References - Ram Pages



Promoting the Nurse Practitioner Role for Diabetes Education in the Primary Care SettingElizabeth C. CobbVirginia Commonwealth UniversityAbstractDiabetes type II (DMT2) is a chronic health condition with over 1.7 million new cases diagnosed yearly in the US. Early and frequent diabetes self-management education (DSME) is recommended as a primary way to improve patient outcomes and decrease long-term complications. The aim of this quality improvement (QI) project is to develop a Nurse Practitioner led educational program in the primary care setting targeting adults ages 18-64 with a HbA1c > 8% and body mass index (BMI) > 30 kg/m2 over a three-month period to lower HbA1c, BMI and improve patient self-efficacy managing DMT2. A structured educational intervention based on the seven self-care behaviors outlined by the American Association of Diabetes Educators will be utilized, along with the electronic health record (EHR) patient portal, MyChart, to reinforce education throughout the three-month period. Program evaluation includes pre- and post-HbA1c and BMI measurements as well as self-efficacy scoring with the Diabetes Self-Management Questionnaire (DSMQ). Utilizing the NP as an education expert aims to improve biomarkers of diabetes care and support patients’ acquisition of self-care skills, leading to improved outcomes and increased patient satisfaction with care.Keywords: Nurse Practitioner, diabetes self-management education, Hemoglobin A1c, Body Mass Index, DSMQ, Diabetes type II Problem StatementThe United States (US) diabetes epidemic affects over 29 million people diagnosed with the disease, with an additional nine million still undiagnosed (Centers for Disease Control [CDC], 2014). Annually, new incident cases of type II diabetes (DMT2) exceed 1.7 million for those aged 20 and older, with the largest burden of diabetes seen in the black and Hispanic communities, accounting for 26% of the population (CDC, 2014). The incidence of DMT2 in adults over 18 years of age in the Commonwealth of Virginia (VA) rose from 4.2% in 1995 to 8.3% in 2010 (Geiss et al., 2012). Diabetes rates are growing parallel with the rates of obesity, with approximately 154 million adults classified as obese having a body mass index (BMI) greater than 30 kg/m2 (Go et al., 2014). The obesity epidemic is closely associated with an increased prevalence of diabetes and cardiovascular disease (Go et al., 2014). Cardiovascular risk increases two to four fold in persons with diabetes (U.S. Department of Health and Human Services [USDHHS], 2016). The complications related to diabetes include lower life expectancy, along with increased risk of kidney failure and amputation (USDHHS, 2016). The complications associated with diabetes directly impact the economic burden of health care across the US. The direct medical cost of diabetes in the US increased from $174 billion in 2007 to $245 billion in 2012 for direct medical costs (American Diabetes Association [ADA], 2015). These costs include inpatient care, medications, diabetic supplies, medical office visits, as well as nursing home admissions (ADA, 2015). Indirect costs of diabetes reach as high as $69 billion a year and correlate to loss of work productivity, disability and mortality (ADA, 2015). Purpose and RationalePatient educational programs recognized by national and international guidelines are recommended as part of comprehensive diabetes management (Lawal & Lawal, 2016). Healthy People 2020 national health promotion initiative recommends diet modifications and exercise as a way to control and prevent complications from diabetes (Campbell, Khan, Cone, & Raisch, 2011; , 2016). Structured diabetes education programs improve patients’ perceived ability to self-manage their diabetes and lower HbA1c levels (Edsen & Nichols, 2013; Kirby, Moore, McCarron, Perkins & Lyle, 2015; Lawal & Lawal, 2016; Peyrot, Peeples, Tomky, Charron-Prochownik, & Weaver, 2007; Zgibor et al, 2007). Therefore, the aim of this project is to develop a structured diabetes educational intervention among adults age 18-64 years, with poorly controlled type II diabetes (defined as HbA1c > 8.0) and comorbid obesity (defined as BMI > 30), in an ambulatory family practice population, to compare the effects of structured diabetes education focusing on behavior change and lifestyle management with a traditional office follow-up visit, in decreasing HbA1c and increasing patient perceived self-efficacy to manage their diabetes within a six month time frame.Literature ReviewHealthy People 2020 identifies lifestyle change as the most substantial modifying factor in diabetes prevention and treatment (, 2016). The literature confirms dietary changes and exercise improve blood sugar control and decrease obesity among people with type 2 diabetes (Boeing et al., 2012; Hall, 2015; Huntriss & White, 2016; McGloin, Timmins, Coates & Boore, 2014; Radhakrishnan, 2011; Stroutenberg, Stanzilis, & Falcon, 2015). Lifestyle interventions demonstrate positive health benefits for patients with diabetes, yet poor adherence to therapy leads to sub-optimal health outcomes and negative impact on healthcare costs (Capal & Schub, 2016; Garcia-Perez, Alvarez, Dilla, Gil-Guillen & Orzoco-Beltran, 2013). Successful interventions include multiple facets of encouraging self-management. Self-management is defined as “the individual’s ability to manage the symptoms, treatment, physical and psychological consequences and lifestyle changes inherent in living with a long term disorder” (Radhakrishnan, 2011, p. 497). The American Association of Diabetes Educators (AADE) and the ADA recommends diabetes self-management education (DSME) at the time of diagnosis and at needed intervals using a structured program (Powers et al., 2015). Additionally, the AADE strongly recommends patient satisfaction surveys of the curriculum for continuous practice improvement (Martin et al., 2013). DSME incorporates information about the disease, nutritional counseling and meal planning, physical activity, goal setting and progress review (Huntriss & White, 2016). Radhakrishkan (2011) examined tailored individual education interventions for persons with diabetes. The individual-specific interventions did not show any significant gain over standardized interventions even when accounting for fidelity, cost effectiveness, and patients receiving personal attention (Radhakrishkan, 2011). A written DSME curriculum remains centrally important in development of behavior change goals for the patient (Martin, Warren, & Lipman, 2013). Teaching individuals the importance of adherence to their diabetes medications significantly lowers HbA1c values during a three-month period (Garcia-Perez, et al., 2013). Adherence also impacts the economic aspect of diabetes, reducing cost to the patient and the health care system (Garcia-Perez et al., 2013). Three factors linked to improved adherence include reduced treatment complexity, increased patient knowledge, and improved continuity of care communicating with patients (Franklin, 2014; Garcia-Perez et al., 2013). Although some educational programs do not show a significant relationship between educational intervention and lower HbA1c, the educational offerings do impact process measure outcomes of regular office follow-ups with their primary care provider and foot and eye examination rates (Franklin, 2014). The National Diabetes Education Program (NDEP) recognizes routine provider follow-up and monitoring for diabetes complications as glucose control outcome measures for complication risk reduction (Gallivan, Greenberg, & Brown, 2008). Adherence is linked to positive regard for self-care when developing programs for persons with diabetes. Hall (2015) describes specific goal setting and behavior change interventions as keys to improving health outcomes. The facets to this approach include healthy lifestyle support, information about diabetes, and training to help increase patient comfort dealing with the disease. Other important self-care tools include ensuring proper glucose monitoring equipment and encouraging development of a support system (Hall, 2015). Laying out a specific plan of information gathering and sharing, along with provider consultation and joint decision making will lead to development of a sustainable diabetes self-care plan (Hall, 2015). The educator and person with diabetes can work together to influence positive clinical and behavioral outcomes (Peyrot et al, 2007; Zgibor et al., 2007). A diabetes education program should include appropriate tools to support an individual’s educational needs and health outcomes (Gallivan et al., 2008). The seven domains of diabetes care established by the AADE provides the framework for a standardized diabetes education program (American Association of Diabetes Educators [AADE], 2010). ?being active,healthy eating,taking medication,monitoring,problem solving,reducing risks, and healthy coping.The seven self-care behaviors identify areas linked with increasing patient knowledge, encouraging behavior change, and influencing health outcomes (AADE, 2014). ?Materials developed by the AADE are specifically designed for obtaining measurable outcomes for continuous quality improvement of diabetes care and policy (AADE, 2014). ?Providing an educational program based on the seven self-care behaviors facilitates improved perceived health status, quality of life, and HbA1c as three of the goals of diabetes care (AADE, 2014). Background and SignificanceIn the Commonwealth of VA, diabetes prevalence approximates 10% of the total population, with 35% of those being age 35-64, and over 10% located in the Shenandoah health district (Virginia Department of Health [VDH], 2016d). Diabetes is the seventh leading cause of death in VA; with ethnic minorities, low income and the poorly educated disproportionality affected (VDH, 2016d). As the incidence of diabetes increases, so does the potential for complications and increased health care service needs (Garfield, 2015). In 2010, overall health care costs in the US for persons with diabetes were two to three times greater than average healthcare expenditures, with $313 million spent in 2011 on inpatient hospitalizations related to diabetes and it’s complications alone (Garfield, 2015, VDH, 2016d). The complexity of diabetes coupled with comorbidities highlights the importance of education while promoting adherence to self-care (Garfield, 2015; Martin, Warren & Lipman, 2013).There are an estimated 637,837 individuals living with diabetes in VA, with 95% of those diagnosed with DMT2 (VDH, 2016d). The mean age of DMT2 diagnosis in VA is 47, with equal distribution between genders. Ethnic minorities, persons with low education and incomes all trend toward early age diagnosis between ages 43-44 (VDH, 2013a). While data on the new incidence of DMT2 diagnosis is unclear, the established data on morbidity and mortality, as well as hospitalizations reflects an ongoing public health issue, reinforcing the need for more widely available DSME services. DSME mitigates the costs of diabetes and associated complications by improving disease self-management that prevents disease progression and reduces health services utilization. Diabetes is notable for the complications of kidney failure, depression, cardiovascular events as well as limb amputations (Garfield, 2015). Needs AssessmentThe VA population of interest is served by Carilion Clinic health care organization. Carilion Clinic is centrally based in Roanoke, VA, serving upwards of 1 million people in western VA. This coverage area includes the Shenandoah health district, including primary care offices, specializing in family medicine, based in the cities of Staunton and Waynesboro (Carilion Clinic, 2016e). Diabetes metrics for the Shenandoah health district varies from other regions of the state. The Shenandoah district versus state averages differ for the age at diagnosis (Shenandoah, 53 years versus State, 47 years), and diabetes screening rates (Shenandoah, 51% versus State, 53%) (VDH, 2013a). Advanced age at diagnosis may be associated with lower HbA1c screening levels among the Shenandoah population (VDH, 2013b). The AADE and ADA’s position on diabetes education is to ensure access and define barriers to DSME for all persons with diabetes (Powers et al., 2015). The diabetes educational program in the local Augusta County region is hospital-based through the Augusta Health nutrition department and not directly affiliated with the Staunton and Waynesboro Carilion family practices (Augusta Health, 2016). This creates a gap in services defining one local group of diabetes educators responsible for the entire population of the Shenandoah health district, and the local cities. Services outside the local region entail traveling anywhere from 45 minutes to two hours for DSME. Carilion adopted the role of the care coordinator within office practices to assist with providing basic diabetes educational needs. The education level of the care coordinator is inconsistent, as a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) may teach individuals. Utilization of a LPN is inconsistent with goals set forth by the American Diabetes Association (ADA) and AADE to have all education programs led by a RN, Registered Dietician (RD), or a Registered Pharmacist (RP) (AOA, 2015). While the office-based educational offerings through Carilion are not AADE certified programs, utilizing a Nurse Practitioner (NP) as the primary educator allows for a more holistic approach to DSME in primary care (Robertson 2014).The target goal for HbA1c, the gold standard for measuring diabetes control, is less than 7% or lower based on comorbidities (Butler, 2011). While the number of persons with DMT2 in the Staunton and Waynesboro Carilion practices is approximated at over 1500, the number of persons with DMT2 with a HbA1c evaluated in 2016 is 485 (Carilion Clinic, 2016c; Carilion Clinic, 2016d). DSME improves HbA1c levels in persons with DMT2 by up to 1% and has shown improved outcomes in many aspects of health (Powers et al., 2015). Within VA, approximately half (56%) of the persons with DMT2 report having HbA1c checked within the past 3 years, compared with only 51% of persons in the Shenandoah health district (VDH, 2013b).The development of DMT2 is strongly correlated with obesity, represented by a BMI > 30 kg/m2 (Butler, 2011). Excess weight increases insulin resistance making glycemic control more challenging (Bell et al., 2014). Therefore even weight loss as minimal as 3% of total body weight can decrease costs associated with diabetes medical care (Bell et al., 2014; Butler, 2011). Additionally, although the ADA and AADE standards support DSME for all newly diagnosed DMT2 at the time of diagnosis and follow-up DSME at timely intervals, DSME referrals for VA, and the Staunton/Waynesboro Carilion are suboptimal. In VA between 2012-2013, 58% of persons with known diabetes were referred for DSME, with the majority being educated females between the ages 45-64 (VDH, 2013c). The Staunton and Waynesboro Carilion offices have over 1,500 individuals with diabetes with an HbA1c on record (Carilion Clinic, 2016c; Carilion Clinic, 2016d). The Waynesboro Carilion office logged 48 encounters with patients in the last five months for DSME teaching, compared with 10 in the Staunton Carilion (Carilion Clinic, 2016c; Carilion Clinic, 2016d). The encounters for DMSE in the documented time frame reflect the need for innovative efforts to encourage increased diabetes education for individuals. While DSME is traditionally based in specialized settings, it is becoming more prevalent in office settings, offering the additional benefit of continuity of care for patients (Franklin, 2014; Powers et al., 2015). Nurse Practitioners are specifically educated and equipped to provide information on disease management to patients within the family practice setting (Bartol, 2011; Edsen & Nicols, 2013; Franklin, 2014; Robertson, 2012). The NP specializing in diabetes care provides an opportunity to improve self-management skills of persons with DMT2 in the office setting while maintaining continuity of care (Franklin, 2014). BarriersThe complexity of diabetes and the numerous factors impeding proper self-care reinforce the role of DSME in diabetes care (Powers et al., 2015). Diabetes is a chronic disease affecting multiple organ systems (CDC, 2014). Multiple comorbidities complicate self-management making delivery of DSME more challenging for the provider (Powers et al., 2015). Hypertension, hyperlipidemia, retinopathy, kidney disease, and neuropathy are all complications resulting from or compounded by diabetes (CDC, 2014). Persons with diabetes and other comorbidities struggle with coping strategies, multiple medications, and often stress related to emotional, psychological, and social factors (Powers et al., 2015). The development of a primary care based diabetes education program relies on several factors to help patients improve their diabetes self-management skills. The American Association of Diabetes Educators (AADE) recognizes that only 50% of patients are referred to diabetes education within the first six months of diagnosis, and approximately 30% of patients completed 10 hours of DSME within their first year of diagnosis (Martin et al., 2013). In the US, socioeconomic factors and ethnicity show disparity among those who receive services. Over 75% of persons receiving diabetes education have at least a high school education and 70% are Caucasian (Martin et al., 2013). Since 25% of persons with diabetes are African American or Hispanic, these statistics reinforce the need to deliver DSME to the underserved population, (CDC, 2014). The delivery of diabetes education is limited by the availability of formal education (Administration on Aging [AOA], 2015). Access to programs is cited as one of the largest barriers (AOA, 2015). Program costs deter many from participating in formal DSME (AOA, 2015). The costs of DSME are linked to program development and utilization (Martin et al., 2013). Direct costs include insurance reimbursement concerns, with private insurance and Medicaid claims accounting for 49% of DSME claims (Martin et al., 2013). While most insurances will pay for up to 10 DSME visits a year, the visits are often underutilized. The reasons for that are unknown and may be related to indirect costs of transportation and time off of work for patients and their family.The two local Carilion Clinic offices support a large diabetes population, but education opportunity remains an area for improvement. Over 1,500 people within the Staunton and Waynesboro Carilion offices are diagnosed with DMT2, and slightly over half show adequate glucose control, with a HbA1c this year < 8% (Carilion Clinic, 2016a; Carilion Clinic, 2016b). Office protocol of documentation regarding DSME referrals is not well established. The Carilion diabetes registry allows for type of diabetes outreach and date to be added to an individual’s medical record, but documentation is not currently updated (Carilion Clinic, 2016c; Carilion Clinic, 2016d). Also, no formal process or tool within the EHR currently captures whether a patients are offered or completed DSME. The gap in documentation is a systems issue, with no certain individual responsible for tracking such information. Local providers refer patients to the Augusta Health program for DSME or utilize the office based Care Coordinator due to the high burden of patients with diabetes on the local office system. Despite scheduled appointments, there is often poor patient follow-through, possibly linked to job conflicts, transportation issues, or poor understanding of diabetes and it’s complications. Nationally, the lack of emphasis to patients with diabetes on the importance of DSME by providers is cited as one reason for patient indifference to participation (Martin et al., 2013). StakeholdersThe providers, office staff, clinic, and the patients are instrumental in successfully implementing a new approach to DSME. The patients within the practice are identified as the biggest beneficiary from implementation of a NP led diabetes education program. Patient self-management relies on clinicians and services in place to assure comprehensive diabetes care. The American Association of Diabetes Educators (AADE) reports that diabetes education is underutilized particularly in individuals with diabetes showing poor control (Powers et al., 2015). Individuals with a HgbA1c of 8% and higher will be targeted by this QI education initiative to improve self-management skills.The physicians are vested stakeholders in a successful office-based diabetes initiative. There are four physicians within the Waynesboro Carilion office, and two within the Staunton Carilion office. Each physician is monitored by a medical scorecard report tracking the percentage of patients with HbA1c below 8%. The physicians receive a financial bonus at the end of the fiscal year based on the percentage of patients with HbA1c < 8%. Both office practices have high patient volumes, with billings averaging 1,300 relative value units (RVUs) a month (Carilion Clinic, 2016f). Due to current high patient volumes, the physicians accept only a limited number of new patients into the practices. Therefore, full daily schedules limit physician time available for additional diabetes education. The goal of utilizing the NP in the role of the diabetes clinical expert within the office setting will allow for decreased physician burnout, improved office workflow and increased patient self-efficacy managing their chronic disease.The NP represents the critical stakeholder in development of an educational initiative. The role of the NP in this office setting is to support the physicians through scheduling acute care patients as well as routine patient follow-up visits. Nurse Practitioners are skilled at delivering patient education and make their role within an office setting more valuable by delivering care as the clinical diabetes expert. (Robertson, 2012; Franklin, 2014). Finally, Carilion Clinic benefits overall with successful implementation of an office based education program. Providing individuals with diabetes education to improve disease outcomes, not only keeps office visit revenues within the health system, it has potential to lower overall patient cost. One of the long term outcome goals associated with DSME is to prevent complications associated with diabetes, leading to reduced economic burden on the health care system as a whole (Gallivan et al., 2008).Project BenchmarksDiabetes care is a major focus for quality improvement and performance measurements (O’Connor et al., 2011). National agencies such as the Centers for Medicare and Medicaid Services (CMS) and National Committee on Quality Assurance (NCQA) have identified control of HbA1c as the most important measure of care; followed by blood pressure and LDL cholesterol monitoring (O’Connor et al., 2011). Additional process measures include urine microalbuminuria and yearly retinal exams (O’Connor et al., 2011). The NCQA stratifies HbA1c levels as poor control > 9%, Adequate control < 8%, and HbA1c < 7% desired in patients with multiple cardiac risk factors (National Committee on Quality Assurance [NCQA], 2015). These biomarkers and process measures are included in physician payment programs (O’Connor et al., 2011). Physicians with Carilion are monitored on quality diabetes care by HbA1c tracking using the diabetes scorecard (Carilion Clinic, 2016a; Carilion Clinic, 2016b). While there are many quality measures for diabetes, the proposed education program will focus on targeting patients for diabetes education when HbA1c > 8%. This HbA1c goal is determined through risk factor assessment, based on cardiovascular events, microvascular complications and mortality (O’Connor et al., 2011). The aim of this project is to use DSME to improve participants’ self-efficacy in managing their diabetes, capturing that improvement through HbA1c level monitoring. FeasibilityA NP led DSME initiative allows the practice to bill for services and provides a feasible alternative to outpatient education. Early diagnosis and effective treatment results in decreased health care costs and utilization of the health care system. A NP focusing on education increases the chances of enhancing diabetes care adherence within the office setting for person with uncomplicated diabetes (Robertson, 2012). In addition, primary care office based diabetes management allows not only for education, but medical management that is not standard in diabetes education outside the medical office (Franklin, 2014). Improved patient outcomes result from early diabetes diagnosis, treatment and education (Robertson, 2012; Gallivan et al., 2008). The workflow of the office setting is structured to allow a smooth transition for incorporating increased educational visits. The DSME visits will be scheduled as follow-up care to routine office visits. The care coordinator medical office assistant (CCMOA) is responsible for tracking data and patient visits which help the office meet the Affordable Care Act (ACA) standards of care. The CCMOA will access the diabetes care registry enabling individuals to be flagged who meet criteria of HbA1c > 8% and BMI > 30 kg/m2. Access to the diabetes registry enables all persons with diabetes to be identified who meet criteria for the educational intervention, rather than relying only on patients who schedule regular interval care visits. The benchmark goal for HbA1c established by Carilion is 8% or lower (Carilion Clinic, 2016b). The physicians in the Staunton and Waynesboro practices range between 70-77% of their patients reaching the goal of HbA1c < 8% (Carilion Clinic, 2016a; Carilion Clinic, 2016b).BudgetBudgeting for a new DSME program in a family practice setting includes direct and indirect costs associated with program preparation and implementation. Indirect costs include fewer appointment slots in the NP schedule when factoring in the longer educational visits. The program will occur within the family practice setting, therefore no additional administrative overhead or additional labor expenses will be incurred. The program will create change within the office workflow, but there are no budgeted labor changes to require additional cost. The labor cost proposed (see Table 1) is assuming the educational initiative is not being absorbed through current staff. The labor cost is variable and takes into account staff training and program development time and salaries. Material costs include purchasing rights to use patient assessment tools and educational literature, estimated at $500.00 for initial supplies. Overall, the cost to begin the program is approximately $2,000.00.The direct program cost reflects staff salary as well as ongoing material cost (See Table 2). The educational program is estimated to have a development cost of $2,000.00 with the implementation over 24 weeks costing approximately $4,000.00, which is also the yearly cost to continue the educational program. This cost will be recouped through the billings of the NP. The complexity of the education, taking into account comorbidities visit will involve greater than 25 minutes of face-to-face counseling time allowing for follow-up visit code 99214, using ICD-9 diagnosis code 250.02 for Diabetes Type II, uncontrolled and 278.00 for Obesity, unspecified (Centers for Medicare and Medicaid Services [CMS], 2014). The 99214 allows $157.00 charge per visit. The estimation of five patients per week, at a chargeable rate of $157.00 a visit, for 24 weeks total, allows for $18,840 billable revenue with this program. The literature supports that office practices save money by offering DSME to patients. DSME can decrease direct medical costs and hospital charges per patient with diabetes in the range of $783.00-$3,356 per year (Garfield, 2015). Theoretical FrameworkThe Health Belief Model (HBM) is a theoretical framework based on how individuals perceive chronic illness. Successful diabetes care involves a holistic approach of not only medication management and education, but also how the patient’s perception of their reality of carrying the diagnosis of diabetes (Hurley, 1990). The model supports the individual’s perceived threat arising from diagnosis of a chronic illness. The outcome of disease management is based on each individual’s disease knowledge, educational level, and socio-economic status (Lo, Chair, & Lee, 2014). The HBM assumes each patient has beliefs about their disease that can be modified to improve treatment compliance and understanding (Hurley, 1990). Acknowledging and targeting patient health beliefs to promote healthy behaviors is one component of diabetes care. Self-efficacy is closely related to patients’ health beliefs and self-care (Beckerle & Lavin, 2013). The self-efficacy theory defined by Bandura relates an individual’s ability to regulate their internal motivation and behaviors as a means to improve their health status (Beckerle & Lavin, 2013). The less a person feels competent managing the challenges of chronic illness the positive outcomes of self-management decline (Beckerle & Lavin, 2013). Aligning self-efficacy with patient health beliefs help the educator implement strategies for behavior change (Beckerle & Lavin, 2013). Diabetes education functions as a tool to support behavior change and influence improved self-care management. The HBM and self-efficacy theory provide theoretical framework principles for health belief and self-care management in patients with DMT2 (Beckerle & Lavin, 2013; Campbell et al., 2011; Hurley, 1990; Peyrot, 2007; Skovlund & Peyrot, 2005). The education program should have a foundation in assessment of an individual’s perceived disease state, as well as the person’s ability to manage diabetes successfully. The NP must be cognizant of each person’s perceived self-management skills to make an impact on the outcomes of improving self-efficacy and diabetes biomarkers of HbA1c. Project ImplementationObjectivesEducation initiatives are part of quality comprehensive diabetes care. ?Diabetes health outcomes rely on DSME as a means to improve individuals’ self-management (Martin et al., 2013). ?The objectives of this quality improvement diabetes education project for adults age 18 – 64 years with HbA1c > 8 % and BMI > 30 kg/m2 conducted over six months in a primary care setting are to:lower HbA1c, lower BMI, andimprove self-efficacy scores using the Diabetes Self-Management Questionnaire (DSMQ).PopulationThe educational program targets adults, ages 18-64 years with DMT2 in a family practice office setting. ?The cohort will be derived from a pool of eligible participants from two family practice groups, Carilion Family Medicine Staunton and Carilion Family Medicine Waynesboro, owned by Carilion Clinic, headquartered in Roanoke, VA. ?Adults diagnosed with DMT2 with a HbA1c > 8% and a BMI > 30 kg/m2 will be recruited through EHR chart reviews, utilizing the diabetes registry. ?Participants with at least one HbA1c collected between January 1, 2016 and December 31, 2016 will be eligible for the education program, excluding those who have been referred to endocrinology or outpatient diabetes education through Augusta Health. ?Additionally, individuals in the registry representing nursing home residents or patients without an office visit on file in 2016 will be excluded. Identified participants will have the option of participating in office-based education or referral for certified DSME with a certified diabetes educator through Augusta Health. ?TimelineEnrollment in the educational program will begin January of 2017 after the VA Commonwealth University and Carilion Clinic Institutional Review Boards grant approval of the project proposal. Participants identified as eligible for inclusion in this project will be 1.) Contacted by phone by the NP or the CCMOA to offer diabetes education for individuals who are not currently scheduled to have an office visit, or 2.) Offered the opportunity to participate by their primary care physician at an office based visit occurring between mid-January 2017-mid-April 2017. ?New participant enrollment will end three months after recruitment begins. ?Participants will be followed for three months after enrollment, placing the end of the educational project approximately July 31, 2017.MeasuresFirst, this project will use the HbA1c, the gold standard to assess the three-month average of glycemic control (The International Expert Committee, 2009). ?The HbA1c level strongly correlates with macro- and microvascular complications. ?Lowering this number decreases the opportunity for complications to arise (Franklin, 2014). The HbA1c will be collected by the Carilion nurses and laboratory technicians, and processed through the Carilion lab system. ?Due to insurance requirements, it may be necessary to have the HbA1c drawn at the local hospital lab, and results retrieved by the CCMOA. ?When feasible, lab work will be collected at the participant’s regularly scheduled follow-up visit with the primary physician, or by the Carilion laboratory technicians during a visit for labs only. ?The labs are filtered automatically into the Epic EHR and will be flagged to the NP’s Epic desktop by the CCMOA for review. ?The results will be reviewed within 48 hours for meeting inclusion criteria of HbA1c. ?Hemoglobin A1c level drawn within the last 30 days will be accepted as a current acceptable result for initial screening. ?To meet the second inclusion criteria of BMI of 30 kg/m2 or greater, a height and weight will be rechecked at the time of their office visit. Three months after the initial education intervention, the participants will return to clinic for a follow-up session to have a HbA1c redrawn as well as height and weight performed for BMI recalculation. These visits will be scheduled by the front office staff immediately following the initial session, with reminder calls made to the participant by the NP or front office staff three days prior to their appointment date. In an effort to decrease attrition, participants who need to cancel these pre-scheduled appointments will be offered another appointment within a two-week time frame.A tool linking self-management skills with glycemic control is the Diabetes Self-Management Questionnaire (DSMQ) (Schmitt et al., 2016). The DSMQ measures the project participant’s perception of how well they successfully manage their diabetes care (Schmitt et al., 2016). ?Successful management of diabetes as a chronic disease is reliant on people having the knowledge and understanding to improve self-care behaviors (Fenwick, Xie, Rees, Finger, & Lamoureux, 2013). The DSMQ is a 16-item Likert-type scale that is a reliable and validated tool strongly correlating self-management behaviors to improved HbA1c control (Fenwick et al., 2013; Schmitt et al., 2016) (see Appendix A). ?The DSMQ provides insight into medication adherence, physical activity, diet choices as well as appropriate medical care follow-up, and will be used to evaluate how well participants self manage their diabetes care, administered as a pre- and post-intervention tool (Schmitt et al., 2016). Therefore, utilization of the DSMQ and HbA1c testing will provide information on short-term outcomes in the cohort of family practice participants.?PreparationThe education project will be presented through an in-service format during both the nursing and physician scheduled staff meetings. Discussion will include how the NP will be utilized for these additional educational appointment slots, as these slots will be scheduled on particular days agreed upon by the NP, collaborating physician and the office manager. ?Information regarding visit structure will be presented to the physicians and office staff. ?The NP visits will be educational in nature only, but can address insulin administration teaching or any diabetes medication adjustments. ?Any other health needs identified by the NP during the visit will be directed by intra-office EHR messaging to the primary physician to be addressed.Methods ?Program DevelopmentThe educational program will utilize EHR data, survey collecting participant perceptions of diabetes using a self-management survey questionnaire, and implementation of an educational intervention. The new program will be evaluated using statistical methods examining pre- and post-intervention data. ?First, a presentation on the initiative and project timeline will be provided for the physicians, as well as nursing and ancillary staff. ?Both the Staunton and Waynesboro office physicians will receive instruction on the project purpose and methods. ?The other NPs within the office will receive a detailed educational session on prior to interaction with patients on project objectives, goals and materials, should they choose to participate. ?Prior to enrollment in the program, consent will be obtained from the practice physicians to access their patient lists and diabetes scorecards. ?The diabetes registry will be accessed with assistance from the CCMOA to receive an updated roster of patients meeting eligibility requirement. ?Physicians will provide an updated diabetes scorecard of their patient caseload documenting the starting benchmark of HbA1c in their participant list. ??Participant RecruitmentOnce the cohort of individuals meeting eligibility criteria of HbA1c > 8% and BMI > 30 has been established, the participants will be recruited by phone calls from the NP, CCMOA or referral by primary physicians at routine office visits and informed consent will be obtained. ?The CCMOA or NP will contact participants by phone and arrange an appointment time. ?The CCMOA or other office support staff will log appointments into the EHR scheduling system. Educational sessions will be offered at both Staunton and Waynesboro Carilion offices in up to one-hour appointment blocks.Program DeliveryFor eligible consenting participants, each appointment will begin with a guided discussion of topics by the NP related to the seven domains of diabetes care established by the AADE (AADE, 2010). ?The seven domains of diabetes care include being active, healthy eating, taking medication, monitoring, problem solving, reducing risks, and healthy coping (AADE, 2010). A standardized office note template in the EHR will be utilized to document the discussed information. Written handouts will be utilized for educational purposes during the visit and participants will be able to take these materials home for review (See Appendix B). ?The initial visit will also involve the NP administering the DSMQ. ?Based on literacy needs, the NP to assist with survey administration at the patient’s request. ?Literacy will be assessed with the Single Item Literacy Screener, a tool with acceptable sensitivity for screening low-health literacy (Cornet, 2009)(see Appendix C). ?Documentation of assistance on the surveys will allow for tracking any potential response bias by participants. ?As part of the formal education session, participants will be encouraged to sign up for MyChart, an EHR based communication system available through Epic EHR. ?MyChart allows practitioners to send messages to patients and the educational participants in a confidential way that is HIPPA approved. ?Bi-weekly messages will be sent to educational participants by the NP based on the seven domains of self-care set forth by the AADE. The messages will be standardized, but at the request of the participant during the education session, information can be individualized to a particular diabetes topic of interest. Utilization of MyChart will allow for interaction with participants after the formal education session to provide ongoing health tips, motivation, respond to any questions regarding self-care. ?Participants will be encouraged to ask questions related to their diabetes care, and will be answered by the NP. Participation is voluntary and will be documented in the concluding statistical analysis.Program EvaluationThe DSME intervention will be evaluated by comparing the pre- and post-HbA1c, and DSMQ results, and from reviewing feedback regarding MyChart. First, follow-up educational sessions will be scheduled three months after the first session. The HbA1c will be redrawn at this visit. Lab results will be flagged to the NP and also shared with the primary care physician. The DSMQ will be re-administered as a post-test for comparison to the original results. Also, a short likert-type scale will assess the participants’ perception of MyChart as a beneficial way of augmenting the educational intervention (See Appendix D).? Gathering information on the usefulness of utilizing MyChart for health reminders is important for ongoing quality improvement of interactions with patients. Physicians will be requested to provide qualitative input on the program at the conclusion of the six months (See Appendix E). ?Statistical AnalysisStatistical analysis by paired t-test will be utilized, assuming there are at least 30 participants in the intervention. Should there be less than 30 participants, a Wilcoxon matched pairs test will be utilized. Data analysis will be conducted using JMP software comparing pre- and post-assessment scores, with a significance level set at p < .05. ?Hemoglobin A1c comparisons pre- and post-intervention will be evaluated using a paired t-test or Wilcoxon matched pairs test, with a significance level set at p < .05. ?Demographical data will be extracted as part of the data analysis. Results of the ordinal data collected by the MyChart survey will be complied in an Excel file, and a bar graph will be constructed to display the results. A likert scale seeking physician satisfaction with the educational program will be utilized at both Carilion offices. Data will be compiled and results displayed in bar graph form.Data extracted pre- and post-intervention will be stored in an Excel spreadsheet, with written survey results scanned into Epic by front office staff and stored as a miscellaneous file. ?All copies of information will be stored with the office managers at the Staunton and Waynesboro offices for privacy and security purposes. Any documentation with patient identifiers once electronically entered into Epic will be shredded for patient confidentiality. The CCMOA will keep a master list of participants for future chart reviews and educational follow-up.Nursing and Clinical ImplicationsThe national standard of care for individuals with DMT2 according to the ADA is to provide self-management education early in the diagnosis of diabetes and at any needed interval (Powers et al., 2015). Certified health professionals should provide education opportunities, which includes Nurse Practitioners, in convenient settings such as primary care offices (Powers et al., 2015). The goal of DSME is for individuals with diabetes to become knowledgeable of their condition to promote problem solving and coping strategies. This approach leads to short and long term outcomes of lower HbA1c and complication prevention (Caple & Schub, 2016; Gallivan et al., 2008; Powers et al., 2015). The Doctor of Nursing Practice (DNP) degree prepares nurses for a variety of roles in the health care landscape. As part of the ongoing need for diabetes education, the DNP essentials highlight how nurses are prepared to participate in the healthcare landscape and add to the care of people with diabetes. According to the NDEP, ADA and the AADE, all diabetes education programs should be based on scientific evidence, utilizing an integrated approach to care (Gallivan et al., 2008; Powers et al., 2015). The DNP essentials I and III prepares the NP with extensive skills in synthesizing the research and determine how information, both scientific and nursing theory based, can best be applied to clinical practice, specifically the development of a diabetes educational program (American Association of Colleges of Nursing [AACN], 2006).Second, the preparation of a diabetes educational program in a primary care office setting requires many logistical considerations to be successful. Implementation of a change in workflow to improve the delivery of care and improve outcomes of chronic disease states requires understanding of policy and business practices. The DNP essential II prepares the NP to develop a quality improvement initiative considering factors such as budget, staffing, and workflow concerns (AACN, 2006). A unique part of this quality improvement initiative is the use of MyChart, an EHR based email communication system. The use of technology with chronic conditions is becoming more commonplace, including innovations in diabetes care (Devkota, Salas, Sayavong, & Scherrer, 2016; Wade-Vuturo, Mayberry, & Osborn, 2013). The DNP essential IV highlights the skills acquired by the DNP graduate to incorporate new technology to influence patient care and outcomes (AACN, 2006). The use of MyChart to help connect patients with the NP after the educational visit aims to improve patient satisfaction and improved HbA1c control compared with a one time educational session (Devkota et al., 2016; Wade-Vuturo et al., 2013). Finally, the goal of DSME is to facilitate skills, confidence and better health outcomes in individuals with DMT2, therefore improving health and lowering the overall burden on the health care system (Powers et al., 2015). The AACN (2016) DNP essential VII prepares the DNP graduate to improve the quality of care for populations, focusing on individuals’ health behaviors and the multiple dimensions factors that affect health care. The development of an educational program at the primary care level helps address the issues of access to care and evaluation of delivery modes associated with improving local diabetes care.Ethical ConsiderationsThe purpose of this educational program is to improve the quality of the diabetes care received on a local level. Patient safety, equality, and consent are considered with development of the program. Institutional Review Boards through both Virginia Commonwealth University and Carilion Clinic will review the quality initiative to ensure ethical standards for working with patients are met. The program will be open to all individuals meeting the program criteria, and education will be provided equally to participants based on their motivation to learn. Individuals who do not meet inclusion criteria will still receive referrals to outpatient diabetes education, as well as the current available office visit education. SustainabilityDiabetes education is not a new concept, yet a NP led educational initiative in the office setting is a workflow change to help improve efficiency, cost, patient satisfaction and outcomes. Educational visits require longer appointment time slots, but the loss of patient volume on the NP schedule has potential to have a positive impact on the overall financial benefits on the office. Diabetes education can reduce hospital admissions and lower overall health care costs (Powers et al., 2015). Based on the success of this DNP quality improvement initiative impacting HbA1c levels and participant self-efficacy, continuation of a NP lead initiative can be improved and incorporated throughout Carilion Clinic primary care offices. NPs are credentialed to provide diabetes education, yet development of a role for the NP as a certified diabetes educator (CDE) can increase the outreach population. This role would allow for specific DMSE reimbursement from Medicare and Medicaid, and also improve access to education opportunities in the office setting for patients of all ages (Powers et al., 2015). Long-term evaluation of the program will be achieved by continuous quality improvement (CQI) utilizing the Carilion Clinic CLEAR research method (Carilion Clinic Nursing Research and Evidence Based Practice Group, 2015) (see Appendix F). Ongoing CQI initiated by a NP led team will allow for changes to the educational program to meet the needs of the office practice over time. Another benefit to keeping DMSE in the office setting is the ability to incorporate technology, with the use of MyChart. Utilization of the NP in the educator role allows individuals to interact with a healthcare provider in an efficient manner, discussing educational and medical questions related to their diabetes care. This provides efficient and reduced workflow for the front office staff, nurses and other providers when the NP manages diabetes care. Therefore, with the shortage of primary care providers in the local Carilion Clinic region, utilization of a NP to help handle chronic disease management should be explored as a method of improving outcomes and controlling health care cost.ADDIN RW.BIBReferences Administraiton on Aging. (2015). Diabetes self-management toolkit. American Association of Colleges of Nursing. The essentials of Doctoral?Education for advanced nursing practice. Retrieved from HYPERLINK "" \t "_blank" American Association of Diabetes Educators. (2010). AADE7 self-care behaviors. Retrieved from HYPERLINK "" \t "_blank" American Association of Diabetes Educators. (2014). 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Increasing prevalence of diagnosed diabetes--united states and peurto rico, 1995-2010. Morbidity and Mortality Weekly Report, 61(45), 918-921. Go, A. S., Mozaffarian, D., Roger, V., Benjamin, E. J., Berry, J. D., Blaha, M. J., . . . Lackland, D. T. (2014). Executive summary: Heart disease and stroke statistics--2014 update: A report from the american heart association. Circulation, 129(3), 399-410 12p. doi:10.1161/01.cir.0000442015.53336.12 Greer, D. M., & Hill, D. C. (2011). Implementing an evidence-based metabolic syndrome prevention and treatment program utilizing group visits. Journal of the American Academy of Nurse Practitioners, 23(2), 76-83. doi:10.1111/j.1745-7599.2010.00585.x Hall, G. (2015). Supporting successful self-management in diabetes. Diabetes & Primary Care, 17(2), 94-101 8p. Retrieved from HYPERLINK "" \t "_blank" Huntriss, R., & White, H. (2016). Evaluation of a 12-week weight management group for people with type 2 diabetes and pre-diabetes in a multi-ethnic population. Journal of Diabetes Nursing, 20(2), 65-71 7p. Retrieved from HYPERLINK "" \t "_blank" Hurley, A. C. (1990). The health belief model: Evaluation of a diabetes scale. Diabetes Educator, 16(1), 44-48. Retrieved from HYPERLINK "" \t "_blank" Kirby, S., Moore, M., McCarron, T., Perkins, D., & Lyle, D. (2015). Nurse-led diabetes management in remote locations. Canadian Journal of Rural Medicine, 20(2), 51-55. Retrieved from HYPERLINK "" \t "_blank" Lawal, M., & Lawal, F. (2016). Individual versus group diabetes education: Assessing the evidence. Journal of Diabetes Nursing, 20(7), 247-250. Retrieved from HYPERLINK "" \t "_blank" Martin, A. L., Warren, J. P., & Lipman, R. D. (2013). The landscape for diabetes education: Results of the 2012 AADE national diabetes education practice survey. Diabetes Educator, 39(5), 614-622. doi:10.1177/0145721713499412 National Committee for Quality Assurance. (2015). HEDIS report card comprehensive diabetes care. Retrieved from HYPERLINK "" \t "_blank" Nicoll, K. G., Ramser, K. L., Campbell, J. D., Suda, K. J., Lee, M. D., Wood, G. C., . . . Hamann, G. L. (2014). Sustainability of improved glycemic control after diabetes self-management education. Diabetes Spectrum, 27(3), 207-211. Retrieved from HYPERLINK "" \t "_blank" O'Connor, P. J., Bodkin, N. L., Fradkin, J., Glasgow, R. E., Greenfield, S., Gregg, E., . . . Wysham, C. H. (2011). Consensus report: Diabetes performance measures: Current status and future directions...this article was reprinted with permission from the july 2011 issue of diabetes care, vol 34, p. 1651-1659. Clinical Diabetes, 29(3), 102-112. doi:dx.10.2337ldc11-073 Peyrot, M., Peeples, M., Tomky, D., Charron-Prochownik, D., & Weaver, T. (2007). Development of the american association of diabetes educators' diabetes self-management assessment report tool. Diabetes Educator, 33(5), 818-826. Retrieved from HYPERLINK "" \t "_blank" Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., . . . Vivian, E. (2016). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the american diabetes association, the american association of diabetes educators, and the academy of nutrition and dietetics...reprinted with permission from diabetes care 2015;38:1372–1382. Clinical Diabetes, 34(2), 70-80 11p. doi:10.2337/dc15-0730 Radhakrishnan, K. (2011). The efficacy of tailored interventions for self-managment outcomes of type 2 diabetes, hypertension or heart disease: A systematic review.68(3), 496-510. doi:10.1111/j.1365-2648.2011.05860.x Robertson, C. (2012). The role of the nurse practitioner in the diagnosis and early management of type 2 diabetes. Journal of the American Academy of Nurse Practitioners, 24, 225-233. doi:10.1111/j.1745-7599.2012.00719.x Schmitt, A., Gahr, A., Hermanns, N., Kulzer, B., Huber, J. ?., & Haak, T. (2013). The diabetes self-management questionnaire (DSMQ): Development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health & Quality of Life Outcomes, 11(1), 138-138. doi:10.1186/1477-7525-11-138 Skovlund, S. E., & Peyrot, M. (2005). Lifestyle and behavior. the diabetes attitudes, wishes, and needs (DAWN) program: A new approach to improving outcomes of diabetes care. Diabetes Spectrum, 18(3), 136-142. Retrieved from HYPERLINK "" \t "_blank" Stoutenberg, M., Stanzillis, K., & Falcon, A. (2015). Translation of lifestyle modification programs focused on physical activity and dietary habits delivered in community settings.22, 312-327. doi:10.1007/s12529-014-9438-y Taghdisi, M., Borhani, M., Solhi, M., Afkari, M., & Hosseini, F. (2012). The effect of an education program utilising PRECEDE model on the quality of life in patients with type 2 diabetes. Health Education Journal, 71(2), 229-238. doi:10.1177/0017896911398812 The International Expert Committee. (2009). International expert committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care, 32(7), 1327-1334. U.S. Department of Health and Human Services. (2016). Diabetes--healthy people 2020. Retrieved from HYPERLINK "" \t "_blank" Virginia Department of Health. (2013a). Age at diagnosis of diabetes by demographics (Race/Ethnicity, education. income, and gender) virginia, 2012-2013. Retrieved from HYPERLINK "" \t "_blank" Virginia Department of Health. (2013b). Blood sugar test within the past three years by demographics (Race/Ethnicity. education, income, age and gender) virginia, 2013. Retrieved from HYPERLINK "" \t "_blank" Virginia Department of Health. (2013c). Ever taken a class in managing diabetes by demographics (Race/Ethnicity, education, income, age, and gender) virginia, 2012-2013. Retrieved from HYPERLINK "" \t "_blank" Virginia Department of Health. (2016d). Diabetes in virginia. Retrieved from HYPERLINK "" \t "_blank" Wade-Vuturo, A., Mayberry, L. S., & Osborn, C. Y. (2013). Secure messaging and diabetes management: Experiences and perspectives of patient portal users. Journal of the American Medical Informatics Association, 20(3), 519-525. doi:10.1136/amiajnl-2012-001253 Wai, S. L., Sek, Y. C., & Fung, K. L. (2015). Factors associated with health-promoting behavior of people with or at high risk of metabolic syndrome: Based on the health belief model. Applied Nursing Research, 28(2), 197-201. doi:10.1016/j.apnr.2014.11.001 Welch, J. L., Fisher, M. L., & Dayhoff, N. E. (2002). A cost-effectiveness worksheet for patient-education programs. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 16(4), 187-192. Zgibor, J. C., Peyrot, M., Ruppert, K., Noullet, W., Siminerio, L. M., Peeples, M., . . . Charron-Prochownik, D. (2007). Using the american association of diabetes educators outcomes system to identify patient behavior change goals and diabetes educator responses. Diabetes Educator, 33(5), 839-842. Retrieved from 1Labor CostPersonnelNo. of HoursHourly RateExt. Labor CostNurse Practitioner 124$49.00$1,176.00Nurse Practitioner 24$35.00$140.00Nurse Practitioner 34$34.00$136.00Medical Office Assistant4$18.00$72.00Total34$1,524.00Table 2Direct Cost—Salaries and MaterialsPersonnelNo. of HoursHourly RateExtended Labor CostTotal CostNurse Practitioner 13 hours a week x 24 weeks$49.00$3,528Nurse Practitioner 21 hour a week x 24 weeksSalariedFixed CostNurse Practitioner 31 hour a week x 24 weeksSalariedFixed CostMedical Office Assistant20 minutes a week x 24 weeksSalariedFixed CostMaterials$500.00Total184 hours$3.528.00$500.00Appendix ADiabetes Self-Management Questionnaire (DSMQ)The following statements describe self-care activities related to your diabetes. Thinking about your self-care over the last 8 weeks, please specify the extent to which each statement applies to you.Applies to me very muchApplies to me to a consider-able degreeApplies to me to some degreeDoes not apply to me1.I check my blood sugar levels with care and attention.? Blood sugar measurement is not required as a part of my treatment. ?3?2?1?02.The food I choose to eat makes it easy to achieve optimal blood sugar levels.?3?2?1?03.I keep all doctors’ appointments recommended for my diabetes treatment.?3?2?1?04.I take my diabetes medication (e. g. insulin, tablets) as prescribed.? Diabetes medication / insulin is not required as a part of my treatment. ?3?2?1?05.Occasionally I eat lots of sweets or other foods rich in carbohydrates.?3?2?1?06.I record my blood sugar levels regularly (or analyse the value chart with my blood glucose meter).? Blood sugar measurement is not required as a part of my treatment. ?3?2?1?07.I tend to avoid diabetes-related doctors’ appointments.?3?2?1?08.I do regular physical activity to achieve optimal blood sugar levels.?3?2?1?09.I strictly follow the dietary recommendations given by my doctor or diabetes specialist.?3?2?1?010.I do not check my blood sugar levels frequently enough as would be required for achieving good blood glucose control.? Blood sugar measurement is not required as a part of my treatment. ?3?2?1?011.I avoid physical activity, although it would improve my diabetes.?3?2?1?012.I tend to forget to take or skip my diabetes medication (e. g. insulin, tablets).? Diabetes medication / insulin is not required as a part of my treatment. ?3?2?1?013.Sometimes I have real ‘food binges’ (not triggered by hypoglycaemia).?3?2?1?014.Regarding my diabetes care, I should see my medical practitioner(s) more often.?3?2?1?015.I tend to skip planned physical activity.?3?2?1?016.My diabetes self-care is poor.?3?2?1?0Schmitt et al., 2013 Appendix BAmerican Association of Diabetes Educator’s Seven Self-Care Behaviors Educational Materials*Please see Attached PDF File for the educational materialsAppendix CSingle Item Literacy ScreenerNeverRarelySometimesOftenAlwaysHow often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?12345Scores greater than 2 were considered positive, indicating some difficulty with reading printed health related material (Cornet, 2009).Appendix DMyChart Evaluation ScalePlease circle the number best describing your feelings about using MyChart for diabetes educationStrongly AgreeAgreeNo OpinionDisagreeStrongly DisagreeMyChart emails increased my understanding of diabetes care12345MyChart emails covered diabetes topics I wanted to learn about12345The NP responded to the MyChart email I would send in a timely fashion12345I wish I could have received more emails each week about diabetes12345I wish I would have received less emails each week about diabetes12345The number of emails I received each week about diabetes was just right12345I would continue using MyChart emails for diabetes education in the future if offered12345Additional thoughts about using MyChart as part of diabetes education: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Appendix EPhysician DSME Quality Improvement Project Evaluation ScaleStrongly AgreeAgreeNo opinionDisagreeStrongly DisagreeUtilizing the NP for DSME improved quarterly patient satisfaction with their care12345Arranging appointments for the NP education sessions was flexible12345The NP utilized provider collaboration for potential patient diabetes complications in a timely manner12345Long-term evaluation of the NP in the educator role would be worthwhile to the practice for diabetes care12345Additional thoughts regarding the NP led quality improvement DSME initiative: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________KeyDSME = Diabetes Self-Management EducationAppendix FCLEAR Research Model*Please see attached CLEAR Research Model handout ................
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