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Patient Centered Care Report

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Evidence-Based Practice for Patient-Centered Care and Population Health

Date: 07/11/2018

Overall Comments:

Thank you for this revision.  Unfortunately the requirements are still not being met because of not following the grading rubric completely for all required items.  I hope you can see the comments on your paper and can use them and follow the rubric for revising this paper if you choose to do so.   

1.  Introduction

2.  Evaluation of the outcomes of the PHII – not ones that were and were not met – all outcomes including missing information. 

3.  Using evidence-based research how can  you improve on the outcomes. 

4.  Identifying another PHII you were to develop approaches to personalizing patient care from the other PHII.  

5.  You were to provide research to validate information about personalizing patient care including a successful PHII.  Then you were to identify knowledge gaps from the research you used.

6.  In this section you were to identify a framework, which contains concepts, which would have been used to evaluate the outcomes of the PHII. You were to acknowledge the limitations of this proposal.  

7.  see paper for APA formatting issues, etc.  

This is a much better paper, but the main thing is to identify a successful PHII.  For example others have used Triple Aim but there are many others.  If you have questions please let me know.  

Patient Centered Care Report


Population health improvement initiative is meant to bring some improvement in a certain health issue in the community (Hack et al., 2017). The initiative must have some outcomes at the end of the improvement process. These are the set goals or achievements that the initiative wishes to achieve at the end of the process.In the case at hand, the expected achievements of the population health improvement plan for elderly people with traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) include; improvement in moods, memory, and muscle control. Most elderly people with TBI and PTSD have frequent cases of loss of memory. They tend to forget things easily (Winter et al., 2016). In addition, they also have issues with their moods. Their muscle control is also very low.

The Outcomes

Out of the above outcomesWhat outcomes? You have not identified any outcomes yet, but you stated – “Out of the above outcomes…” This is very confusing that the initiative wished to achieve, the achievements that were made are going to be focused in this section. The first one is improvement in memory. The initiative managed to improve the memory of the participants using various interventions. Exercise was the most effective treatment (Duzel, van Praag, & Sendtner, 2016). About four hundred people agreed to participate in the exercise therapy. This was about half the number of the total participants. They followed the Center incorrect name – Centers – not Centerfor Disease and Prevention’s recommendations for aerobics and after four weeks, there was a general improvement in mood, memory, and muscle control for all the four hundred participants. 75% of the four hundred participants continued with the therapy and after three weeks, they showed a great improvement in short to medium term memory (Winter et al,. 2016). Although there was an improvement in mood and muscle control, it was not as great as improvement in memory. How do you know this? There is no reference.

The second one was improvement in mood. The medication and therapy were very effective in the improvement of mood. While analyzing the needs of the population, it was discovered that most of the patients did not receive any form of psychotherapy immediately they were diagnosed with TBI and PTSD. Therefore, the healthcare health care is two words – not one. giver decided to introduce the patients to anti-depressant medication. Forty percent of the total population started the anti-depressant medication and nine percent started taking anti psychotics and the outcomes were measured after six months. They recorded a twenty-six percent improvement in mood and six percent improvement in memory. Again, no reference – where did you obtain this information?

The third outcome is improvement in muscle control. Elderly people generally become weak such that they can hardly control their muscles. To improve on this need, the patients were introduced to strength training which they preferred as compared to aerobics. This showed a great improvement in muscle control but did not have any impact on mood and memory. No references to validate this information

Outcomes that were not achieved

However, the following outcomes were not achieved as expected. The section was to identify outcomes and an evaluation of them. This section was not required.The initiative planned to use Sudoku and crossword puzzles as a therapy to improve on the memory of the elderly people. However, they did not how any gains even after the healthcare givers tried to take the patients through the therapy. Also, meditation is another intervention that the healthcare givers planned to use to improve health of the population. It is a very effective intervention when it comes to TBI and PTSD. However, it did not work as expected because only a few participants were willing to take part in it. For those who accepted the mediation intervention, they recorded more than seventy percent improvement in mood and memory and over thirty-two percent improvement in muscle control.

Evaluation of outcomes

The outcomes of the above interventions are a reflection of the most effective interventions that can be used for similar cases. Exercise is an effective intervention for people suffering from TBI and PTSD because in this case, seventy five percent of those who adhered to the rules of the exercise therapy showed great improvement in their muscle support and memory. Medication is also another strategy though it is not very effective. It has to go hand in hand with other therapies. No references to validate any of the information in this section.

Strategy for improving outcomes

Therefore, in order to ensure that all the outcomes are achieved, the plan should include a strategy to deal with the outcomes that were not achieved. For example, in order to ensure thatthe cases of people being unable to control their muscles, the population should be educated on the importance of body exercise. To ensure that there is a great improvement on moods; patients should be encouraged to embrace medication because its outcomes were excellent. Some people were disinterested in meditation because it seems boring and requires a lot of discipline and they did not know its outcome. Before beginning the initiative, the stakeholders should come together and make a plan and the steps to be followed and also define clearly the roles of each stakeholder. This will ensure that all the anticipated outcomes will be achieved by the end of the initiative. Where is the references to validate any of this information.

In the previous section, it was pointed out that Sudoku and crossword puzzles could not be helpful in improvement elder people’s memory. This can be improved, however, by ensuring that they are provided with periodic monitoring, providing lifestyle guidance, and training them on cognitive function. Training programs and cognitive activities that include Sudoku, novels, and crosswords puzzles should be provided to them more frequently to aid in slowing down cognitive decline and to improve their cognitive ability (Eshkoor et al., 2015).

Another strategy for improving the outcomes of the population health improvement plan is by involving the community so as to ensure that the initiative is patient-centered. The community members should be consulted on their preferences and their opinions towards improving the issue of TBI and PTSD (Wick et al., 2015). The community will give the initiative light on the areas and factors that need to be improved. The initiative should not come up with outcomes that are against the community members’ cultures, preferences, and beliefs. If the outcomes are not in line with the needs of the community members, they will not be effective in improving the situation. This aspect is correlated with patient-centered care where the nurse should evaluate the patient’s needs and preferences before providing care to the patient.

Community Needs

A shared-decision making intervention would be very helpful in ensuring that care provided for TBI and PTSD patients is personalized. This intervention primarily emphasizes on collaboration between the patient and the physician. It involves the sharing of information reading the pros and cons of the various available treatment options; exploration of the preferences and expectations of the patient; and formulating a treatment option that is mutually agreed on by both the patient and the health care provider (Raue & Sirey, 2011). This intervention is helpful in clarifying personal patient values to enhance more informed treatment options. This intervention would be delivered to the patients by nurses with the involved primary care settings. It would involve face-to-face sessions and telephone follow-ups (Raue & Sirey, 2011).

Communication strategy

Communication is also a very important factor when carrying out a population health improvement initiative. In cases of communication barriers, the initiative may not bear fruits as expected. Communication barriers may be as a result of illiteracy of the community members or difference in ethnicity among the stakeholders (Smith& Topham, 2016). The community is made up both literate and illiterate people and all of them should benefit from the initiative. Therefore, in order to find a solution for miscommunication, the initiative should include some members of the community to communicate the process to the community in a language that every person will understand (Davis Boykins, 2014). It is very important to involve community members in the initiative.


In conclusion, patient centered care includes involving the patient in the healthcare by listening to the patient and also informing the patient about the healthcare process. Patients have the rights to know about their illnesses, and the form of healthcare that the healthcare givers plan to give the patients. Patient-centered care provides care that is respectful to the preferences, the values, and the needs of the patient. The healthcare givers are guided by the preferences of the patient. This has improved the quality of healthcare given to the patients.


Davis Boykins, A. (2014). Core communication competencies in patient-centered care. ABNF Journal25(2).

Duzel, E., van Praag, H., & Sendtner, M. (2016). Can physical exercise in old age improve memory and hippocampal function? Brain139(3), 662–673.

Eshkoor, S. A., Hamid, T. A., Mun, C. Y., & Ng, C. K. (2015). Mild cognitive impairment and its management in older people. Clinical Interventions in Aging10, 687–693.

Hack, S. M., Muralidharan, A., Brown, C. H., Lucksted, A. A., & Patterson, J. (2017). Provider behaviors or consumer participation: How should we measure person-centered care?.International Journal of Person Centered Medicine7(1), 14-20.

Raue, P. J., & Sirey, J. A. (2011). Designing Personalized Treatment Engagement Interventions for Depressed Older Adults. The Psychiatric Clinics of North America34(2), 489–500.

Smith, K., & Topham, C. (2016). Patient-Centered Care. Journal of Medical Imaging and Radiation Sciences47(4), 373-375.

Wick, E. C., Galante, D. J., Hobson, D. B., Benson, A. R., Lee, K. K., Berenholtz, S. M., … & Wu, C. L. (2015). Organizational culture changes result in improvement in patient-centered outcomes: implementation of an integrated recovery pathway for surgical patients. Journal of the American College of Surgeons221(3), 669-677.

Winter, L., Moriarty, H. J., Robinson, K., Piersol, C. V., Vause-Earland, T., Newhart, B., … & Gitlin, L. N. (2016). Efficacy and acceptability of a home-based, family-inclusive intervention for veterans with TBI: A randomized controlled trial.Brain injury30(4), 373-387.

COMPETENCY:Evaluate the value and relative weight of available evidence upon which to make a clinical decision.

CRITERION:Justify the value and relevance of evidence used to support an approach to personalizing patient care.



Presents a weak justification of the value and relevance of evidence used to support an approach to personalizing patient care.

Faculty Comments:“You were to provide research to validate information about personalizing patient care including a successful PHII. Then you were to identify knowledge gaps from the research you used.”

COMPETENCY:Evaluate outcomes of evidence-based interventions.

CRITERION: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.



Attempts to propose a framework for evaluating the outcomes of an approach to personalizing patient care, but proposed criteria are not measurable or not relevant, or aspects of the approach are not likely to be transferable to other cases.

Faculty Comments:“In this section you were to identify a framework, which contains concepts, which would have been used to evaluate the outcomes of the PHII. You were to acknowledge the limitations of this proposal. ”

COMPETENCY:Apply evidence-based practice to design interventions to improve population health.

CRITERION: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.



Proposes a strategy that is not useful for improving outcomes or ensuring that all outcomes are being addressed, or the strategy is not based on the best available evidence.

Faculty Comments:“Did not use evidence-based information to validate the information in this evaluation. ”

COMPETENCY:Synthesize evidence-based practice and academic research to communicate effective solutions.

COMPETENCY:Apply evidence-based practice to plan patient-centered care.

CRITERION:Develop an approach to personalizing patient care that incorporates lessons learned from a population health improvement initiative.



Develops an approach to personalizing patient care that does not clearly incorporate lessons learned from a population health improvement plan.

Faculty Comments:“Identifying another PHII you were to develop approaches to personalizing patient care from the other PHII. ”

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