care models, Sacred Heart Hospital can navigate the complexities of care coordination more effectively, ultimately advancing towards the Triple Aim goals. Through continuous process improvement, stakeholder engagement, and a commitment to patient-centered care, SHH can serve as a beacon of excellence in healthcare delivery, ensuring that every individual in our community receives the high-quality, comprehensive care they deserve. 



Bardhan, I., Chen, H., & Karahanna, E. (2020). Connecting systems, data, and people: A multidisciplinary research roadmap for chronic disease management. MIS Quarterly: Management Information Systems, 44(1), 185–200. 

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

Cantiello, J. (2022). To what extent are ACO and PCMH models advancing the triple aim objective? Implications and considerations for primary care medical practices. Journal of Ambulatory Care Management, 45(4), 254–265. 

Kokko, P. (2022). Improving the value of healthcare systems using the Triple Aim framework: A systematic literature review. Health Policy, 126(4), 302–309. 

Lan, Y., Chandrasekaran, A., Goradia, D., & Walker, D. (2022). Collaboration structures in integrated healthcare delivery systems: An exploratory study of accountable care organizations. Manufacturing & Service Operations Management, 24(3). 

Metusela, C., Usherwood, T., Lawson, K., Angus, L., Kmet, W., Ferdousi, S., & Reath, J. (2020). Patient centered medical home (PCMH) transitions in western Sydney, Australia: A qualitative study. BMC Health Services Research, 20(1). 

North, S. E., Lafky, R., Porta, C., & Sick, B. (2023). Interprofessional students’ insights into the experiential learning environment: Values, impacts, and alignment with interprofessional collaborative practice competencies and the triple aim. Journal of Interprofessional Education & Practice, 100639. 

Sarawad, S. S. (2023). Evidence-based practice in nursing – A review. International Journal of Nursing Education and Research, 11(1), 82–84. 

Schmidt, A., Ilango, S. M., McManus, M. A., Rogers, K. K., & White, P. H. (2020). Outcomes of pediatric to adult health care transition interventions: An updated systematic review. Journal of Pediatric Nursing, 51, 92–107. 

Singer, C., & Porta, C. (2022). Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health. Health & Social Care in the Community, 30(6).


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