Programs and Communities

Diabetes, a common chronic condition, effects many individuals causing poor quality of life, expensive medical bills, and devastating medical complications. While health care providers try to manage diabetes during short office visits, many patients still struggle to control their diabetes at home. Lack of diabetes self-management (DSM) is a potential barrier for people with diabetes having to maintain healthy hemoglobin A1cs (HgA1c).

In hopes of addressing this concern, an evidenced-based intervention; diabetic education and phone calls, using the chronic care model as its framework was implemented. The intervention targeted people with type II diabetes at a transitional care setting. Measured variables included HgA1c and DSM. Statistically significant improvements were seen in reported physical activity. Average improvements were seen in HgA1c and DSM after three months of diabetes self-management education (DSME). Attrition, cultural sensitivity, and increasing DSME hours should be further evaluated for future projects.

Background and Purpose: Over 30 million people in the United States (U.S.) have diabetes mellitus, which comprises about 9% of the population, and about 90% of individuals with diabetes have type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2017). Adults with type 2 diabetes at a local internal medicine clinic were consistently having high glycated hemoglobin (HbA1C) levels, demonstrated by data collected from the electronic health record (EHR), and there was no ordering process for referring patients to diabetes management education and support (DSMES) services. The purpose of this project was to improve glycemic control, demonstrated by lower HbA1C levels, and reach a diabetes education attendance rate of 62.5% at an internal medicine clinic in Chandler, Arizona.

Methods: An electronic health record (EHR) template was created and brief staff training was completed to connect patients with diabetes in the community to a local formal diabetes education program. HbA1C levels were measured before and three months after adults with education program. HbA1C levels were measured before and three months after adults with type 2 diabetes mellitus (T2DM) received physicians’ orders for a DSMES program, and rates of attendance to the program were calculated. Data was collected through the EHR and through feedback from the DSMES program. Descriptive statistics were used in data analysis.

Outcomes: The participants’ results did not demonstrate significant differences in pre-referral and post-referral HbA1C results after they were ordered DSMES services (p = .506). The proportion of education attendance (30%) was lower than the project goal of 62.5%, but increased from the clinic baseline.

Conclusions: EHR template implementation for referral to DSMES may increase rates of formal diabetes education and improve glycemic control. Larger sample sizes, longer project periods, alternative methods of communication, and increased follow-up of participants may be required to produce significant results.

Background: Healthcare providers are encouraged to prepare their practice to effectively manage the care of mild to moderate adolescent depression. Cost-effective screening, diagnostic, and newly developed pediatric primary care depression management guidelines have been established. To integrate guidelines into practice, primary care providers (PCPs) must document effectively to ensure a complete treatment plan is in place in the patient’s electronic health record (EHR).

Intervention: Elements from a flowsheet were implemented into the EHR to promote thorough assessment and documentation of care delivered to adolescents with depression.

Methods: An initial chart review was completed on patients diagnosed with depression. An updated depression template was implemented within the EHR for six weeks. A follow-up chart review was completed post-intervention to determine if documentation of elements from the adolescent depression guidelines improved after the EHR update. Pre-intervention and post- intervention surveys were delivered to PCP’s to understand their perspective on adolescent depression management.

Outcomes: The chart review revealed that baseline PHQ-9 screenings were documented in 91% (n=43) of the charts reviewed in the pre-intervention timeframe. Only 78% (n=7) of the charts reviewed during post-intervention included PHQ-9 screenings. Early intervention treatment options documented in the pre-intervention timeframe included education 100% (n=47), medication prescriptions 53% (n=25), and psychotherapy referrals 18% (n=18). During post- intervention, education 100% (n=9), medication prescriptions 78% (7), and psychotherapy referrals 22% (n=7) were documented by the PCPs.

Recommendation: The quality improvement project focused heavily on documentation completed over a one year pre-intervention timeframe compared to a six-week post-intervention timeframe. Further evaluation and chart review over the next year will provide a more adequate comparison of documentation within primary care practice.

Background: The global prevalence of all types of diabetes increased from 108 million in 1980 to 422 million in 2014 (Nazir et al., 2018). The Centers for Disease Control and Prevention (2017) ranks diabetes as the 7th leading cause of death in the United States with an estimated annual expense of $327 billion. Within the rural setting, patients typically have less resources available for the treatment and self-management of their diseases. It is important to explore self-management techniques that can be utilized by patients with type 2 diabetes living in rural areas. Research demonstrating the importance of education, exercise, diet, glucose monitoring, medications, and supportive measures is prominent throughout the literature.

Objective: The purpose of this Doctor of Nursing Practice (DNP) applied project is to investigate the effects of delivering biweekly text messages containing diabetes self-management education (DSME) materials to patients in an effort to support successful self-care.

Methods: During an 8 week period, DSME was provided via text messaging, bi-weekly (Sunday and Wednesday), to 23 rural participants with type 2 diabetes, in a family clinic in Payson, Arizona. Participants were asked to complete the Skills, Confidence, and Preparedness Index both pre- and post-intervention to evaluate their knowledge of diabetes self-management.

Results: Twenty-three adults aged 52 to 78 years (M = 64.91) participated in the project. Of the participants, 57% (13/23) were female. The majority of participants had T2DM diagnosis less than 10 years (M=13.8 years). There was a statistical difference between the pre- and post-Skills, Confidence and Preparedness Index questionnaire (p < .001) indicating an improvement in self-efficacy scores post- intervention.

Conclusion: DSME delivered via text message is a cost-effective way to increase patients' self-efficacy and potentially improve their ability to successfully self-manage their disease.

Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.

The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.