NRS 440 Topic 2 DQ 2: Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team

NRS 440 Topic 2 DQ 2: Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team

NRS 440 Topic 2 DQ 2

Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. Explain how this model is advantageous to patient outcomes.


A current nursing model of nursing care delivery is case management, which relies on clinical pathways to evaluate care (Masters, 2017). Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care (Hinkle & Cheever, 2014). Case managers may be nurses or may have backgrounds in other health professions, such as social work. The clinical pathway refers to expected outcomes and interventions established by the collaborative practice team (Masters, 2017).NRS 440 Topic 2 DQ 2

To manage the cases of a group of patients, a team is selected that includes clinical experts from the disciplines needed such as nursing, medicine, or physical therapy. Coordination of care beginning from admission up to discharge is vital to ensure that clinical pathway and benchmark are recognized, and care plan is updated according to the current patient status and needs. Care coordination failure results when a patient is readmitted within thirty days with the same readmission diagnosis. Case management is beneficial to patients as there is a follow through and continuity of care from admission up to the point of discharge to home where the case management team do wellness check and sets up home health care when deemed necessary to prevent re-hospitalization.

The Transitional Care Model is one that can help reduce readmissions by coordinating outpatient and home health care services to aid the patient and family with recovery. In one study, patients recovering from a stroke were studied. The model provides “uninterrupted and rapid service to the patients and their families by setting up a network of communi­cation between institutions immediately after pa­tients with stro

NRS 440 Topic 2 DQ 2 Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team

NRS 440 Topic 2 DQ 2 Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team

ke are discharged from the hospital” (Demir Avci & Gözüm, 2021, p. 176-185). NRS 440 Topic 2 DQ 2

These patients often experience frequent readmissions or are admitted to a long-term care facility after discharge due to the burden of their care of their families. However, with the Transitional Care Model, the patient has the chance to be home, in their comfort zone, surrounded by their family. This opportunity aides in a faster, more effective recovery period. They are motivated to return to their baseline mobility. The model helps promote complete communication between the different care members to keep the patient as the main focus. The patient and their caregiver(s) are the number one focus of the model. They are involved and their opinions valued. This model is said to be “effective in coordinating care between settings, improving the quality and efficiency of care, and reducing the overall cost of care” (Clarke, et al., 2017).

Masters, K. (2017). Role development in professional nursing practice. Fourth edition. Burlington, MA: Jones & Bartlett Learning.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.


Case management has shown improvements in some health outcomes. Case management is “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes” (Jerez-Barranco et al., 2022). Case management is a huge help in the hospitals I work at. The case managers help set up care for patients weather it be at home or in a nursing home. The case managers work hand in hand with the patient, their families, the nurses, and other health organizations. Case mangers don’t receive enough credit for all they do.

Jerez-Barranco, D., Gutiérrez-Rodríguez, L., Morilla-Herrera, C., Cuevas Fernandez-Gallego, M., Rojano-Perez, R., Camuñez-Gomez, D., Sanchez-Del Campo, L., & García-Mayor, S. (2022). Components of case management in caring for patients with dementia: a mixed-methods study. BMC Nursing21(1), 1–9.


Nice information on this weeks discussion. I agree that case management has help with so much of patient care. For

DQ 2 Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team

DQ 2 Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team

my hospital when I worked on the emergency department the workload that was placed on case managers was almost infinite. We relied on them to be able to set up transportation for patients going to different care facilities or going to a different hospital. They would also help with patients who come in to the unit without insurances be able to apply for emergency insurance. The case management would also help with the grieving process of the family when their loved one would pass away. They would supply the information they needed for the loved one that passes away.

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With the emergence of the Affordable Care Act and the shift towards pay per performance payment model, new and innovative healthcare delivery systems must be implemented in order to provide quality and cost-effective care. One healthcare delivery system that involves an interdisciplinary team is the Patient-Centered Medical Home (PCMH) model. PCMH involves a community based health team that supports primary care practices (Haas, 2011) . Each PCMH is made up of a primary physician that develops an ongoing relationship for comprehensive care.

This practice arranges for all the patients needs, including coordinating with other specialty providers, hospitals, home health agencies, and nursing homes. This model takes into account the whole person, and also includes the patients family and community services (O’Dell, 2016). In this model, rather than the patient coordinating care between all the different providers and services they need, the primary care practice takes on that coordination to alleviate gaps in communication and understanding.

This model is adventitious for patient outcomes because the patient is treated holistically and ideally all of their needs are addressed. Because there is one primary provider who coordinates with other providers and services, there is less passing of the patient back and forth which leaves less room for communication gaps, medication interactions and duplications, and unnecessary medical costs. Patient-centered medical homes have been shown to improve patient outcomes and satisfaction (O’Dell, 2016).

NRS 440 Topic 2 DQ 2References:

Haas, S. A. (2011). Health reform act: new models of care and delivery systems. AAACN Viewpoint33(2), 11–12.


O’Dell, M. (2016). What is a Patient-Centered Medical Home? Mo Med.


Thank you for your post! I agree that the PCMH model is a good plan for patient’s care. What I like about medical homes is the power that RNs and NPs have when delivering care for their patients. Nurses are taught in school that we must deliver holistic care to patients, and by allowing nurses to take control over patient’s plan of care, this can be passed to clinicians that might not be as aware of the term “holistic” as nurses are (Haney, 2010). Therefore, this model allows for a complete patient-centered care that is led by nurses, but collaborating with members of the health care teams.


Haney, C. (2010). ANA Issue Brief. Retrieved August 3, 2022, from—final—haney—6-9-10-1532.pdf NRS 440 Topic 2 DQ 2


You made some good points on this week’s discussion. It was interesting to read about what you wrote on the Patient-Centered Medical Home. Looking it up with the website you provided I read that originally it was developed for specialty of pediatrics. Which was called Medical Home for children with special health care needs (CSHCN). As you previously mentioned in your discussion the CSHCN was developed in a way to coordinate care for pediatric patients that had multiple providers that were not always from the same group. It first published and used in 1967 from the American Academy of Pediatrics (AAP). NRS 440 Topic 2 DQ 2

Also Read: DQ 1: Explain how interprofessional collaboration will help reduce errors, provide higher-quality care, and increase safety

The “Patient Protection and Affordable Care Act” of 2010 includes a number of amendments and additions that tend to combine the quality of medical care together with the expenditures that are involved with it. Personnel in the healthcare industry, such as registered nurses, possess the professional breadth, educational background, and necessary abilities that position them as the most important innovators in the successful commissioning of new patient-centered delivery models. Accountable Care Organizations, or ACOs for short, are one example of a forward-thinking paradigm for the delivery of medical care (Lan et al.,2022). NRS 440 Topic 2 DQ 2

The model is an association that coexists among specialists, the hospital, clinicians, and other healthcare practitioners who are in agreement with the various roles that facilitate the provision of cost-effective care and high-quality services to its customers. This association is known as the model. As a result, it requires the participation of a provider group that promotes patient population accountability, establishes ties between the many services and items covered by Medicare, and drives care procedures and investment infrastructure in order to ensure effective service delivery.NRS 440 Topic 2 DQ 2

The feature of reduced costs is one that constitutes a substantial advantage that occurs as a result of ACO’s implementation. One additional benefit brought about by accountable care is an improvement in patient outcomes as well as better management of the health of the population (Lewis et al.,2018).  NRS 440 Topic 2 DQ 2

According to the research that was bolstered by the “Center for Health Care Strategies and the Urban Health Research and Practice,” the shown models for the delivery of medicine, such as ACOs, offer payers distinct new methods for achieving a substantial health outcome among populations. There are a variety of benefits that are made available to the community, such as improved outcomes for patients. They receive care that is of high quality, are involved in perfect collaboration with other healthcare professionals, and pay expenses that are not prohibitive overall (Lan et al.,2022).


NRS 440 Topic 2 DQ 2 Reference

Lan, Y., Chandrasekaran, A., Goradia, D., & Walker, D. (2022). Collaboration structures in integrated healthcare delivery systems: An exploratory study of accountable care organizations. Manufacturing & Service Operations Management.

Lewis, V. A., D’Aunno, T., Murray, G. F., Shortell, S. M., & Colla, C. H. (2018). The hidden roles that management partners play in accountable care organizations. Health Affairs37(2), 292-298. NRS 440 Topic 2 DQ 2

Great Job Truth. That was a fantastic example of the unity of professionals working together! Another innovative healthcare delivery that I will address that requires the prodfessional communication and collaboration is Mobile Integrated Healthcare (MIH). The model helps in leveraging the Emergency Medical Service. The system is formed tohelp in providing emergency medical care. For instance, it helps address the issues of care transition, unplanned episodes, and longitudinal care (Roeper et al., 2018).

NRS 440 Topic 2 DQ 2 Therefore, depending on the existing resources, enabling data and information sharing among the health systems and other providers is essential. The model is readily adaptable and helps in meeting the needs of the

population .it is also designed to help deliver urgent care when needed. The MIH is normally the real-time reactive response to 911 calls. It helps in ensuring that care is mobile, safe, and timely. It can help improve the quality of life and reduce patient NRS 440 Topic 2 DQ 2

hospitalization rates. Integrated care plays a crucial role in hospitals, ensuring improved access to care. It also helps in reducing the rate of readmission and hospitalization (Roeper et al., 2018). It makes it better adherence to treatment. It also increases patient satisfaction for health workers leading to an overall health increase. Therefore, Mobile Integrated healthcare is need-based care and helps in preventing services.

Roeper, B., Mocko, J., O’Connor, L. M., Zhou, J., Castillo, D., & Beck, E. H. (2018). MobileNRS 440 Topic 2 DQ 2

integrated healthcare intervention and impact analysis with a Medicare advantage

population. Population Health Management 21

(5), 349-356.NRS 440 Topic 2 DQ 2