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1. NURS FPX 8008 Assessment 3 Taking the Person-Centered
Capella University
NURS-FPX8008
Instructor Name
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NURS FPX 8008 Assessment 3

2. Taking the Person-Centered Collaborative Care Forward
Effective implementation of the Patient-Centered Medical Home (PCMH) model relies on
advanced practice nurses (APNs) and their evidence-based, pragmatic approaches to clinical
management. Despite challenges such as organizational resistance, poorly defined protocols, and
limited patient engagement, APNs can lead the integration of person-centered interventions
through structured, evidence-informed care. This approach incorporates interdisciplinary
collaboration, care coordination, and patient-focused strategies, ultimately fostering
improved patient outcomes and long-term sustainability (Kloos et al., 2020).
APNs begin with systematic surveillance and monitoring, advancing toward evidence-based
practices that emphasize coordination of care, interdisciplinary facilitation, and a holistic,
patient-centered approach.
Strategic Outline for Person-Centered Care Intervention
The goal of the intervention is to improve patient outcomes, care delivery, and satisfaction within
six months by adopting a person-centered care (PCC) framework. This will be achieved
through five structured phases:
Phase 1: Weeks 1–4 – Baseline Assessment and Leadership Training
Identification of stakeholders.
Initial training for leaders and staff on PCMH and Watson’s Theory of Human Caring.
Establishing baseline measures for care delivery (Leidner et al., 2021).
Phase 2: Weeks 5–8 – Workforce Training and Workflow Redesign
Mass training of interdepartmental staff.
Educational modules covering communication, ethics, cultural competence, and empathy.
Development of long-term standardized care pathways (Samardzic et al., 2020).
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Phase 3: Weeks 9–16 – Shared Decision-Making and Active Patient Engagement

3. Addressing uneven resource allocation by engaging managers and multidisciplinary
teams.
Incorporation of collaborative care planning and shared decision-making with patients.
Phase 4: Weeks 17–20 – Data Collection and Outcome Evaluation
Measurement of qualitative and quantitative outcomes, including care coordination,
patient satisfaction, and alignment with organizational performance benchmarks
(Handley et al., 2020).
Phase 5: Weeks 21–24 – Sustainability and Administrative Oversight
Continued monitoring and adjustment of interventions.
Integration of long-term sustainability mechanisms and outcome-based evaluations.
Specific Components of the Intervention and Outcomes
The PCMH model will employ Plan-Do-Study-Act (PDSA) cycles, digital health decision-
support systems, enhanced communication tools, family engagement, and interprofessional
services.
Planning (Phases 1–2): Stakeholder involvement, staff training, and protocol
development.
Implementation (Phase 3): Scaling interventions from pilot to organizational level.
Evaluation (Phase 4): Measuring outcomes quantitatively and qualitatively.
Refinement (Phase 5): Continuous improvement and expansion based on data (Manandi
et al., 2023).
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Expected Outcomes
Short-term (0–6 months): 80% of staff trained in PCMH principles, improved patient
engagement, and better utilization of resources.

4. Medium-term (6–12 months): 10% decrease in emergency visits, 15% increase in
preventive care, and improved patient satisfaction.
Long-term (12+ months): Chronic disease management improvements, reduction of
hospital readmissions to <10%, and reduced staff burnout.
Comparing Current Data Metrics with Targeted Improvements
Preventive Care
Preventive care adherence remains a significant challenge. Current adherence is below target,
with national averages reflecting underutilization (Jackson et al., 2024). The PCMH model, with
electronic health record reminders and improved patient-provider communication, aims to
achieve 70% adherence within six months.
Emergency Department (ED) Utilization
Excessive ED use for non-emergent conditions reflects gaps in primary care. Studies show
PCMH adoption reduces ED visits by 1.9% nationally (Saynisch et al., 2021). This intervention
targets a 5% reduction in six months, achieved through patient education, expanded clinic
access, and improved chronic disease management.
Patient Satisfaction
Patient satisfaction rates currently average 26%, far below desired levels. With PCMH practices
such as shared decision-making and empathetic communication, satisfaction rates could increase
to 40% or higher (Platonova et al., 2020).
30-Day Readmissions
National readmission rates average 14.7% (Khau et al., 2020). Through coordinated discharge
planning, early follow-up, and patient education, this intervention seeks to reduce readmissions
to <10% (Pugh et al., 2021).
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5. Connecting the Intervention to Organizational Strategic Goals
The PCMH model directly supports organizational goals of care coordination, quality
improvement, and patient engagement. By standardizing workflows, leveraging digital health
tools, and enhancing team-based care, the model aligns clinical practice with organizational
outcomes.
Improved Care Coordination: Enhanced communication between providers, staff, and
patients (Kloos et al., 2020).
Enhanced Patient Activation: Longer appointment times, shared decision-making, and
culturally sensitive care.
System Sustainability: Lower readmissions, reduced ED misuse, and optimized
healthcare resource utilization (Handley et al., 2020).
Conclusion
The PCMH framework is a transformative model for advancing person-centered, collaborative
care. By integrating evidence-based practices, interdisciplinary teamwork, and patient
engagement strategies, organizations can achieve measurable improvements in preventive care,
ED utilization, patient satisfaction, and readmission rates.
Through structured phases of implementation, ongoing data collection, and continuous
refinement, the intervention aligns directly with organizational goals of delivering ethical,
coordinated, and high-quality care. Ultimately, this approach enhances not only patient
outcomes but also the sustainability and efficiency of the healthcare system.
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6. References
Handley, M. A., et al. (2020). Patient-centered care and collaborative models in healthcare.
Journal of Nursing Care Quality. https://doi.org/10.1097/mlr.0000000000001474
Jackson, J., et al. (2024). Improving preventive care through patient-centered interventions.
Preventing Chronic Disease, 21, 230415. https://doi.org/10.5888/pcd21.230415
Khau, M., et al. (2020). Hospital readmissions and coordinated care strategies. Geriatric
Nursing, 41(4), 380–386. https://doi.org/10.1016/j.gerinurse.2020.04.018
Kloos, J., et al. (2020). Facilitating interdisciplinary collaboration in PCMH implementation.
BMJ Open, 11(4), e050054. https://doi.org/10.1136/bmjopen-2021-050054
Manandi, R., et al. (2023). Plan-Do-Study-Act cycles in healthcare improvement. BMJ Open
Quality. https://www.cms.gov/files/document/impact-readmissions-reduction-initiatives-
report.pdf
Platonova, E., et al. (2020). Patient satisfaction and engagement in care. Medical Care Research
& Review, 77(2), 124–135. https://doi.org/10.1097/mlr.0000000000001474
Pugh, J., et al. (2021). Coordinated care transitions and patient education. CMS Report.
https://www.cms.gov/files/document/impact-readmissions-reduction-initiatives-report.pdf
Saynisch, P., et al. (2021). ED utilization and the PCMH model. BMJ Open, 11(5), e050054.
https://doi.org/10.1136/bmjopen-2021-050054
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