Doctor of Nursing Practice (DNP) Final Projects

Pregnancy is a specific time in a woman’s life filled with complex changes in health, including the oral cavity. During this time, dental and perinatal care teams can be influential in helping women initiate and maintain essential habits to improve health and prevent adverse outcomes. There is research evidence that dental providers are reluctant to treat dental problems during pregnancy. Barriers to practice identified by dentists include lack of education, time, financial constraints, and concern for the safety treating pregnant women. Factors that facilitate dental care for pregnant women include purposeful assessment, referrals from prenatal providers, and continuing education for dental team members.

Multiple organizations recommend the treatment of oral health conditions during pregnancy to promote health and prevent pregnancy complications. In order to promote community-based partnerships in a healthcare system, dentists are encouraged to develop an intentional plan to increase collaboration with other members of the women’s healthcare team. Prior to developing a system wide intervention to improve access to dental care during pregnancy, dental team members were surveyed to identify barriers and facilitators which promote or hinder care in their practice. The data acquired will be used to inform the design and implementation of an intervention to specifically meet the needs of patients and providers in that system.

Stress of transitioning to parenthood, hormonal fluctuations as well as physical changes, and complications during postpartum could be addressed at the routine postpartum follow-up visit to avoid long-term adverse effects. While emphasis on preconception and prenatal care has increased nationwide, attendance at this important visit is on the decline. The purpose of this project was to investigate how enhanced prenatal education and concurrent scheduling of a well-baby visit at four weeks, instead of the traditional six weeks, could increase adherence to recommended follow-up care at a federally qualified health clinic in the Southwestern United States.

The Theory of Reasoned Action guided the intervention while Rosswurum and Larrabee’s evidence-based practice model was used to develop the project. The pre-existing weekly prenatal education program was enhanced with information regarding the importance of a four-week postpartum follow-up visit. Front desk schedulers were educated to offer same day appointments for the postpartum care visit and one-month well-baby appointment. Data collection took place for three months after implementation of the project and was compared to adherence rates during the three months prior to the intervention. Providers and scheduling staff members participated in a short post-intervention interview. Prenatal education and convenience of concurrent scheduling increased the percentage of adherence to follow-up visits over a three-month period. Providers and clinic staff recommend continuing with the process changes to increase patient’s access to family centered care.

Maintaining good oral health during pregnancy is a significant contributor to healthy pregnancy outcomes. The physiological changes that happen during pregnancy can adversely affect women’s oral health and place her at risk for pregnancy outcomes such as miscarriage and preeclampsia. The unborn child’s health can also be affected by premature birth and low birth weight. Although professional organizations have evidence-based practice guidelines for both prenatal and dental providers, the evidence shows a gap between recommendations and practice. An oral health promotion project for pregnant women was implemented in a federally qualified community health center where there was a lack of adherence to the guidelines.

The purpose of this project was to implement established oral health screening guidelines for pregnant women and to increase dental visits among pregnant women. For this project, a two-item maternal oral health-screening tool (MOS) for the prenatal providers was added into the electronic health record to standardize and document oral health screening for pregnant women at their first prenatal visit. After three months of implementation, there was a significant increase in maternal oral health screening and referral. This project may be replicated at any prenatal setting to improve oral health during pregnancy.

Interprofessional collaboration (IP) is an approach used by healthcare organizations to improve the quality of care. Studies examining effects of IP with patients with type 2 diabetes mellitus (T2DM) have shown improvement in A1C, blood pressure, lipids, self-efficacy and overall greater knowledge of disease process and management. The purpose of this project was to evaluate the impact of IP with attention to identifying and addressing social needs of patients with T2DM. Participants at least 18 years of age with an A1C >6.5% were identified; Spanish speaking patients were included in this project. The intervention included administration of Health Leads questionnaire to assess social needs. Monthly in person or phone meetings were conducted during a 3-month period.

The patient had the option to meet with the doctor of nursing practice (DNP) student as well as other members of the team including the clinical pharmacist and social work intern. Baseline A1C levels were extracted from chart at 1st monthly meeting. Post A1C levels were drawn at the 3 month follow up with their primary care provider. Study outcomes include the difference in A1C goal attainment, mean A1C and patient satisfaction. Pre A1C levels in participants ranged from 7.1% to 9.8% with a mean of 8.3%. Post A1C levels ranged from 6.9% to 8.6% with a mean of 7.7%. Two cases were excluded as they did not respond to the intervention. A paired-samples t test was calculated to compare the mean pre A1C level to the post A1C level. The mean pre A1C level was 8.24 (sd .879), and the post A1C level was 7.69 (sd .631). A significant decrease from pre to post A1C levels was found (t (6) = 2.82, p<.05).

The prevalence of Type 2 Diabetes is on the rise, as are the costs. This nation’s healthcare system must promote interprofessional collaboration and do a better job of addressing SDOH to more effectively engage patients in the management of their disease.

Gestational diabetes mellitus (GDM), diabetes diagnosed in the second or third trimester of
pregnancy that is not clearly overt diabetes, has become more common as the rates of obesity in women of childbearing age have increased. Undiagnosed, uncontrolled diabetes in pregnancy can lead to maternal and infant health comorbidities as well as have adverse long-term effects for mother or baby. Although routine screening for gestational diabetes mellitus (GDM) occurs between 24 and 28 weeks gestation, the American Congress of Obstetricians and Gynecologists (ACOG) recommends screening earlier in pregnancy for women at risk for undiagnosed type 2 diabetes. Risk factors include previous history of GDM, known impaired glucose metabolism, or obesity (BMI > 30).

The purpose of this project is to implement the clinical practice guideline for early maternal glucose screening during pregnancy in women with risk factors through the integration of a clinical decision support (CDS) tool in an electronic health record (EHR). CDS tools can be utilized as a point of care strategy to remind providers of the clinical practice guidelines and to assist providers in decision-making related to screening. Participating providers (n=18) utilized the CDS tool during the initial obstetrical visit for at risk women without a pre-pregnancy diabetes diagnosis and entering prenatal care prior to 24 weeks. The impact of
implantation of the CDS tool shows that an increase in screening was statistically significant (p<.001).

The reactionary nature of the current healthcare delivery system in the United States has led to increased healthcare spending from acute exacerbations of chronic disease and unnecessary hospitalizations. Those who suffer from chronic diseases are particularly at risk. The dynamics of health care must include grappling with the complexities of where and how people live and attempt to manage their health and disease. Team-based care may offer a solution due to its interdisciplinary focus on proactive, preventative care delivered in outpatient primary care.

Studies examining the effects of team-based care have shown improvement in; HbA1c, blood pressure, lipids, healthcare team morale, patient satisfaction rates, quality of care, and patient empowerment. In an effort to improve type 2 diabetes health outcomes and patient satisfaction a team based care project was implemented. The setting was an outpatient primary care clinic where the patients are known to have limited social resources. The healthcare team was comprised of a DNP Student, Master of Social Work Student, Clinical Pharmacist, and Primary Care Physician, who discussed patient specifics during informal meetings and referral processes.

Adult patients whose HbA1c level was greater than 6.5% were eligible to participate, 183 were identified and invited. Fourteen (14) agreed to participate and seven (7) completed the initial screening with a mean HbA1c of 9.7%. Significant social needs were identified using the Health Leads Questionnaire. The diabetes and social needs were addressed by members of the team who met individually with patients monthly over the course of three months. Of those who completed the initial evaluation only two (2) returned for a follow-up and had a repeat HbA1c. Both participants had important improvements in their A1C with a decrease of 2.3%, and 3.4%. The others were lost to follow up for unknown reasons. Despite the small numbers of participants this project suggests that patients can benefit when an interdisciplinary team addresses their needs and this could improve health outcomes.