Student Name

Capella University

NURS-FPX8008 Person-Centered Care in Doctoral Practice

Professor name

Submission Date

Taking the Person-Centered Collaborative Care Intervention Forward

The concept of person-centered care (PCC) is a major shift in healthcare provision which focuses on the person and not the disease. Emotional support, patient participation in decisions, and a relational model of care have been identified as having good potential to impact health outcomes, especially among people with chronic conditions (Gartner et al., 2022). This proposed initiative aims to further the development of PCC for older adults with chronic illnesses using the theory of human caring developed by Watson. An intervention plan (based on the plan-do-study-act [PDSA] model) includes what is done, what needs to be changed, and how all processes will be connected to the organization’s goals.

Strategic Outline for Person-Centered Care Intervention

The use of the PCC intervention is dependent on the PDSA (plan-do-study-act) framework used as a base for continuous quality improvement of managing chronic diseases in older adults. A period of six months has been set, and the first two weeks are dedicated to planning, after which the implementation will start. At the ‘plan’ stage, interdisciplinary team meetings will take place to review baseline data of patient satisfaction, hospital readmission rate, and medication adherence. At the same time, all care staff will be trained on Watson’s theory of human caring and motivational interviewing techniques, consistent with humanistic values and ethical practice. Evidence shows that using human caring principles in conjunction with motivational interviewing improves adherence and self-management (Curcio et al., 2024). During the ‘do’ phase, the first three months will be dedicated to engaging in individualized care plans through motivational interviewing in patients’ care. Interdisciplinary meetings will take place each week, which will enable flexible changes to the care plan based on patient needs and feedback. Engagement strategies focus on emotional, social, and cultural needs; they include a focus on shared decision-making and trust.

In month 4 during the ‘study’ phase, data will be collected and analyzed to gauge patient outcomes such as adherence to medication, patient-reported satisfaction, hospitalization rates, among others. Patient stories will also be taken into consideration for qualitative improvements in emotional state and perceived empowerment. Findings will be shared with executive leaders and stakeholders at the end of the ‘act’ phase. Adjustments will be made to enhance the embedding of successful practices into long-term working practices. Evidence shows that a combination of quantitative data and patient stories can result in a full picture of person-centered interventions and promote sustainable quality improvement (Arsenault et al., 2022). The desired outcomes are a 25% decrease in hospital readmission, a 30% improvement in medication management, and improved patient satisfaction scores, all emphasizing the importance of compassionate, collaborative care. The combined outcomes identify the long-term effects of evidence-based and person-centered approaches.

Comparing Current Data Metrics with Targeted Improvements

Taking Current Data Metrics and Targeted Improvements, it is evident that they are not the same thing. Current Data Metrics are not Targeted Improvements.

Caring for and treating older people who have chronic diseases still presents difficulties, particularly in terms of poor links between practitioners, the proportion of patients who fail to take their medicines, and readmission to hospital. Patient satisfaction scores reveal the current rate as 68%, indicating low perceived social support and limited involvement in the decision-making process. The compliance rate with medication is 62%, and for 30 days of hospitalization, the readmission rate is 21%. The Agency for Healthcare Research and Quality (2024) benchmark estimates that adherence to medications among adults with chronic conditions is around 75-80%, with adherence defined as having 80% or more of days covered (PDC). However, another important measure, interdisciplinary cooperation quality, is suboptimal, with care coordination audits indicating so (Arsenault et al., 2022). The gaps identified highlight the need for more robust patient-oriented strategies for quality improvement.

Measures that will be implemented under the plan involve improving patient satisfaction, which will be reached at 85% by improving interpersonal communication and patient participation. It is expected that medication adherence will increase to 80 percent or higher with motivational interviewing and individualized education. Early care planning and comprehensive support post-discharge will achieve a 25% reduction in the hospital readmission rate. The national standard for Medicare beneficiaries’ 30-day hospital readmission rates is around 15–16% (Betancourt, 2024), and this is used as a target for any efforts aiming at improving quality when working with chronic illness management. The effectiveness of the interdisciplinary coordination will be monitored for each team monthly by checking team performance, with a target that 90% of teams will meet the benchmark of coordinated care delivery. Every improvement planned will help to create more humane, efficient, and sustainable healthcare experiences.

Connecting the Intervention to Organizational Strategic Goals

The PCC intervention is in complete collaboration with the organization’s strategic goals of increasing patient satisfaction and avoiding unnecessary readmissions. Incorporating Watson’s theory of caring into clinical care involves the value of meaningful relationships to support caring for patients. MI fits in well with the organization’s major goal of patient-centered care planning, which promotes patient engagement. Organizational goal: Improve health outcomes through continuity, which is enabled by care coordination improvements, including team conferences and structured follow-up processes. Chronic disease management for the elderly is made more efficient with planned actions, and these actions also help reduce healthcare costs, thus meeting the overall goal of value-based care (VBV) (Albertson et al., 2021). Challenges the status quo, in relation to organizational change and the development of compassion as a companion to clinical excellence while maintaining the focus on caring for a diverse population in a relational and/or relational care model.

Conclusion

The PCC’s are changing the nature of health care by focusing on patient needs, values, and preferences. Watson’s human caring theory provides an ethical and caring approach to the improvement of the relationship with the patient. Interventions using motivational interviewing foster shared decision-making and care coordination. Better care metrics are associated with greater adherence, satisfaction, and hospitalizations. A strategic and team-oriented collaboration approach – sustainable improvements that fit the organization’s goals.