A Faculty and BSN Student Care Delivery Model for Patients with Diabetes

The integrated, conceptual framework of faculty nurse practitioners (NPs) and BSN nursing students caring for a chronic disease population in the community clinic serves as a model of applied health service research. A teaching/learning clinical partnership environment serves as the pedagogy for effective, active synthesis of critical thinking and skills building with a focus on prevention by the BSN students.  The care delivery model challenges faculty and nursing students to be part of the solution in providing an example of health system reform by driving improved clinical outcomes for people with chronic disease. In this study, NPs provide primary care and BSN students participate on a care delivery team with the faculty NPs. Student team members provide disease management and care coordination as a part of their BSN Community Health Curriculum. The care delivery team is evaluated based upon achievement of improved standard outcome metrics, such as HbA1c and blood pressure, for their assigned patient population. The care delivery team documents and provides evidence-based, disease-specific standard interventions and documents patient outcomes in the electronic health record. Nursing interventions administered by the BSN students promote patient adherence and include individual patient follow-up care calls, review of outcome goals, assistance in patient self-care and patient selection of healthy foods at the grocery store. The successful execution of the care delivery model has the potential for saving health care dollars by driving improved health status and preventing complications of diabetes and hypertension (Orr & Ciampini, 2014).

The primary research question is: Can a faculty/student nurse partnership care delivery model, by which students and faculty provide primary care and disease management interventions for a diverse population, significantly impact improvement in disease-specific, evidence-based outcomes? The second research question is: Can the faculty/student nurse partnership system of care provide a teaching/learning environment that supports the student nurse in: developing competencies in providing patient-centered care; working as an effective member of an interdisciplinary nursing team employing evidence-based practice; and using data in order to report outcomes and apply quality improvement tactics? Outcomes measured over a recent 6 month period indicate that both research questions are possible.     

Literature to support this study centers on Institute of Medicine (IOM) recommendations, which serve as a guide to developing innovative systems of care delivery that offer the opportunity for improvement in the quality and safety for recipients of heath care. Two central strategies proposed by the IOM include the use of systems for care delivery and the request to improve patients’ knowledge about their treatment plans (Hurtado, Swift, & Corrigan, 2001; Kohn, Corrigan, & Donaldson, 2000). This model incorporates both central strategies.

Using funding from two community grants obtained by the school of nursing, the school of nursing care delivery model supports faculty NPs in delivering primary care for an underserved population with chronic disease. Through a student/teacher learning partnership, the study tests a model of health care delivery that offers innovation in clinical nursing education and subsequent student evaluation of clinical performance. The care delivery model supports faculty NPs practicing with BSN students to provide evidence-based standards of care for the identified population and to achieve improvement in the corresponding key disease-specific outcome metrics. BSN students learn evidence-based practice for managing and coordinating care for certain chronic disease, how to effectively influence change in patient behavior and how to assist patients in taking responsibility for self-care interventions that promote improvement in patient health status. Interventions are documented, measured and evaluated. Performance of faculty and students is based upon the achievement of evidence-based outcome metrics for the target patient population. Students have an opportunity to experience measureable success in improving the health status for a diverse and underserved patient population. Faculty NPs and students know in advance the key goals for patient outcomes and are held accountable for results.    

Tactics to facilitate an effective systems approach for care delivery include the use of culturally competent care, chronic disease management, a nurse-managed primary care medical home and use of evidence-based care guidelines. In reference to culturally competent care, the IOM addresses unequal treatment with specific recommendations to provide interventions which eliminate racial and ethnic disparities in healthcare and also makes the request for research to “provide a better understanding of the contribution of patient, provider, and institutional characteristics on the quality of care for minorities” (Smedley, Stith, & Nelson, 2003, p. 22). This study population includes primarily minorities and demonstrates effective strategies and tactics for culturally competent care that results in improved outcomes for an underserved population. Prior diversity training helped assure that faculty and students accept patients’ beliefs and values while providing care for the diverse and underserved study population.

Disease management interventions, in support of the primary care provider’s plan of care, assist the patient in actively contributing to their success in adhering to the plan of care and have been proven to drive improvement in achieving evidence-based care for large populations (Coberly et al., 2006; Coberly et al., 2007; Orr et al., 2006a; Orr et al., 2006b; Orr et al., 2006c). Follow-up support with ongoing disease management interventions integrated with culturally competent care assist the patient population in actively participating and receiving evidence-based care. These interventions contribute to improvements in the patient’s knowledge of their treatment plans. 

An initial aggregate of participants cared for by the nursing/student partnership – care which includes follow-up calls, review of outcome goals, assisting the patient to practice self-care, and patient selection of healthy foods at the grocery store – shows an overall drop in HbA1c. During this 6-month study (which is still ongoing), participants’ aggregate HbA1c dropped 1 point (9.5 to 8.5). The most significant changes occurred with participants who saw a decrease in HbA1c of 11.8 to 7.3, 11 to 6.8, and 13.1 to 10. As of December 2^nd, 2013, twenty-two participants have seen a combined 22.1-point HbA1c decrease. A subset of 11 participants was evaluated before and after interventions for biometric changes.  Participant's average weight dropped 3.6 pounds, the systolic BP remained stable but essentially unchanged (129 to 128) and the diastolic BP dropped 7 points (84 to 77). These trends suggest that the teaching/learning care delivery model delivered by the NP/student team increases patient awareness and promotes positive and consistent changes in self-care for a diverse and underserved population.

The Institute of Medicine (IOM) recommends that nursing education programs “prepare and enable nurses to lead change to advance health” (Institute of Medicine, 2011, p. S-12). As guided by the IOM, this study provides a model of care delivery that transforms practice and education by providing a planned educational experience for BSN students who intervene as team members to provide affordable, quality, patient-centered, evidence-based care to an underserved population. The NP faculty/student team’s systems approach to care delivery results in improved health outcomes for the diverse population. The model of care delivery provides the faculty NP an opportunity to practice as a NP with a chronic disease patient population while providing the setting for BSN students to integrate leadership theory with clinical practice, thereby contributing to improved patient outcomes. This care delivery team effort supports faculty and BSN students in leading change and advancing the health of a diverse population.