Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Cost Savings Analysis Care coordination refers to the systematic collaboration of healthcare professionals to plan, deliver, and evaluate patient care while ensuring accurate information exchange. Its primary purpose is to deliver timely, safe, and patient-centered services in the most appropriate care setting (CMS, n.d.). This analysis examines cost savings at Miami Valley Hospital from the perspective of a senior care coordinator. The focus is on how care coordination—supported by Health Information Technology (HIT)—enhances financial efficiency, improves patient outcomes, and strengthens the use of evidence-based data for community health improvement. Care Coordination and Cost-Effectiveness Health Information Technology (HIT) is a foundational enabler of effective care coordination because it allows real-time access to patient information across providers. This capability supports clinical decision-making and reduces inefficiencies in care delivery. A key question arises: How does care coordination reduce healthcare costs? Care coordination reduces costs through several mechanisms: NURS FPX 6612 Assessment 4 Cost Savings Analysis For example, avoiding a single Medicare readmission can result in savings ranging from $10,000 to $58,000 under the Hospital Readmissions Reduction Program (HRRP). At a system level, lowering readmission rates can generate annual savings of up to $170 million (Yakusheva & Hoffman, 2020). Another critical question is: Why is resource utilization more efficient under coordinated care? The answer lies in the integration of patient data through HIT systems. Providers can make evidence-informed decisions about diagnostics, referrals, and treatment plans, minimizing duplication and aligning care with value-based models (Williams et al., 2019). Chronic disease management further illustrates cost efficiency. Since approximately 85% of healthcare expenditures are linked to chronic conditions (Holman, 2020), coordinated care plays a crucial role by: These strategies collectively reduce hospital admissions and long-term treatment costs. Care Coordination and Positive Health Outcomes Patient engagement is central to modern healthcare delivery. A relevant question is: How does care coordination improve patient outcomes? Care coordination enhances outcomes by encouraging active patient participation in care decisions. Tools such as Electronic Health Records (EHRs) and patient portals allow individuals to access their medical information, increasing transparency and informed decision-making (Choi & Powers, 2023). Through structured communication and personalized care plans, patients become more involved in managing their conditions. This leads to: Another important question is: What role does HIT play in preventive care? HIT supports preventive care by providing patients and providers with timely, individualized health data. This enables early interventions and promotes healthier lifestyle choices. Additionally, coordinated communication among providers ensures continuity of care, which reduces complications and enhances patient satisfaction (Cha, 2023). Care Coordination and Enhanced Evidence-Based Data The Patient-Centered Medical Home (PCMH) model exemplifies a structured approach to coordinated care. It integrates patient-centered practices with continuous quality improvement. A critical question is: How does care coordination strengthen evidence-based practice? Care coordination improves evidence-based practice through: Within the PCMH model, HIT enables providers to access complete patient histories, facilitating personalized and evidence-based interventions (Jubril, 2019). Another question is: How is data used to improve healthcare quality? Healthcare organizations analyze collected data to: These data-driven strategies enhance population health management and ensure alignment with best practices (Quigley et al., 2021). Cost Savings Data and Information The following table presents estimated financial outcomes associated with one year of HIT-supported care coordination at Miami Valley Hospital: Cost-Saving Element Current Costs ($) Anticipated Savings ($) Reduced Readmission Rates 2,500,000 500,000 Streamlined Care Transitions 750,000 300,000 Efficient Resource Utilization 800,000 200,000 Enhanced Chronic Disease Management 1,800,000 600,000 Prevention of Adverse Events 1,000,000 300,000 Decreased Emergency Room Utilization 1,200,000 500,000 Total Anticipated Savings – 2,400,000 This projection indicates that implementing HIT-enabled care coordination could yield approximately $2.4 million in annual savings. These savings result from fewer hospital readmissions, improved care transitions, optimized use of resources, better chronic disease control, reduced adverse events, and lower emergency department utilization. Overall, the findings demonstrate that care coordination not only enhances clinical outcomes but also delivers measurable economic value, aligning with both organizational goals and broader healthcare quality standards. References Albertson, E. M., Chuang, E., O’Masta, B., Miake-Lye, I., Haley, L. A., & Pourat, N. (2022). Systematic review of care coordination interventions linking health and social services for high-utilizing patient populations. Population Health Management, 25(1), 73–85. https://doi.org/10.1089/pop.2021.0057 Cha, D. (2023). Digital healthcare: The new frontier of holistic and efficient care. Clinical and Experimental Emergency Medicine, 10(2), 235–237. https://doi.org/10.15441/ceem.23.054 Choi, S., & Powers, T. (2023). Engaging and informing patients: Health information technology use in community health centers. International Journal of Medical Informatics, 177, 105158. https://doi.org/10.1016/j.ijmedinf.2023.105158 NURS FPX 6612 Assessment 4 Cost Savings Analysis CMS. (n.d.). Care coordination. https://www.cms.gov/priorities/innovation/key-concepts/care-coordination De Marchis, E. H., Doekhie, K., Willard-Grace, R., & Olayiwola, J. N. (2019). The impact of the patient-centered medical home on health care disparities: Exploring stakeholder perspectives on current standards and future directions. Population Health Management, 22(2), 99–107. https://doi.org/10.1089/pop.2018.0055 Holman, H. R. (2020). The relation of the chronic disease epidemic to the health care crisis. ACR Open Rheumatology, 2(3), 167–173. https://doi.org/10.1002/acr2.11114 Jubril, A. (2019). Optimizing clinical processes using the electronic health record to improve patient outcomes in primary care. Grand Valley State University. https://scholarworks.gvsu.edu/cgi/viewcontent.cgi?article=1102&context=kcon_doctoralprojects Quigley, D. D., Slaughter, M., Qureshi, N., Elliott, M. N., & Hays, R. D. (2021). Practices and changes associated with patient-centered medical home transformation. The American Journal of Managed Care, 27(9), 386. https://doi.org/10.37765/ajmc.2021.88740 NURS FPX 6612 Assessment 4 Cost Savings Analysis Williams, M. D., Asiedu, G. B., Finnie, D., Neely, C., Egginton, J., Finney Rutten, L. J., & Jacobson, R. M. (2019). Sustainable care coordination: A qualitative study of primary care provider, administrator, and insurer perspectives. BMC Health Services Research, 19, 92. https://doi.org/10.1186/s12913-019-3916-5 Yakusheva, O., & Hoffman, G. J. (2020). Does a reduction in readmissions result in net savings for most hospitals? An examination of Medicare’s hospital readmissions reduction program. Medical Care Research and Review, 77(4), 334–344. https://doi.org/10.1177/1077558718795745

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Patient Discharge Care Planning Patient discharge care planning is a structured clinical process aimed at ensuring safe transition from inpatient hospital care to home or another care setting, while reducing complications and hospital readmissions. In this case, the patient is Marta Rodriguez, a college freshman who was involved in a motor vehicle accident in Nevada. She was admitted to a regional trauma center, where she underwent multiple surgical interventions and received prolonged antibiotic therapy for a systemic infection during a four-week hospitalization. Marta recently relocated from New Mexico to Nevada for academic purposes and is enrolled under student health insurance coverage. A significant consideration in her discharge preparation is her linguistic background, as Spanish is her primary language and English is her secondary language. This factor directly affects communication, comprehension of discharge instructions, and adherence to post-discharge care plans. The interprofessional team, coordinated by the senior care coordinator, is responsible for identifying clinical, psychosocial, and technological needs to design a safe, culturally appropriate, and patient-centered discharge strategy. The discharge planning process will incorporate Health Information Technology (HIT), structured data reporting systems, and patient-reported outcomes to ensure continuity of care. A collaborative interprofessional meeting will be conducted to align all providers on Marta’s recovery plan and ensure consistency in post-discharge management. Longitudinal Patient Care Plan A longitudinal care plan focuses on continuous, coordinated care over time rather than isolated clinical encounters. Health Information Technology (HIT) serves as a core enabler of this approach by supporting communication, monitoring, and clinical decision-making across settings. Digital tools such as telehealth platforms allow healthcare professionals to conduct virtual follow-ups, monitor recovery remotely, and maintain ongoing engagement with patients after discharge (Abraham et al., 2022). For Marta, an Electronic Health Record (EHR) system with multilingual functionality is essential to ensure accurate documentation of her surgical history, antibiotic regimen, and rehabilitation progress. Real-time data sharing through integrated health systems enhances coordination among providers, allowing timely updates and improved clinical decision-making (Khoong et al., 2020). This is particularly important in trauma recovery cases where complications may develop after discharge. Key Components of Marta’s Longitudinal Care Plan Component Application in Marta’s Case Expected Clinical Outcome Multilingual EHR system Records surgical procedures, infection treatment, and medication history in both English and Spanish (Khoong et al., 2020) Improves comprehension, reduces documentation errors, and enhances continuity of care Telehealth follow-ups Scheduled virtual consultations and remote monitoring of recovery progress (Abraham et al., 2022) Reduces unnecessary readmissions and supports early detection of complications Remote patient monitoring Tracking vital signs and post-surgical recovery indicators Enables early clinical intervention and improves recovery outcomes Implications of Health Information Technology (HIT) in Care Planning The integration of HIT into discharge planning significantly strengthens patient safety, care coordination, and clinical efficiency. For Marta, these technologies ensure that her recovery process is continuously monitored and supported beyond hospital discharge. Predictive analytics and Clinical Decision Support Systems (CDSS) assist clinicians in identifying early warning signs of complications such as reinfection or delayed wound healing (Somsiri et al., 2020). This enables proactive interventions rather than reactive treatment. HIT also enhances interprofessional collaboration by allowing multiple healthcare providers to access synchronized patient data. This improves consistency in clinical decision-making and reduces fragmentation of care (Srinivasan et al., 2020). Key benefits include: Overall, HIT supports a shift toward a patient-centered, data-driven care model that improves both safety and long-term recovery outcomes. NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Patient Data, Reporting, and Engagement Strategies Effective discharge planning also depends on continuous monitoring of patient behavior and outcomes after discharge. Patient-reported data plays a critical role in evaluating recovery progress and identifying barriers to adherence. For Marta, structured follow-up mechanisms will track medication adherence, attendance in virtual consultations, and self-reported symptoms. These inputs allow clinicians to tailor interventions based on real-time patient feedback (Kumar et al., 2022). Culturally responsive communication strategies are particularly important in Marta’s case due to her bilingual background. Ensuring that educational materials and digital tools are available in Spanish improves comprehension and engagement. Additionally, patient participation in reporting outcomes contributes to more accurate clinical assessments and supports shared decision-making between providers and patients (Real et al., 2020). Integrated Discharge Planning Summary The following table consolidates key elements of Marta Rodriguez’s discharge care plan and their expected outcomes. Care Domain Implementation Strategy Clinical Benefit Longitudinal care coordination Use of multilingual EHR and telehealth monitoring systems Ensures continuity and reduces readmission risk HIT integration Application of CDSS and predictive analytics for risk detection (Somsiri et al., 2020) Enables early intervention and improves patient safety Patient engagement and reporting Monitoring adherence and incorporating patient-reported outcomes (Kumar et al., 2022) Enhances personalization and treatment effectiveness Interprofessional collaboration Real-time shared data access among providers (Srinivasan et al., 2020) Improves coordination and care consistency Conclusion Marta Rodriguez’s discharge care plan demonstrates the importance of integrating clinical coordination, cultural competence, and Health Information Technology to ensure safe recovery. The use of multilingual EHR systems, telehealth services, predictive analytics, and patient-reported outcomes creates a comprehensive framework for continuity of care. This approach not only reduces the likelihood of hospital readmission but also empowers Marta to actively participate in her recovery process through improved communication and self-management support. 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 Khoong, E. C., Rivadeneira, N. A., Hiatt, R. A., & Sarkar, U. (2020). The use of technology for communicating with clinicians or seeking health information in a multilingual urban cohort: Cross-sectional survey. Journal of Medical Internet Research, 22(4), e16951. https://doi.org/10.2196/16951 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Kumar, S., Qiu, L., Sen, A., & Sinha, A. P. (2022). Putting analytics into action in care coordination research: Emerging issues and potential solutions. Production and Operations Management, 31(6). https://doi.org/10.1111/poms.13771 Real, K., Bell, S., Williams, M. V., Latham, B.,

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Triple Aim Outcome Measures Introduction This presentation outlines how Sacred Heart Hospital (SHH), under the role of a case manager, can operationalize the Triple Aim framework, which focuses on improving population health, enhancing care quality, and reducing per capita costs. Achieving these outcomes requires coordinated engagement among clinical teams, hospital leadership, and external healthcare stakeholders. In addition, regulatory frameworks and standardized performance metrics are considered essential to ensure that SHH delivers integrated, efficient, and sustainable care within Barnes County Community. Purpose What is the primary goal of this presentation? The main objective is to guide SHH leadership and clinical teams in strengthening coordinated care systems to achieve the Triple Aim within Barnes County Community. This is achieved through structured, evidence-informed strategies that include: Effective implementation depends on collaboration across disciplines, ensuring that all healthcare professionals contribute to improved patient outcomes, cost efficiency, and overall population health advancement. Triple Aim and Its Contribution to Healthcare Organizations Experience of Care / Patient Satisfaction How can SHH enhance patient experience? Improving patient experience at SHH requires a patient-centered care model that prioritizes communication, responsiveness, and individualized care planning. Clear and consistent provider–patient communication significantly improves trust and engagement in care processes (Kwame & Petrucka, 2021). Key areas of improvement include: These measures collectively strengthen satisfaction and reinforce long-term patient-provider relationships. Improving Population or Community Health How can SHH improve population health? Population health outcomes in Barnes County can be improved through preventive health initiatives and structured community education programs. Integrating healthy behavioral practices into everyday life is essential for long-term impact (Yamada & Arai, 2020). Important contributing factors include: These strategies improve equity in access and enhance community-wide health outcomes. Decreasing Per Capita Costs How can SHH reduce healthcare costs per patient? Reducing healthcare costs requires balancing financial efficiency with high-quality care delivery. SHH can achieve this through system optimization and technology integration. Key strategies include: These interventions support financial sustainability while maintaining clinical excellence (Fichtenberg et al., 2020). Analyzing the Relationship Between Health Models and the Triple Aim Patient Self-Management Model (PSMM) What is the Patient Self-Management Model and how does it support the Triple Aim? The Patient Self-Management Model (PSMM) empowers individuals to actively participate in managing their health conditions through structured education and access to digital tools (Fu et al., 2020). This model shifts care from provider-directed to collaborative decision-making. Contributions of PSMM to the Triple Aim Care Coordination Model (CCM) What is the Care Coordination Model and how does it support the Triple Aim? The Care Coordination Model (CCM) ensures seamless integration of healthcare services across providers and care settings. It relies heavily on structured communication systems such as electronic health records (EHRs) to maintain continuity and accuracy in care delivery (Karam et al., 2021). Contributions of CCM to the Triple Aim Structure of Selected Healthcare Models Healthcare Model Structure and Core Components Impact on Triple Aim Patient Self-Management Model (PSMM) Patient education, self-monitoring tools, digital health integration, shared decision-making Enhances autonomy, improves outcomes, reduces costs (Solomon & Rudin, 2020) Care Coordination Model (CCM) Interdisciplinary collaboration, EHR integration, cross-setting communication Improves continuity, reduces readmissions, increases efficiency (Awad et al., 2021) Evidence-Based Data in Coordinated Care How does evidence-based data enhance coordinated care? Evidence-based practice strengthens clinical decision-making by ensuring that care delivery is grounded in validated research and clinical guidelines. This approach improves consistency in treatment and enhances interdisciplinary communication (Belita et al., 2020). Effective use of evidence-based data leads to: Governmental Regulatory Initiatives and Outcome Measures Which regulatory initiatives support the Triple Aim, and what outcomes do they target? Initiative Description Outcome Measures Health Information Exchange (HIE) Enables secure sharing of patient data across systems Reduces duplicate testing, improves continuity of care (Zhuang et al., 2020) Medicare Shared Savings Program (MSSP) Promotes accountable care organizations to improve efficiency Enhances cost savings and patient satisfaction (McWilliams et al., 2020) Meaningful Use Program Encourages EHR adoption and meaningful data use Improves interoperability and reduces medical errors (Mohammadzadeh et al., 2021) These initiatives collectively strengthen coordinated care delivery and support measurable improvements in healthcare outcomes. Process Improvement Recommendations for Stakeholders Stakeholders Challenges and Concerns Recommended Solutions Healthcare Providers Concerns regarding workflow disruption and cost of implementation Introduce phased pilot programs to support gradual transition Hospital Administration Workforce adaptation to digital systems and automation Provide structured training and continuous professional development Interdisciplinary Teams Communication gaps across departments Establish standardized communication protocols (Karam et al., 2021) Conclusion Achieving the Triple Aim at SHH requires a structured focus on care coordination, patient empowerment, and system-level integration. The Patient Self-Management Model and Care Coordination Model serve as foundational frameworks for improving clinical outcomes, reducing healthcare costs, and strengthening population health. Through interdisciplinary collaboration and adherence to regulatory standards, SHH can deliver sustainable, high-quality healthcare services to Barnes County Community. Continued adoption of evidence-based strategies will ensure long-term improvements in healthcare delivery systems. References Awad, K., et al. (2021). Integrating care coordination across settings: Outcomes and effectiveness. Journal of Healthcare Management, 66(4), 254–267. Belita, L., et al. (2020). Evidence-based practice in nursing: Decision-making and communication. Nursing Research Journal, 72(3), 145–158. Bloem, B. R., et al. (2020). Reducing fragmented care through care coordination. International Journal of Integrated Care, 20(2), 1–12. Carayon, P., et al. (2020). Improving patient safety with care coordination. BMJ Quality & Safety, 29(7), 553–561. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Du, S., et al. (2019). Patient self-management and collaborative healthcare. Patient Education and Counseling, 102(6), 1120–1128. Facchinetti, G., et al. (2020). Continuity of care in chronic disease management. Health Services Research, 55(5), 801–812. Fichtenberg, C., et al. (2020). Strategies for cost-effective healthcare delivery. Health Affairs, 39(8), 1357–1365. Fu, H., et al. (2020). Empowering patients through self-management models. Journal of Chronic Disease Management, 12(4), 221–230. Hoffmann, T., et al. (2023). Evidence-based practice and interdisciplinary communication. Journal of Interprofessional Care, 37(2), 101–112. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Karam, R., et al. (2021). Care coordination models and organizational strategies. Journal of Nursing Management,

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Triple Aim Outcome Measures Introduction This presentation outlines how Sacred Heart Hospital (SHH), under the role of a case manager, can operationalize the Triple Aim framework, which focuses on improving population health, enhancing care quality, and reducing per capita costs. Achieving these outcomes requires coordinated engagement among clinical teams, hospital leadership, and external healthcare stakeholders. In addition, regulatory frameworks and standardized performance metrics are considered essential to ensure that SHH delivers integrated, efficient, and sustainable care within Barnes County Community. Purpose What is the primary goal of this presentation? The main objective is to guide SHH leadership and clinical teams in strengthening coordinated care systems to achieve the Triple Aim within Barnes County Community. This is achieved through structured, evidence-informed strategies that include: Effective implementation depends on collaboration across disciplines, ensuring that all healthcare professionals contribute to improved patient outcomes, cost efficiency, and overall population health advancement. Triple Aim and Its Contribution to Healthcare Organizations Experience of Care / Patient Satisfaction How can SHH enhance patient experience? Improving patient experience at SHH requires a patient-centered care model that prioritizes communication, responsiveness, and individualized care planning. Clear and consistent provider–patient communication significantly improves trust and engagement in care processes (Kwame & Petrucka, 2021). Key areas of improvement include: These measures collectively strengthen satisfaction and reinforce long-term patient-provider relationships. Improving Population or Community Health How can SHH improve population health? Population health outcomes in Barnes County can be improved through preventive health initiatives and structured community education programs. Integrating healthy behavioral practices into everyday life is essential for long-term impact (Yamada & Arai, 2020). Important contributing factors include: These strategies improve equity in access and enhance community-wide health outcomes. Decreasing Per Capita Costs How can SHH reduce healthcare costs per patient? Reducing healthcare costs requires balancing financial efficiency with high-quality care delivery. SHH can achieve this through system optimization and technology integration. Key strategies include: These interventions support financial sustainability while maintaining clinical excellence (Fichtenberg et al., 2020). Analyzing the Relationship Between Health Models and the Triple Aim Patient Self-Management Model (PSMM) What is the Patient Self-Management Model and how does it support the Triple Aim? The Patient Self-Management Model (PSMM) empowers individuals to actively participate in managing their health conditions through structured education and access to digital tools (Fu et al., 2020). This model shifts care from provider-directed to collaborative decision-making. Contributions of PSMM to the Triple Aim Care Coordination Model (CCM) What is the Care Coordination Model and how does it support the Triple Aim? The Care Coordination Model (CCM) ensures seamless integration of healthcare services across providers and care settings. It relies heavily on structured communication systems such as electronic health records (EHRs) to maintain continuity and accuracy in care delivery (Karam et al., 2021). Contributions of CCM to the Triple Aim Structure of Selected Healthcare Models Healthcare Model Structure and Core Components Impact on Triple Aim Patient Self-Management Model (PSMM) Patient education, self-monitoring tools, digital health integration, shared decision-making Enhances autonomy, improves outcomes, reduces costs (Solomon & Rudin, 2020) Care Coordination Model (CCM) Interdisciplinary collaboration, EHR integration, cross-setting communication Improves continuity, reduces readmissions, increases efficiency (Awad et al., 2021) Evidence-Based Data in Coordinated Care How does evidence-based data enhance coordinated care? Evidence-based practice strengthens clinical decision-making by ensuring that care delivery is grounded in validated research and clinical guidelines. This approach improves consistency in treatment and enhances interdisciplinary communication (Belita et al., 2020). Effective use of evidence-based data leads to: Governmental Regulatory Initiatives and Outcome Measures Which regulatory initiatives support the Triple Aim, and what outcomes do they target? Initiative Description Outcome Measures Health Information Exchange (HIE) Enables secure sharing of patient data across systems Reduces duplicate testing, improves continuity of care (Zhuang et al., 2020) Medicare Shared Savings Program (MSSP) Promotes accountable care organizations to improve efficiency Enhances cost savings and patient satisfaction (McWilliams et al., 2020) Meaningful Use Program Encourages EHR adoption and meaningful data use Improves interoperability and reduces medical errors (Mohammadzadeh et al., 2021) These initiatives collectively strengthen coordinated care delivery and support measurable improvements in healthcare outcomes. Process Improvement Recommendations for Stakeholders Stakeholders Challenges and Concerns Recommended Solutions Healthcare Providers Concerns regarding workflow disruption and cost of implementation Introduce phased pilot programs to support gradual transition Hospital Administration Workforce adaptation to digital systems and automation Provide structured training and continuous professional development Interdisciplinary Teams Communication gaps across departments Establish standardized communication protocols (Karam et al., 2021) Conclusion Achieving the Triple Aim at SHH requires a structured focus on care coordination, patient empowerment, and system-level integration. The Patient Self-Management Model and Care Coordination Model serve as foundational frameworks for improving clinical outcomes, reducing healthcare costs, and strengthening population health. Through interdisciplinary collaboration and adherence to regulatory standards, SHH can deliver sustainable, high-quality healthcare services to Barnes County Community. Continued adoption of evidence-based strategies will ensure long-term improvements in healthcare delivery systems. References Awad, K., et al. (2021). Integrating care coordination across settings: Outcomes and effectiveness. Journal of Healthcare Management, 66(4), 254–267. Belita, L., et al. (2020). Evidence-based practice in nursing: Decision-making and communication. Nursing Research Journal, 72(3), 145–158. Bloem, B. R., et al. (2020). Reducing fragmented care through care coordination. International Journal of Integrated Care, 20(2), 1–12. Carayon, P., et al. (2020). Improving patient safety with care coordination. BMJ Quality & Safety, 29(7), 553–561. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Du, S., et al. (2019). Patient self-management and collaborative healthcare. Patient Education and Counseling, 102(6), 1120–1128. Facchinetti, G., et al. (2020). Continuity of care in chronic disease management. Health Services Research, 55(5), 801–812. Fichtenberg, C., et al. (2020). Strategies for cost-effective healthcare delivery. Health Affairs, 39(8), 1357–1365. Fu, H., et al. (2020). Empowering patients through self-management models. Journal of Chronic Disease Management, 12(4), 221–230. Hoffmann, T., et al. (2023). Evidence-based practice and interdisciplinary communication. Journal of Interprofessional Care, 37(2), 101–112. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Karam, R., et al. (2021). Care coordination models and organizational strategies. Journal of Nursing Management,