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NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Contribution of Triple Aim to Improve the Patient Care and Reduce Health Care Costs

The Triple Aim project was introduced by the Institute for Healthcare Improvement (IHI) in October 2007 with the goal of assisting healthcare organizations in enhancing the general well-being of patients. The IHI developed the IHI Triple Aim framework, which outlines a strategy for improving the performance of the healthcare system. IHI thinks new designs are necessary to simultaneously fulfil the “Triple Aim” of bettering population health, enhancing patient experience of treatment (including satisfaction and quality), and lowering the per capita cost of healthcare. Healthcare companies can spot and address issues like inadequate care coordination and overuse of medical services by focusing on these three goals at once. They can also direct money and attention to initiatives that have the biggest positive effects on health (Bachynsky, 2019).

Healthcare organizations run the risk of increasing quality at the expense of cost or the opposite if these three major goals are not given equal consideration. Alternatively, they can save costs while giving patients a bad experience. One or more of these goals can be linked to a variety of issues that healthcare systems experience. Overbuilding, preventable readmissions, and supply-driven care issues are examples of issues that could indicate failure on all three points (Culmer et al., 2019).

Relationships between Health Care Models and the Ways in which they support the Triple Aim

Now, I’ll talk about the different Health care models and how they support the idea of the triple aim. A care delivery paradigm called the Patient-Centered Medical Home (PCMH) makes sure that essential care is delivered to patients when and where they need it in a way they can understand. The goal is to create a centralized environment that encourages cooperation between specific patients, their private physicians, and, as necessary, the patient’s family. Certificates, healthcare technologies, the interchange of health data, and other techniques are used to facilitate care and to make sure that patients receive the recommended care in a culturally and linguistically appropriate manner when, where, and at the appropriate time for them. Patient satisfaction, one of the triple aim’s three objectives, is supported by this model since it provides care to patients in accordance with their cultural and linguistic needs. Additionally, by utilizing healthcare technology, the overall cost of treatment is also decreased (Perez Jolles et al., 2019).

A master’s-level “Transitional Care Nurse” with experience in the care of patients with chronic conditions will oversee the patient’s home follow-up as part of the Transitional Care Model, which aims to shield older, chronically sick hospital patients from health issues and rehospitalizations. This care model strives to lower the cost of treatment, improve the quality of care, and increase patient satisfaction with the aim of reducing readmissions of patients and caring for older people at home (Morkisch et al., 2020).

Dorothea Orem made a self-management nursing model between years 1959 and 2001. Orem’s Model of Nursing is another name for the theory. It is primarily utilized in primary care and rehabilitation settings where patients are urged to maintain as much independence as feasible. The premise of nursing theory is that all “patients seek to care for themselves.” If they are permitted to take care of themselves to the best of their abilities, they can heal more rapidly and completely also, which will decrease the overall cost of treatment (Xu et al., 2020).

According to the Guided Care model, 50 to 60 of their chronically ill patients will receive coordinated, patient-centred care from 2 to 5 doctors and other members of the care team while a Guided Care nurse is based in a primary care office (Graby et al., 2021).

Models of care coordination frequently contain methodical steps meant to improve consistency and facilitate treatment transitions. This model promotes self-management strategies by patients, either taught to them by a nurse or the whole healthcare team (Smeltzer et al., 2021).

In one way or another, the aforementioned models are achieving the objectives outlined in the triple aim.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

How the Structure of Particular Health Care Models Contributes to the Process of Gathering and Evaluating the Quality of Evidence-Based Data

A variety of public and commercial data-gathering systems are utilized in the healthcare industry by different organizations, including hospitals, CHCs, doctors, and health plans. These systems include administrative registration and billing data, medical records, and surveys on people’s health. All of these organizations gather some data on racial, ethnic, and linguistic diversity, indicating the possibility for each to provide information on patients or enrollees.

For policy decisions concerning the PCMH to be supported by reliable data, the Triple Aim of improved patient outcomes, better patient experience, and better value must be attained. The research methods covered in this PCMH research method series, such as the anthropological approach, cognitive task analysis, and formative analysis, can be used to assess and improve PCMH models and other healthcare interventions. Consumers and patients are asked to report on and assess their experiences with healthcare in a variety of thorough and evolving standardized questionnaires that are developed and supported by research techniques (Rosland et al., 2017).

A “transition of care” occurs when an individual moves from one type of care setting, such as a hospital or nursing home, to any other (CMS). The execution, maintenance, and assessment of a patient’s treatment plan depend heavily on the delivery of healthcare throughout the entire healthcare ecosystem. Between various levels of care and locations, patient information is sent and received in order to maintain continuity and advance effective treatment. Unfortunately, disruptions in these procedures and inefficient information transfer between healthcare professionals can result in subpar transitions and misunderstandings (Naylor et al., 2018).

Orem’s care model gives nurses and other professionals a more thorough way to assess the applicability of health information and instructional materials since it incorporates crucial evaluation variables utilized in literacy research. Nurses have a crucial role in informing patients about important facts that will affect their decision-making and participation in treatment, as well as in educating consumers and their families (Yip, 2021).

In the Guided Care model, a registered nurse completes a training course before using a personalized electronic health record (EHR) in collaboration with two to five primary care physicians to address the complicated requirements of 50 to 60 older patients with multi-morbidity. The primary care office serves as the GCN’s basis of operations. Clinical decisions made by the GCN are influenced by scientific data, patient priorities, and the EHR (Graby et al., 2021).

The planned organizing of patient care chores and information exchange among all stakeholders involved in a patient’s care is known as care coordination, and it helps to deliver safer and more effective care. This suggests that the patient’s needs and preferences are taken into account when providing safe, appropriate, and effective treatment. It also means that these considerations are communicated to the right parties at the right time (McAllister et al., 2018).

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

How Evidence-Based Data Shapes the Care Coordination Process in Nursing

Today’s hospitals and health networks are prioritizing coordinated care delivery in their efforts to perform better. Inter-professional collaboration has been a priority for the industry for more than ten years as part of its ambition to improve a system long defined by fragmented care and unaffordable expenses. In order to achieve quality improvement goals associated with better chronic illness management, better clinical outcomes, and reduced healthcare costs, fewer medical errors, care coordination is a key factor. The industry’s ongoing investment in cutting-edge care models like patient-centred medical homes may help to explain this (PCMH) (Rosen et al., 2018).

Care coordination demands that decisions regarding medical care be backed by the best available, reliable, relevant, and timely data. People who are receiving care make these decisions, guided by the implicit and explicit knowledge of those providing care and taking into account the resources that are available. The IHI worldwide method for analyzing adverse events offers both quantitative and qualitative data and is used as a guide to identify and evaluate adverse occurrences. Two examples of tracking metrics are adverse events per 500 patient days and adverse events per 50 admissions. (Chakurian & Popejoy, 2021).

Evidence-based SBAR tool: This is a tool for the healthcare team’s effective communication in order to accurately collect patient information. S- Situation: Problem statement of the patient, B- Background: a brief explanation of the issue, A- Assessment: Evaluate the circumstance, R- Recommendation: What to do. Care needs can be determined using evidence-based data: Understanding the coordination of care and being aware of the requirements of your demographic. Know your healthcare provider, and get to know the nurse coordinating and transitioning your care. Identify leaders and the interdisciplinary care team to establish a relationship and understanding of how to use technology, such as medical records. Engage the family

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Governmental Regulatory Initiatives and Outcome Measures

Healthcare reform initiatives under the Affordable Care Act are focused on the triple objective, which has influenced the industry’s shift to value-based care. The IHI created the Triple Aim in 2008 to promote concurrent enhancements in patient interactions, public health, and cost per person. All Americans now have access to high-quality, reasonably priced healthcare thanks to the 2010 passage of the Patient Protection and Affordable Care Act (ACA). It is easily believable that the ACA’s drafters were aware of the Triple Aim, and it is likely that IHI’s positions had a significant impact on a large portion of the ACA. Enhanced supervision of health insurance premiums and practices, a focus on preventative measures, family medicine, and effective care, a decrease in health care corruption and theft, and a decrease in uninsured patients to prevent a shift onto insurance premiums are some of the important aspects of the ACA that sought to solve rising health care costs and accomplish the objective of the triple aim. Additionally, mortality and readmission rates are reduced by World Health Organization. Joint Commission – improve patient outcomes, lower medication errors, and lower death and readmission rates. The Goal of the Leapfrog group is to lower yearly deals, medical errors, and accidents (Kokko, 2022)

Recommendation to Stakeholders for Improvement

A foundation for the Patient Protection and Affordable Care Act was adopted by Triple Aim. Only Triple Aim is responsible for all of our patient’s healthcare needs in three different areas: communities, schools, and the healthcare system, providing great results while simultaneously addressing each of the three needs. Triple Aim assists a company in fulfilling Joint Commission criteria.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures


As more organizations adopt the program’s objectives and share distinctive and efficient strategies for tackling the challenging issues of care coordination, chronic disease management, and preventive health, the Triple Aim program is likely to generate more innovations that can be used in a variety of settings. It is hoped that over time, evidence will accumulate on how these models affect community health, cost management, and patient treatment experiences.


 Bachynsky, N. (2019). Implications for policy: The Triple Aim, Quadruple Aim, and interprofessional collaboration. Nursing Forum, 55(1).

Chakurian, D., & Popejoy, L. (2021). Utilizing the care coordination Atlas as a framework: An integrative review of transitional care models. International Journal of Care Coordination, 24(2), 57–71.

Culmer, N., Smith, T., Stager, C., Meyer, H., Quick, S., & Grimm, K. (2019). Evaluation of the triple aim of medicine in prehospital telemedicine: A systematic literature review. Journal of Telemedicine and Telecare, 1357633X1985346.×19853461

Graby, J., Metters, R., Kandan, S. R., McKenzie, D., Lowe, R., Carson, K., Hudson, B. J., & Rodrigues, J. C. L. (2021). Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)- guided care in the National Health Service. Clinical Radiology, 76(11), 862.e19–862.e28.

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, (2021). Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: a Scoping Review. International Journal of Integrated Care, 21(1).

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

McAllister, J. W., Keehn, R. M., Rodgers, R., & Lock, T. M. (2018). Care Coordination Using a Shared Plan of Care Approach: From Model to Practice. Journal of Pediatric Nursing, 43, 88–96.

Morkisch, N., Upegui-Arango, L. D., Cardona, M. I., van den Heuvel, D., Rimmele, M., Sieber, C., & Freiberger, E. (2020). Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC Geriatrics, 20(1).

Naylor, M. D., Hirschman, K. B., Toles, M. P., Jarrín, O. F., Shaid, E., & Pauly, M. V. (2018). Adaptations of the evidence-based Transitional Care Model in the U.S. Social Science & Medicine, 213, 28–36.

Perez Jolles, M., Lengnick-Hall, R., & Mittman, B. S. (2019). Core Functions and Forms of Complex Health Interventions: a Patient-Centered Medical Home Illustration. Journal of General Internal Medicine, 34(6), 1032–1038. 7

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high- quality care. American Psychologist, 73(4), 433–450.

Rosland, A.-M., Wong, E., Maciejewski, M., Zulman, D., Piegari, R., Fihn, S., & Nelson, K. (2017). Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study. Health Services Research, 53(4), 2503– 2522.

Smeltzer, M. P., Boehmer, L. M., Kramar, A., Asfeldt, T. M., Faris, N. R., Amorosi, C. F., Ray, A., Nolan, V. G., Oyer, R. A., Lathan, C. S., & Osarogiagbon, R. U. (2021). An Optimal Care Coordination Model for Medicaid Patients with Lung Cancer: Results from Beta Model Testing. Oncology Issues, 36(3), 80–94.

Xu, X., Han, J., Li, Y., Sun, X., Lin, P., Chen, Y., Gao, F., Li, Z., Zhang, S., & Sun, W. (2020). Effects of Orem’s Self-Care Model on the Life Quality of Elderly Patients with Hip Fractures. Pain Research and Management, 2020, 1–6.

Yip, J. Y. C. (2021). Theory-Based Advanced Nursing Practice: A Practice Update on the Application of Orem’s Self-Care Deficit Nursing Theory. SAGE Open Nursing, 7, 237796082110119.


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Develop a presentation containing 10-15 slides on the Institute for Healthcare Improvement’s Triple Aim, how current and emerging healthcare models support the Triple Aim, and how governmental regulatory initiatives and outcome measures can be applied in the care coordination process to achieve the Triple Aim in a population.

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