Patient-Centered Care Report example
Assignment: Patient-Centered Care Report
Evidence–Based Health Evaluation and Application
Question description
Patient-Centered Care Report:Write a report on the application of population health improvement initiative outcomes to patient-centered care, based on information presented in an interactive multimedia scenario.
In this assessment, you have an opportunity to apply the tenets of evidence-based practice in both patient-centered care and population health improvement contexts. You will be challenged to think critically, evaluate what the evidence suggests is an appropriate approach to personalizing patient care, and determine what aspects of the approach could be applied to similar situations and patients. Patient-Centered Care Report example.
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Patient-Centered Care Report
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Apply evidence-based practice to plan patient-centered care. ◾Evaluate the outcomes of a population health improvement initiative.
◾Develop an approach to personalizing patient care that incorporates lessons learned from a population health improvement initiative. Patient-Centered Care Report example.
Competency 2: Apply evidence-based practice to design interventions to improve population health. ◾Propose a strategy for improving the outcomes of a population health improvement initiative, or for ensuring that all outcomes are being addressed, based on the best available evidence.
Competency 3: Evaluate outcomes of evidence-based interventions. ◾Propose a framework for evaluating the outcomes of an approach to personalizing patient care and determining what aspects of the approach could be applied to similar situations and patients. Assignment: Patient-Centered Care Report
Competency 4: Evaluate the value and relative weight of available evidence upon which to make a clinical decision. ◾Justify the value and relevance of evidence used to support an approach to personalizing patient care.
Competency 5: Synthesize evidence-based practice and academic research to communicate effective solutions. ◾Write clearly and logically, with correct grammar and mechanics.
◾Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Preparation
In this assessment, you will base your Patient-Centered Care Report on the scenario presented in the Evidence-Based Health Evaluation and Application media piece. Some of the writing you completed and exported from the media piece should serve as pre-writing for this assessment and inform the final draft of your report. Even though the media piece presented only one type of care setting, you can extrapolate individualized care decisions, based on population health improvement initiative outcomes, to other settings.
Requirements
Note: The requirements outlined below correspond to the grading criteria in the scoring guide, so be sure to address each point. In addition, you may want to review the performance level descriptions for each criterion to see how your work will be assessed. Patient-Centered Care Report example Assignment: Patient-Centered Care Report
Writing, Supporting Evidence, and APA Style
◾Write clearly and logically, using correct grammar and mechanics.
◾Integrate relevant evidence from 3–5 current scholarly or professional sources to support your evaluation, recommendations, and plans. •Apply correct APA formatting to all in-text citations and references.
•Attach a reference list to your report.
Report Content
Address the following points in a 4–6 page Patient-Centered Care Report example:
◾Evaluate the expected outcomes of the population health improvement initiative that were, and were not, achieved. •Describe the outcomes that were achieved, their positive effects on the community’s health, and any variance across demographic groups.
•Describe the outcomes that were not achieved, the extent to which they fell short of expectations, and any variance across demographic groups.
•Identify the factors (for example: institutional, community, environmental, resources, communication) that may have contributed to any achievement shortfalls.
◾Propose a strategy for improving the outcomes of the population health improvement initiative, or ensuring that all outcomes are being addressed, based on the best available evidence. •Describe the corrective measures you would take to address the factors that may have contributed to achievement shortfalls.
•Cite the evidence (from similar projects, research, or professional organization resources) that supports the corrective measures you are proposing.
•Explain how the evidence illustrates the likelihood of improved outcomes if your proposed strategy is enacted
◾Develop an approach to personalizing patient care that incorporates lessons learned from the population health improvement initiative outcomes. •Explain how the outcomes and lessons learned informed the decisions you made in your approach for personalizing care for the patient with a health condition related to the population health concern addressed in the improvement initiative. Patient-Centered Care Report example.
•Ensure that your approach to personalizing care for the individual patient addresses the patient’s: •Individual health needs.
•Economic and environmental realities.
•Culture and family.
•Incorporate the best available evidence (from both the population health improvement initiative and other relevant sources) to inform your approach and actions you intend to take.
◾Justify the value and relevance of evidence you used to support your approach to personalizing care for your patient. •Explain why your evidence is valuable and relevant to your patient’s case.
•Explain why each piece of evidence is appropriate for both the health issue you are trying to correct and for the unique situation of your patient and their family.
◾Propose a framework for evaluating the outcomes of your approach to personalizing patient care. •Ensure that your framework includes measurable criteria that are relevant to your desired outcomes.
•Explain why the criteria are appropriate and useful measures of success.
•Identify the specific aspects of your approach that are most likely to be transferable to other individual cases.
Evidence–Based Health Evaluation and Application
Introduction
Public health improvement initiatives (PHII) provide invaluable data for patient–centered care, but their research is often conducted in a context different from the needs of any individual patient. Providers must make a conscious effort to apply their findings to specific patients’ care.
In this activity, you will learn about a PHII, and explore its application to a particular patient’s care plan.
Patient Assignment
Overview
You continue in your role as a nurse at the Uptown Wellness Clinic. You receive an email from the charge nurse, Janie Poole. Click the button to read it. Patient-Centered Care Report example.
Patient Profiles
From: Janie Poole4/21/2019
To: Student
Good morning!
At last week’s conference I spoke with Alicia Balewa, Director of Safe Headspace. They’re a relatively new nonprofit working on improving outcomes for TBI patients, and I immediately thought of Mr. Nowak. At his last biannual cholesterol screening he mentioned having trouble with his balance. This may be related to his hypertension, but he believes it’s related to the time he was hospitalized many years ago after falling out of a tree, and expressed distress that this might be the beginning of a rapid decline.
Ms. Balewa will be on premises next week, and I’d like to set aside some time for you to talk. Assignment: Patient-Centered Care Report
— Janie
Overview
Interview Alicia Balewa to find out more about a public health improvement initiative that might apply to Mr. Nowak’s care.
Alicia Balewa
Director of Safe Headspace
Interview
:
I have a patient who might benefit from some of the interventions for TBI and PTSD you recently studied. What populations did your public health improvement initiative study?
My father came home from Vietnam with a kaleidoscope of mental health problems. That was the 1970s, when treatment options for things like PTSD, TBI, and even depression were very different. Since then there has been a lot of investment in treatment and recovery for combat veterans. That’s excellent news for veterans in treatment now, but they’re not looking at my dad, and how his TBI and PTSD have affected him through mid–life and now as a senior. That’s why I started Safe Headspace: to focus on older patients who are years or decades past their trauma, and find ways to help them. Patient-Centered Care Report example.
Which treatments showed the strongest improvement?
Exercise. We were able to persuade about half of our participants — that’s around 400 people, mostly men ages 45–80 — to follow the CDC’s recommendations for moderate aerobic exercise. Almost everyone showed improvement in mood, memory, and muscle control after four weeks. After that a lot of participants dropped out, which is disappointing. But of the 75 who stuck with it for another three months, muscle control improved 15%, mood improved 22%, and short–to–medium term memory improved 61%. We didn’t specify what kind of exercise, but we did ask them to record what they did every week, so that data is available. Assignment: Patient-Centered Care Report
Second was medication and therapy. Most of our participants didn’t receive any kind of psychotherapy in the years immediately following their trauma, so we had everyone assessed by a team of psychotherapists. As a result of those assessments, 40% of participants started on anti–depressant medication and 9% started taking anti–psychotics. Those who started taking medications now have regular contact with a therapist to manage that care. With some help at home to stick to the regimen, all but a few have successfully followed their treatment plans. They’ve reported a 26% improvement in mood over six months, and a 6% improvement in memory. Patient-Centered Care Report example.
The third treatment I want to mention is meditation. We only had a small group interested in trying it, but the results were dramatic. We prescribed daily meditation at home, just 10 to 15 minutes, with a weekly hour–long guided group meditation for all 23 participants. After three weeks we lost two to disinterest, but the other 21 showed improvements of over 70% in mood and memory, and 32% in muscle control.
Have you tried anything that hasn’t worked?
Sure. There are memory exercises for patients in elderly care, and things like Sudoku and crossword puzzles. We didn’t see any gains with those. Some of our participants preferred strength training to aerobic exercise, and the only improvement we saw in that group was in muscle control, but only 4%, which is significantly less than the aerobic group.
I should also say that we were working with a willing group of participants. They knew they needed help, and were motivated to get it. One of the hurdles we see with veterans, especially in older generations, is an unwillingness to acknowledge that they have a problem. We haven’t had to wrestle with that because everyone who volunteers to participate wants to be there.
Your organization is intervening with people who have TBI and PTSD simultaneously. We have a patient with moderate TBI suffered almost 40 years ago, but no history of PTSD. Have you separated your population and studied each separately? Assignment: Patient-Centered Care Report
What were the outcomes of the PHII? .
How could they have been improved? .
How do the results of the PHII relate to Mr. Nowak’s case?
Conclusion:
As you’ve seen, a PHII can apply to a patient under your care. But it’s not always a perfect fit, and it’s important to think carefully about how your patient’s condition, symptoms, background, and experience compare to that of participants in a PHII.
You may find it helpful to download the responses you made in this activity. Assignment: Patient-Centered Care Report.
[Title Here, up to 12 Words, on One to Two Lines]
Learner’s Name
Capella University
Evidence-Based Practice for Patient-Centered Care and Population Health
Patient-Centered Care Report
July, 2017
[Title Here, up to 12 Words, on One to Two Lines]
Health care organizations in the United States are realizing the importance of health improvement initiatives aimed at large population groups. Population health improvement initiatives (PHIIs) were introduced to reduce health care costs in general and improve the health of people in different population groups such as pregnant women or the elderly. Additionally, PHIIs provide vital data on patient-centered care and per capita cost in the form of measurable clinical, humanistic, procedural, economic, and utilization outcomes (Huber, 2017). Health care professionals consider a PHII’s outcomes as evidence for care plans that meet the individual needs of patients treated by a health organization.
Often, the evidence that a health care professional encounters is not presented in the exact context of that professional’s practice because of differences in the patient population, illnesses, or care environment. In such situations, health care professionals analyze a PHII’s evidence and select only those variables that apply to the context of the specific patient care plan. The process of transferring evidence into practice from one context to another is discussed using the example of Uptown Wellness Clinic’s (UWC) patient Mr. Nowak, who suffered a traumatic brain injury (TBI) after a fall. At his cholesterol screening, Mr. Nowak complained that he has been losing his balance lately. According to him, the balance problems are symptomatic of the brain injury. A charge nurse at UWC recommended that Mr. Nowak’s patient care plan be based on evidence gathered from Safe Headspace, a nonprofit PHII that works to improve outcomes for people with TBI and posttraumatic stress disorder (PTSD; Capella University, n.d.). Once the PHII’s outcomes are evaluated, the evidence will be transferred into Mr. Nowak’s treatment context. Patient-Centered Care Report example.
The objective of the evaluation is to reveal knowledge gaps in the PHII, devise strategies to bridge the gaps, and incorporate the new strategies into Mr. Nowak’s patient care plan. The evidence will help create a new assessment framework for the patient care plan as well.
Evaluation of a Population Health Improvement Initiative’s Outcomes
Since its formation, Safe Headspace PHII significantly improved health outcomes in older patients suffering from PTSD because of head trauma. The PHII uses various interventions to treat mental health problems, such as exercise, therapy, and meditation. Regular exercise was the initiative’s most successful intervention. Of the 400 participants in the intervention, mostly men in the 45–80 age bracket, 75 participants followed aerobic exercise routines for four months. 15% of the men showed improved muscle control, 22% showed improved mood, and 61% showed improved short- to medium-term memory (Capella University, n.d.). Patient-Centered Care Report example.
Those who volunteered for medication and therapy were assessed by a team of psychotherapists and provided therapy support—40% of the participants started on antidepressants and 9% started taking antipsychotics. Within six months, 26% of the participants showed improvement in their mood and 6% showed improvement in memory. The third intervention, meditation, had only 23 participants but showed positive outcomes. In three weeks, 21 participants—two dropped out—showed over 70% improvement in mood and memory and 32% improvement in muscle control. Strength training and puzzle solving to improve memory were unsuccessful interventions because the interventions did not give any significant gains (Capella University, n.d.). Patient-Centered Care Report example.
However, these statistics do not give a complete picture. To begin with, the PHII intervened with people who were diagnosed with both PTSD and TBI. The impact of interventions on patients with either PTSD or TBI was not studied separately. Therefore, the outcomes of cases like Mr. Nowak’s, who has TBI and no history of PTSD, are unknown and need further evaluation. Moreover, Safe Headspace’s outcomes do not explain why patients were demotivated from following self-management plans and whether the lack of motivation relates to factors such as high medical costs or unsatisfactory care. Evaluating these unexplored outcomes expands the evidence base and helps health care professionals in deciding interventions that will be appropriate for a patient’s symptoms, background, and experiences.
Strategies to Improve Outcomes of a Population Health Improvement Plan
The launch of the Triple Aim by the Institute for Healthcare Improvement in 2007 was a landmark development toward quality improvement in health care in the United States. The Triple Aim is a broad framework of linked goals designed to optimize health system performance: (a) improving the patient’s experience of care, (b) improving the health of populations, and (c) reducing per capita cost of health care (American Hospital Association, 2015). The framework has influenced national initiatives such as the Patient Protection and Affordable Care Act and Centers for Medicare and Medicaid Services. Assignment: Patient-Centered Care Report
The Triple Aim goals have five preconditions for high-quality care: (a) focus on individuals and families, (b) redesign of primary care services and structures, (c) population health management, (d) cost control platform, and (e) system integration and execution (Institute for Healthcare Improvement, n.d). The evaluation of Safe Headspace’s data reveals the poorly integrated Triple Aim goals. As UWC’s patient care plan is based on evidence collected from Safe Headspace’s PHII outcomes, the new care setting may inherit the poor outcomes. Incorporating the Triple Aim prevents the transfer of faulty evidence into UWC’s patient care plan by setting achievable goals and improving the quality of care delivery at the clinic. Patient-Centered Care Report example.
By bridging the gaps in Safe Headspace’s programs, the PHII’s methods can be applied to UWC’s care plan for patients like Mr. Nowak. Bellin Health, an integrated health delivery system in Wisconsin, illustrates the effectiveness of the Triple Aim. Using the framework, Bellin improved the health of its enrolled employee and Medicare populations. The three Triple Aim goals reflected in the way Bellin’s health care professionals imparted cost-effective, patient satisfactory, and holistic care for large-scale health programs and individual cases (Whittington, Nolan, Lewis, & Torres, 2015). Patient-Centered Care Report example.
Despite its successes, the Triple Aim is facing many challenges. According to the American Healthcare Organization (2016), diverse health markets and a lack of shared vision make moving all health care systems to one approach challenging and impractical. A second challenge is the Triple Aim’s phantom limb, which refers to the well-being of health care professionals. According to a study, the three goals ignore the needs of caregivers, creating a stressful workplace that carries a high-risk of staff burnout (Spinelli, 2013). Therefore, quality improvement should include steps to improve the workplace for health care professionals.
It is important to consider the benefits and limitations of any quality improvement effort. Health care professionals at UWC should identify the advantages and disadvantages of using the Triple Aim for Mr. Nowak’s care plan. Likewise, the plan should incorporate lessons learned from the PHII outcomes and introduce changes to address inadequacies. Assignment: Patient-Centered Care Report
Approaches to an Individualized Personal Care Plan
UWC has two objectives behind developing an evidence-based patient care plan from Safe Headspace’s outcomes. The short-term objective is to diagnose and treat Mr. Nowak’s health problems. The long-term objective is to use Mr. Nowak’s care plan as the foundation for similar cases in the future. To achieve these objectives, UWC must change its organization and delivery systems. The need to change UWC’s health system is based on certain assumptions developed from the PHII evaluation: (a) the new delivery design should achieve the Triple Aim goals, (b) primary care providers should be competent in evidence-based practice (EBP), and (c) patients should receive self-management support and cost-effective care.
A current and innovative approach that satisfies the first assumption is the patient-centered medical home (PCMH). The PCMH can implement the Triple Aim goals by adopting new technologies and care delivery methods and establishing caring relationships with patients and families. The PCMH improves the delivery of primary care by making primary care comprehensive, patient-centered, coordinated, accessible, and committed to quality and patient safety (Patient-Centered Primary Care Collaborative, n.d.). These functions help understand the health, economic, and cultural needs of specific patients.
The process of implementing the PCMH includes training and evaluating health care professionals, especially primary care providers. Training and evaluation are important to integrating EBP into care delivery to improve outcomes. Among the methods that facilitate EBP, self-management is very successful. Patient-Centered Care Report example. One self-management practice is mobile health (mHealth), which is the use of mobile technologies to “inform, assess, anticipate, and aid in interventions while monitoring and coordinating patient health status and care” (Lahue, Hughes, Hills, Li, & Hiatt, 2015, para. 1). Mobile health is cost-effective because it reduces the number of clinical visits and circumvents the limited availability of care providers and resources (Nundy, 2012).
Once applied to UWC’s patient care plan, the PCMH, EBP, and mHealth can guide Mr. Nowak’s care in the hospital and in his home. The three approaches can improve Mr. Nowak’s awareness of his condition, motivate him to start self-management methods, and make health care more accessible to him. In addition, the approaches will help UWC achieve its second objective regarding the patient care plan. The value and relevance of the approaches can be justified by evaluating current research on their application.
Value and Relevance of Evidence Used in Patient Care Plan
Many studies advocate incorporating the PCMH, EBP, and self-management practices in population health improvement efforts. Evidence-based practice is a fundamental guideline (Huber, 2017) for all levels, initiatives, and sectors in health care, not just population health improvement. Therefore, justifying the value of EBP is unnecessary. The PCMH and mHealth, however, are relatively new approaches and require evaluations of their evidence-base.
The PCMH was very successful at improving the relationship between primary care teams, patients, and families. One three-year study described the successful integration of the PCHM in the Pennsylvania Chronic Care Initiative. Adjusted costs observed in the PCMH pilot year were 17.5% lower than data from non-PCMH practices. As a result, rates of hospitalization, emergency department visits, and ambulatory visits reduced (Nielsen, Buelt, Patel, & Nichols, 2016). Similar results were seen in the Texas Children’s Health Plan and Hudson Valley initiative. Patient-Centered Care Report example.
The second approach, mHealth, has great potential in areas with high clinical and cost burdens, such as urban areas. One such setting was the University of Chicago Medicine (UCM), an academic medical center serving predominantly urban, working-class African American communities. The mHealth initiative included texting services for self-management support, sending e-mail and text alerts about appointments, follow-up contact through phone calls, e-mails, and texts. These steps greatly enhanced care management processes and motivated patients to practice self-management methods regularly (Nundy et al., 2012).
However, these approaches have limitations. To begin with, the PCMH is mostly used in chronic disease management (Nielsen, Buelt, Patel, & Nichols, 2016) and there is a dearth of information on its use in managing mental health problems. In the context of mHealth, Nundy et al. (2012) observed that patients using the platform needed a human face to be involved in the program. Patient-Centered Care Report example. Hence, the UCM assigned staff members to monitor mHealth participants. Furthermore, there are uncertainties about the implementation of mHealth because of the complex and highly regulated nature of technology and health markets.
The studies conducted on the PCMH and mHealth enhance UWC’s efforts in population health improvement. The evidence gathered from these studies will help the clinic take steps to improve the quality of these approaches. One of the ways to do that is to choose a sustainable evaluative framework to ensure that all patient care plan parameters are met.
Framework for Evaluation of Patient Care Plan Outcomes
A critical component of evidence-based practice is evaluation, without which improvements are difficult to achieve. Measurable data identify both effective and ineffective components of a health care initiative. Additionally, PHII evaluations help secure government funding, a necessity for organizations with enrolled Medicaid and Medicare populations.
The evaluative framework has certain prerequisites: Progress is tracked using the Triple Aim, and the framework is evaluated against the entire health system. The latter prerequisite is essential because allocating funds and resources for population health improvement needs the whole organization to make adjustments in primary, secondary, tertiary, and ancillary care systems. One Triple-Aim-aligned framework that UWC can implement is New Zealand’s County Manukau Health’s (CMH) System Level Measures (SLMs), which were adapted from the IHI’s Whole System Measures (Doolan-Noble, Lyndon, Hau, Hill, Gray, & Gauld, 2015).
The SLMs complement each other and represent measures across the continuum of care. Therefore, UWC can monitor how a change in one SLM increases or decreases other measures. The SLMs adapted by CMH are as follows: a) provide for patients with health care needs, (b) improving the process of providing services—access and end-of-life, (c) ensuring effectiveness, (d) reporting clinical outcomes, (e) reporting functional and efficiency outcomes, and (f) ensuring patient satisfaction. The measures are further comprised of process and outcome indicators. For example, some clinical outcome indicators are hospital standardized mortality ratios and adverse event rates (Doolan-Noble et al., 2015). As these indicators are specific to the population context, UWC needs to add or remove indicators accordingly Patient-Centered Care Report example.
While implemented successfully at the CMH, the SLMs have certain limitations. To begin with, a whole system evaluation presents a methodological challenge because of population variations and lack of standardization in coding and definitions of indicators. Furthermore, the SLM can present operational challenges at UWC—the clinic may not have the technical capability to capture, analyze, and publish SLM-related data. The solution is to create a team of data analysts for data collection and analyze data over a long period of time (Doolan-Noble et al., 2015).
The limitations, by themselves, are not challenging as there are specific strategies available that can address these problems. Nor do they dilute the importance of the measures. An evaluation is the only way UWC can gather robust information about the quality and safety of its initiative and realize the Triple Aim.
Conclusion
The implementation process of a population health improvement plan is complex and comprises many steps and strategies. In fact, errors can still arise despite using evidence-based methods and frameworks. In spite of the difficulties associated with implementing a PHII, it helps health care professionals create a comprehensive care plan for patients, such as Mr. Nowak, who exhibit physiological and mental health problems. The approaches help health care professionals adapt to changing care settings in the long term. Understanding the continuum of care from creation to evaluation is the first step to innovating existing health structures and achieving the Triple Aim. Patient-Centered Care Report example.
References
American Hospital Association. (2015, April).
Zeroing in on the Triple Aim
(Issue brief). Retrieved from American Hospital Association website: http://aha.org/content/15/brief-3aim.pdf
American Hospital Association, Committee on Research and Committee on Performance Improvement. (2016, January).
Care and payment models to achieve the Triple Aim
. Chicago, IL: American Hospital Association. Retrieved from http://aha.org/content/16/care-payment-models-achieve-triple-aim-report-2016.pdf Patient-Centered Care Report example
Capella University. (n.d.). Evidence-based health evaluation and application [Transcript]. Retrieved from http://media.capella.edu/CourseMedia/MSN6011/evidenceBasedHealthEvaluation/media.asp?
Doolan-Noble, F., Lyndon, M., Hau, S., Hill, A., Gray, J., & Gauld, R. (2015). How well does your healthcare system perform? Tracking progress toward the Triple Aim using system level measures.
The New Zealand Medical Journal, 128
(1415), 44–50. Retrieved from http://search.proquest.com.library.capella.edu/docview/1686373805/fulltextPDF/2505807F00D0482BPQ/1?accountid=27965
Huber, D. L. (2017).
Leadership and nursing care management
(6th ed.). Philadelphia: W. B. Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14 Patient-Centered Care Report example
Institute for Healthcare Improvement. (n.d.). The IHI Triple Aim. Retrieved from http://ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
Lahue, B. J., Hughes, K. E., Hills, B. J., Li, S. S., & Hiatt, J. C. (2015, July). Can mHealth revolutionize evidence-based practice in diabetes care? [Special section].
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Nielsen, M., Buelt, L., Patel, K, & Nichols, L. M. (2016).
The patient-centered medical home’s impact on cost and quality: Annual review of evidence, 2014-2015
. Retrieved from https://pcpcc.org/sites/default/files/resources/The%20Patient-Centered%20Medical%20Home%27s%20Impact%20on%20Cost%20and%20Quality%2C%20Annual%20Review%20of%20Evidence%2C%202014-2015.pdf
Nundy, S., Dick, J. J., Goddu, A. P., Hogan, P., Lu, C. E., Solomon, M. C., . . . Peek, M. E. (2012). Using mobile health to support the chronic care model: Developing an institutional initiative.
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Patient-Centered Primary Care Collaborative. (n.d.). Defining the medical home: A patient-centered philosophy that drives primary care excellence. Retrieved from https://pcpcc.org/about/medical-home
Spinelli, W. M. (2013). The phantom limb of the Triple Aim.
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Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the Triple Aim: The first 7 years.
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