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

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

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

Although the healthcare reform movement has brought about positive changes, lingering inefficiencies and communication gaps continue to hamper system-wide progress toward achieving the overarching goal, higher quality healthcare and improved population health outcomes at a lower cost (Clarke et al.,2017). Healthcare reform increased coverage to millions of people who were uninsured, keeping them from using the Emergency Room for non chronic issues. Patients were able to make preventative care appointments encouraging them to schedule follow ups and get annual influenza vaccinations allowing them more participation in their health outcome. This will give the healthcare team more access to much more data and information about each individual patient, which will ultimately enhance the continuity of care and communication among the interprofessional team. The nurse of the future must establish positive working relationships and changes within interprofessional health care teams and ensure coordination of care for each patient and the patient’s family. Some of the changes, such as the surge in telehealth and telemedicine and the deployment of home-based care solutions, is quite visible to patients the have allowed continuity of care (McCahan, 2020).


Clarke, J.,Bourn, S.,Castillo, D. (2017). An Innovative Approach to Healthcare Delivery for Patients with Chronic Conditions. Population Health Management. The National Center for Biotechnology Information. 20(1): 23-30


McCahan, C. (2020). Pandemic Accelerating Uptake of New Care Models. Healthcare Promoting Management and Leadership.Volume 20 – Issue 8. -new-care-models

You mentioned something interesting that sent me down a research rabbit hole, the nurse of the future. A good indication of where the nursing field is heading is detailed in The Future of Nursing 2020-2030 Report, compiled by the Institute of Medicine to improve community health. The committee created ten outcomes that they see as essential to improving public health through quality nursing. The outcomes are that nurses be socially and culturally competent. That they focus on treated causes of disease. That the nursing field represent the communities they serve. That healthcare systems support the nurses while giving culturally competent care. Nurses continue to server underserved areas, natural disasters and in emergency situations. Nurses are encouraged to continue their education and collaborate to create new best evidence practices. And finally, the continued focus on patient centered care and self-care of the nurse. Public health will be greatly improved though these initiatives and the nursing field will continue to grow (NASEM, 2021).



National Academies of Sciences Engineering and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert, Menestrel, Williams, et al. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. National Academies Press; 2021 May 11.

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In today’s healthcare, there is often a lag in the care between discharge and outpatient care services. The patient can

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

see a decline in health between this time and can then be readmitted due to symptoms. This readmission is costly for the healthcare system as the Center’s for Medicare and Medicare reduce payment for readmissions (CMS, 2022).

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 stroke are discharged from the hospital” (Demir Avci & Gözüm, 2021, p. 176-185). 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).


Clarke, J. L., Bourn, S., Skoufalos, A., Beck, E. H., & Castillo, D. J. (2017). An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions. Population health management20(1), 23–30.

CMS (2022). Hospital readmissions reduction program (HRRP). Centers for medicare and medicaid services.

Demir Avcı, Y., & Gözüm, S. (2021). Effect of transitional care model-based interventions for patients with stroke and their caregivers on increasing caregiver competence and patient outcomes: A study protocol for a randomized controlled trial. Florence Nightingale Journal of Nursing, 29(2), 176-185.

A strategy for providing top-notch, economical primary care is the patient-centered medical home (PCMH) paradigm. The PCMH paradigm unifies patient care across the healthcare system by employing a patient-centered, culturally sensitive, and team-based approach (, 2021). Effective chronic illness management, higher levels of patient and provider satisfaction, cost savings, higher levels of preventive treatment, and enhanced quality of care have all been linked to the PCMH model. I like this model because it involves patient-centered care. Patients with chronic diseases need to continue disease management and prevention at home to prevent frequent hospitalizations. The PCMH primary care model is thought to be superior to standard care for enhancing clinical outcomes in patients’ quality of care and lowering hospital admissions (John et al., 2018). To help patients achieve the best results, home healthcare clinicians who are well-versed in the effects of how the community and family systems interact will be crucial in bridging the gap between the home environment and the PCMH based in primary care. As part of the PCMH model, a general practitioner (GP) and MDT frequently collaborate to deliver coordinated, patient-centered care that encourages long-term patient participation using a long-term chronic disease strategy (John et al., 2018).

This model is advantageous to the patient because it is centered around the patient. The healthcare team can work together to manage the patient’s disease in the comfort of their home. The patient-centered medical home (PCMH) model tends to get screenings and preventative care for patients more frequently than people who don’t use PCMHs, keeping them healthy; also, the concept has a focus on improving access, which enables individuals to obtain clinical counseling or medical records as needed (, 2020). For example, patients with diabetes can continue to monitor their blood glucose at home and communicate how they are doing with their healthcare team to obtain clinical counseling or any medical advice from their physicians.


Benefits to practices, clinicians and patients. NCQA. (2020, August 12). Retrieved from


Centers for Disease Control and Prevention. (2021, May 12). Patient-centered medical home (PCMH) model. Centers for Disease Control and Prevention. Retrieved from


John, J. R., Ghassempour, S., Girosi, F., & Atlantis, E. (2018). The effectiveness of patient-centred medical home model versus standard primary care in chronic disease management: protocol for a systematic review and meta-analysis of randomised and non-randomised controlled trials. Systematic Reviews, 7(1), N.PAG.