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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Triple Aim Outcome Measures

Hi, my name is Tremone Mcleod. For this presentation, I am assuming the role of a case manager in the rural hospital Sacred Heart. The presentation will be delivered to hospital leadership and other practitioners within the hospital. This presentation will guide the members of the hospital about care coordination that will be achieved through the process of Triple Aim.


The purpose of this presentation is to aware the leadership of Sacred Heart Hospital to gain a better understanding of the care coordination process and align their practices to achieve the Triple Aim with the hospital’s rural population. Also, this presentation will help them understand the models that support Triple Aim and make them able to compare those models. I have chosen two models for the presentation, i.e., Patient-Centered Medical Home (PCMH) and Transitional care.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Triple Aim

The concept of Triple Aim entails a set of objectives focused on enhancing healthcare quality services. A better patient experience, healthier populations, and lower healthcare costs are the objectives. Efficient care coordination plays a crucial role in achieving Triple Aim objectives. The subsequent sections elaborate on how the Triple Aim contributes to community health boosts the patient care experience, and reduces healthcare costs

Patient Experience of Care

One of the primary goals of the Triple Aim is to improve patient experience, which is attainable through several means. These include minimizing waiting times, enhancing communication, and engaging patients in treatment plans. Patient satisfaction is paramount since it affects patient adherence to treatment, care engagement, and general 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 aims to boost community health by recognizing and addressing their health requirements. Healthcare providers must evaluate population data and formulate plans to enhance health outcomes to achieve this objective. Care coordination is crucial in this process as care coordinators can identify high-risk patients and ensure they get appropriate care. Healthcare organizations can collaborate with community partners to address social determinants of health and execute preventive measures like immunization and health screenings.

Reducing Per Capita Costs

The Triple Aim aims to decrease per capita healthcare costs by improving care quality and minimizing waste. Efficient care coordination can contribute to cost savings by reducing hospital stays, unnecessary procedures and tests and preventing readmissions. Healthcare providers can reduce chronic disease management costs by collaborating with community partners and addressing social determinants of health. Populace health management programs that promote preventive care can also decrease healthcare costs by addressing health issues before they become severe and costly to treat.

It can be said that Triple Aim objectives necessitate healthcare providers to improve patient experience and community health and minimize healthcare costs. Effective care coordination plays a critical role in achieving these goals since it helps to identify high-risk patients, minimize waste, and promote preventive care. Healthcare providers can achieve Triple Aim objectives and enhance patient care quality by assessing population data, working with community partners, and implementing evidence-based strategies. 

Analyze the Relationships Health Model and Triple Aim

The Patient-centered medical home (PCMH) and Transitional Care are two healthcare models that have gained popularity in recent years due to their potential to improve patient outcomes and support the Triple Aim, which includes improving patient experience, enhancing population health, and reducing healthcare costs.

The PCMH model is based on the philosophy of providing comprehensive, coordinated, and patient-centered care that is accessible, continuous, and team-based. It aims to empower patients to become active partners in their own care, while also improving care coordination among healthcare providers. The model has evolved over time to incorporate technology, patient engagement tools, and quality metrics to improve patient outcomes and reduce healthcare costs (Kaufman et al., 2018).

On the other hand, Transitional Care is a model 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). The rationale behind this model is to prevent adverse events, such as readmissions or medication errors that can occur during these transitions. The model involves a team-based approach that includes a care coordinator who works with the patient and their family to ensure a smooth transition and follow-up care. The model has incorporated technology like telehealth to enhance communication and improve care coordination.

There are several ways in which these healthcare models enhance healthcare quality. For example, the PCMH model has improved patient outcomes by reducing hospital readmissions and emergency department visits and improving chronic disease management (Ruediger et al., 2019). Additionally, the model has improved patient and provider satisfaction ((Ruediger et al., 2019). Similarly, Transitional Care has been found to reduce hospital readmissions and improve patient outcomes, such as reducing medication errors and adverse events. The model has also improved patient satisfaction and reduced healthcare costs (Fønss Rasmussen et al., 2021).

Overall, the PCMH and Transitional Care models have the potential to improve patient outcomes, enhance care coordination, and reduce healthcare costs. They both support the Triple Aim by focusing on patient-centered care and improving population health. As healthcare continues to evolve, these models will likely continue to be refined and adapted to meet the changing needs of patients and providers.

Structure of Health Care Models

The Patient-centered medical home (PCMH) and Transitional Care model are two healthcare models designed to improve the quality of care provided to patients while also ensuring better health outcomes (McNabney et al., 2022). These models employ various strategies to gather and evaluate evidence-based data to help healthcare providers make informed decisions and improve patient care quality.

The PCMH model emphasizes a team-based approach to healthcare that focuses on providing comprehensive and coordinated care to patients. This model relies heavily on the use of 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, which helps them make more informed decisions regarding patient care (M. & Chacko, 2021). Furthermore, the PCMH model emphasizes the use of evidence-based guidelines to ensure that patients receive the most appropriate care. These guidelines are based on the latest research and clinical evidence, which helps to ensure that patients receive the most effective treatments and interventions.

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

The Transitional Care model, on the other hand, is designed to provide continuity of care for patients who are transitioning from one healthcare setting to another. This model emphasizes using evidence-based interventions to ensure that patients receive the most appropriate care during the transition process. One of the key features of the Transitional Care model is the use of a transitional care team, which is responsible for coordinating care for patients during the transition process. This team relies heavily on evidence-based data to make informed decisions regarding patient care.

The structure of these healthcare models contributes to gathering and evaluating evidence-based data by emphasizing the use of electronic health records and evidence-based guidelines. These models also rely on interdisciplinary teams and evidence-based interventions to ensure patients receive the most appropriate care. By utilizing these strategies, healthcare providers can improve patient care quality while ensuring better health outcomes.

Evidence-based Data Shaping Care Coordination Process

The nursing practice of care coordination is significantly influenced by data based on scientific evidence. Using data in care coordination helps identify gaps and areas that require improvement, enabling healthcare providers to design more effective interventions. The process of care coordination involves collaboration and communication among healthcare providers, patients, and family members to ensure that patients receive comprehensive and high-quality care.

Furthermore, 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). These data also help 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 inform the development of care plans and pathways that facilitate the delivery of coordinated care across different healthcare settings. Nurses use this information to design interventions tailored to each patient’s unique needs and preferences, ensuring that 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 that 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 this regard, it can be concluded that 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 are working together to deliver the best possible care, care coordination helps improve patient care quality while reducing costs and improving efficiency.

Governmental Regulatory Initiatives

Achieving the Triple Aim will necessitate modernizing Sacred Heart Hospital’s care coordination process, and incorporating regulatory initiatives and outcome measures from the government is one method 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 and improve quality while reducing healthcare costs (Bravo et al., 2022). By participating in this program, Sacred Heart Hospital can work with other healthcare providers in the region to coordinate care for patients and ensure that they receive appropriate care in the most cost-effective way possible. This will help to reduce the per capita cost of healthcare while improving patient outcomes, thereby contributing to the Triple Aim.

Another regulatory initiative that can be applied to the care coordination process at Sacred Heart Hospital is the Hospital Readmissions Reduction Program (HRRP), which aims to reduce hospital readmissions by penalizing hospitals with higher-than-expected readmission rates. By implementing effective care coordination processes, Sacred Heart Hospital can reduce the likelihood of readmissions, improving patient outcomes and reducing healthcare costs. This will contribute to the achievement of the Triple Aim by bettering the experience of care provided to patients, enhancing the health of populations, and lowering the cost of providing healthcare to individuals.

In addition to these regulatory initiatives, outcome measures such as patient satisfaction, clinical quality measures, and healthcare utilization can be used 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 health care.


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. 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. 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 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 community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207–213. https://doi.org/10.1377/hlthaff.2019.00981 

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. https://www.sciencedirect.com/science/article/pii/B9780128193143000021 

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. https://doi.org/10.1111/jgs.17811 

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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. https://doi.org/10.1080/10790268.2019.1671075 

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

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