NURS-FPX6612 examines the healthcare delivery models that shape effective care coordination. Students explore the IHI Triple Aim framework, quality improvement methodologies, and discharge planning strategies, learning to connect theoretical models to practical care coordination challenges in today's complex healthcare environment.
Course Overview
Health Care Models Used in Care Coordination builds on the foundational concepts from NURS-FPX6610 by examining the systems-level frameworks that drive coordinated care. The course centers on three major areas: outcome measurement through the Triple Aim, structured quality improvement using recognized methodologies, and comprehensive discharge planning that prevents gaps in care continuity.
Each assessment requires students to move beyond theoretical understanding and apply these models to real or realistic healthcare scenarios. The Triple Aim analysis demands working with actual outcome data, the QI proposal requires systematic problem identification before solution design, and the discharge plan must address the full complexity of care transitions including social, clinical, and logistical factors.
Key Assessments
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1
Triple Aim Outcome Measures
Analyze healthcare outcomes using the IHI Triple Aim framework, addressing better patient experience, improved population health, and reduced per capita cost. This assessment requires identifying specific metrics for each aim, using actual or realistic data to evaluate current performance, and proposing strategies for improvement across all three dimensions.
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2
Quality Improvement Proposal
Develop a structured quality improvement proposal using a recognized QI methodology such as PDSA, Lean, or Six Sigma to address an identified care coordination gap. The proposal must include a clear problem statement, root cause analysis, evidence-based interventions, implementation timeline, and measurable outcomes for evaluation.
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3
Patient Discharge Care Planning
Create a comprehensive discharge care plan that coordinates resources, patient education, follow-up care, and community services to prevent readmissions. The plan must address medication reconciliation, social determinants of health, caregiver involvement, follow-up scheduling, and contingency planning for potential complications.
How We Help
- Applying the Triple Aim framework with measurable outcome indicators and realistic data analysis across all three aims
- Developing quality improvement proposals with thorough root cause analysis and evidence-based interventions using PDSA, Lean, or Six Sigma
- Designing discharge care plans that address social determinants of health, medication reconciliation, and coordinated follow-up
- Connecting healthcare delivery models to real-world care coordination challenges with specific, actionable recommendations
- Ensuring proper APA formatting, scholarly integration of current literature, and clear academic writing throughout
Common Challenges
Assessment 1 on Triple Aim requires students to use actual or realistic outcome data rather than simply describing the framework conceptually. The analysis must connect specific metrics to each of the three aims and demonstrate how they interrelate. Many students describe the Triple Aim in general terms without grounding their analysis in measurable indicators and data-driven findings.
The quality improvement proposal in Assessment 2 needs a clear problem statement with root cause analysis before proposing solutions. Students frequently skip straight to interventions without establishing why the problem exists, which undermines the logical foundation of the entire proposal. Tools like fishbone diagrams or the 5 Whys technique strengthen this section significantly.
Discharge planning in Assessment 3 must account for social determinants, medication reconciliation, and follow-up scheduling simultaneously. Students often focus heavily on clinical instructions while neglecting transportation barriers, health literacy considerations, caregiver capacity, and community resource coordination that determine whether a discharge plan actually succeeds.
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Frequently Asked Questions
For patient experience, consider HCAHPS scores, patient satisfaction surveys, or wait time data. For population health, look at readmission rates, chronic disease prevalence, or preventive screening rates. For cost reduction, examine per capita spending, length of stay, or emergency department utilization. The key is selecting metrics that are specific, measurable, and relevant to your chosen healthcare setting.
Select the methodology that best fits your identified problem. PDSA (Plan-Do-Study-Act) works well for iterative, smaller-scale improvements. Lean is ideal for eliminating waste and streamlining processes. Six Sigma suits problems with measurable variation and defect rates. Your choice should be justified based on the nature of the care coordination gap you identified, not personal preference alone.
The discharge plan should address the full scope of a patient's transition needs. This includes medication reconciliation with clear instructions, follow-up appointments with specific dates and providers, patient and caregiver education materials, social determinant considerations such as transportation and housing stability, community resource referrals, and contingency plans for potential complications or setbacks after discharge.
Application means taking a model's components and showing how they would function in a specific clinical scenario. For example, rather than defining the Triple Aim, identify a real healthcare setting, pull relevant data for each aim, analyze where performance falls short, and propose targeted interventions. Use concrete examples, specific data points, and actionable recommendations tied directly to the model's framework.
All assessments require current peer-reviewed sources, typically published within the last five years. Use primary research studies, systematic reviews, and clinical practice guidelines rather than textbooks or websites. Each claim or recommendation should be supported by evidence, and your reference list should demonstrate breadth across nursing, public health, and healthcare administration literature relevant to care coordination.