NURS FPX 6612 Assessment 4 Cost Savings Analysis
Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Cost Savings Analysis This report provides a synthesized evaluation of cost-reduction strategies associated with the senior care coordinator role, emphasizing financial sustainability and quality improvement. The analysis demonstrates that structured care coordination—supported by Health Information Technology (HIT)—can simultaneously reduce operational expenditures and improve patient outcomes. Technological integration, including telehealth platforms, preventive care systems, and optimized electronic health records (EHRs), enables healthcare organizations to minimize inefficiencies such as duplicated services, avoidable hospitalizations, and administrative redundancies. These efficiencies translate into measurable economic gains while reinforcing value-based care delivery. Cost-Saving Elements The following table summarizes the major interventions, their estimated current expenditures, and projected annual savings. These estimates are derived from evidence-based assumptions and peer-reviewed findings. Cost-Saving Intervention Current Annual Cost ($) Projected Annual Savings ($) Preventive Care Programs 15,000 8,000 Care Transition Management 10,000 5,000 Telehealth Implementation 7,500 3,000 EHR Optimization 12,000 6,500 Each intervention contributes to cost containment through distinct operational mechanisms: Mechanisms Through Which Care Coordination Reduces Costs Care coordination involves structured collaboration among multidisciplinary healthcare professionals to ensure continuous and patient-centered service delivery. This model emphasizes proactive intervention rather than reactive treatment. A critical cost-saving pathway is disease prevention. Although preventive strategies require upfront investment, they significantly reduce long-term healthcare expenditures. For example, preventive interventions accounted for only a small fraction of pandemic-related healthcare costs, highlighting their economic efficiency (Dobson et al., 2020). Another key mechanism is chronic disease management, where coordinated care improves medication adherence and reduces emergency department utilization. Evidence indicates that integrated care coordination can substantially lower healthcare spending, particularly among patients with complex conditions (Caskey et al., 2019). Role of Health Information Technology in Cost Optimization HIT serves as a foundational enabler of cost-efficient care coordination. Its impact is particularly evident in the following areas: Large-scale analyses estimate that optimized EHR systems alone can generate substantial annual savings across healthcare systems (Kumar et al., 2022). However, these outcomes depend on several critical assumptions: Care Coordination, Consumer Engagement, and Health Outcomes Beyond financial benefits, care coordination strengthens health consumerism, encouraging patients to take an active role in managing their health. Engaged patients are more likely to: This increased engagement is directly associated with improved clinical outcomes and reduced long-term costs (Vogus et al., 2020). Additionally, addressing social determinants of health—such as education, income, and lifestyle—enhances the effectiveness of coordinated care. Personalized interventions that consider these factors contribute to better health outcomes and reduced disparities (Karam et al., 2021). Technology-Supported Care Coordination The integration of digital tools further strengthens coordination efforts by maintaining continuous communication between patients and providers. Key advantages include: Empirical evidence shows that technology-enabled coordination significantly improves outcomes in chronic conditions such as type 2 diabetes (Crowley et al., 2022). NURS FPX 6612 Assessment 4 Cost Savings Analysis Data-Driven Decision Making in Coordinated Care Modern care coordination models increasingly rely on data analytics to guide clinical and financial decision-making. Data Strategy Function Impact on Cost Savings Risk Stratification Identifies high-risk patients for targeted interventions Reduces unnecessary utilization Health Information Exchange Enables secure sharing of patient data across providers Prevents duplication of services Population Health Analytics Supports value-based care planning Improves resource allocation efficiency Accountable Care Organizations (ACOs) exemplify this approach by aligning financial incentives with patient outcomes. These models prioritize quality over service volume, reinforcing sustainable cost reduction (Coran et al., 2021; Fraze et al., 2020). Health Information Exchanges (HIEs) further enhance this framework by ensuring timely access to patient data, thereby supporting informed clinical decisions and minimizing redundant care (Kharrazi et al., 2023). Conclusion Strategic care coordination, supported by advanced HIT systems, represents a high-impact approach to reducing healthcare costs while improving patient outcomes. By integrating preventive care, optimizing care transitions, leveraging telehealth, and utilizing data-driven decision-making, healthcare organizations can achieve sustained financial and clinical benefits. This integrated model not only enhances operational efficiency but also creates a continuous improvement cycle in care delivery, aligning with modern value-based healthcare principles. References Abraham, J., Meng, A., Tripathy, S., Kitsiou, S., & Kannampallil, T. (2022). Effect of health information technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: A systematic review. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocac013 Caskey, R., Moran, K., Touchette, D., Martin, M., Munoz, G., Kanabar, P., & Van Voorhees, B. (2019). Effect of comprehensive care coordination on Medicaid expenditures compared with usual care among children and youth with chronic disease. JAMA Network Open, 2(10). https://doi.org/10.1001/jamanetworkopen.2019.12604 Coran, J. J., Schario, M. E., & Pronovost, P. J. (2021). Stratifying for value: An updated population health risk stratification approach. Population Health Management. https://doi.org/10.1089/pop.2021.0096 NURS FPX 6612 Assessment 4 Cost Savings Analysis Crowley, M. J., Tarkington, P. E., Bosworth, H. B., Jeffreys, A. S., Coffman, C. J., Maciejewski, M. L., & Edelman, D. (2022). Effect of a comprehensive telehealth intervention vs telemonitoring and care coordination in patients with persistently poor type 2 diabetes control. JAMA Internal Medicine, 182(9), 943. https://doi.org/10.1001/jamainternmed.2022.2947 Dobson, A. P., Pimm, S. L., Hannah, L., Kaufman, L., Ahumada, J. A., Ando, A. W., & Vale, M. M. (2020). Ecology and economics for pandemic prevention. Science, 369(6502), 379–381. https://doi.org/10.1126/science.abc3189 Fraze, T. K., Beidler, L. B., Briggs, A. T., Joynt Maddox, K. E., & Colla, C. H. (2020). Safety-net accountable care organizations: Advancing equity through delivery system reform. Health Affairs, 39(6), 946–954. https://doi.org/10.1377/hlthaff.2019.01557 Karam, M., Chouinard, M. C., Poitras, M. E., & Hudon, C. (2021). Patient-centered care and outcomes: A systematic review of the literature. BMC Family Practice, 22, 150. https://doi.org/10.1186/s12875-021-01498-3 NURS FPX 6612 Assessment 4 Cost Savings Analysis Kharrazi, H., Zhang, Y., & Lasser, E. C. (2023). Health Information Exchange (HIE) utilization and hospital quality metrics: A review. Journal of Biomedical Informatics, 137, 104364. https://doi.org/10.1016/j.jbi.2023.104364 Kumar, S., Calvo, R. A., & Patel, V. (2022). Optimizing electronic health records for improved care coordination and reduced cost: A systems review. Health Systems, 11(3), 246–260. https://doi.org/10.1057/s41306-022-00113-8 Tomlinson, J., Cheong, V., Forde, E., & Kraus, S. (2020). Supporting patient transitions from hospital to home: A systematic review of discharge interventions. Journal of General Internal Medicine, 35(2), 504–520. https://doi.org/10.1007/s11606-019-05302-6 Vogus, T. J., McClelland, L. E., & Lee, M. K. (2020). The impact of
NURS FPX 6612 Assessment 3 Patient Discharge Care Planning
Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Patient Discharge Care Planning Marta Rodriguez’s discharge planning centers on a structured, patient-focused approach following her prolonged hospitalization due to a severe accident. After four weeks in a trauma unit, multiple surgical interventions, and antibiotic therapy, her transition from hospital to home requires meticulous coordination. As the senior care coordinator, the case presentation to the interdisciplinary team aims to align clinical priorities, ensure continuity of care, and minimize post-discharge risks. A key question arises: Why is discharge planning critical in Marta’s case?Discharge planning is essential because it ensures continuity of care, reduces complications, and prevents avoidable readmissions by aligning clinical interventions with patient-specific recovery needs. Longitudinal, Patient-Centered Care Plan A longitudinal care strategy emphasizes continuity, personalization, and coordinated communication across Marta’s recovery trajectory. Health Information Technology (HIT) plays a central role in operationalizing this model. How do HIT tools support patient-centered care? HIT systems enhance care delivery by enabling real-time data sharing, improving communication, and supporting clinical decision-making. Key components include: NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Table 1 Role of HIT Components in Marta’s Care Plan HIT Component Primary Function Impact on Patient Outcomes Electronic Health Records Centralized patient data access Improved clinical decision-making Secure Messaging Real-time provider communication Reduced communication gaps Telehealth Remote monitoring and follow-up Early intervention, fewer complications Medication Reconciliation Medication accuracy verification Reduced medication errors How can readmission within 48 hours be prevented? Preventing early readmission requires: Telehealth and messaging platforms further strengthen post-discharge engagement, allowing early identification of warning signs and timely intervention (Oksholm et al., 2023). Data Reporting Data reporting is a foundational element in modern healthcare systems, influencing coordination, efficiency, and innovation. Why is data reporting important in Marta’s recovery? Data reporting supports evidence-based decision-making and enhances care quality by providing actionable insights into patient status and behavior. Table 2 Applications of Data Reporting in Marta’s Care Domain Data Utilized Clinical Benefit Care Coordination Medication adherence, vital signs Improved team collaboration Care Management Pain levels, mobility, nutrition Tailored interventions Interprofessional Innovation Cultural preferences, language needs Personalized, culturally competent care How can data quality be ensured? Maintaining high-quality data requires: These practices ensure reliability and clinical relevance, directly impacting patient outcomes (Brooks et al., 2020). Client’s Record Influencing Health Outcomes Patient records are critical assets in improving healthcare delivery and outcomes. How do patient records improve health outcomes? Patient records provide comprehensive clinical insights, including medical history, treatment plans, and risk factors. When analyzed through HIT systems, these data enable: How does HIT enhance interprofessional collaboration? HIT tools enable synchronized communication and shared access to patient data, ensuring all team members operate with consistent information. This reduces errors and enhances care coordination. What ensures effective interdisciplinary coordination? Effective collaboration depends on: HIT platforms act as centralized systems that support these elements, enabling holistic and integrated care delivery (Rawlinson et al., 2021). Conclusion Marta Rodriguez’s discharge planning exemplifies the importance of a coordinated, patient-centered approach supported by advanced HIT systems. Technologies such as EHRs, telehealth, secure messaging, and medication reconciliation tools significantly enhance communication, safety, and care continuity. Data reporting further strengthens clinical decision-making by offering insights into patient behaviors and needs, while patient records provide the foundation for personalized care strategies. Through structured collaboration and effective use of technology, the interdisciplinary team can ensure safe discharge, reduce readmission risks, and optimize Marta’s recovery outcomes. References Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “behind-the-scenes” look at interprofessional care coordination: How person-centered care in safety-net health system complex care clinics produces better outcomes. International Journal of Integrated Care, 20(2). https://doi.org/10.5334/ijic.4734 Chowdhury, D., Hope, K. D., Arthur, L. C., Weinberger, S. M., Ronai, C., Johnson, J. N., & Snyder, C. S. (2020). Telehealth for pediatric cardiology practitioners in the time of COVID-19. Pediatric Cardiology, 41(6), 1081–1091. https://doi.org/10.1007/s00246-020-02411-1 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Flickinger, T. E., Waselewski, M., Tabackman, A., Huynh, J., Hodges, J., Otero, K., Schorling, K., Ingersoll, K., Tiouririne, N. A.-D., & Dillingham, R. (2022). Communication between patients, peers, and care providers through a mobile health intervention supporting medication-assisted treatment for opioid use disorder. Patient Education and Counseling. https://doi.org/10.1016/j.pec.2022.02.014 Leslie, M., & Paradis, E. (2018). Is health information technology improving interprofessional care team communications? An ethnographic study in critical care. Journal of Interprofessional Education & Practice, 10, 1–5. https://doi.org/10.1016/j.xjep.2017.10.002 Oksholm, T., Gissum, K. R., Hunskår, I., Augestad, M. T., Kyte, K., Stensletten, K., Drageset, S., Aarstad, A. K. H., & Ellingsen, S. (2023). The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care—A systematic review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.15579 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care, 21(2), 32. https://doi.org/10.5334/ijic.5589 Schwab, P., Mehrjou, A., Parbhoo, S., Celi, L. A., Hetzel, J., Hofer, M., Schölkopf, B., & Bauer, S. (2021). Real-time prediction of COVID-19 related mortality using electronic health records. Nature Communications, 12(1). https://doi.org/10.1038/s41467-020-20816-7
NURS FPX 6612 Assessment 2 Quality Improvement Proposal
Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Quality Improvement Proposal Introduction Why should healthcare organizations pursue Accountable Care Organization (ACO) status, and how does it improve care delivery? Healthcare institutions aiming to enhance care quality and patient safety are increasingly aligning with the ACO model. This framework strengthens patient trust by ensuring coordinated, value-based care while simultaneously reducing unnecessary expenditures. Research indicates that structured, evidence-based tools—particularly individualized care plans—enable providers to manage complex patient conditions more efficiently, leading to improved clinical outcomes and cost reductions (Fraze et al., 2020). As a result, ACOs are strategically positioned to integrate such approaches into routine practice. Success of ACOs in Delivering Quality Healthcare How effective are ACOs compared to traditional healthcare models? Evidence demonstrates that ACO-affiliated facilities outperform non-ACO institutions in several quality metrics. For instance, patients diagnosed with depression experience fewer avoidable hospital admissions when treated within ACO systems. This improvement reflects better care coordination, early intervention, and proactive management strategies (Barath et al., 2020). Key Outcomes of ACO Implementation: Enhanced Quality and Safety Outcomes within ACOs NURS FPX 6612 Assessment 2 Quality Improvement Proposal What mechanisms within ACOs contribute to improved patient safety and quality outcomes? ACOs emphasize integrated, population-based care models that align provider incentives with patient outcomes. By fostering collaboration among stakeholders, these organizations ensure that healthcare delivery remains both cost-efficient and patient-centered. Shared accountability reduces redundant services and promotes evidence-based interventions, ultimately minimizing waste and enhancing safety (Moy et al., 2020). Recommendations for Expanding Health Information Technology (HIT) Importance of HIT in Healthcare Why is Health Information Technology essential for modern healthcare systems? HIT serves as a foundational component in delivering efficient and high-quality care. It enables seamless access to patient data, supports clinical decision-making through analytics, and improves communication across care teams. Each patient’s medical history, tracked באמצעות a unique Medical Registration Number (MRN), allows providers to develop precise treatment plans, thereby improving outcomes while lowering hospitalization rates. Comprehensive Expansion of HIT How can healthcare organizations effectively expand HIT systems? A comprehensive HIT strategy should ensure accessibility, usability, and interoperability across all care settings. Systems must be designed to support both patients and healthcare professionals. Recommended Features of an Expanded HIT System: Component Description Patient Access Mobile applications enabling patients to view medical records and updates Provider Access Secure access through hospital-based systems and remote databases Data Integration Unified platforms that consolidate patient information across departments User-Friendly Interface Simplified navigation to enhance efficiency and reduce clinician workload Illustrative Case and Importance of HIT How does HIT improve individual patient outcomes in real-world scenarios? Consider a patient such as Caroline McGlade: through effective use of HIT, her healthcare providers can track medical history, monitor ongoing conditions, and identify potential diagnoses more accurately. This level of data integration enhances clinical decision-making and contributes to better overall health outcomes (Alaei et al., 2019). Focus on Information Gathering and Guiding Organizational Development Objective of Information Gathering What is the role of data collection in improving healthcare quality? The systematic collection and analysis of healthcare data are critical for informed decision-making. Informatics tools enable organizations to identify trends, allocate resources efficiently, and design targeted interventions. This approach not only improves patient outcomes but also enhances workforce productivity. Challenges and Solutions What challenges arise in managing healthcare data systems, and how can they be addressed? Despite its benefits, managing large-scale healthcare data presents operational and security challenges. Challenges Proposed Solutions Data security risks Implementation of advanced cybersecurity protocols Staff skill gaps Ongoing training and professional development programs Inefficient data storage Adoption of scalable and secure cloud-based storage solutions System integration issues Use of interoperable platforms and standardized data formats Conclusion What is the overall impact of HIT on ACO development and healthcare quality? Health Information Technology is integral to the successful operation of ACOs, enabling efficient data utilization and coordinated care delivery. Although challenges such as data management and security persist, they can be mitigated through targeted strategies, including workforce training and improved infrastructure. Ultimately, the integration of HIT within ACO frameworks supports the delivery of high-quality, cost-effective healthcare services. References Alaei, S., Valinejadi, A., Deimazar, G., Zarein, S., Abbasy, Z., & Alirezaei, F. (2019). Use of health information technology in patients care management: A mixed methods study in Iran. Acta Informatica Medica, 27(5), 311. Barath, D., Amaize, A., & Chen, J. (2020). Accountable care organizations and preventable hospitalizations among patients with depression. American Journal of Preventive Medicine, 59(1), e1–e10. NURS FPX 6612 Assessment 2 Quality Improvement Proposal Fraze, T. K., Beidler, L. B., Briggs, A. D. M., & Colla, C. H. (2020). Translating evidence into practice: ACOs’ use of care plans for patients with complex health needs. Journal of General Internal Medicine, 36(1), 147–153. Gardner, R. L., Cooper, E., Haskell, J., Harris, D. A., Poplau, S., Kroth, P. J., & Linzer, M. (2018). Physician stress and burnout: The impact of health information technology. Journal of the American Medical Informatics Association, 26(2), 106–114. Moy, H., Giardino, A., & Varacallo, M. (2020). Accountable Care Organization. StatPearls Publishing. NURS FPX 6612 Assessment 2 Quality Improvement Proposal Robert, N. (2019). How artificial intelligence is changing nursing. Nursing Management (Springhouse), 50(9), 30–39. Ruediger, M., Kupfer, M., & Leiby, B. E. (2019). Decreasing re-hospitalizations and emergency department visits using a specialized medical home. The Journal of Spinal Cord Medicine, 44(2), 221–228. https://doi.org/10.1080/10790268.2019.1671075 Shahsavari, H., Zarei, M., & Aliheydari Mamaghani, J. (2019). Transitional care: Concept analysis. International Journal of Nursing Studies, 99, 103387. https://doi.org/10.1016/j.ijnurstu.2019.103387
NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures
Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Triple Aim Outcome Measures Introduction This presentation is framed from the perspective of a case manager at Sacred Heart Hospital, a rural healthcare facility. It outlines how care coordination can be optimized using the Triple Aim framework. The focus is on equipping hospital staff and leadership with structured, evidence-based strategies to improve care delivery, patient outcomes, and operational efficiency. Purpose The primary objective is to guide hospital leadership in aligning care coordination practices with Triple Aim goals for rural populations. Additionally, the discussion evaluates two established healthcare delivery models—the Patient-Centered Medical Home (PCMH) and Transitional Care—to demonstrate how they support care coordination and improve outcomes through comparative analysis. Understanding the Triple Aim Framework The Triple Aim framework is built on three interdependent goals: Effective care coordination is the operational mechanism that connects these goals, ensuring continuity, efficiency, and patient-centered delivery of services. Patient Experience of Care Improving patient experience requires a systematic approach that prioritizes accessibility, communication, and patient engagement. Healthcare organizations can achieve this by minimizing delays, fostering transparent communication, and involving patients in clinical decision-making. Improved patient experience contributes to: These factors collectively lead to improved clinical outcomes and patient satisfaction. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Enhancing Community and Population Health Population health improvement requires healthcare systems to analyze demographic and epidemiological data to identify high-risk groups and unmet health needs. Care coordination facilitates targeted interventions by connecting patients with appropriate services. Key strategies include: These approaches enable proactive healthcare delivery rather than reactive treatment. Reducing Per Capita Healthcare Costs Cost reduction under the Triple Aim is achieved by improving care quality while eliminating inefficiencies. Coordinated care minimizes duplication of services and prevents avoidable complications. Cost-saving mechanisms include: Summary of Triple Aim Components Dimension Key Focus Impact on Outcomes Patient Experience Communication, engagement, access Higher satisfaction and adherence Population Health Preventive care, risk identification Improved community health outcomes Cost Reduction Efficiency, waste minimization Lower healthcare expenditure Analyzing the Relationship Between Health Models and Triple Aim The Patient-Centered Medical Home (PCMH) and Transitional Care models are widely recognized for supporting Triple Aim objectives through structured, patient-focused care delivery. Patient-Centered Medical Home (PCMH) The PCMH model emphasizes continuous, coordinated, and team-based care. Patients are active participants in their care, supported by integrated health systems and digital tools. Core characteristics include: Evidence indicates that PCMH improves chronic disease management, reduces hospital utilization, and enhances satisfaction among patients and providers (Kaufman et al., 2018; Ruediger et al., 2019). Transitional Care Model Transitional Care focuses on maintaining continuity when patients move between care settings, such as hospital discharge to home care. Key elements include: Research shows that this model reduces readmissions, improves safety, and lowers costs by preventing care gaps (Shahsavari et al., 2019; Fønss Rasmussen et al., 2021). Comparison of Healthcare Models Feature PCMH Model Transitional Care Model Primary Focus Continuous, patient-centered care Care continuity during transitions Approach Long-term, comprehensive care Short-term, transition-focused interventions Technology Use EHRs, patient portals Telehealth, communication tools Outcomes Reduced ED visits, improved chronic care Reduced readmissions, improved recovery Structure of Healthcare Models Both PCMH and Transitional Care models rely on structured systems and evidence-based practices to enhance care quality. Data and Technology Integration Electronic Health Records (EHRs) play a central role in both models by enabling: Interdisciplinary Collaboration Healthcare teams composed of physicians, nurses, and care coordinators work collaboratively to: Evidence-Based Data in Care Coordination Evidence-based practice is foundational to effective care coordination. It allows providers to design interventions based on validated clinical data and patient-specific needs. How Does Evidence-Based Data Improve Care Coordination? Evidence-based data supports: Additionally, it helps uncover barriers such as financial limitations or transportation challenges, enabling targeted interventions (Kangovi et al., 2020). Governmental Regulatory Initiatives Healthcare organizations can strengthen care coordination by aligning with federal programs and outcome measures. What Regulatory Programs Support Triple Aim Goals? Program Purpose Impact Medicare Shared Savings Program (MSSP) Incentivizes coordinated, value-based care Improves quality while reducing costs (Bravo et al., 2022) Hospital Readmissions Reduction Program Penalizes excessive readmissions Encourages better discharge planning and follow-up Outcome Measurement Metrics Hospitals should monitor: These metrics provide actionable insights for continuous improvement. Process Improvement Recommendations to Stakeholders Sacred Heart Hospital must redesign its care coordination processes to align with Triple Aim objectives and improve overall system performance. Stakeholders Key stakeholders include: What Are Stakeholders’ Likely Concerns? Stakeholders may raise concerns regarding: How Should These Concerns Be Addressed? Conclusion Achieving the Triple Aim requires a coordinated, data-driven, and patient-centered approach. Models such as PCMH and Transitional Care demonstrate how structured care delivery can enhance outcomes, improve patient experiences, and reduce costs. By integrating evidence-based practices, leveraging technology, and aligning with regulatory frameworks, healthcare organizations can significantly improve care quality and operational efficiency. References Bravo, F., Levi, R., Perakis, G., & Romero, G. (2022). Care coordination for healthcare referrals under a shared‐savings program. Production and Operations Management. https://doi.org/10.1111/poms.13830 Fønss Rasmussen, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1), e040057. https://doi.org/10.1136/bmjopen-2020-040057 NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207–213. https://doi.org/10.1377/hlthaff.2019.00981 Kaufman, B. G., Spivack, B. S., Stearns, S. C., Song, P. H., O’Brien, E. C., & Kansagara, D. (2018). Impact of patient-centered medical homes on healthcare utilization. American Journal of Managed Care, 24(5), 237–243. M., S., & Chacko, A. M. (2021). Interoperability issues in EHR systems: Research directions. ScienceDirect. https://www.sciencedirect.com/science/article/pii/B9780128193143000021 McNabney, M. K., Green, A. R., Burke, M., et al. (2022). Complexities of care: Common components of models of care in geriatrics. Journal of the American Geriatrics Society. https://doi.org/10.1111/jgs.17811 NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Ruediger, M., Kupfer, M., & Leiby, B. E. (2019). Decreasing re-hospitalizations and emergency department visits using a specialized medical home. The