Design and implementation of an outcomes management model

Area of Science:

• Nursing
• Healthcare Management
• Health Informatics

Background:

• The current capitation-based reimbursement model necessitates comprehensive patient care coordination.
• Acute care staff nurses require effective tools for predicting patient needs and managing care across the continuum.
• Accurate prediction and outcome evaluation are crucial for optimizing patient care delivery.

Purpose of the Study:

• To describe the design and implementation of a model supporting acute care staff nurses in care coordination.
• To evaluate the effectiveness of the implemented model in enhancing nurses' care planning abilities.

Main Methods:

• A model was designed and implemented to assist staff nurses in care coordination.
• A ten-item pre- and post-implementation survey was used to evaluate the model's impact.
• Educational offerings on the model were provided to participating staff nurses.

Main Results:

• Staff nurses who received training on the model showed a significant increase in using aggregate data for care planning.
• The model's implementation demonstrated a positive impact on nurses' data utilization for planning care.
• The survey indicated improved practices among nurses involved in the educational sessions.

Conclusions:

• The developed model supports acute care nurses in utilizing aggregate data for enhanced care planning.
• For maximum impact, the model should be integrated earlier in the patient care process, ideally during wellness visits or health plan enrollment.
• Further evolution of the model is recommended for application prior to initial hospitalization to optimize its effectiveness.