Institute for Healthcare Improvement Essay.

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.Institute for Healthcare Improvement Essay.

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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.Institute for Healthcare Improvement Essay.

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.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:Institute for Healthcare Improvement Essay.

• 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.Institute for Healthcare Improvement Essay.

Preparation

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. Institute for Healthcare Improvement Essay.

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 Challenge

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.Institute for Healthcare Improvement Essay.

Triple Aim Outcomes

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.Institute for Healthcare Improvement Essay.

IT LOOKS LIKE YOU GOT MAIL

Inbox – (1)

Triple Aim Outcomes

From: Karen Dellington, Admissions and Discharge Director

To: New hire

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:Institute for Healthcare Improvement Essay.

1. 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.
2. 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.Institute for Healthcare Improvement Essay.

Good luck!

Thanks,
Karen

Barnes County Community Health Profile

Please click the ‘Download PDF’ link for more data regarding population data in relation to specific health conditions.

Barnes County, North Dakota Community Health Profile by Age Group, 2000 Census

Barnes County, North Dakota Community Health Profile by Race, 2000 Census

Marital Status of Persons Age 15 and Older, 2000 Census

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.

Select a questionand listen to the interviewee’s response.

1^st personis:Courtney Donovan (Emergency Room Doctor)

What are some of the major patient care concerns for SHH?

Courtney: 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.Institute for Healthcare Improvement Essay.

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.Institute for Healthcare Improvement Essay.

But it’s not just that we’re understaffed. The emergency room is often packed because people over-rely on emergency care. They aren’t getting the preventative care or the follow-up care they need, so they turn up in the emergency room for problems that could have been prevented or treated earlier.That’s because they don’t have the money to see a doctor, or it’s really inconvenient for them to do so because there aren’t enough physicians or specialists in this area.

What are some of the major cost concerns for SHH?

Courtney: 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!

What are some particular challenges with the population of this area that relate to your ability to achieve Triple Aim outcomes?

Courtney: 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.Institute for Healthcare Improvement Essay.

2^nd Person is:Mary Loudsinger (Sacred Heart Hospital Social Worker)

Question, and the interviewee’s response.

What are some of the major patient care concerns for SHH?

Mary: 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.Institute for Healthcare Improvement Essay.

What are some of the major cost concerns for SHH?

Mary: 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.Institute for Healthcare Improvement Essay. 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 who was recently diagnosed with diabetes, and the care coordinator gave her dietary instructions without considering the fact that she doesn’t eat a traditional American diet. The care coordinator told the woman to avoid rice and noodles—well, that’s a major part of her diet. We could avoid having that kind of patient readmitted into the hospital if we took the time to ascertain her needs better.Institute for Healthcare Improvement Essay.

What are some particular challenges with this area’s population that relate to your ability to achieve Triple Aim outcomes?

Mary: 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.Institute for Healthcare Improvement Essay.

3^rd Person is:Ned Walsh (Barnes Community Health Department Director)

Question and the interviewee’s response.

What do you think are this community’s most serious health care needs?

Ned: 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.Institute for Healthcare Improvement Essay.

How can SHH do a better job serving this community?

Ned: 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.

What are some ways the Valley City Health Department could partner with the hospital to help achieve Triple Aim outcomes?

Ned: 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 arecreative 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.Institute for Healthcare Improvement Essay.

4^th Person is:Trish Walstrom (Care Coordination Manager)

Questionand the interviewee’s response.

What could care coordinators do better that would help control costs?

Trish: 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. Institute for Healthcare Improvement Essay.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 thespecialists are.Institute for Healthcare Improvement Essay.

What could care coordinators do better that would help improve patient care?

Trish: 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.Institute for Healthcare Improvement Essay.

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?

Trish: 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?Institute for Healthcare Improvement Essay.

From: Karen Dellington, Admissions and Discharge Director

• To: New hire
• 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.

Thank you for all your hard work!

–Karen

Requirements

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:Institute for Healthcare Improvement Essay.

• 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.Institute for Healthcare Improvement Essay.
• 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

PRESENTATION FORMAT AND LENGTH

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.

SUPPORTING EVIDENCE

• 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.Institute for Healthcare Improvement Essay.

Triple Aim Outcome Measures Scoring Guide

Institute for Healthcare Improvement Essay.