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Patient-Centered Care Report12

Patient-Centered Care Report

Learner’s NameComment by John Schmidt: This is a well-developed articulate submission. The submission is written is a scholarly voice. I only have one comment in my tracked changes.

School of Nursing and Health Sciences, Capella University

NURS-FPX6011: Evidence-Based Practice for Patient-Centered Care and Population Health

Faculty

Date, Year

Patient-Centered Care Report

Health care organizations in the United States are realizing the importance of health improvement initiatives aimed at large population groups. Population health improvement initiatives (PHIIs) were introduced to reduce health care costs in general and improve the health of people in different population groups such as pregnant women or the elderly. Additionally, PHIIs provide vital data on patient-centered care and per capita cost in the form of measurable clinical, humanistic, procedural, economic, and utilization outcomes (Huber, 2017). Health care professionals consider a PHII’s outcomes as evidence for care plans that meet the individual needs of patients treated by a health organization.

Often, the evidence that a health care professional encounters is not presented in the exact context of that professional’s practice because of differences in the patient population, illnesses, or care environment. In such situations, health care professionals analyze a PHII’s evidence and select only those variables that apply to the context of the specific patient care plan. The process of transferring evidence into practice from one context to another is discussed using the example of Uptown Wellness Clinic’s (UWC) patient Mr. Nowak, who suffered a traumatic brain injury (TBI) after a fall. At his cholesterol screening, Mr. Nowak complained that he has been losing his balance lately. According to him, the balance problems are symptomatic of the brain injury. A charge nurse at UWC recommended that Mr. Nowak’s patient care plan be based on evidence gathered from Safe Headspace, a nonprofit PHII that works to improve outcomes for people with TBI and posttraumatic stress disorder (PTSD; Capella University, n.d.). Once the PHII’s outcomes are evaluated, the evidence will be transferred into Mr. Nowak’s treatment context.

The objective of the evaluation is to reveal knowledge gaps in the PHII, devise strategies to bridge the gaps, and incorporate the new strategies into Mr. Nowak’s patient care plan. The evidence will help create a new assessment framework for the patient care plan as well.

Evaluation of a Population Health Improvement Initiative’s Outcomes

Since its formation, Safe Headspace PHII significantly improved health outcomes in older patients suffering from PTSD because of head trauma. The PHII uses various interventions to treat mental health problems, such as exercise, therapy, and meditation. Regular exercise was the initiative’s most successful intervention. Of the 400 participants in the intervention, mostly men in the 45–80 age bracket, 75 participants followed aerobic exercise routines for four months. 15% of the men showed improved muscle control, 22% showed improved mood, and 61% showed improved short- to medium-term memory (Capella University, n.d.).

Those who volunteered for medication and therapy were assessed by a team of psychotherapists and provided therapy support—40% of the participants started on antidepressants and 9% started taking antipsychotics. Within six months, 26% of the participants showed improvement in their mood and 6% showed improvement in memory. The third intervention, meditation, had only 23 participants but showed positive outcomes. In three weeks, 21 participants—two dropped out—showed over 70% improvement in mood and memory and 32% improvement in muscle control. Strength training and puzzle solving to improve memory were unsuccessful interventions because the interventions did not give any significant gains (Capella University, n.d.).

However, these statistics do not give a complete picture. To begin with, the PHII intervened with people who were diagnosed with both PTSD and TBI. The impact of interventions on patients with either PTSD or TBI was not studied separately. Therefore, the outcomes of cases like Mr. Nowak’s, who has TBI and no history of PTSD, are unknown and need further evaluation. Moreover, Safe Headspace’s outcomes do not explain why patients were demotivated from following self-management plans and whether the lack of motivation relates to factors such as high medical costs or unsatisfactory care. Evaluating these unexplored outcomes expands the evidence base and helps health care professionals in deciding interventions that will be appropriate for a patient’s symptoms, background, and experiences.

Strategies to Improve Outcomes of a Population Health Improvement Plan

The launch of the Triple Aim by the Institute for Healthcare Improvement in 2007 was a landmark development toward quality improvement in health care in the United States. The Triple Aim is a broad framework of linked goals designed to optimize health system performance: (a) improving the patient’s experience of care, (b) improving the health of populations, and (c) reducing per capita cost of health care (American Hospital Association, 2015). The framework has influenced national initiatives such as the Patient Protection and Affordable Care Act and Centers for Medicare and Medicaid Services.

The Triple Aim goals have five preconditions for high-quality care: (a) focus on individuals and families, (b) redesign of primary care services and structures, (c) population health management, (d) cost control platform, and (e) system integration and execution (Institute for Healthcare Improvement, n.d). The evaluation of Safe Headspace’s data reveals the poorly integrated Triple Aim goals. As UWC’s patient care plan is based on evidence collected from Safe Headspace’s PHII outcomes, the new care setting may inherit the poor outcomes. Incorporating the Triple Aim prevents the transfer of faulty evidence into UWC’s patient care plan by setting achievable goals and improving the quality of care delivery at the clinic.

By bridging the gaps in Safe Headspace’s programs, the PHII’s methods can be applied to UWC’s care plan for patients like Mr. Nowak. Bellin Health, an integrated health delivery system in Wisconsin, illustrates the effectiveness of the Triple Aim. Using the framework, Bellin improved the health of its enrolled employee and Medicare populations. The three Triple Aim goals reflected in the way Bellin’s health care professionals imparted cost-effective, patient satisfactory, and holistic care for large-scale health programs and individual cases (Whittington, Nolan, Lewis, & Torres, 2015).

Despite its successes, the Triple Aim is facing many challenges. According to the American Healthcare Organization (2016), diverse health markets and a lack of shared vision make moving all health care systems to one approach challenging and impractical. A second challenge is the Triple Aim’s phantom limb, which refers to the well-being of health care professionals. According to a study, the three goals ignore the needs of caregivers, creating a stressful workplace that carries a high-risk of staff burnout (Spinelli, 2013). Therefore, quality improvement should include steps to improve the workplace for health care professionals.

It is important to consider the benefits and limitations of any quality improvement effort. Health care professionals at UWC should identify the advantages and disadvantages of using the Triple Aim for Mr. Nowak’s care plan. Likewise, the plan should incorporate lessons learned from the PHII outcomes and introduce changes to address inadequacies.

Approaches to an Individualized Personal Care Plan

UWC has two objectives behind developing an evidence-based patient care plan from Safe Headspace’s outcomes. The short-term objective is to diagnose and treat Mr. Nowak's health problems. The long-term objective is to use Mr. Nowak’s care plan as the foundation for similar cases in the future. To achieve these objectives, UWC must change its organization and delivery systems. The need to change UWC’s health system is based on certain assumptions developed from the PHII evaluation: (a) the new delivery design should achieve the Triple Aim goals, (b) primary care providers should be competent in evidence-based practice (EBP), and (c) patients should receive self-management support and cost-effective care.

A current and innovative approach that satisfies the first assumption is the patient-centered medical home (PCMH). The PCMH can implement the Triple Aim goals by adopting new technologies and care delivery methods and establishing caring relationships with patients and families. The PCMH improves the delivery of primary care by making primary care comprehensive, patient-centered, coordinated, accessible, and committed to quality and patient safety (Patient-Centered Primary Care Collaborative, n.d.). These functions help understand the health, economic, and cultural needs of specific patients.

The process of implementing the PCMH includes training and evaluating health care professionals, especially primary care providers. Training and evaluation are important to integrating EBP into care delivery to improve outcomes. Among the methods that facilitate EBP, self-management is very successful. One self-management practice is mobile health (mHealth), which is the use of mobile technologies to “inform, assess, anticipate, and aid in interventions while monitoring and coordinating patient health status and care” (Lahue, Hughes, Hills, Li, & Hiatt, 2015, para. 1). Mobile health is cost-effective because it reduces the number of clinical visits and circumvents the limited availability of care providers and resources (Nundy, 2012).Comment by John Schmidt: As a graduate learner, it is best to synthesize the literature and paraphrase instead of using quoted materials.

Once applied to UWC’s patient care plan, the PCMH, EBP, and mHealth can guide Mr. Nowak’s care in the hospital and in his home. The three approaches can improve Mr. Nowak’s awareness of his condition, motivate him to start self-management methods, and make health care more accessible to him. In addition, the approaches will help UWC achieve its second objective regarding the patient care plan. The value and relevance of the approaches can be justified by evaluating current research on their application.

Value and Relevance of Evidence Used in Patient Care Plan

Many studies advocate incorporating the PCMH, EBP, and self-management practices in population health improvement efforts. Evidence-based practice is a fundamental guideline (Huber, 2017) for all levels, initiatives, and sectors in health care, not just population health improvement. Therefore, justifying the value of EBP is unnecessary. The PCMH and mHealth, however, are relatively new approaches and require evaluations of their evidence-base.

The PCMH was very successful at improving the relationship between primary care teams, patients, and families. One three-year study described the successful integration of the PCHM in the Pennsylvania Chronic Care Initiative. Adjusted costs observed in the PCMH pilot year were 17.5% lower than data from non-PCMH practices. As a result, rates of hospitalization, emergency department visits, and ambulatory visits reduced (Nielsen, Buelt, Patel, & Nichols, 2016). Similar results were seen in the Texas Children’s Health Plan and Hudson Valley initiative.

The second approach, mHealth, has great potential in areas with high clinical and cost burdens, such as urban areas. One such setting was the University of Chicago Medicine (UCM), an academic medical center serving predominantly urban, working-class African American communities. The mHealth initiative included texting services for self-management support, sending e-mail and text alerts about appointments, follow-up contact through phone calls, e-mails, and texts. These steps greatly enhanced care management processes and motivated patients to practice self-management methods regularly (Nundy et al., 2012).

However, these approaches have limitations. To begin with, the PCMH is mostly used in chronic disease management (Nielsen, Buelt, Patel, & Nichols, 2016) and there is a dearth of information on its use in managing mental health problems. In the context of mHealth, Nundy et al. (2012) observed that patients using the platform needed a human face to be involved in the program. Hence, the UCM assigned staff members to monitor mHealth participants. Furthermore, there are uncertainties about the implementation of mHealth because of the complex and highly regulated nature of technology and health markets.

The studies conducted on the PCMH and mHealth enhance UWC’s efforts in population health improvement. The evidence gathered from these studies will help the clinic take steps to improve the quality of these approaches. One of the ways to do that is to choose a sustainable evaluative framework to ensure that all patient care plan parameters are met.

Framework for Evaluation of Patient Care Plan Outcomes

A critical component of evidence-based practice is evaluation, without which improvements are difficult to achieve. Measurable data identify both effective and ineffective components of a health care initiative. Additionally, PHII evaluations help secure government funding, a necessity for organizations with enrolled Medicaid and Medicare populations.

The evaluative framework has certain prerequisites: Progress is tracked using the Triple Aim, and the framework is evaluated against the entire health system. The latter prerequisite is essential because allocating funds and resources for population health improvement needs the whole organization to make adjustments in primary, secondary, tertiary, and ancillary care systems. One Triple-Aim-aligned framework that UWC can implement is New Zealand’s County Manukau Health’s (CMH) System Level Measures (SLMs), which were adapted from the IHI’s Whole System Measures (Doolan-Noble, Lyndon, Hau, Hill, Gray, & Gauld, 2015).

The SLMs complement each other and represent measures across the continuum of care. Therefore, UWC can monitor how a change in one SLM increases or decreases other measures. The SLMs adapted by CMH are as follows: a) provide for patients with health care needs, (b) improving the process of providing services—access and end-of-life, (c) ensuring effectiveness, (d) reporting clinical outcomes, (e) reporting functional and efficiency outcomes, and (f) ensuring patient satisfaction. The measures are further comprised of process and outcome indicators. For example, some clinical outcome indicators are hospital standardized mortality ratios and adverse event rates (Doolan-Noble et al., 2015). As these indicators are specific to the population context, UWC needs to add or remove indicators accordingly.

While implemented successfully at the CMH, the SLMs have certain limitations. To begin with, a whole system evaluation presents a methodological challenge because of population variations and lack of standardization in coding and definitions of indicators. Furthermore, the SLM can present operational challenges at UWC—the clinic may not have the technical capability to capture, analyze, and publish SLM-related data. The solution is to create a team of data analysts for data collection and analyze data over a long period of time (Doolan-Noble et al., 2015).

The limitations, by themselves, are not challenging as there are specific strategies available that can address these problems. Nor do they dilute the importance of the measures. An evaluation is the only way UWC can gather robust information about the quality and safety of its initiative and realize the Triple Aim.

Conclusion

The implementation process of a population health improvement plan is complex and comprises many steps and strategies. In fact, errors can still arise despite using evidence-based methods and frameworks. In spite of the difficulties associated with implementing a PHII, it helps health care professionals create a comprehensive care plan for patients, such as Mr. Nowak, who exhibit physiological and mental health problems. The approaches help health care professionals adapt to changing care settings in the long term. Understanding the continuum of care from creation to evaluation is the first step to innovating existing health structures and achieving the Triple Aim.

References

American Hospital Association. (2015, April). Zeroing in on the Triple Aim (Issue brief). http://aha.org/content/15/brief-3aim.pdf

American Hospital Association, Committee on Research and Committee on Performance Improvement. (2016, January). Care and payment models to achieve the Triple Aim. American Hospital Association. http://aha.org/content/16/care-payment-models-achieve-triple-aim-report-2016.pdf

Capella University. (n.d.). Evidence-based health evaluation and application [Transcript]. http://media.capella.edu/CourseMedia/MSN6011/evidenceBasedHealthEvaluation/media.asp?

Doolan-Noble, F., Lyndon, M., Hau, S., Hill, A., Gray, J., & Gauld, R. (2015). How well does your healthcare system perform? Tracking progress toward the Triple Aim using system level measures. The New Zealand Medical Journal, 128(1415), 44–50. http://search.proquest.com.library.capella.edu/docview/1686373805/fulltextPDF/2505807F00D0482BPQ/1?accountid=27965

Huber, D. L. (2017). Leadership and nursing care management (6th ed.). W. B. Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14

Institute for Healthcare Improvement. (n.d.). The IHI Triple Aim. http://ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Lahue, B. J., Hughes, K. E., Hills, B. J., Li, S. S., & Hiatt, J. C. (2015, July). Can mHealth revolutionize evidence-based practice in diabetes care? [Special section]. The American Journal of Managed Care, 21(11). https://ajmc.s3.amazonaws.com/_media/_pdf/EBDM_7'15_full-lowrez.pdf

Nielsen, M., Buelt, L., Patel, K, & Nichols, L. M. (2016). The patient-centered medical home's impact on cost and quality: Annual review of evidence, 2014-2015. https://pcpcc.org/sites/default/files/resources/The%20Patient-Centered%20Medical%20Home%27s%20Impact%20on%20Cost%20and%20Quality%2C%20Annual%20Review%20of%20Evidence%2C%202014-2015.pdf

Nundy, S., Dick, J. J., Goddu, A. P., Hogan, P., Lu, C. E., Solomon, M. C., . . . Peek, M. E. (2012). Using mobile health to support the chronic care model: Developing an institutional initiative. International Journal of Telemedicine and Applications, 2012. https://dx.doi.org/10.1155/2012/871925

Patient-Centered Primary Care Collaborative. (n.d.). Defining the medical home: A patient-centered philosophy that drives primary care excellence. https://pcpcc.org/about/medical-home

Spinelli, W. M. (2013). The phantom limb of the Triple Aim. Mayo Clinic Proceedings, 88(12), 1356–1357. https://dx.doi.org/10.1016/j.mayocp.2013.08.017

Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the Triple Aim: The first 7 years. The Milbank Quarterly, 93(2), 263–300. http://mydocvault.us/uploads/7/5/8/6/7586208/pursuing_the_triple_aim-the_first_7_years.pdf

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.