Unit 9 Assignment HS499-5: Health Care Administration: Demon ✓ Solved

Unit 9 Assignment HS499-5: Health Care Administration: Demon

Unit 9 Assignment HS499-5: Health Care Administration: Demonstrate an understanding of the forces impacting health delivery systems and the effective management of health care administration. Choose one aspect that challenges health delivery systems (e.g., access to care, quality improvement, lack of coordinated care, continuity of care) and describe the issue. After reviewing the Logic Model Development Guide, create a logic model for a new program you would fund to address this issue. Discuss how the program can be applied to reduce the impact on the health delivery system. The paper should be at least 975 words in length. Your paper must include a logic model that you create. Include a list of references in APA format.

Paper For Above Instructions

Introduction

One of the most persistent challenges facing health delivery systems is lack of coordinated care, which undermines continuity, increases fragmentation, and drives up costs while reducing quality and patient satisfaction (AHRQ, 2014; WHO, 2016). This paper describes the problem of poor care coordination, proposes a fundable program to address it, and presents a logic model for implementation. The program—Integrated Primary Care Access & Coordination Program (IPCAP)—focuses on strengthening transitions, integrating primary and specialty care, and using care navigators and health information exchange to create continuity of care. The logic model follows the W.K. Kellogg Foundation approach to link inputs, activities, outputs, outcomes, and ultimate impact (W.K. Kellogg Foundation, 2004).

Problem Description: Lack of Coordinated Care

Lack of coordinated care manifests as poor information transfer between providers, fragmented services during transitions (e.g., hospital discharge to home), duplicated tests, medication errors, and unmet social needs (Donabedian, 1988; Naylor et al., 1999). Fragmentation erodes quality and safety and contributes directly to avoidable readmissions, higher emergency department use, and increased cost (Berwick, Nolan, & Whittington, 2008). Vulnerable populations—older adults, patients with multiple chronic conditions, and those with limited access—are most affected (Bodenheimer & Sinsky, 2014). The Institute of Medicine (IOM) identified coordinated, patient-centered care as a hallmark of a high-quality health system (IOM, 2001).

Program Overview: IPCAP

IPCAP is a community-based program designed to improve care coordination across primary, specialty, behavioral health, and social service sectors. Core components include assignment of a care navigator for high-risk patients, standardized discharge planning and follow-up within 48 hours, interoperable care plans using health information exchange (HIE), multidisciplinary care conferences for complex cases, and linkage to community resources (AHRQ, 2014; Coleman et al., 2006). The program aims to reduce avoidable readmissions, improve medication reconciliation, increase patient activation, and lower total cost of care over 12–24 months.

Logic Model for IPCAP

Inputs

  • Funding for staffing (care navigators, project manager, IT specialist)
  • Partnership agreements between hospitals, primary care clinics, specialists, behavioral health providers, and community organizations
  • Health information exchange (HIE) platform and EHR interoperability tools
  • Training materials on care coordination best practices
  • Performance measurement tools and data analytics

Activities

  • Screen patients for care coordination risk and enroll high-risk patients
  • Assign care navigators to coordinate care plans, medications, and appointments
  • Conduct standardized discharge planning and follow-up phone calls within 48 hours
  • Implement shared care plans via HIE and schedule monthly multidisciplinary case conferences
  • Provide patient education and self-management coaching
  • Connect patients to social services (transportation, housing, nutrition)

Outputs

  • Number of patients enrolled and assigned a care navigator
  • Percentage of discharges with 48-hour follow-up completed
  • Number of shared care plans accessible through HIE
  • Number of multidisciplinary case conferences held
  • Patient education sessions delivered

Short-Term Outcomes (6–12 months)

  • Improved medication reconciliation rates
  • Increased follow-up visit adherence
  • Improved patient activation scores
  • Reduced gaps in documentation across providers

Intermediate Outcomes (12–24 months)

  • Reduced 30-day readmission rates
  • Reduced emergency department utilization for ambulatory care–sensitive conditions
  • Increased continuity of care measures and patient satisfaction
  • Lowered total cost of care for enrolled patients

Long-Term Impact

System-level improvement in integrated, patient-centered care delivery, greater health equity through better access and coordination for vulnerable populations, and sustainable reductions in unnecessary utilization and healthcare expenditures (Berwick et al., 2008; WHO, 2016).

How IPCAP Reduces the Impact of Poor Coordination

IPCAP addresses key failure points identified by the literature. Assigning care navigators reduces fragmentation by providing a single point of accountability for care transitions and follow-up, a strategy shown to lower readmissions and improve outcomes (Naylor et al., 1999; Coleman et al., 2006). Use of HIE and shared care plans ensures timely information transfer, reducing duplicated testing and medication errors (AHRQ, 2014). Multidisciplinary case conferences address complex needs and align plans across clinicians and social service providers, improving continuity (IOM, 2001).

By integrating social determinants screening and referral pathways, IPCAP reduces nonmedical barriers to care that often undermine clinical plans (Bodenheimer & Sinsky, 2014). Training and standardized protocols foster consistent practice across partners and support measurement for continuous improvement (W.K. Kellogg Foundation, 2004). The combined interventions target both process measures (medication reconciliation, follow-up) and outcome measures (readmissions, ED visits), aligning with Triple/Quadruple Aim goals of improving population health, experience, and cost (Berwick et al., 2008; Bodenheimer & Sinsky, 2014).

Evaluation and Sustainability

Evaluation will use pre/post comparisons and matched control cohorts to measure changes in readmissions, ED visits, costs, and patient-reported outcomes over 24 months. Continuous quality improvement cycles and shared savings agreements can finance ongoing operations: cost reductions from fewer readmissions and duplicative services can be partially reinvested to sustain navigator positions and IT maintenance (IHI; Berwick et al., 2008). Policy levers such as value-based payment and accountable care arrangements further support scalability.

Conclusion

Fragmented care coordination is a major force undermining health delivery systems, producing inefficient, unsafe, and inequitable care. The IPCAP program—grounded in evidence-based strategies including care navigation, standardized transitions, HIE-enabled shared care plans, and multidisciplinary collaboration—offers an actionable, fundable solution. The attached logic model outlines how inputs and activities can produce measurable outputs and outcomes that reduce the system-level impacts of poor coordination while supporting long-term sustainability and scalability (W.K. Kellogg Foundation, 2004; AHRQ, 2014).

References

  • Agency for Healthcare Research and Quality. (2014). Care coordination. Retrieved from https://www.ahrq.gov
  • Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759–769.
  • Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576.
  • Coleman, E. A., et al. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828.
  • Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743–1748.
  • Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.
  • Naylor, M. D., et al. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613–620.
  • W.K. Kellogg Foundation. (2004). Logic model development guide. Battle Creek, MI: W.K. Kellogg Foundation.
  • World Health Organization. (2016). Framework on integrated, people-centered health services. Geneva: WHO.
  • Kaiser Family Foundation. (2019). Improving care coordination: Policy strategies and evidence. Retrieved from https://www.kff.org

Related Assignments