DNP 714 Module 7 Transdisciplinary Care Model Example

Course	DNP 714 Professional Relationships in Healthcare
Module	Module 7
Paper type	Team care model with presentation
Length	About 763 words, 5 pages
Format	APA 7 student paper
School	Arizona State University
Program	Doctor of Nursing Practice
Updated	October 2026

Free sample paper for DNP 714 Module 7

Care That Comes to the Door: A Scalable Transdisciplinary Model of Home-Based Primary Care for Homebound Older Adults in Rural Arizona

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

DNP 714: Professional Relationships in Healthcare

Instructor Name

Month Day, Year

What this page is doingThe title states what the model does and for whom, and the word scalable from the prompt is carried into the subtitle so the board sees it addresses that criterion.

Care That Comes to the Door: A Scalable Transdisciplinary Model of Home-Based Primary Care for Homebound Older Adults in Rural Arizona

The Population and the Problem

Our population is adults 65 and older in a rural Arizona county who are homebound because of frailty, dementia, heart or lung disease or limited mobility. Many cannot drive the 40 to 70 miles to a clinic. They miss visits, their medications go unreviewed and they reach the emergency department when a problem has become a crisis. Family caregivers carry much of the work, often alone.

The Model

A transdisciplinary team brings primary care to the home. Each enrolled patient has a nurse practitioner who leads care, visits monthly or as needed and is backed by a physician. A registered nurse coordinates care, visits between practitioner visits and runs a weekly phone check. A pharmacist reviews medications at enrollment and after any hospital stay. A social worker addresses caregiver strain and community resources. Telehealth fills gaps between visits. The team meets weekly to review every patient whose status has changed.

Roles Across Four Levels

Level	Role	Responsibilities in the model
Individual	Patient and caregiver	Set goals for care; report changes; join the weekly phone check
Team	Nurse practitioner	Leads assessment, diagnosis, treatment and advance care planning
Team	Physician	Consults on complex cases; covers after hours with the nurse practitioner
Team	Registered nurse	Coordinates care, educates, triages calls, monitors vital signs remotely
Team	Pharmacist	Medication review and deprescribing recommendations; works with the dispensing pharmacy on blister packs
Organization	Executive	Secures funding, sets targets, removes barriers between departments
Organization	Supply vendor	Delivers durable equipment, wound supplies and remote monitoring devices to the home within 48 hours
Community	Area agency on aging, churches, fire district	Meals, transportation, caregiver respite and wellness checks during heat warnings

What this page is doingThe roles table places every role the prompt names at one of the four required levels and says what each does in this model, so the board can see that no required role is missing.

Evidence for the Model

Team members share goals, knowledge and respect across disciplines, the conditions relational coordination research ties to better quality and efficiency (Gittell et al., 2000). The weekly team meeting builds the closed-loop communication and shared mental models that teamwork research identifies as core mechanisms (Salas et al., 2005). Bringing primary care home has also been tested directly: in a matched comparison of high-risk older adults in Washington, D.C., those in a home-based primary care program had 17% lower Medicare costs over two years, with lower hospital and nursing facility costs and higher home health and hospice use (De Jonge et al., 2014). That was one program with a matched rather than randomized design, so this model includes its own evaluation.

Culture, Vision, Structure and Strategy

Culture: the model needs a culture in which the nurse practitioner leads and every discipline's input is expected, including the supply vendor's report that a patient has not ordered supplies. Leaders will build psychological safety by asking for concerns at every weekly meeting (Edmondson, 1999).

Vision: "Every homebound older adult in the county can stay safely at home with care that comes to them."

Structure: a home-based primary care unit inside the county's federally qualified health center, with its own team, budget and scheduling, linked to the hospital through shared records.

Strategy: start with 100 patients, prove value in 18 months, then expand.

Scalability

The model scales by adding teams of the same shape rather than enlarging one team, which keeps relationships small enough to work.

Phase	Scope	Team size	Trigger to move on
1	One county, 100 patients	2 nurse practitioners, 2 nurses, 0.5 pharmacist, 1 social worker	Hospital days and costs below comparison group at 18 months
2	Same county, 250 patients	Add a second team and a telehealth nurse	Stable quality and staff retention
3	Three counties	Regional team with shared pharmacist and physician	Payer contracts in place

Value Measures

Hospital stays and emergency department trips for every thousand enrolled patients; days at home; medication problems resolved; caregiver strain scores; patient goal attainment; and total cost per patient compared with similar homebound adults not enrolled.

Evaluation of Our Team Process

Our team used Tannenbaum and Salas (2021) to rate itself at the end of the project: purpose and roles were strong, while trust built slowly in the first month. Next time we would hold a short check-in on how the team is working at the midpoint, not only at the end.

Area	Strength	Area for growth
Communication	Weekly call with an agenda; summaries posted the same day	Early messages went unanswered for days
Collaboration	Every member drafted a section; disagreements about scale were settled by data	One member's community perspective entered late
Coordination	Shared timeline met every deadline	Final slides assembled the night before

References

De Jonge, K. E., Jamshed, N., Gilden, D., Kubisiak, J., Bruce, S. R., & Taler, G. (2014). Effects of home-based primary care on Medicare costs in high-risk elders. Journal of the American Geriatrics Society, 62(10), 1825-1831. https://doi.org/10.1111/jgs.12974

Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350-383. https://doi.org/10.2307/2666999

Gittell, J. H., Fairfield, K. M., Bierbaum, B., Head, W., Jackson, R., Kelly, M., Laskin, R., Lipson, S., Siliski, J., Thornhill, T., & Zuckerman, J. (2000). Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital study of surgical patients. Medical Care, 38(8), 807-819. https://doi.org/10.1097/00005650-200008000-00005

Salas, E., Sims, D. E., & Burke, C. S. (2005). Is there a "Big Five" in teamwork? Small Group Research, 36(5), 555-599. https://doi.org/10.1177/1046496405277134

Tannenbaum, S., & Salas, E. (2021). Teams that work: The seven drivers of team effectiveness. Oxford University Press.

What the DNP 714 Module 7 instructions ask for

The posted syllabus grades Team Assignment 3 at 25 points in Module 4, the largest team assignment. Teams create a scalable, transdisciplinary, value-driven patient care model for a population they define from their collective experience. The model must show individual, team, organization and community involvement, describe the impact of organizational culture, vision, structures and strategy, and include at least the patient, physician, nurse practitioner, pharmacist, registered nurse, supply vendor and executive. The rubric also rewards evidence for implementation and an evaluation of the team's own communication, collaboration and coordination, with strengths and areas for growth. Each team has 20 minutes to present, and the model can be presented in any vehicle that can be submitted. Define the population narrowly enough that the model is concrete.

Inside the DNP 714 Module 7 example

The model opens by defining the population and the problem it faces. A short description of the model is followed by a table placing every required role at the individual, team, organization or community level with its responsibilities. An evidence section links the model to relational coordination and teamwork research and notes what published evaluations of similar programs suggest. A section addresses culture, vision, structure and strategy in turn. A scalability table sets out three phases with team size and triggers for moving on, and value measures follow. The model closes with the team's evaluation of its own process. Four sources support it, including the course text.

Reading the DNP 714 Module 7 grading rubric

The rubric lists points for designing a model for a designated population, including roles and requirements at the individual, team, organizational and community levels, discussing impact across culture, vision, structure and strategy, the adequacy of evidence for implementation and recommendations, and an evaluation of the team's own process covering communication, collaboration, coordination, strengths and areas for growth. Models earn most when every required role is placed and explained. Scalability should be shown with phases and triggers rather than asserted. Value measures should include cost and patient outcomes. The team process evaluation should be honest, with specific areas for growth. Cited evidence for the model's core features makes the recommendations more convincing.

DNP 714 Module 7 help: mistakes that cost marks

A frequent weakness is a model that names the required roles in a list without explaining what each does. Use a table that places each role at a level. Another is ignoring the supply vendor and executive, which the prompt names explicitly. Show how the model scales instead of only saying it can. Do not skip the team process evaluation; it carries points of its own. Give the desk your team's population and the roles you plan to include, and a model can be drafted for the presentation. Rehearse the 20-minute presentation, leaving time for questions. Make sure the submitted version stands on its own without the spoken presentation. Give each teammate a section of the presentation they drafted.

Write yours, or have the desk draft it

This paper is an original model document written by our desk, not a submitted student paper and not an official Arizona State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.

More DNP 714 and Doctor of Nursing Practice sample papers

DNP 714 Module 7 questions, answered

Where can I find a free DNP 714 Module 7 sample paper?

The model above is a complete DNP 714 Team Assignment 3 sample, a scalable transdisciplinary home-based primary care model for homebound older adults with roles, scale-up phases and a team process evaluation.

How many points is DNP 714 Team Assignment 3?

The posted syllabus lists it at 25 points, the largest team assignment, with a 20-minute presentation in Module 4.

Which roles must the DNP 714 care model include?

At least the patient, physician, nurse practitioner, pharmacist, registered nurse, supply vendor and executive.

How do I show a care model is scalable?

Set out phases with team size, scope and the results that trigger each expansion, and explain how the model grows without losing what makes it work.

Does the DNP 714 final project include a team evaluation?

Yes. The rubric asks for an evaluation of the team's communication, collaboration and coordination, with strengths and areas for future growth.

DNP 714 Module 7 Team Assignment 3: A Scalable Transdisciplinary Care Model Example