Emerging models of Care Coordination identifies effective ways of promoting better patient care, reduce healthcare costs, eliminate adverse events while decreasing the number of hospital re-admissions. With the complexity of patient illnesses and specific care needs, the healthcare system is in need of rapid changes. Are Care Coordination Models the answers? According to a RWJF/Health Affairs, “analysis of the Medicare Hospital Readmissions
Reduction Program, readmissions refer to a patient being admitted to a hospital within a certain
time period from an initial admission - generally within 30 days of an initial hospital stay. If a
hospital has a high proportion of patients readmitted within a short time frame, it may be an
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This Transitional Care Intervention is also defined in the emerging model Care Coordination Model. This Care Coordination Model, is a framework for identifying those with multiple needs and constructing coordination services to ensure that their health and life goals are met while improving their health.
This framework relies on a methodical approach to delivering coordination services, not just health interventions, to improve health outcomes. Ensuring efficient access to the health care system and other needed support, is one of the main goals of the framework. The role of strong partnerships between health care and community organizations, are a necessity in preventing re-admission hospitalizations. Eby,
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A team consisting of resources that can be used as leverage to improve those with continued health needs is extremely important. This team referred as The Triple Aim Initiative, believe that following an individual to the entire care coordination process through their health journey, will allow for better patient outcomes. Eby, (2011).
The Triple Aim Team has incorporated a Care Coordination Model consisting of family contribution to patient care with resources of value propositions, services designed for specific individual needs and delivery of these services. The Care Coordinator will complete this cycle by gathering feedback of all three services while working closely with the
The Physician/Hospital alignment model is the teamwork between physicians and hospitals to achieve the common goal of providing quality care to patients (med synergies). Physician/hospital alignment opportunities have come into play more predominantly in recent years due to quality, financial, and regulatory aspects of healthcare reform. Physicians and hospitals are more motivated to align now because the new healthcare reform requires an improvement on key aspects such as quality, cost, and efficiency. Moreover, an increase in patient numbers, a decrease in reimbursements, and a shift among new physician goals and values have contributed to the drive for this alignment. Physician/hospital alignment can be characterized in the range of tactical to transformational. Tactical alignments can include joint ventures, co-management agreements, volunteer medical staff, etc.
Integrated services help arrange services that are easy for users to scroll through. It provides financial and medicine management to work together on a goal and make the most of resources provided in the hospital (World Health Organization, 2008). For instance in the case study the hospital had a health food store, a physiotherapy clinic, an alternative medicine clinic, a pharmacy, and a home health care store under one management, making it a lot more easier for patients to access. Overall integrated services in health care can escalate the quality of care, enhance access to services and lower overall health care expenditures. Due to the fact that is more economically efficient to share human resources than have health care systems be dedicated to one particular disease, and it makes more sense to deal with all of the problems the patient is facing rather than focussing separately on just one health problem (World Health Organization,
There is limited data on predictors of discharge and readmission for hospital inpatients. According to Rothman, Rothman, & (), “Unplanned hospital admissions are a major quality and cost issue in the US healthcare system”. About 20% of Medicare patients are readmitted to the hospital within 30 days, at an estimated cost of $17 billion per year (). Now that Medicare has begun to reduce payment to hospitals with high readmission rates, hospitals are looking for more effective ways of reducing readmissions. In order to develop new systems to address these concerns, there must be evidence in place to support to their use.
Typically, in current healthcare, case management assist in dissolving fragmented care for consumers, assisting in the progression of care. For example, in a hospital setting, patient care delivery provided by a combination of a surgeon, hospitalist, and a medical specialist allows for pathways of inefficient continuity of care. A case manager evaluates the entire treatment plan, managing complex care, and limiting the lack of continuity among providers (Daniels & Frater 2011). Collaboration with physicians’ decisions on clinical services and implementing accurate delivery of services by the facility exhibits strength of a case management program. However, limitations exist if physicians’ or administration do not allow the case management a respected position in decreasing healthcare fragmented delivery. Consistently, evaluation of medical goals, recommended clinical services, and patient treatment plans making sure they are in correlation with evidence based protocols and treatments, actually will improve healthcare quality, reducing length of stay and costs (Daniels and Frater 2011). Additionally, strengths of a typical case management program allow decrease in duplicate testing, improved discharge planning, and connections of ancillary departments. Case management programs assist in deleting
health care team who, with doctors, provide quality care to patients. In order to do that,
In order to increase patient satisfaction by providing a more efficient method of continuity of care, Clark and the staff nurses proposed an innovative care delivery model that placed a Patient Care Facilitator (PCF) in charge of about 12 patients each (Clark, 2011). She further explains that each PCF will head 2 Registered Nurses (RN) and a Certified Nursing Assistant (CNA) for the same group of patients (Clark, 2011). Staffing plays a key role in continuity of care by having the same nurses staffed to the same group of patients with the PCF available 24/7.
Having a common goal for the team and understanding each members role in reaching this goal – allows each of the healthcare professionals to focus on the overall outcome for the patient and the most effective means of reaching such outcome through inter-professional healthcare
Improvement in quality of healthcare: Work in interprofessional teams, employ evidence-based practice, utilize informatics, provide patient-centered care, and apply quality improvement (QI).
As part of the health care reform, many hospitals have focused their marketing strategies on population health management as part of the transformation to value-based care. Managing population health requires a close relationships with physicians, partnerships with organizations in the community, and expansion into preventive and outpatient care and therefore must be implemented further. Likewise, comprised as key components are investing in technology - to connect with physicians, customers and the community and gather data necessary for improving quality (Takvorian, 2015) and merging with other hospitals and health care systems - consolidation as a strategy to gain capital necessary for health IT investments, outpatient facility construction, physician partnerships and other projects (Johns Hopkins Bloomberg School of Public Health, 2015; Ropak, 2012).
According to the Institute for Healthcare Improvement’s article “A Primer on Defining the Triple Aim”, the Triple Aim was introduced as a framework as opposed to a concept. Frameworks are structures derived from a series of related concepts; in this case: patient experience, cost of care, and population health. Comparatively, William Kissick’s Iron
Involvement of the family is a big part of the collaboration and also with patient-centered care. Family at that moment may have in site information that the patient isn’t sharing
The chronic care model calls for an organizational change in the way individuals with illnesses are cared for, and the involvement of nurses, social workers and patients themselves. The challenge is moving in an effective way of improving quality from research carried out predominantly in health maintenance organizations to the mainstream of health care practice (Wielawski, 2006). Wagner’s explanation is to substitute the customary physician-centric office structure with one that supports clinical teamwork in association with the patient. The notion spreads outside the health care organization to collaborative associations in the community. Wagner et al. (2001) termed this approach the “chronic care model.” With this model, physicians, nurses, case managers, dieticians, and patient educators
In 1983, the Medicare prospective payment program was implemented, which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007).... ... middle of paper ... ... Case Management Related to Other Nursing Care Delivery Models.
There are always going to be aspects like customer service or procedural changes that can be done to improve quality of care. I believe that this project will make healthcare more open and accessible to all populations. In my practice, I hope to become a leader that is efficient yet maintains good relations with patients. I plan to implement the five principles of the Triple Aim initiative into my practice to provide patients with a satisfying medical experience. If patients are thoroughly taken care of and emotionally content, there will be less complaints and more people willing to seek medical
The demands on health care providers to provide the best quality care for patients is increasing. With added responsibilities and demands on our health care workers, it is hard not become overwhelmed and forget the reason and purpose of our profession. However, there is a way where all professionals can meet and come together for a common cause, which is the patient. A new approach in patient care is coming of age. This approach allows all health care professionals to collaborate and explore the roles of other professions in the hope of creating a successful health care team. This approach is referred to as the Interprofessional Collaboration Practice (IPC). To become an effective leader and follower, each professions will need to work together