Design and implementation of an outcomes management model.

In today's capitation-based reimbursement environment, acute care staff nurses must coordinate patient care considering the full continuum of care. To do so effectively, staff nurses need tools to accurately predict patient needs, adjust service intensity accordingly, and evaluate the outcomes of the care provided. The design and implementation of a model to support acute care staff nurses in that effort is described. The model's implementation was evaluated, in part, using a ten-item pre- and post-implementation survey. The survey showed that staff nurses who participated in the final educational offering on the model increased significantly their reported use of aggregate data for planning care. To achieve the greatest impact, the model needs to evolve so that it is applied earlier in the care process than at initial hospitalization. Ideally, this should occur during a wellness visit or enrollment in a health plan.