Care Management;Care management consists of several healthcare professionals, such as nurses, social workers, and patent educators.



Care Management

Kimberly Boynton

Grand Canyon University

HCA-699- Evidence Based Research Project

Edward Paulch


Care Management

Care management is a term that refers to the activities carried out to improve patient care and reduce the need for medical services by enhancing care coordination and helping patients and caregivers to manage their healthcare conditions effectively. Care management utilizes several integrated programs which extend beyond current clinical care. Care management consists of several healthcare professionals, such as nurses, social workers, and patent educators. These healthcare management professionals work collaboratively to create a health care plan that will help meet the specific needs. Care management services include patient education, medication management, managing symptoms, and preventative testing. This essay aims to formulate a PICOT question associated with care management, describing the problem’s background and identifying the key stakeholders.Care Management

Background of the Problem

The problem that is aimed to be solved in care management is high rehospitalization rates due to poor care management among adults. Older adults are at risk have several complex medical and social needs that are fatal and can result in high increased mortality rates among older adults if care management for these adults is not efficient and effective. These medical conditions and social needs result in rapid hospitalization of older adults, which can be prevented through care management ((Wideman, 2012). Although the united states government has put in place several regulations and policies to ensure that the care management offered to older people is the best, several challenges have made it impossible to meet goals that have been put in place. One of the challenges includes a lack of guidelines to address care transitions between the hospital and the nursing home. Standardized disease management approaches should be introduced in geriatric care management to help lower hospitalization rates of the intended population. One of the ways to improve the quality of geriatric care management is through the use of pay for performance incentives. Pay for performance incentives are offered to healthcare providers if they meet specific performance results instead of their work. This incentive will motivate the healthcare team responsible for geriatric care management to improve the quality of care, efficiency, and the overall care they will be providing for the older adults, resulting in reduced hospitalization rates.


Several stakeholders are involved in the care management of older persons. These stakeholders are older adults, healthcare providers, the united states government, payers and policymakers, and the Medicare and Medicaid Services center. These stakeholders need to work together to ensure the successful implementation of the proposed solution. Implementing the proposed solution will help reduce the rehospitalization rates of older adults by improving care management which will benefit the older population.

PICOT Question

In older patients (P), what is the effect of pay for performance incentives for nurses (I) on improving care management and reducing rehospitalization rates (O) compared with the use of social support (C) within six months?

Purpose and Project Objective

This project aims to improve the quality of geriatric care management, which will reduce rehospitalization rates among patients. The study’s objectives are: to improve the quality of geriatric care management within six months and reduce the rehospitalization rates of older adults within six months.


It is important to address the issue of care management in older adults for several reasons. The first reason is that it will help reduce the mortality rates of older people, and the second reason is that it will help reduce rehospitalization rates (Vogeli et al., 2007). It is also important to address this issue to ensure quality and improved care for older adults.

Initial Reference List

Golden, A. G., Tewary, S., Dang, S., & Roos, B. A. (2010). Care management’s challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. The Gerontologist, 50(4), 451-458.

Donelan, K., Chang, Y., Berrett-Abebe, J., Spetz, J., Auerbach, D. I., Norman, L., & Buerhaus, P. I. (2019). Care management for older adults: The roles of nurses, social workers, and physicians. Health Affairs, 38(6), 941-949.

Bodenheimer, T., & Berry-Millett, R. (2009). Care management of patients with complex health care needs. Policy, 1(6).

Moyle, W., Olorenshaw, R., Wallis, M., & Borbasi, S. (2008). Best practice for the management of older people with dementia in the acute care setting: a review of the literature. International journal of older people nursing, 3(2), 121-130.


Vogeli, C., Shields, A. E., Lee, T. A., Gibson, T. B., Marder, W. D., Weiss, K. B., & Blumenthal, D. (2007). Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. Journal of general internal medicine, 22(3), 391-395.

Wideman, M. (2012). Geriatric care management: role, need, and benefits. Home Healthcare Now, 30(9), 553-559.



PICOT Question Template

Section 1: In this section, provide one word to describe each section of your proposed PICOT question.



Older adults



Pay for performance



Social support



Improve care management and reduce rehospitalization rates



6 months

Section 2: Write your PICOT question below using the words listed above.


Section 3: Use your PICOT to develop a formalized statement. Use the examples below to help formulate the statement.

In ___older patients____ (P), what is the effect of _pay for performance incentives for nurses______ (I) on __improving care management and reducing hospital reshoplizaton rates____(O) compared with _the use social support ______(C) within _six months_______ (T)?

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

For ________ (P) does the use of ______ (I) reduce the future risk of _hospitalization _______ (O) compared with _________ (C)?

Does __________ (I) influence ________ (O) in (subject) who have _______ (P) over ______ (T)?

PICOT Template

Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed methods approach. Sage Publications.

Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. Lippincott Williams & Wilkins

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