Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Cost Savings Analysis Care coordination involves collaboration among healthcare professionals to organize, implement, and monitor patient care activities while sharing critical information to ensure safe, effective, and patient-centered care. This process is central to healthcare management, aiming to provide timely care in the most appropriate setting (CMS, n.d.). This assessment provides a cost-savings analysis for Miami Valley Hospital, where I serve as a senior care coordinator. The objective is to examine how care coordination, supported by Health Information Technology (HIT), impacts cost efficiency, patient outcomes, and the collection of evidence-based data to enhance healthcare quality for the community. Care Coordination and Cost-Effectiveness Health Information Technology (HIT) plays a pivotal role in facilitating effective care coordination. By enabling seamless sharing of patient information, HIT supports the delivery of safe, high-quality care. Effective coordination can significantly reduce healthcare costs by preventing complications, minimizing unnecessary hospital stays, and optimizing resource allocation. The core assumption underlying this analysis is that structured care coordination improves patient outcomes, streamlines transitions between care settings, and reduces overall healthcare expenditures. Coordinated care helps prevent unnecessary hospital readmissions, particularly when patients transition from hospital to home or rehabilitation facilities. Research shows that preventing a single Medicare patient readmission can save between $10,000 and $58,000 under the Hospital Readmissions Reduction Program (HRRP). On a broader scale, reducing readmissions can save healthcare organizations up to $170 million annually (Yakusheva & Hoffman, 2020). In addition, care coordination improves resource utilization. By sharing real-time patient data through HIT, healthcare providers can make informed decisions regarding diagnostic tests, specialist consultations, and treatment plans. This reduces duplication of services, enhances value-based care delivery, and generates savings for both organizations and patients (Williams et al., 2019). Chronic disease management is another area where coordinated care is crucial. Approximately 85% of healthcare costs are associated with chronic conditions (Holman, 2020). Through ongoing monitoring, early intervention, and proactive management, coordinated care helps prevent disease exacerbations and recurrent hospitalizations, resulting in significant cost reductions. In essence, HIT-enabled care coordination supports a balance between high-quality patient care and financial efficiency. Care Coordination and Positive Health Outcomes Health consumerism emphasizes patients’ active engagement in their healthcare. Patient engagement is an integral component of care coordination, allowing individuals to participate in decision-making and manage their health effectively. HIT tools such as Electronic Health Records (EHRs) and patient portals empower patients to access their health data and make informed choices about treatment and lifestyle (Choi & Powers, 2023). Through consistent communication, monitoring, and personalized care planning, coordinated care encourages patients to actively participate in discussions regarding their treatment, medications, and wellness strategies (Albertson et al., 2022). This patient-centered approach fosters shared decision-making, promoting informed health consumerism. Additionally, HIT-driven coordination enables preventive care and timely interventions. Access to individualized health data allows patients to implement preventive strategies and adopt healthier behaviors, ultimately improving overall well-being. Collaboration among providers ensures a comprehensive understanding of each patient’s needs, reducing complications and supporting continuity of care across multiple settings. Continuity, in turn, enhances patient satisfaction and contributes to better health outcomes (Cha, 2023). Care Coordination and Enhanced Evidence-Based Data The Patient-Centered Medical Home (PCMH) model exemplifies a coordinated, holistic, and patient-focused approach to care. By fostering communication, patient engagement, and continuous quality improvement, PCMH supports the collection and utilization of evidence-based data (De Marchis et al., 2019). HIT facilitates integration of EHRs within PCMH, providing a complete view of patient health and streamlining care processes. This integration allows providers to make evidence-based decisions, tailoring care to individual needs and improving quality outcomes (Jubril, 2019). Improved collaboration among providers ensures timely sharing of relevant patient information, enhancing both data accuracy and care coordination. Performance metrics, benchmarking, and systematic data collection under PCMH allow healthcare organizations to measure care quality, identify gaps, and implement evidence-based improvements (Quigley et al., 2021). By analyzing trends, predicting health risks, and customizing interventions, care coordination enables data-driven decision-making that supports population health management. Continuous monitoring of outcomes and patient feedback further refines care delivery to align with best practices. Cost Savings Data and Information The table below illustrates estimated cost savings resulting from 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 Implementing HIT-supported care coordination at Miami Valley Hospital is projected to yield $2.4 million in annual savings. These reductions are achieved through fewer readmissions, smoother care transitions, optimized resource use, improved chronic disease management, fewer adverse events, and decreased emergency department utilization. This analysis highlights both the economic and clinical benefits of leveraging HIT to enhance coordinated care practices. 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 NURS FPX 6612 Assessment 4 Cost Savings Analysis 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 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 NURS FPX 6612 Assessment 4 Cost Savings Analysis 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., &

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 fundamental component of ensuring seamless continuity of care and minimizing the risk of hospital readmissions. This assessment focuses on Marta Rodriguez, a college freshman who experienced a motor vehicle accident in Nevada. Marta was admitted to a shock trauma center, where she underwent multiple surgical procedures and received antibiotic therapy for a systemic infection over a four-week hospitalization period. She recently moved from New Mexico to Nevada for her college studies and is covered by student health insurance. An essential factor in Marta’s care planning is her language preference, as Spanish is her native language and English is her second language. As the senior care coordinator responsible for her case, it is critical to identify the primary concerns the interprofessional team must address to create an effective and patient-centered discharge plan. This plan will integrate Health Information Technology (HIT) for care continuity, utilize data reporting systems to enhance clinical efficiency, and incorporate patient-reported health information to improve health outcomes. The interprofessional team will present the plan during a collaborative meeting to ensure that Marta receives comprehensive post-discharge care tailored to her unique needs. Longitudinal Patient Care Plan Health Information Technology (HIT) plays a pivotal role in facilitating a smooth transition from hospital-based care to home or outpatient management. Digital health tools, including telehealth services, enable remote patient monitoring, virtual follow-ups, and active engagement in recovery (Abraham et al., 2022). For Marta, implementing Electronic Health Records (EHR) with multilingual support is essential to maintain a complete, accessible record of her surgeries, medications, and infection management. Real-time data sharing ensures that healthcare providers can collaborate effectively and make informed decisions regarding her post-discharge care (Khoong et al., 2020). NURS FPX 6612 Assessment 3 Patient Discharge Care Planning To support Marta’s recovery, the interprofessional team will employ remote monitoring and telehealth platforms to track her adherence to medication, schedule virtual follow-ups, and monitor vital signs. Predictive analytics and Clinical Decision Support Systems (CDSS) will help identify risk factors such as infection recurrence or post-surgical complications, enabling early intervention (Somsiri et al., 2020). These strategies are designed to reduce readmission risks and ensure a seamless care transition while empowering Marta to actively participate in her own recovery process. Implications of HIT in Care Planning Incorporating HIT into Marta’s discharge plan enhances patient-centered care, strengthens care coordination, and reduces the likelihood of readmission. Access to real-time clinical data allows the interprofessional team to respond promptly to emerging health concerns while actively involving Marta in decision-making about her care (Srinivasan et al., 2020). The use of EHR and CDSS facilitates improved communication among providers, promoting collaborative care that is structured, consistent, and personalized. HIT also supports a longitudinal approach to patient management, enabling proactive interventions and personalized care strategies. By leveraging comprehensive patient data, healthcare providers can optimize recovery outcomes and encourage Marta to engage in self-management of her health (Somsiri et al., 2020). Additionally, HIT ensures that patient information is current, accurate, and accessible, reducing the risk of treatment errors and enhancing the overall efficiency of care delivery. Table Representation Key Area Implementation in Marta’s Care Expected Outcomes Longitudinal Patient Care Plan Utilize EHR with multilingual capabilities to document Marta’s medical history, surgeries, and medication regimens (Khoong et al., 2020). Implement telehealth platforms for virtual follow-ups and remote monitoring (Abraham et al., 2022). Ensures continuity of care, enables real-time updates, reduces hospital readmissions, and supports informed clinical decisions. Implications of HIT in Care Planning Integrate predictive analytics and CDSS to identify risks and guide post-discharge decisions (Somsiri et al., 2020). Use real-time data sharing for collaborative care coordination (Srinivasan et al., 2020). Promotes patient-centered care, enhances interprofessional collaboration, and enables proactive health interventions. Patient Data and Reporting Monitor medication adherence and virtual follow-up attendance for personalized interventions (Kumar et al., 2022). Incorporate patient-reported outcomes to develop culturally competent care strategies (Real et al., 2020). Improves clinical efficiency, facilitates timely interventions, and increases patient engagement and satisfaction. 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 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning 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 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., Talari, P., & Li, J. (2020). Patient perceptions and real-time observations of bedside rounding team communication: The Interprofessional Teamwork Innovation Model (ITIM). The Joint Commission Journal on Quality and Patient Safety, 46(7). https://doi.org/10.1016/j.jcjq.2020.04.005 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Somsiri, V., Asdornwised, U., O’Connor, M., Suwanugsorn, S., & Chansatitporn, N. (2020). Effects of a transitional telehealth program on functional status, rehospitalization, and satisfaction with care in Thai patients with heart failure. Home Health Care Management & Practice, 108482232096940. https://doi.org/10.1177/1084822320969400 Srinivasan, M., Jayant, P., Zulman, D., Thadaney, I., Samuel, M., Robert, S., Lance, D. M., Ian, N., Artandi, M., & Sharp, C. (2020). Enhancing patient engagement during virtual care: A conceptual model and rapid implementation at an academic medical center. NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0262

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Quality Improvement Proposal The Centers for Medicare & Medicaid Services define Accountable Care Organizations (ACOs) as healthcare entities that voluntarily deliver high-quality care to Medicare beneficiaries through coordinated and patient-centered approaches (Millwee, 2020). Sacred Heart Hospital (SHH), operating under Vila Health, aims to achieve ACO status. As a case manager at SHH, this quality improvement proposal outlines strategies to enhance quality metrics by expanding the hospital’s Health Information Technology (HIT), with a particular emphasis on upgrading Electronic Health Records (EHRs). Ways to Expand Hospital’s HIT to Include Quality Metrics The current EHR system at SHH is outdated and limits the hospital’s capacity to monitor quality metrics effectively, especially for preventive screenings like mammograms and colonoscopies. Upgrading the EHR system will improve its functionality by adding modules such as social work tabs, which integrate patient health data and track follow-ups. Furthermore, incorporating quality metrics directly into the EHR will allow real-time monitoring of key performance indicators, such as preventive screening rates, medication errors, patient satisfaction, and overall quality of care (Aerts et al., 2021). SHH plans to collaborate with local public health departments and affiliated clinics to collect information on patients who are missing recommended preventive screenings (Dawson et al., 2021). Using population health data, SHH can identify patterns and barriers in care delivery, such as women who frequently visit gynecologists but do not complete recommended screenings (Eckelman et al., 2020). By leveraging EHR alerts, reminders, and care coordination strategies, the hospital can target these at-risk populations and improve preventive care adherence. This approach also allows the integration of community health data to inform improvements in hospital care. Table 1: Proposed HIT Enhancements and Targeted Quality Metrics HIT Enhancement Purpose Target Metrics Social Work Tabs Track patient visits and health history Preventive screening completion, follow-up adherence Integrated Alerts & Reminders Notify providers of at-risk patients Mammogram & colonoscopy rates EHR Analytics Module Population health trend analysis Medication errors, patient satisfaction, preventive care metrics Data Sharing with Public Health Identify patients missing screenings Outreach completion rates, preventive care coverage Challenges in Expanding HIT Several challenges may arise while expanding HIT and upgrading EHR systems: Strategies to Address Challenges: Challenge Proposed Solution Financial constraints Collaborate with other healthcare organizations to secure funding; prioritize cost-effective EHR vendors Data standardization Implement standardized protocols for data entry and reporting Staff resistance Conduct targeted training on EHR benefits, care coordination, and quality improvement outcomes (Cho et al., 2021) Role of Nurse Informaticists in HIT Expansion Upgrading EHRs at SHH emphasizes the essential role of nurse informaticists in coordinating care through HIT. Nurse informaticists facilitate care planning, streamline communication among staff, and implement training programs tailored to nursing workflows. These initiatives foster a culture of continuous improvement, enabling nurses to provide feedback on EHR usability and inform future system enhancements (Gill et al., 2020; Eckelman et al., 2020). Through informatics tools, quality metrics can be effectively tracked and leveraged to enhance patient care outcomes. Information Gathering in Healthcare Comprehensive information gathering is critical for assessing quality metrics and identifying gaps in patient care. At SHH, data collection includes patient demographics, clinical histories, lab results, medication lists, and treatment plans. This information supports evidence-based decision-making and operational efficiency (Hathaliya & Tanwar, 2020; Eckelman et al., 2020). Table 2: Key Sources of Information for Quality Improvement Information Source Purpose Example Use EHR Clinical Data Evaluate patient care outcomes Track preventive screening rates, medication errors Patient Interviews Identify knowledge gaps Tailor patient education programs (e.g., Caroline McGlade case for mammogram awareness) Operational Data Optimize resource utilization Adjust staffing levels, improve workflow efficiency Patient Feedback Measure satisfaction & quality of care Implement targeted quality improvement initiatives Case example: Caroline McGlade, a breast cancer patient, lacked knowledge about preventive screenings. Collecting her information through EHR and interviews highlights gaps in patient education and financial barriers to care (Ye, 2021). Addressing these gaps ensures better preventive care adherence and supports SHH’s ACO objectives. Potential Problems with Data Gathering Systems While HIT expansion provides significant opportunities, challenges may arise during data collection and analysis: NURS FPX 6612 Assessment 2 Quality Improvement Proposal Mitigation Strategies: Problem Mitigation Strategy Privacy & security concerns Use encryption, multi-factor authentication, and access controls Information overload Prioritize actionable data and utilize dashboards for concise visualization Data accuracy uncertainties Employ validation protocols and continuous monitoring tools to ensure data integrity Conclusion Sacred Heart Hospital can achieve ACO status by prioritizing EHR upgrades and HIT expansion. Addressing current system limitations, integrating nurse informaticists, and leveraging comprehensive information gathering will improve care coordination, preventive care, and quality metrics. Proactively addressing potential challenges in data collection ensures that SHH can implement sustainable, evidence-based quality improvement initiatives. References Aerts, H., Kalra, D., Sáez, C., Ramírez-Anguita, J. M., Mayer, M.-A., Garcia-Gomez, J. M., Durà-Hernández, M., Thienpont, G., & Coorevits, P. (2021). Quality of hospital Electronic Health Record (EHR) data based on the International Consortium for Health Outcomes Measurement (ICHOM) in heart failure: Pilot data quality assessment study. JMIR Medical Informatics, 9(8), e27842. https://doi.org/10.2196/27842 Cho, Y., Kim, M., & Choi, M. (2021). Factors associated with nurses’ user resistance to change of electronic health record systems. BMC Medical Informatics and Decision Making, 21(1). https://doi.org/10.1186/s12911-021-01581-z Dawson, W. D., Boucher Oucher, N. A., Stone, R., & Van Houtven, C. H. (2021). COVID‐19: The time for collaboration between long‐term services and supports, health care systems, and public health is now. The Milbank Quarterly, 99(2). https://doi.org/10.1111/1468-0009.12500 Eckelman, M. J., Huang, K., Lagasse, R., Senay, E., Dubrow, R., & Sherman, J. D. (2020). Health care pollution and public health damage in the United States: An update. Health Affairs, 39(12), 2071–2079. https://doi.org/10.1377/hlthaff.2020.01247 NURS FPX 6612 Assessment 2 Quality Improvement Proposal Gill, E., Dykes, P. C., Rudin, R. S., Storm, M., McGrath, K., & Bates, D. W. (2020). Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics, 137, 104102. https://doi.org/10.1016/j.ijmedinf.2020.104102 Hathaliya, J. J., & Tanwar, S. (2020). An exhaustive survey on security and privacy issues in healthcare 4.0. Computer Communications, 153(1), 311–335. https://doi.org/10.1016/j.comcom.2020.02.018 Ihnaini, B., Khan, M.

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Triple Aim Outcome Measures Introduction Hello everyone, my name is ——. As a case manager, I will discuss the implementation of the Triple Aim framework—enhancing population health, reducing costs, and improving care quality—at Sacred Heart Hospital (SHH). Achieving this goal requires collaboration between hospital leadership, clinical teams, and external stakeholders. This presentation will also examine governmental regulations and outcome measures that support a coordinated care approach, ensuring SHH attains the Triple Aim objectives efficiently and sustainably. Purpose What is the primary goal of this presentation? The central aim of this presentation is to educate hospital leadership and clinical teams on strategies to optimize coordinated care processes to achieve the Triple Aim in Barnes County Community, the region served by SHH. This will be accomplished by: Successful implementation depends on interdisciplinary collaboration, fostering a healthcare environment where each professional contributes to improved patient outcomes, cost reduction, and population health advancement. Triple Aim and Its Contribution to Healthcare Organizations Experience of Care / Patient Satisfaction How can SHH enhance patient experience? Enhancing patient satisfaction at SHH requires a comprehensive, patient-centered approach. Prioritizing effective communication between providers and patients ensures that care is responsive to individual needs (Kwame & Petrucka, 2021). Additionally, identifying community needs—such as improving health literacy, expanding insurance coverage, reducing wait times, and ensuring consistent follow-up care—can foster trust and strengthen patient-provider relationships. Improving Population or Community Health How can SHH improve population health? Population health in Barnes County can be enhanced by implementing preventive care programs and educational initiatives that integrate healthy practices into daily life (Yamada & Arai, 2020). Addressing social determinants, including transportation challenges, low health literacy, and limited access to care, is crucial. Collaboration with regional healthcare organizations promotes resource-sharing and ultimately leads to better community-wide health outcomes. Decreasing Per Capita Costs How can SHH reduce healthcare costs per patient? Reducing per capita costs involves balancing cost-efficiency with quality care. Strategies include adopting technology-enabled care models, streamlining care delivery, and forming partnerships with governmental and healthcare organizations. These measures can decrease hospital readmissions, improve financial sustainability, and maintain high-quality care standards (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 patients to actively manage their health conditions through education and access to health tools (Fu et al., 2020). This model emphasizes collaboration rather than a paternalistic approach, encouraging patient autonomy and accountability. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures PSMM improves healthcare quality by: Care Coordination Model (CCM) What is the Care Coordination Model and how does it support the Triple Aim? The Care Coordination Model (CCM) integrates services across providers and healthcare settings, ensuring comprehensive and continuous care (Karam et al., 2021). Technological advancements, such as electronic health records (EHRs), have improved communication and efficiency across disciplines. CCM enhances care quality by: Both models collectively contribute to the Triple Aim by improving patient outcomes, optimizing care quality, and lowering costs. Structure of Selected Health Care Models Healthcare Model Structure and Components Impact on Triple Aim Patient Self-Management Model (PSMM) Focuses on patient-centered care, self-monitoring, digital health tools, and education Enhances autonomy, lowers costs, and improves patient outcomes (Solomon & Rudin, 2020) Care Coordination Model (CCM) Integrates care across settings, utilizes EHRs, enhances interdisciplinary collaboration Reduces readmissions, improves efficiency, and ensures continuous care (Awad et al., 2021) Evidence-Based Data in Coordinated Care How does evidence-based data enhance coordinated care? Utilizing evidence-based data allows healthcare teams to make informed decisions and improve interprofessional communication. By applying research findings and clinical guidelines, providers can implement best practices tailored to patient needs (Belita et al., 2020). Coordinated communication among interdisciplinary teams ensures precise care planning and efficient treatment delivery, ultimately enhancing patient outcomes (Hoffmann et al., 2023). 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 electronic sharing of patient data across providers Reduces duplicate tests, improves medication reconciliation, and strengthens care continuity (Zhuang et al., 2020) Medicare Shared Savings Program (MSSP) Encourages accountable care organizations (ACOs) to coordinate care and lower costs Enhances cost savings and patient satisfaction (McWilliams et al., 2020) Meaningful Use Program Incentivizes EHR adoption for data sharing and care coordination Improves interoperability, patient engagement, and reduces medical errors (Mohammadzadeh et al., 2021) By integrating these initiatives, SHH can optimize coordinated care and achieve measurable improvements in patient outcomes. Process Improvement Recommendations for Stakeholders Stakeholders Challenges and Concerns Recommended Solutions Healthcare Providers Concerns about initial costs and workflow changes Pilot programs for gradual adaptation to minimize disruption Hospital Administration Workforce adaptability to automation Implement comprehensive training for a smooth transition Interdisciplinary Teams Communication gaps between departments Develop structured protocols to ensure effective cross-team collaboration (Karam et al., 2021) Conclusion To successfully achieve the Triple Aim, SHH must prioritize care coordination through the integration of models such as PSMM and CCM. These strategies enhance patient outcomes, reduce costs, and strengthen community health. By fostering collaboration among healthcare leaders, administrators, and external partners, SHH can deliver sustainable, high-quality care to the Barnes County Community. Stakeholders are encouraged to adopt these evidence-based strategies to drive continuous improvement in healthcare delivery. 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. Du, S., et al. (2019). Patient self-management and collaborative healthcare. Patient Education and Counseling, 102(6), 1120–1128. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Facchinetti, G., et al. (2020). Continuity of care in chronic disease management. Health Services Research, 55(5), 801–812. Fichtenberg,