(Vila Health review info for assignment) Introduction Hospitals and other health

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Aug 12, 2022


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(Vila Health review info for assignment)
Hospitals and other health care providers increasingly are measuring quality through a set of standards called the Triple Aim. To achieve the Triple Aim, health care organizations are tasked with (1) improving the patient experience of care, (2) improving the health of populations, and (3) reducing the per capita cost of health care.
Effective care coordination is an important part of achieving the Triple Aim, as care coordinators are involved in all three Triple Aim standards. Therefore, when health care organizations seek to make the quality improvements necessary to achieve the Triple Aim, the care coordination process at the organization may need to be updated.
After completing the activity, you will be prepared to:
Develop strategies for modifying a hospital’s care coordination process in order to achieve the Triple Aim.
Analyze population data in order to develop strategies for achieving the Triple Aim.
Interview stakeholders in order to develop strategies for achieving the Triple Aim.
Challenge Details
You have just been hired as a case manager at Sacred Heart Hospital (SHH), a 21-bed rural hospital located in Valley City, North Dakota. SHH was recently acquired by Vila Health, a large health care system that operates hospitals and clinics in several Midwestern states.
Vila Health is committed to improving the quality of its regional hospitals, and one of the primary standards they use to measure quality is the Triple Aim. As part of the effort to help the hospital achieve Triple Aim outcomes, you will be asked to investigate ways that the care coordination process can or must be updated.
Exterior image of Sacred Heart Hospital.
Your Office
It looks like you have email from Karen Dellington, Admissions and Discharge Director. Read the message, then review the Barnes County Regional Health Profile document.
From: Karen Dellington, Admissions and Discharge Director
Subject: Triple Aim Outcomes
We’re so glad to have you here at Sacred Heart! Please let me know if you have any questions as you get settled in.
As you know, we’re going to be updating our care coordination processes here at Sacred Heart so that we can achieve Triple Aim Outcomes. I’m sure you’re familiar with Triple Aim, but if you’re not, that’s a set of standards that refers to (1) improving the patient experience of care, (2) improving the health of populations, and (3) reducing the per capita cost of health care. In summary–Triple Aim is care, health, and cost.
We’re going to be meeting with representatives from Vila Health next week to discuss Triple Aim. I know that’s not much time! What I need you to do is put together a PowerPoint presentation with specific suggestions for how we can improve our care coordination process to achieve Triple Aim outcomes. That’s a tall order, but I know you’re up for the challenge! To do that, I’d like for you to complete the following tasks:
I’m going to be sending you a detailed Barnes County Community Profile. This document will give you a great deal of information about the community and its health needs. As you read through this document, think carefully about what is needed to achieve Triple Aim outcomes for this community, and how an effective care coordination process might facilitate this strategy. You will be including this information in your PowerPoint presentation.
I’d like for you to interview people at the hospital and in the community. You’ll be asking them questions about care, health, and cost, and you will include this information in your presentation. You have limited time for these interviews, so choose wisely—and try to get the right combination of people to get the information you need.
Good Luck!
Barnes County Community Health Profile
Barnes County, North Dakota Community Health Profile by Age Group, 2000 Census
Age Group Barnes County North Dakota
0-9 1288 10.9% 82,382 12.8%
10-19 1811 15.4% 101,082 15.7%
20-29 1371 11.6% 89,295 13.9%
30-39 1303 11.1% 85,086 13.2%
40-49 1803 15.3% 98,449 15.3%
50-59 1327 11.3% 66,921 10.4%
60-69 1057 9.0% 47,649 7.4%
70-79 998 8.5% 29,492 4.6%
80+ 817 6.9% 29,492 4.6%
Total 11,775 100% 642,200 100%
0-17 2624 22.3% 160,849 25.0%
65+ 2332 19.8% 94,478 14.7%
Triple Aim Interviews
Choose four individuals from the hospital staff and the community to interview. These individuals will give you more information to help you develop a strategy to achieve Triple Aim Outcomes.
Todd Chester: Director of Quality Assurance, Sacred Heart Hospital
Courtney Donovan: Emergency Room Doctor
Sarah Kealey: Nurse Practitioner, Southwest Medical Clinic
Floyd Knutson: Mayor Of Valley City
Mary Loudsinger: Social Worker, Sacred Heart Hospital
Bob Van Ness: Home Care Liaison
Ned Walsh: Barnes Community Health Department Director
Trish Walstrom: Care Coordination Manager
Todd Chester
Director of Quality Assurance, Sacred Heart Hospital
1. What are some of the major cost concerns for SHH?
Like many rural hospitals, we have some serious financial concerns. For one thing, we are incurring way too many costs in relation to readmission rates. I can’t emphasize enough how problematic this is from a quality assurance standpoint. We’ve always had a problem with readmission, but because of the Affordable Care Act, this problem has become especially costly for us—and I know that Vila Health is highly concerned. Readmission rates are high for a number of reasons. For one thing, I don’t think we’re doing a good enough job assessing barriers to care—especially the barriers involving financial and logistical concerns. We’re sending people home with instructions for follow-up care, and then people don’t follow up because we’ve asked them to do things that they can’t. So for example, we tell them to make a follow-up appointment with a provider who’s an hour away in Fargo, and they don’t have easy access to transportation, so they don’t ever schedule the appointment. That scenario happens quite a bit around here, since we don’t have a lot of health care providers in the area, and there’s a lot of poverty. And there’s just the simple fact that people can’t always pay for medication and follow-up care—so they skip these things and then end up back at the hospital. Insurance deductibles are higher than ever and people are really struggling financially around here, and even with the Affordable Care Act, we have a fairly high percentage of uninsured patients.
Also, with smaller hospitals like ours, you always get issues involving economy of scale. We’re a small hospital, which means that cost per case tends to be higher. And when you’re smaller, that means your financial position is less predictable, which makes long-range planning and contingency planning difficult.
2. What are some of the major patient care concerns for SHH?
Considering the constraints we have as a rural hospital, I’m proud of the care we’re able to provide. But there’s serious room for improvement. Like many hospitals, one of our biggest problems is turnover. It’s very challenging to get talent to come to a community like this one and stay, especially when we can’t compete financially with the pay in larger cities. It’s a brain drain. We’ve had a heck of a time retaining doctors—they come here, get some experience, and move to a bigger city at a hospital that can pay more. Or if they want to stay in the general area, they wait for something to open up at Valley City Regional Hospital, or in Fargo. Turnover definitely impacts patient care, as does our ability to find new talented people.
3. What are some particular challenges with the population of this area that relate to your ability to achieve Triple Aim outcomes?
One of our biggest problems is that this population is not getting the preventative care it needs. Part of that has to do with income. Part of that has to do with education—this isn’t the most educated population, and that demographic tends to know less about health care and use preventative services less often. But a lot of it has to do with geography. For a lot of people, going to a doctor or a specialist means driving to Fargo, which is an hour away. An hour drive might not seem like a big deal, but for an older person who doesn’t drive much anymore, or someone who doesn’t have access to a vehicle because of poverty? That hour is a real barrier to care. And there are a lot of family farmers in this area, and they can’t drive for an hour, go to a time-consuming trip to the doctor, and then drive for an hour back, because they literally can’t get away from the farm for that long. They have time-sensitive chores like milking the cows, and finding someone else to do these chores might be an expense they can’t afford. And frankly, some of our patients are simply stubborn, old guys who won’t go to the doctor because they’re too self-reliant. They refuse to go to the doctor when they think they can take care of things themselves—which is fine if they have a minor cut, but it’s not fine when they have undiagnosed diabetes.
Courtney Donovan
Emergency Room Doctor
1. What are some of the major patient care concerns for SHH?
Older equipment is a huge problem here. We definitely see that in the ER. We can’t afford state-of-the-art equipment here. In fact, we often can’t afford new equipment at all, so we wind up pumping money into fixing the older stuff as best as we can. The building itself really could use some work too. The hospital rooms get really cold, and we wind up eating up a lot of money on heat—and it’s still cold! I mean, this is North Dakota, right? Basic problems like room temperature can really impact patient experience. I mean, nobody expects this place to be a luxury hotel, but if the rooms aren’t warm and comfortable, people are going to be very unhappy.
We’re also struggling with patient wait times. We’re often understaffed because it’s so hard to retain people at a rural hospital, but the demand on the hospital is increasing—for a number of reasons. For one thing, the population is older, and that means more trips to the hospital per person. On top of that, there are more people with access to medical care than ever before—which is a wonderful thing, except that we haven’t been able to increase our budget to the level we need to accommodate that increased demand. I know the care coordinators have been dealing with those issues as well. I’m so glad they hired you, because I know the current care coordination team has had a difficult time keeping up with their workload! Many of our patients have lots of barriers to care and complicated needs, and it’s time-consuming for care coordinators to work with them effectively.
2. What are some of the major cost concerns for SHH?
Well, that over-reliance on the emergency room is very expensive for the hospital! We see people in here all the time with issues like uncontrolled diabetes, or infections that could have been cleared up with antibiotics. You know—issues that could have been addressed with a primary physician? Or we get people coming into the ER with advanced cancer that they could have caught early. Just a few days ago we had a 65-year-old man in here with a form of colorectal cancer that would have been highly treatable if we’d caught it early. But this man has never had a colonoscopy. That’s the kind of heartbreaking thing we see all the time here—and in addition to the human tragedy of this, it escalates costs. The people in this community need preventative care!
3. What are some particular challenges with the population of this area that relate to your ability to achieve Triple Aim outcomes?
The biggest challenge is simply that the population is older. That’s what happens in rural communities like this. Younger people move away—especially when there’s a decent sized city like Fargo an hour from here. So we have a huge population of older people here who don’t have younger relatives to help them out. And the majority of older people here are on very modest incomes. When you’re thinking about updating the care coordination process, you should definitely think about how care coordinators can better serve the elderly population. I know they’re not always getting the follow-up care they need because of barriers to care. And I also know that falls are a real problem. I can’t even tell you how many elderly people we’ve had in here because they’ve fallen. That’s always dangerous for an older person, but it’s worse for older folks who live alone in isolated areas and who don’t always have frequent contact with people who check on them. A few months ago we had a 90-year-old woman who was alone on the floor of her kitchen for almost two days before her daughter found her! She was lucky to be alive. These kinds of issues for rural elderly people are ones that I’d like to see care coordinators address more.
Sarah Kealey
Nurse Practitioner, Southwest Medical Center
1. Can you tell me about the people you see in your clinic?
Well, it’s funny you should ask me. I’m actually from Minneapolis and married my way into this community—I fell in love with a turkey farmer! So I think I have a lot of perspective on the population here because I’m an outsider. And you know for the most part, I really like the people in this community. They’re kind of rugged… very German and Norwegian at heart. They don’t like to go to the doctor unless it’s an emergency—they see it as an unnecessary expense, especially because money is pretty tight for a lot of the folks around here. We try to build relationships with them so that they like and trust us, but that’s a challenge. There’s been a lot of turnover at this clinic, unfortunately, and they don’t like that—but you know how it goes. Retaining medical professionals in a rural area isn’t easy. I guess you could say that going to the doctor and getting preventative care just isn’t part of the culture here? People just didn’t grow up going to the doctor every year to go for a checkup, and now that they’re older and they really need regular appointments, they don’t get them. But it’s also part of the culture out her for people to help each other out, and that’s really nice. When someone is sick, people line up with casseroles. They might not get the medical attention they need, but at least they have some chicken tetrazzini!
Oh, and another thing I should mention about the population in this area…there are a lot of returning vets who served in Afghanistan and Iraq. There aren’t a lot of jobs for young people around here, so a lot of high school grads go into the military. And a lot of them have come back with post-traumatic stress disorder. If you look at the Barnes County Community Health profile, you’ll see that suicide rates are higher than you might expect? That’s mostly because of PTSD. And that’s really awful. We see some of those people in our clinic sometimes… the fact that we’re in the middle of nowhere is actually helpful for PTSD patients, since a lot of them have anxiety around crowds and would rather come here than the hospital. I wish the hospital would do more to help out with that!
2. What are some of the biggest challenges you face at your clinic?
Geography. People just can’t get here! We have a pretty decent facility as far as middle-of-nowhere clinics go, but we’re a good 20 miles from Valley City. A lot of our older patients don’t drive anymore, or they only drive to a few familiar places. And if they need a specialist, that usually means driving to Fargo, which is an hour away—or even further to Minneapolis, since Fargo isn’t exactly a health care mecca. I don’t think the care coordination process at the hospital takes that into account enough. Like…here’s a good example. There’s a woman in her eighties who lives on a farm out here who has a heart condition. She was hospitalized, and the care coordinator gave her instructions to come to our clinic four times a week for a blood pressure check. I guess the care coordinator thought that wasn’t a big deal because they only live about five miles from here. But the thing is, this woman and her husband own an older vehicle that’s not good in the snow. So she doesn’t feel comfortable driving to the clinic when it’s snowy out—I mean, it’s not like they plow the roads around here, other than the main ones. And on top of that, she’s very forgetful. So she didn’t come to the clinic very often and wound up back in the hospital. Care coordinators need to come up with better plans for helping people like this. I don’t know why they don’t call up the churches around here and ask for help. There’s a lot of nice people who would be perfectly happy to give an old lady a ride to the clinic a few times a week. Someone just has to organize that. Or in this particular case, they could have just sent her home with a blood pressure monitor. I don’t know why nobody thought of that.
3. Do you have any other suggestions for how SHH could better serve the patients out here?
I wish the hospital would invest in telehealth or mobile health options. There’s been talk about telehealth, but the hospital hasn’t followed up on that yet. Telehealth for mental health would especially help with PTSD, since some of those patients don’t like to leave home. I also think we could use telehealth to help with issues that otherwise tend to escalate to the ER. For example, I had a man in here with a bad cut that had gotten infected. I had to send him to the ER. He didn’t want to see a doctor about the cut, so he kept trying to treat it himself until it got so bad that amputation is actually a possibility. If he could have contacted a health professional remotely, then maybe he could have gotten instructions of how to treat the cut properly—or maybe someone could have looked at the cut remotely and told him that he needed to go to the clinic right away. And there’s so many things we could do with mobile care—maybe even mobile mammogram units? If you look at the Barnes County data, you’ll see that one of our biggest problems is that women aren’t going to the doctor for Pap smears and mammograms. We could really use a mammogram mobile.
Floyd Knutson
Mayor of Valley City
1. Can you tell me a little bit about the people in this community?
Oh, Valley City’s a great place to live. I’ve lived here all my life and I’ve been the mayor for 36 years now! I’m a lucky guy. People come from all over the state to see our beautiful bridges and the Sheyenne River Valley Scenic Byway. The people here are terrific. Very helpful. Very self-reliant. People don’t like to take advantage of government services around here unless they really have to. I guess the same applies to health care? I know I’m a stubborn old mule when it comes to the doctor. I only go if my wife nags me enough!
2. What are the biggest problems around here that have to do with health care?
Well, we have a lot of us old folks around here. There are a lot of falls. That’s an issue that hits close to home for me. My sister passed away recently after she broke her hip. She was reaching for something on a high shelf. That happens way too much around here. Like I said, we pride ourselves on being self-reliant, but maybe we need to do a better job looking in on people like my sister. And we also have to do a better job looking in on our boys who fought in Iraq and Afghanistan. We have a lot of them here and some of them aren’t doing so well. Depression, suicide, that sort of thing. It’s a darned shame. Those boys fought for our country and they deserve our help.
3. What changes can we make at Sacred Heart that would benefit this community?
Oh, gosh, the wait time in the ER is so long. I was there with my wife because she broke her finger—nothing too serious, mind you, but it hurt like a bear—and we were there for hours. I guess that’s because people are going to the ER because they let minor health problems go for too long. And then we had to go to Fargo to a specialist because they didn’t have the right equipment at the hospital here. The hospital needs to update their equipment. I know that those sort of things cost money, and I for one do not want to raise taxes around here. But maybe we could spend a little more money so that patients have a nicer experience in the hospital? I hear a lot of people complaining—they have to wait a long time, the paint is chipping, the heat is broken, stuff like that.
Mary Loudsinger
Social Worker, Sacred Heart Hospital
1. What are some of the major patient care concerns for SHH?
I think we’re not doing a good enough job meeting the specific needs of this community. There’s a lot of turnover at the hospital—I guess a lot of rural hospitals have that problem—and one problem that creates is that the people in the hospital don’t know the population well enough. They treat patients here the same way they would treat patients in Minneapolis or some larger community, and that doesn’t work. And to be completely honest with you… well, a lot of patients think that the hospital staff is talking down to them. A lot of our patients are farmers or mechanics, or they’re in the military, and most of them don’t have a college education. And we get these doctors and nurses from out of the area who are here to get some experience and move on—and they don’t always treat our patients with the respect they deserve. And even when hospital staff is respectful, I think they don’t always pay enough attention to the health care needs of this particular community. They need to understand that there’s just not an established norm around here for getting preventative care, and that a lot of people have real obstacles that make it difficult to get to specialists in Fargo or even just to the local clinics.
2. What are some of the major cost concerns for SHH?
There’s a lot of cost associated with readmission rates. We get people back in the hospital because they don’t follow the care coordinators’ instructions. I hear a lot of venting about this in the hospital, and the tendency is to blame the patients for failing to follow through. And there’s something to that—I mean, it really is frustrating when patients don’t take care of themselves–but I think we also need to look at how care coordinators can do a better job so that patients can follow instructions. Some of that has to do with addressing barriers to care–like working with churches and community organizations to make sure older people have a ride to the doctor, or helping people find ways to pay for their medication. And some of that is just developing better relationships with patients so that they trust the people who are giving them instructions about their care. I think we all need to take the time to figure out what each patient specifically needs before we try to send them home with a care plan. I know we definitely don’t do a good job of taking cultural considerations into account. Obviously this isn’t a very diverse area, but we do get people in here who have last names other than Johnson and Nelson! And unfortunately our staff doesn’t always have enough experience to help them. Like, I recently met with an older Vietnamese woman who lives in this area.
3. What are some particular challenges with this area’s population that relate to your ability to achieve Triple Aim outcomes?
It’s really hard getting people around here to get the preventative care they need. There’s a lot of reasons for that, including cost. But some of it is that going to the doctor just isn’t something people do around here. People are very self-reliant. They’d rather take the time to stock their first aid kits than to get a check-up. So if you look at the Barnes County Community Profile, the numbers for things like Pap smears and mammograms are really low. It’s going to be difficult to achieve Triple Aim outcomes with numbers that are that low.
Bob Van Ness
Home Care Liaison
1. What are some of SHH’s major patient care concerns?
Getting patients the home health care they need is really tough. Part of the challenge is helping people pay for their home care, and that’s a big part of what I do—helping people navigate their way through Medicare and insurance, or finding them alternative resources if they need it. The hardest part, though, is that there aren’t enough home health care resources in this part of the state for the aging population. That means that people who really need care right away get waitlisted, or they can only have someone come to their homes a few times a week when they really need more than that. Unfortunately, this is the kind of region where we need more home health care, not less, because the population is older and because transportation is harder for people in rural areas.
We also don’t have nearly enough assisted living or nursing home care in this area—or hospice either, for that matter—which means that people who really need assisted living either have to leave their community and move to Fargo, or they stay at home. That means we have to get creative, like making sure there’s a relative who can look in on someone to fill in care gaps, or someone from the neighborhood or a church. Or sometimes it means calling to check on people ourselves. All of that is time-consuming and less than ideal, but we really do have to make do. I think that the care coordinators need to be more aware of this home health care gap and put more effort into helping to fill that gap. I do what I can, but I’m just one person.
2. What are some of SHH’s major cost concerns ?
Well, what do you think happens when people don’t get the home health care they need? They wind up back at the hospital! I can’t even tell you how many older people get sent to the hospital with injuries related to falls. We can’t prevent all of that, but we could definitely cut that down with better home health care. I don’t think this will ever happen, but I think the hospital could save a lot of money if they opened an adjacent facility – maybe in partnership with Valley City Regional Hospital – that offered nursing home care, and possibly assisted living and hospice as well. Then we’d have a place to send people who really shouldn’t be at home.
3. What are some particular challenges with this area’s population that relate to your ability to achieve Triple Aim outcomes?
I’ve already talked about some of the challenges of our older population. They don’t have a lot of money, they live in remote areas, and we don’t have enough health care resources for them in the community. But another population I’m concerned about are returning vets. I don’t know if anyone else is particularly concerned about these guys, but I’m a vet myself. I served in Iraq, and I count myself lucky that I came back healthy both physically and mentally. Injured vets have home health care needs too, and we don’t even have the resources in the community to provide for older folks’ home health care needs, never mind a population that people don’t think of as needing that kind of care. And on top of that, we have many returning vets in this area who are depressed and who sometimes take their lives. That’s a hard population to reach before it’s too late, because there’s such a stigma associated with mental health care for a lot of them. I don’t think we can achieve Triple Aim outcomes until we make sure the vets in this area are taken care of better.
Ned Walsh
Barnes Community Health Department Director
1. What do you think are this community’s most serious health care needs?
People aren’t getting preventative care and seeing primary physicians on a regular basis. Did you look at the Barnes County Community Health Profile? About one in four people don’t have a regular primary physician, and I know that even the people who do have a primary physician don’t often go for an annual checkup. Only one out of four people have gotten a cholesterol test in the last five years. More than half of people over 50 have never had a colonoscopy. Too many women are not getting Pap smears and mammograms.
There are a lot of reasons for this. For one thing, there just aren’t enough providers in the area. Physicians’ offices have long waiting periods. And of course, cost is an issue, as is transportation for some residents. But part of it is that many people just aren’t educated about the importance of health care, and especially preventative care. It’s not the culture of what people do around here.
2. How can SHH do a better job serving this community?
I think Sacred Heart could do a better job working with the community. They need better partnerships with the local clinics and the health department. They also need to be integrated better with informal networks of care—like churches and schools, and other community organizations that can help people out with health care needs. In a small community like this one, care coordinators should be able to call upon those informal networks for help. I think we could have programs in places like churches to teach people about health care, or even to do screenings—and we ask places like churches to help people get to their appointments and things like that.
3. What are some ways the Valley City Health Department could partner with the hospital to help achieve Triple Aim outcomes?
I would love to see the hospital and the health department come together for public health initiatives to promote preventative care, that emphasize the importance of seeing a primary care physician on a regular basis. These things are in the best interests of patients, of course, but they’re also in the hospital’s best interests because they drive down costs. If we could get people to go to the doctor when they’re sick, then they wouldn’t be going to the emergency room for expensive care. We could partner with schools as well to help kids learn about nutrition and healthy eating habits. Obesity levels are high in this area. I don’t have statistics about childhood obesity, but my sense is that it’s pretty high around here. That’s an area where we could work together. And I’m sure there are creative ways that care coordinators could team up with the public health department to help meet patients’ needs better. For one thing, we could be more involved in helping coordinators and patients find the resources they need.
Trish Walstrom
Care Coordination Manager
1. What could care coordinators do better that would help control costs?
We absolutely need to get readmission rates under control. People are coming back to the hospital way too often because they’re not following the care instructions that we’re sending them home with—and I know that costs the hospital a fortune. And it’s tempting to blame the patients for not following through. I know I hear a lot of venting about this, and some of that is justified—I mean, we have some stubborn old people around here that just refuse to go to the doctor and think they can solve their problems by themselves! But I have to keep reminding myself and my staff that venting does nothing to control costs.
We also need to find ways to update our care coordination process so that people follow through as instructed. That means we have to do a lot of things differently. First of all, we have to make sure patients understand the instructions we’re giving them. Then we have to take the time to make follow-up calls with patients to make sure they’re doing what we told them to do, and help them problem-solve if they’re running into any problems. Follow-up calls just are not a part of our process, mostly because we’re just so busy. And that has to change. We have to prioritize follow-up calls or people are going to continue to end up back in the hospital. In addition, I think we need to better address barriers to care—cost, transportation, and whatever it is that’s keeping people from taking care of themselves. It’s a huge problem that there aren’t a lot of specialists around here. We need to find ways to help people get to Fargo who don’t have the time or the money or the vehicle to get there—because that’s where the specialists are.
2. What could care coordinators do better that would help improve patient care?
Frankly, I think we need to build up a better sense of trust with our patients. We have so much turnover at the hospital, so they don’t know us. They know me, because I’ve been here a long time, but I’m the exception—and I’m often supervising and not working directly with patients. In a small community like this one, trust is essential. If we tell a patient she needs to get a follow-up test done, she needs to believe we have her best interests in mind—and she needs to know we know what we’re talking about. Maybe that means more community outreach? If the people in this community felt like they knew us better, they would feel more comfortable at the hospital.
3. What are some particular challenges with the population of this area that relates to your ability to achieve Triple Aim outcomes–and to be effective care coordinators?
You know, there are a lot of challenges, but there’s one that kind of creates them all: Nobody in the process sees themselves as part of a bigger picture. The health care department, the patients, us, the churches – we’re all doing our own thing and seeing only our own turf, and the whole idea of working together seems like a huge leap. But unless we get creative about working together, none of those individual factors will ever get solved. There are always going to be transportation issues and self-reliant, stubborn older folks in a place like this. The question is, how can we get creative so that those things – which aren’t going to change – don’t stand in the way of our attempts to change for Triple Aim?
Email Response
Email from Karen
Review Karen’s latest message to you and send a reply with your initial thoughts on what Sacred Heart Hospital needs to do to achieve Triple Aim Outcomes.
From: Karen Dellington, Admissions and Discharge Director
Subject: Triple Aim Outcomes
Thank you for conducting emails with individuals from the hospital and the community! You should now have the information you need to create a Power Point presentation outlining a strategy to achieve Triple Aim Outcomes at Sacred Heart. Remember, as you create your presentation, you will also want to draw upon the data in the Barnes County Community Health Profile.
In the meantime, could you please email your initial thoughts about strategies for achieving Triple Aim?
Thank you for all your hard work!
Your Email Response:
Assignment Instructions:
Develop a presentation, containing 10-15 slides, on the Institute for Healthcare Improvement’s Triple Aim, how current and emerging health care 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.
The Triple Aim is a framework by the Institute for Healthcare Improvement (n.d.) for “simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities.” Care coordinators must have a model and framework to guide their practice and enable them to achieve the Triple Aim. Presently, many rural hospitals are using archaic models that must be updated to achieve the Triple Aim. For example, the patient-centered medical home model has been around for 30 years, but it has evolved during that time.
This assessment provides an opportunity for you to develop an evidence-based presentation of the ways in which an organization’s care coordination process can be modified to achieve the Triple Aim.
Models of Care
National initiatives focus on health care organizations to continuously improve the quality, safety, and coordination of care. In response to these initiatives, health care models have surfaced with the goal to guide national health safety and quality improvement efforts.
Nursing is an art and science with a foundation that embraces evidence, research, and quality. The thought “we have always done it this way” has long been discarded and replaced by standards based on evidence-based research. As the specialization of care coordination has evolved, care coordination has proven to be a vital element that links patients and families to safer and higher quality care. One care coordination model, the patient-centered medical home (PCMH), has gained momentum and support from governmental and regulatory agencies.
Institute for Healthcare Improvement. (n.d.). Triple Aim for populations. http://www.ihi.org/Topics/TripleAim/Pages/default.aspx
In this assessment, you will assume the role of a new case manager at a small rural hospital, Sacred Heart. You have been asked to deliver an evidence-based presentation to hospital leaders and clinical leadership teams about the ways in which the care coordination process at Sacred Heart can be modified to achieve the Triple Aim within the hospital’s rural population.
To gain a better understanding of current health care models and their support for the Triple Aim, examine and compare such models as:
Patient-centered medical home (PCMH).
Transitional care.
Patient self-management.
Guided care.
Care coordination (Institute for Healthcare Improvement).
Then, finish gathering the information needed to prepare for your presentation by completing the following simulation exercise:
Vila Health: Triple Aim Outcomes.
Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.
Presentation Software
You may use Microsoft PowerPoint or any other suitable presentation software to create your slides. If you elect to use an application other than PowerPoint, check with faculty to avoid potential file compatibility issues.
You are encouraged to review the various presentation resources provided for this assessment. These resources will help you to design an effective presentation, whether you choose to use PowerPoint or other presentation design software.
Develop a presentation of specific suggestions for improving the care coordination process at Sacred Heart Hospital to achieve Triple Aim outcomes.
Developing the Presentation
The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your presentation addresses each point, at a minimum. You may also want to read the Triple Aim Outcome Measures Scoring Guide to better understand how each criterion will be assessed.
Explain how the Triple Aim contributes to population health, improves the patient care experience, and reduces health care costs on a regional, state, and national level. You will do this on slides with these specific headings:
Experience of Care/Patient Satisfaction.
Improving Population or Community Health.
Decreasing Per Capita Costs.
Analyze the relationships between various current and emerging health care models you have chosen to examine and the ways in which they support the Triple Aim by answering these guiding questions:
How do I define the rationale and philosophy of these health care models?
Can I explain how these health care models have evolved? How do I believe that these health care models have changed over time?
Can I cite at least three ways in which health care quality is enhanced through these models? In which three ways do I believe that these models most enhance health care quality? (Cite references to support your assertion.)
Explain how the structure of these models contribute to the process of gathering and evaluating the quality of evidence-based data.
Explain how evidence-based data shapes the care coordination process in nursing.
Describe three governmental regulatory initiatives and outcome measures that can be applied in the care coordination process to achieve the Triple Aim within a population.
Present process improvement recommendations to a stakeholder group clearly and concisely.
Address the anticipated needs and concerns of your audience.
What questions or objections are they likely to raise? How will you respond?
Support your main points, arguments, and conclusions with relevant and credible evidence, correctly formatting citations and references using current APA style.
Is your supporting evidence clear and explicit?
How or why does particular evidence support a claim?
Will your audience see the connection?
Additional Requirements
Your slide deck should consist of 10–15 slides that address the presentation criteria, not including the title slide, purpose slide, and references slide.
Begin your presentation with the following slides:
Purpose (the reasons for the presentation).
Definition of the Triple Aim outcome measures.
Use the speaker’s notes section of each slide to develop your talking points and cite your sources, as appropriate.
Cite 3–5 sources of credible scholarly or professional evidence to support your presentation.
List your sources on the references slide at the end of your presentation.
Apply APA formatting to all in-text citations and references.
Portfolio Prompt: You may choose to save your presentation to your ePortfolio.
This resource provides information about ePortfolio, including how to use the different features of the product.
Online ePortfolio Guidelines [PDF].
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Apply care coordination models to improve the patient experience, promote population health, and reduce costs.
Explain how the Triple Aim contributes to population health, improves the patient care experience, and reduces health care costs on a regional, state, and national level.
Analyze the relationships between various current and emerging health care models and the ways in which they support the Triple Aim.
Explain how the structure of particular health care models contributes to the process of gathering and evaluating the quality of evidence-based data.
Describe governmental regulatory initiatives and outcome measures that can be applied in the care coordination process to achieve the Triple Aim within a population.
Competency 2: Explain the relationship between care coordination and evidence-based data.
Explain how evidence-based data shapes the care coordination process in nursing.
Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Present process improvement recommendations to a stakeholder group clearly and concisely.
Support main points, arguments, and conclusions with relevant and credible evidence, correctly formatting citations and references using current APA style.


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