INSPIREd Healthcare

In today’s environment where healthcare costs are outpacing the economy, healthcare systems are shifting from fee-for-service to value-based payment to deliver high-quality care while reducing costs. This shift presents nurses with the opportunity to take the lead in transforming care delivery and achieve the Triple Aim goals: improving patient experience of care, improving health of populations, and reducing per capita healthcare costs.

INSPIREd Healthcare follows author Billie Lynn Allard and her team of nurses as they successfully implement an accountable community of health in pursuit of the Triple Aim. The INSPIRE Model they follow provides an evidence-based blueprint for other healthcare systems hoping to solve the complicated problems surrounding care transitions and health promotion.

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Table of Contents

• Part 1: The Road to INSPIRE
• Chapter 1 Healthcare Reform in the U.S.
• Chapter 2 Answering the Call for Change
• Chapter 3 Laying the Groundwork for a Transitional Care Nurse Program
• Chapter 4 Piloting the Transitional Care Nurse Program
• Chapter 5 Challenges and Roadblocks
• Chapter 6 Evaluating and Addressing Highest-Priority Care Transition Needs
• Chapter 7 Getting the Chief Financial Officer to Buy In
• Chapter 8 Creating Successful Partnerships
• Chapter 9 Compliance and Regulatory Concerns Associated with Transitional Care Nursing Programs
• Chapter 10 Documentation and Data Management
• Chapter 11 Spreading the TCN Program and INSPIRE Model Across the Profession
• Part 2: INSPIRE Across the Care Continuum
• Chapter 12 INSPIRE: Mental Health and Substance Abuse
• Chapter 13 INSPIRE: Pulmonary Rehabilitation for Patients With COPD
• Chapter 14 INSPIRE: Decreasing Hospital Readmissions From Skilled Nursing Facilities
• Chapter 15 INSPIRE: The Clinical Pharmacist and Medication Management
• Chapter 16 INSPIRE: Pediatric Community Care
• Chapter 17 INSPIRE: Management of the Diabetic Patient
• Chapter 18 INSPIRE: Physical Therapy Evaluation in the Emergency Department
• Chapter 19 INSPIRE: Palliative Care Program
• Chapter 20 Community Projects

About the Author

Billie Lynn Allard, MS, RN, FAAN, is the Administrative Director of Population Health and Transitions of Care at Southwestern Vermont Health Care. As an exceptional nursing leader for the past 35 years, Allard has spent her career leading innovation in community hospital settings, serving as Director of Cardiopulmonary Nursing, Director of the Emergency Department, and Chief Nursing Officer. Her visionary leadership style inspired nurses to function at the height of their capabilities, achieving 100% certification, implementing cutting-edge evidence-based practice, transforming care delivery, and improving patient satisfaction and clinical outcomes. In the past decade, Allard has led the implementation of an Accountable Community of Health as part of an all-payer model in Vermont.