NURS FPX 8008 Assessment 3 - Capella DNP.pdf

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1. NURS FPX 8008 Assessment 3 Taking the Person-
Centered Collaborative Care Intervention Forward
Capella University
NURS FPX 8008
Professor Name
Date: June 20, 2025









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2. Taking the Person-Centered Collaborative Care Intervention Forward
Advancing the Patient-Centered Medical Home (PCMH) framework depends on the capacity of
Advanced Practice Registered Nurses (APRNs) to integrate evidence-based practices,
measurable quality outcomes, and ethical standards into care delivery. Despite organizational
barriers such as workforce resistance, patient disengagement, and inadequate standardized
workflows, the PCMH model offers a structured approach to patient engagement and system
transformation (Nguyen et al., 2022). By maintaining ongoing evaluation, leveraging practice-
based evidence, and fostering interprofessional dialogue, APRNs act as central agents of change.
This intervention highlights continuous, person-centered care supported by clinical data, shared
accountability, and collaborative leadership.
Strategic Plan for Person-Centered Care Intervention
The intervention is designed as a six-month rollout built upon principles of collaboration,
patient empowerment, and system redesign. The plan follows five structured phases.
Phase 1 (Weeks 1–4): Stakeholder engagement and assessment of current practices. APRNs,
administrators, and clinical educators will review workflows and align them with Jean Watson’s
theory of human caring, ensuring that empathy and dignity guide care delivery (Perez et al.,
2021).
Phase 2 (Weeks 5–8): Interprofessional training and workflow development. Teams of nurses,
physicians, social workers, and educators will undergo modules on cultural humility,
communication strategies, and ethical decision-making. This stage will also establish daily
workflows for team-based care and patient navigation (Thompson et al., 2022).
Phase 3 (Weeks 9–16): Pilot testing in a controlled clinical setting. Unit managers will oversee
test runs, integrating new workflows while gathering feedback from both staff and patients.
Phase 4 (Weeks 17–20): Evaluation of outcomes through qualitative and quantitative measures,
including patient-reported outcomes, staff performance data, and system efficiency metrics.
Phase 5 (Weeks 21–24): Full-scale integration. Leadership will refine the model based on pilot
results and scale it organization-wide. Performance monitoring systems will be embedded for
long-term accountability and improvement.
Key strategies include:
• Interprofessional care teams
• Family engagement in decision-making
• Enhanced collaboration across departments
• Use of electronic health records (EHRs) for real-time decision support
• Continuous improvement through Plan-Do-Study-Act (PDSA) cycles
Implementation and Evaluation Plan

3. The intervention uses a phased evaluation approach to ensure both rigor and adaptability.
• Short-term evaluation: Focuses on immediate adoption of workflows, training
completion rates, and early patient feedback.
• Medium-term evaluation: Assesses service accessibility, adherence to care plans, and
care coordination improvements.
• Long-term evaluation: Measures health outcomes, cost-effectiveness, and staff well-
being.
Data will be gathered through surveys, EHR analytics, patient experience tools, and quality
indicators. Results will inform continuous cycles of refinement, ensuring sustainability and
alignment with organizational goals (Lee et al., 2023).
Intervention Outcomes and Goals
The PCMH intervention aims to strengthen both patient experiences and system performance.
• Short-term outcomes: 80–85% of staff will demonstrate competency in collaborative
care models; at least 65% of patients will report improved involvement in care decisions.
• Medium-term outcomes: 15% reduction in avoidable emergency department (ED)
visits; 20% increase in preventive care utilization; higher adherence to chronic disease
management plans.
• Long-term outcomes: Less than 10% 30-day readmission rates; reduced clinician
burnout by 15%; and improved population health measures across chronic disease
registries.
These goals are tied directly to patient activation, interprofessional teamwork, and organizational
accountability (Ramirez et al., 2022).
Evaluation Metrics and Data-Driven Insights
Evaluation relies on clear, measurable indicators that reflect both clinical and patient-centered
outcomes:
• Preventive care compliance: Aim for at least 70% adherence to screenings and
vaccinations within six months.
• ED utilization: Target a 5–10% reduction in non-urgent visits by improving primary care
accessibility and patient education.
• Patient satisfaction: Increase reported satisfaction from 30% baseline to 45%+ by
embedding shared decision-making and culturally responsive communication (Miller et
al., 2023).
• Readmissions: Achieve <10% 30-day readmission rate through improved discharge
planning, transitional care follow-ups, and treatment reconciliation.

4. These metrics not only measure effectiveness but also provide actionable insights for scaling
improvements.
Enhancing Care and Reducing Readmissions
Reducing fragmented care and preventable readmissions is central to the intervention. National
statistics indicate readmission rates exceed 14% (CMS, 2024). Through transitional care
programs, proactive follow-ups, and enhanced care coordination, the PCMH model is projected
to cut this figure significantly.
Key strategies include:
• Strengthened hospital-to-home transition planning
• Expanded evening and weekend clinic access
• Medication reconciliation at discharge
• Patient education programs tailored to literacy and cultural needs
These steps improve continuity of care while optimizing resource use and reducing avoidable
costs.
Conclsion
The NURS FPX 8008 Assessment 3 project advances person-centered collaborative care through
structured PCMH implementation. By combining interprofessional collaboration, patient
empowerment, and continuous evaluation, the intervention promotes higher-quality care, reduces
inefficiencies, and fosters sustainable improvements in both outcomes and satisfaction. The
model exemplifies a shift toward evidence-driven, compassionate healthcare delivery that meets
organizational, provider, and patient needs alike.
References
Centers for Medicare & Medicaid Services (CMS). (2024). Impact of readmission reduction
initiatives. https://www.cms.gov/files/document/impact-readmissions-reduction-initiatives-
report.pdf
Lee, J., Smith, T., & O’Connor, H. (2023). Evaluating integrated care pathways: Outcomes from
a multi-site PCMH initiative. BMC Health Services Research, 23(1), 457.
https://doi.org/10.1186/s12913-023-09457-1
Miller, A., Johnson, P., & White, R. (2023). Shared decision-making in collaborative care
models: Patient outcomes and satisfaction. Patient Experience Journal, 10(2), 15–23.
https://doi.org/10.35680/2372-0247.1743

5. Nguyen, K., Patel, S., & Brown, L. (2022). Overcoming barriers to implementing PCMH:
Lessons from primary care transformation. Journal of Nursing Care Quality, 37(4), 289–296.
https://doi.org/10.1097/NCQ.0000000000000657
Perez, D., Harris, C., & Green, J. (2021). Human caring in modern nursing: Applying Watson’s
theory in practice transformation. Journal of Advanced Nursing, 77(9), 3748–3757.
https://doi.org/10.1111/jan.14822
Ramirez, E., Lopez, F., & Daniels, R. (2022). Measuring the impact of collaborative care models
on chronic disease management. Health Policy and Technology, 11(2), 100612.
https://doi.org/10.1016/j.hlpt.2022.100612
Thompson, L., Zhao, Y., & Morris, A. (2022). Training for interprofessional collaboration:
Building effective PCMH teams. Journal of Interprofessional Care, 36(5), 634–640.
https://doi.org/10.1080/13561820.2021.1964325










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8008-assessment-3-taking-the-person-centered/