Student Name
Capella University
NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations
Prof. Name
Date
Stakeholder Presentation
Delays in implementing an integrated diabetes education program at St. Paul Regional Health Center (SPRHC) are significantly affecting patient adherence to self-management practices. Fragmented care coordination and inconsistent communication among healthcare professionals hinder real-time collaboration, resulting in suboptimal diabetes management outcomes. To address these challenges, this assessment proposes an interdisciplinary care plan aimed at improving communication, enhancing patient education, and strengthening overall diabetes care coordination.
Organizational Issue
SPRHC is facing notable delays in the implementation of a structured diabetes education program, leading to poor patient adherence and unfavorable clinical outcomes. These delays are largely attributed to fragmented care coordination, inconsistent communication across interdisciplinary teams, and the absence of standardized workflows. Without real-time collaboration among primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists, treatment plans often become misaligned, contributing to inadequate glycemic control and increased hospital readmissions. Additionally, ineffective interdisciplinary coordination contributes to staff burnout, as unclear roles and inefficient workflows add to their workload. The hospital’s reputation is at risk as poor diabetes management may deter potential patients and hinder the recruitment of top healthcare professionals.
A systematic review by Tandan et al. (2024) analyzed 54 studies on team-based interventions for chronic disease management in primary care, revealing significant improvements in clinical outcomes. These improvements included reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%), particularly when interdisciplinary teamwork was emphasized. These findings highlight the critical need for a structured, interdisciplinary diabetes education program at SPRHC to improve collaboration, enhance patient outcomes, and reduce overall healthcare costs.
Importance of the Issue
Addressing the gaps in diabetes education and interdisciplinary collaboration at SPRHC is essential to delivering high-quality, patient-centered care. The implementation of a formalized diabetes education program will introduce standardized protocols, shared decision-making, and common electronic health record (EHR) templates to facilitate real-time treatment adjustments. Weekly interdisciplinary team meetings will promote collaboration among primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists, ultimately improving patient outcomes and fostering a teamwork-oriented culture.
Improved communication and reduced treatment variability will enable healthcare professionals to provide more consistent, evidence-based care, leading to higher job satisfaction. This initiative aligns with SPRHC’s mission to offer comprehensive diabetes management, strengthen patient trust, and promote long-term engagement in care. Furthermore, it will contribute to lower hospital readmissions, reduced healthcare costs, and enhanced organizational efficiency, ensuring the sustainability of high-quality diabetes care.
Table: Key Aspects of the Interdisciplinary Diabetes Care Plan
| Category | Details |
|---|---|
| Interdisciplinary Team Approach | Enhances coordination among primary care providers, endocrinologists, diabetes educators, dietitians, pharmacists, and behavioral health professionals. |
| Standardized Communication Protocols | SBAR (Situation, Background, Assessment, and Recommendation) framework will be used for patient handoffs to ensure effective and structured communication. |
| Real-Time Data Sharing & Integration | EHR systems will be integrated with a dedicated diabetes management platform for real-time access to patient data, lab results, and medication adherence. |
| Collaborative Decision-Making & Care Pathways | Development of interdisciplinary care pathways for personalized insulin management, lifestyle interventions, and behavioral support. |
| Training & Cross-Disciplinary Education | Regular training on diabetes management, motivational interviewing, and shared decision-making will enhance collaboration and patient education. |
Implementation and Resource Management
Successfully implementing an interdisciplinary diabetes education program at SPRHC requires a structured approach with appropriate resource allocation. The Plan-Do-Study-Act (PDSA) cycle will be used to ensure sustainability and continuous improvement.
- Planning Phase: The first phase will identify key challenges such as low patient compliance, inadequate diabetes education, and inefficient care coordination. Training programs will be developed for primary care teams, nurses, dietitians, pharmacists, and behavioral health professionals to improve communication and patient education.
- Doing Phase: A pilot group of patients will be enrolled in the diabetes education program. Staff will participate in simulation exercises and workshops to refine teamwork and engagement strategies.
- Study Phase: Performance indicators, including improved glycemic control (A1C levels), medication adherence, and reduced hospital readmissions, will be assessed. Feedback from staff and patients will help refine the program.
- Act Phase: The program will be expanded hospital-wide, supported by ongoing training, quarterly interdisciplinary meetings, and continuous monitoring of patient outcomes.
Strategic Financial Planning
Sustaining the diabetes education program requires strategic financial planning. The estimated annual costs for training, technology, and patient education range from $250,000 to $450,000. However, this investment is expected to yield long-term savings by improving glycemic control, reducing hospital admissions, and minimizing diabetes-related complications (American Diabetes Association [ADA], 2024). Effective resource allocation, including optimized staffing and EHR integration, will further enhance care coordination and efficiency (Tamunobarafiri et al., 2024).
References
American Diabetes Association (ADA). (2024). About diabetes. Diabetes.org. https://diabetes.org/about-diabetes
Colvin, C. L., Akinyelure, O. P., Rajan, M., Safford, M. M., Carson, A. P., Muntner, P., Colantonio, L. D., & Kern, L. M. (2023). Diabetes, gaps in care coordination, and preventable adverse events. The American Journal of Managed Care, 29(6), e162–e168. https://doi.org/10.37765/ajmc.2023.89374
Dhediya, R., Chadha, M., Bhattacharya, A. D., Godbole, S., & Godbole, S. (2022). Role of telemedicine in diabetes management. Journal of Diabetes Science and Technology, 17(3), 193229682210811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10210114/
Nurchis, M. C., Sessa, G., Pascucci, D., Sassano, M., Lombi, L., & Damiani, G. (2022). Interprofessional collaboration and diabetes management in primary care: A systematic review and meta-analysis of patient-reported outcomes. Journal of Personalized Medicine, 12(4). https://doi.org/10.3390/jpm12040643
NURS FPX 4005 Assessment 4
Tamunobarafiri, G., Aderonke, J., Cosmos, C., None Mojeed Dayo Ajegbile, & None Samira Abdul. (2024). Integrating electronic health records systems across borders: Technical challenges and policy solutions. International Medical Science Research Journal, 4(7), 788–796. https://doi.org/10.51594/imsrj.v4i7.1357
Tandan, M., Dunlea, S., Cullen, W., & Bury, G. (2024). Teamwork and its impact on chronic disease clinical outcomes in primary care: A systematic review and meta-analysis. Public Health, 229, 88–115. https://doi.org/10.1016/j.puhe.2024.01.019