The CNS, now embedded in the selected primary care clinic, led the clinic effort. A population assessment of this primary care population was conducted, using the PRECEDE PROCEED planning framework, to identify factors playing a role in the patient’s diabetes self-management decisions. Data retrieved from the EHR lacked psychosocial and environmental factors expected to be playing a role. So key informant interviews were pursued which revealed patients: 1) relied heavily on non-pharmacy interventions; 2) had significant financial barriers, and 3) desired information and support from the healthcare team. Based on these assessment findings, the CNS designed a diabetes program and embedded it within the primary care clinic, which also provided the testing ground for the clinical tools developed for delivering quality diabetes care. The 10-week program blended diabetes care and diabetes self-management training (DSMT) and incorporated both interprofessional and individualized diabetes-focused visits. Findings revealed statistically significant improvements in hemoglobin A1c levels, while validating the utility of the clinical tools in caregiving.
It became evident that the role of nursing within the clinic needed to be reexamined; the task-oriented focus of current clinical responsibilities needed to expand to draw upon the full scope of professional nursing practice. In this clinic, a registered nurse devoted to population management was considered. In anticipation of this new role, the CNS developed the Diabetes Health Maintenance Standard of Care (DHMSOC), which provided direction for managing the diabetes population. The nursing role and DHMSOC were piloted by two currently employed registered nurses. These nurses had previously been educated in DSMT by the CNS and were actively engaged in the delivery of DSMT. The expectation is that they will sit for the diabetes educator certification. Patients were contacted by phone to: 1) elicit their interest in participating in the diabetes program; 2) address the diabetes-related quality metrics, i.e. annual ophthalmic exam, annual foot exam, vaccinations, etc., and 3) schedule visits and deliver DSMT. The success of the pilot in terms of patient and nurse satisfaction led to the securing of a Population Health RN position.
The final focus of the initiative was redesigning clinic processes to address diabetes-related quality metrics when the patient was present for a primary care appointment. Multiple PDSA cycles were employed to create viable process changes. Certified Medical Assistants (CMA) were trained to monitor the electronic health maintenance tool, identify unaddressed diabetes metrics, and communicate patient needs to the provider. Data revealed CMAs were prompting providers, but providers were not consistently acting upon these prompts. Consequently, an educational symposium describing the quality improvement initiative was presented to the resident-physician providers. The national movement to value-based reimbursement was included. Individual and group quality metric data are now being prepared so these providers can compare and contrast their own performance with their peers. It is expected that the inherent competitiveness of these providers will spawn changes in their individual clinical practice behaviors.
In summary, the CNS has forged multiple changes in the ambulatory care practice environment to transform the care of PWD. There is now a culture of attentiveness to diabetes quality metrics and an understanding that these metrics are equated with quality patient care. She has been an effective agent in marshaling the quality improvement process that has disseminated best practice in delivering quality diabetes care in this primary care setting.
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