NURS FPX 6612 Assessment 1

NURS FPX 6612 Assessment 1

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

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The Institute for Healthcare Improvement (IHI) has developed the Triple Aim Framework, which is generally referred to as a strategy concerning three aspects of healthcare process improvement to result in population health betterment, improved patient experience and per capita costs. The Heart and soul of Triple Aim is to improve healthcare for individual and populations and also lower cost by enhancing care delivery systems and the processes involved in them. For care coordinators it is very important to achieve so called Triple Aim. It could help them in give top quality and affordable care to individuals especially to those who dwell in rural areas in Sacred Hart Hospital. When we explore the nuances of coordinated care within our rural hospital, it is important to consider the Triple aim model and how it can be integrated into our strategies to strive to accomplish the best possible outcome for our rural population.

Triple Aim Contribution to Population Health

The coordinated approach to health system improvement advocated by the Institute for Healthcare Improvement (IHI) describes the Triple Aim framework as a multi-faceted goal targeting population health, patient experience, and health care cost simultaneously (Institute for Healthcare Improvement [IHI], n.d.). The Triple Aim Model aims to provide efficient health outcomes for an entire population by paying more attention to preventive care, health education and addressing social determinants of health. Through implementing population health strategies including disease prevention programs, and community health initiatives, and also by fostering public awareness efforts for healthy choices, healthcare organizations can significantly make communities’ health to improve, better and more robust. Such programs like vaccination programs, screening campaigns as well and health education programs contribute to the reduction in disease prevalence and enhance the overall health status of people, it means that they become healthier. The Triple Aim, in focus on population health, also touches on the patient experience as one of the its core components (IHI [Institute for Healthcare Improvement], n.d.). This is achieved via patient-centered care, medical communication, and providing and guaranteeing continuous care. Through empowering patients to take an active role, listening to patient concerns and offering prompt responses, as well as facilitating patients to make decisions together, healthcare organizations can improve patient satisfaction and engagement. Such as, the provision of a care coordination system that involves care transition program and patient-centered medical homes improves seamless care transition and develops personal care plan, these results in better patients’ experience.

Relationships Between Various Current and Emerging Health Care Models

First and foremost, in the Patient-Centered Medical Home (PCMH) model, comprehensive patient-centered care with coordination is prioritized and these elements provide a good fit for the Triple Aim goals of improving the experience of care for the patients (Golnik & Scal, 2020). Through the intervention of 24/7 accessible care and coordination, PMCs ensure patient satisfaction, engagement, and health outcomes by decreasing costly utilization associated with avoidable health services. On top of that, PCMHs incorporates preventive care and chronic disease management in their strategies, which contributes to improved population health outcomes by addressing the underlying health issues proactively before they become a major problem (Golnik & Scal, 2020).

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Moreover, transitional care models are aimed at reducing the JBN noise among healthcare settings, like hospitals, skilled nursing facilities, and home care, the thing that follows the Triple Aim effort of reducing healthcare costs and improving patients’ care experience. The transitioning process that is characterised by a seamless transition and continuity of care, transitional care programs minimize the chance of hospital readmissions, which in turn decreases healthcare costs and improves the level of patient satisfaction (Golnik & Scal, 2020). For this reason, transitional care programs usually involve patient education, medication reconciliation, and follow-up assistance as many of the patients have various co-morbidities, leading to improved health status and decreased healthcare utilization.

Structure of Particular Health Care Models

At first, the Patient-Centered Medical Home (PCMH) model aims at the way to process patient data on a systematic basis through the means of comprehensive health assessments, electronic health records (EHRs), and patient registries (Golnik and Scala, 2020). PCMHs centralize patient data and allow access to healthcare providers who can determine a patient’s progress, those who fail to adhere to care plans and find areas for improvement. On top of this, the PCMH model accentuates the sustained quality improvement through performance measuring and the comparison of findings with the evidence-based guidelines which are used as benchmarks to ensure that the treatment programs are based on the available data (Golnik & Scal, 2020). Simply, transition care models are designed to allow the flow of information between various healthcare settings, consequently without fragmentation. Through enhancement of care continuity. Through the method of implementing the standardized communication protocols and care coordination mechanisms, the transitional care programs help the healthcare providers in getting the crucial patient data during the transitioning period as well. Last but not least, therapeutic and caregiver involvement techniques add to the credibility of evidence-based data by including patients’ reported outcomes and feedback as a part of the process of database collection.

Evidence-Based Data Shapes the Care Coordination Process in Nursing

The role of data with evidence base can not be overemphasized in guiding the process of coordinating care in the field of nursing. As a foundation for the best-informed decisions, this data provides the big picture for all other healthcare team members; also, it allows patients to be part of their health outcome planning process. Peer-to-peer using evidence-based data for care coordination in clinical nursing helps deliver high-quality patient-centered care that is written according to individual patient needs and preferences. Firstly, evidence-based data becomes the quorum for the assessment phase in the entire care coordination process that provides nurses with detailed medical information about patients’ recent history and current health care needs (Swanson et al., 2020). Through purposively collecting and reviewing the required data, nurses may easily pick out the patients subjected to critical conditions, priority care interventions, and individualized plans that ideally cater to patients’ ailments and tastes. For instance, nursing researchers have developed evidence-based directives and clinical pathways that are used by nurses to standardize the ways they look at patients for risk factors that may be involved in other diseases, do screenings, and recommend a treatment that is appropriate for each patient, therefore decreasing unnecessary costs for us as taxpayers.

NURS FPX 6612 Assessment 1

Government-Regulated Initiatives and Outcome Measures

The government own efforts in control and auditing olfyning ensures that policy interventions are guiding the ideas behind care coordination and the resultant improvements are being monitored within the population. Several important efforts and steps have been adopted such as quality, affordable care for patients to increase population health, better patient relationships, and reducing the healthcare costs. The government has achieved a lot through the implementation of value-based payment modals like ACOs and bundled payment models. One common such example is the one by CMS in 2020 (CMS, 2020). ACOs have members who are health providers rather than individuals, and they work together for delivering coordinated care to a distinct patient group, in a bid to enhance quality of care and decrease costs. Bundled payment arrangement are the type that is used to encourage participating healthcare providers to be paid a fixed amount for a particular service episode traditionally associated with inpatient care, where all parties involved have an interest in ensuring processes efficiency and value delivery across the care continuum. They create a financial incentive for the health care providers to participate in care coordination, which is being billed for high quality, cost-effective, and good patient outcomes (CMS, 2020). Another section of regulation is the stimulation of interoperability and data sharing through legislation like Health Information Technology Act and 21st Century Cures act (ONC, 2020). These systems aspire to strengthen the continuity of care by facilitating the interchange of patient information between every healthcare provider without restriction regarding where the care is delivered or which system of EHR (Electronic Health Record) is used. One of the main purposes of interoperability is the enablement of access to the entire range of patient data which encourages care coordination mechanisms, limits duplication of services, and makes the system safer and more continuous for the patients.

Improvement Recommendations to a Stakeholder Group

The beginning of the session with stakeholders should certainly focus on setting the context and introducing the overview of how the care coordination is performed at Sacred Health Care Hospital (Smith et al., 2020). The purpose of this paragraph however, is to draw attention to the relevance of the initiatives already introduced in the context of the hospital’s problems and goals. Highlighting the necessity to promote care coordination as a method of achieving the threefold aim—health improvements of population, higher patient satisfaction, and lowered healthcare costs—gives a straight rationale for actions and keeps them in a harmonious ecosystem of the organization (Jones & Lee, 2019). Building relationships with stakeholders around the proper apprehension of the range of both good and bad effects to be expected with the implementation of changes plays a crucial role in the forthcoming constructive interaction and mutual collaboration.

Having laid the foundation, the presentation then articulates targeted and concreate improvement suggestions which towards this to an end; these are the means through which care coordination can be enhanced in hospitals. These might be developed to propose implementing care pathways and protocols that standardize care, better communication and information exchange among team members of healthcare, engagement of patients and their caregivers in care decision and planning, and the use of data in performance to monitor and enhance care coordination effectiveness (Davis & White, 2020). Each suggestion has its separate point that will show up the estimated results regarding improved quality of care, higher patient satisfaction, and better utilization of resources. Hence, properly defining the outcomes that the recommendations are expected to have is a crucial point because this way, the effectiveness of these solutions will be behind the comprehension of the audience and the improvement of patient care will become evident.

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NURS FPX 6026 Inventory Assessment 3 Population Health Policy Advocacy


In conclusion, the Triple Aim framework steps as a cornerstone for healthcare entities who focus on improving patient health, bettering healthcare service delivery, and reducing healthcare spending. The adopting of evidence-based collaborative care models, such as patient-centered medical home, transitional care, patient’s self-management, and guided care, the healthcare providers can sufficiently satisfy the diversity needs of the patient. Both governmental legislation and introduction of the measures (e.g. value-based payment models, interoperability, and performance) can serve as the tool to establish coordination of care worthy of the Triple Aim objectives. The organizational attitude and actions can be demonstrated by those positive outcomes. As we go moving as it is significant that the stakeholders will has another session of coming together and putting their minds together to know the way out and the way to enhance the health care coordination processes.


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