I interviewed Mr. Mathew, a patient of diabetes, for 3 hours of my practicum. This proposal seeks to improve the patient’s quality of life and satisfaction by proposing a diabetes management program by evidence from the literature. Diabetes is a leading cause of morbidity and mortality in US that contributes significantly to health care cost. Therefore, it should be managed to decrease the cost on the healthcare systems and enhance the quality of the life of the patient.
The assessment aims at discussing the management of diabetes with medication therapy, psychological therapy, diet, exercise regime and community care, and the social and cultural context as well.
Meeting and Intervention Plan Highlights
The patient Mr. Mathew, 45 years, male is diabetic since last twenty years’ patient. The encounters with the patient were conducted on four different occasions between the 15/08/2024 and 30/08/2024. The location of the meeting was North Shore Medical Center. The total duration of the meeting was approximately 9 hours. The aim of these meetings was to establish the diabetes as a health issue and to form a strategy on its management. Although diabetes is a patient related issue, it is of equal significance to the family as the family is involved in the management and active care of the patient.
The details of an intervention plan devised with the help of the care coordination team are that the interdisciplinary team for the management of diabetes consists of a physician, endocrinologist, nurse, nutritionist and a physiotherapist. The can make the use of medical devices, software, and mobile application for monitoring the changes in blood glucose level was
defined. Another aspect that was considered was the use of the latest technology to record the health information of the patient. The importance of the communication and coordination between the patient and the health care provider was also taken into consideration. The role of the patient family in the decision making process was studied. The role of the stakeholders including the healthcare authorities, private organizations and social care providers is also underlined.
Hence, the knowledge on medical disorders including diabetes enabled me to be able to design a comprehensive care plan covering the medical, psychological, physical and the social aspects of the disease. Meeting the medical needs of the patient within the affordable cost was also taken into consideration. The equipment such as glucometers, wearable monitoring devices, mobile apps and software were suggested as helpful technologies to monitor the symptoms of the diabetes. Interprofessional relations and teamwork in the health care team and the patient was also emphasized especially in the area of information exchange. It will result in the development of the comprehensive care coordination plan. The patient and the family were also taught the importance of early management of the disease. It helps protect the patient against other cardiovascular, neurological and renal diseases which would otherwise worsen the patient’s quality of life. I found it helpful to involve the patient and the family in the disease management plan to improve compliance. In addition, the stakeholders’ involvement, including the healthcare authorities and the social care organizations, were also discussed.
The role of self-monitoring of diabetes through the use of wearable monitoring equipment and software and application on the smart mobile devices was also examined. The patient will be required to adhere to certain dietary restrictions and physical exercise regimen as recommended by the nutritionist. It is also important to ensure that follow up visits are done as diabetes is a chronic illness, which even when well managed requires constant attention.
Sometimes, the patient may consult the healthcare team using the telehealth services. Information and knowledge given by the health care team remotely can enhance the quality of life on the permanent bases.
The treatment plan which includes medication, diet, exercise and psychological treatment will continue since the illness is chronic. However, the frequency of use of the medication may be modified depending on the condition of the patient and the changes in the blood glucose levels. The regiment should be followed until the patient returns to his or her normal activities. If the patient starts developing symptoms with potential of developing a cardiovascular or renal issue, or neurological complications, the above plan shall be applied again strictly followed with the help of coordination team, medications and follow ups.
The patient understood the details about the intervention plan and did not have any difficulty in the understanding it. Through the care coordination team, effective communication, the use of digital technology, mobile health, and telehealth services the support was easy and efficient. In the event that at any one time the patient requires the help of the medical team, the team is ever ready to help in the putting into practice the intervention plan for the patient.
There were no significant problems or barriers encountered by the patient and the family in implementing the intervention plan. This could be attributed to the fact that they were well educated on the intervention plan by the care team effectively. Nevertheless, some challenges which were identified in the use of the medical devices and the mobile health technologies. These were attended to by ensuring that patient gets educated by the educational workshops, brochures and the physical demonstration.
The patient and the family were explained and empowered on the importance of adhering to the medication and therapeutic plan to improve the outcomes. The cultural and linguistic competency was applied to transfer information between the healthcare provider team and the
patient. It was useful in determining the severity of the disease and in improving the treatment program.
The patient and the family had a positive attitude towards the efficacy of the intervention plan since it helped in the management of the signs of diabetes. It is also contributed by the well-coordinated and efficient functioning of the healthcare setting and the healthcare workers.
The follow ups of the patient by the healthcare team will still be required to continue the positive results from the intervention in order to enhance the health. This can be achieved through physical visits or the use of telemedicine. If there is any issue the patient can always call the healthcare team for help.
The above intervention has been very useful in enhancing the quality of care for patient and the family. The family and the patient adhered to the interventional plan as evidenced by improvement of the health status of the patient.
Therefore, the overall result of the intervention conducted in this case was positive for the patient. Medical and nursing services were also considered as the significant factor by the patient and the family. By the records and from the patient’s feedback, it can be concluded that the quality of life of the patient improved through the interventions. Intervention plan enhanced the overall wellbeing of the patient.
The extent to which the particular intervention strategy has an impact on the health status of the patient could be measured by the scores of patient satisfaction and clinical results. These were expressed in terms of milder symptoms, improved quality of life, fewer incidences of diabetic crisis, better social adjustment, better adherence to treatment and increased physical health.
Contribution of an Intervention
The evaluation of the contribution of the intervention can be done by determining the efficacy of intervention plans. The intervention plan developed for Mr. Mathew was a multidimensional in nature. It is patient centered and is incorporated in the the patient’s life history with respect. This includes a medication plan, change of diet, addition of physical exercise, compliance to the doctor’s orders and living a healthy and stress free lifestyle (Yasmin et al., 2020).
The patient also has to self-manage by using good quality medical devices and products that are made available at an affordable cost through the intervention plan. By the use of technological devices along with software and apps that are used to track the symptoms of diabetes and medication, the patients are enabled to change their conditions and improve the results. Social care initiatives are applicable because it enables the people to share their experiences with other people hence increasing the desire to have a better health status. This eliminates isolation of the patient and makes them feel they are still a part of the community. The intervention plan removes the barriers of social and economic status that keep middle and lower middle class patients from accessing the healthcare products and services. (Christensen et al., 2020).
The feasibility of the intervention plan in relation to cost was made possible with help from social care agencies and state and government health departments. The medical devices, applications and software were made available at lower costs through the process of copayment with the help of the charitable organizations or the state facilities. It helped in reducing the cost of care to the patient as well as the burden of the health care system through reduction in visits, admissions and procedures. The social support of the community helps with the coping patients of chronic diseases such as diabetes. Thus, the implemented intervention enhances the quality of life of people like Mr. Mathew (Higa et al., 2020).
As I was able to interact with Mr. Mathew, I realized that he is positive towards idea of individualization of the program including medication, diet and exercise plan with consideration to culture. He stated that he feels empowered of his condition, which made him more active in the management. Therefore, the level of compliance turned out to be high concerning the medication plan and lifestyle modification. He also acknowledged the community based management of the disease as an integrated approach (Flor et al., 2020).
The program can be life changing one in the life of Mr. Mathew and his family. The family is also satisfied with the holistic care concept that has minimized their concern on the health of Mr. Mathew. In short, the activity made the family experience more available in using all the skills and knowledge for the best use in diabetes.
In my opinion, the major strength of the plan developed for Mr. Mathew is that the plan covers all aspects of the roles and responsibilities of the care coordination team in terms of knowledge and skills. This also facilitated the enhancement of culture based and personal approaches and the need to combat diabetes.
Planning and Implementation of Capstone Project and Use of Peer Reviewed Literature
The efficient review of the scientific literature was important before planning and implementing the capstone project. The review was conducted to obtain the information about such interventions and practices which have been used to prevent and treat diabetes in the community. The evidences based studies, and the collected data facilitated me in providing direction on the strategy to be adopted for the formulation of intervention plan for diabetes for Mr. Mathew (Siegel et al., 2020).
Next, I sought a medical advice from physicians, dieticians specialists, endocrinologists, nurses, nutritionist, social care workers and health care authorities on effective management of the patient. Besides involvement of the field experts, the evidence and research available to
develop an appropriate care plan for both the patient and the healthcare team was also considered. For example, cultural sensitivity in dealing with Mr. Mathew and his family was enhanced by providing them with the information required with regard to their ways of life. Mr. Mathew was treated in a culturally competent way by the medical team. The information from them helped in assessing the effectiveness of the intervention plan (Griffith et al., 2023).
I also made sure that the capstone project is individualized based on the medical and psychological requirements of the patient without compromising on the quality of care, safety and cost-effectiveness. It included customized diet and exercise plan along with stress reduction. In addition to this, the project incorporated the guidelines and protocols of evidence based practice as framework for handling all the planning and implementation.
The change models that were used included the McKinsey’s 7S model of change and the ADKAR model depending on the situation. McKinsey’s model was derived from the change process that encompassed the policy which included Strategy, Structure, Systems, Shared Values, Skills, Style and Staff. The patient and the family were informed regarding intervention plan for the management of diabetes by the healthcare team. The plan is then implemented and if the plan is effective it is incorporated into the system that will be scaled up for health care sector for management of diabetes (Barney, 2023).
Similarly, the ADKAR model of change works by providing awareness, desire, knowledge, ability, and reinforcement of the healthcare team, the patient, and the family regarding the need of change in the management plan. It works on the need to advance the management of patient health by providing the patients with the required knowledge. The knowledge and abilities of the team, patient and the family are enhanced in order to sustain the change and adapt to new approach for managing diabetes. Lastly, change is made sustainable for improving the health of diabetes in the patient (Nakibuuka, 2022). Hence, in this way, the Patient
and the family receive the required knowledge and skills for the more effective management of the problem of diabetes.
Leveraging Health Care Technology in the Capstone Project
In today’s world technology is very important tool to improve self-management and follow-up for chronic diseases. Devices like digital glucometers and wearable monitoring devices are useful in monitoring the physiological parameters like the blood glucose levels, BP, lipid profile and BMI etc. It gives an idea of the health status of the patient. This monitoring can assist in modifying the treatment plan when required (Trout et al., 2022). The mobile apps and software are all in one management source for the diet, exercise, and medicine routine. They also help in education of the patient and recording the sign and symptoms. It also helps to improve the communication and coordination between the doctor and patient regarding to the changes in the therapeutic plan.
My capstone project can be of great benefit to the healthcare system in the management of diabetes. I engaged technology and care coordination in a constructive and innovative way in an effort to improve the results for diabetes for Mr. Mathew. Important technologies included the glucometers, wearable devices and mobile health applications that helped in monitoring the signs and symptoms and the physiological changes. The roles members of coordination team among themselves and to the patient regarding communication was also emphasized (Sørensen et al., 2020). In addition, knowledge and education provided to the patient helped him to follow the medication plan, its adherence and enhance the physical activity and dietary pattern. Mr. Mathew effectively employed the mobile applications to track the progress and forward the information to his medical care team. This enhanced the use of consultation’s effectiveness. Also, due to the provision of telehealth services to Mr. Mathew the access to care was facilitated. Hence the follow-up appointments were also possible to be done virtually (Batch et al., 2021).
The intervention plan makes it possible to ascertain that future opportunities can be enhanced to optimize the healthcare. The use of HIT in order to share information with other care givers also enhances the level of healthcare. Standardizing the tests on a singular protocol system ensures that some information can will be made available to the care providers across the board. Electronic Health Record (EHR) is important in serving this purpose. Moreover, mobile apps can be used and optimized for data storage for monitoring and can go a step further to benefit patients such as Mr. Mathew who are not so proficient in the use of technology (Hatef, 2021).
Additionally, the education and the awareness on proper use of these technologies for patients and their caregivers is also of importance to be able to get the maximum benefits. The enhanced communication with the patient and the healthcare team helps improve the healthcare outcomes for Mr. Mathew. The enhanced supervision of the physiological variables such as the blood glucose levels, blood pressure, BMI and lipid profile etc. are also useful in formulating a care coordination plan. Patient engagement in decision making and with the support of the family and the healthcare providers also enhances the compliance.
Impact of Health Policies on Planning and Implementation
The care plan or interventions are formulated with reference to the State Board Nursing Practice and the state policies. ANA provides the most important practice standards of nursing. It includes preventive, diagnostic and treatment aspects of diabetes strive to adhere to the four principles of health care namely beneficence, non-maleficence, autonomy and justice. Of these guidelines, the most relevant relates to the nursing care and the safety of the patient as well as the patient’s outcomes (American Nurses Association, 2019).
Health Information Technology (Health IT) facilitates the sharing of information among the healthcare organizations. The increase in the quality of the care coordination plan improves
Mobile Health (mHealth) Policies encourage the adoption of the latest use of technology by the patients and the care providers. It can be in the form of devices, for example glucose monitoring devices, (single point or continuous) or software and application on mobiles. They are also very useful for the patients who live in the rural areas or are not in the position to visit the health care facility because of any medical or logistical problem (Ali Sherazi et al., 2022).
NDPP is a project of CDC in collaboration with other federal health agencies that manages obesity and other diseases such as diabetes. It assists in reduction of diabetes incidences through early detection and prevention. This aims at population with high risk of developing disease. It also fosters the practice of health related behavior change by the integration of exercise and proper diet management regimen (Ritchie et al., 2020).
Electronic Health Record (EHR) Incentive is a policy of maintaining the record of patient’s information and health status in an electronic form. It helps in replicating information in form of data or statistics to the healthcare staff when needed to change the intervention or in policy making. The meaningful use of EHR can be ensured in the form of incentive for the healthcare professionals is done by the involvement of Center for Medicare Aid and Services (CMS, 2023).
Regarding the diabetes intervention plan, nurses play a role key in coordinating care and devising policies aligned with ANA practice standards, HIT and mHealth. The application of the four principles of beneficence, non-maleficence, autonomy and justice underlines that the intervention is safe, accessible, and effective for the patient. The use of HIT and EHRs in nursing practice for diabetes intervention plan allows nurses to record information about the patient and observe data such as the patient’s glucose levels. Hence, they can make necessary changes in the
care plan if required. Through early detection and changes in behavior as recommended by NDPP, the nurses play a central role in preventing diabetes through preventive measures
Moreover, nurses encourage the use of mHealth technologies including glucose monitoring devices and mobile applications that enables patients to manage their condition even remotely. Hence, this integration of policies allows the nurses to provide constant support and education to the patients, improving the patient involvement.
Nurses Role in Policy Development and Implementation
BSN nurses have a vital role to play in policy development and implementation due to their knowledge, leadership qualities, advocacy and ability to analyze evidence based practice. The policies can enhance the service in the health sector, collaboration with other practitioners, and improve research with an aim of making the policies effective for the patients. ANA plays a pivotal role in development of protocols for nursing care. Health information technology (HIT) and public health can be employed by the nurses for effective transfer of information. Therefore, they can develop technologies like EHRs, mHealth and other technologies for the purpose of improving the care delivery and for the benefit of the patient. Hence, when the BSN prepared nurse engages in the community health activities, and working on the social determinants of health, he or she is responsible for the equitable enhancement of the health care systems (Fareed et al., 2023).
Regarding diabetes intervention plan, the BSN-prepared nurses can assume an important function by establishing policies aimed at enhancing the quality of care delivery. With the use of HIT tools such as EHRs and mHealth applications, nurses can enhance the ways on how to effectively manage diabetes, patient’s personal information and health information. This information can be used to and intervene at the right time in consultation with the healthcare team, to improve the quality of care for the patient.
Moreover, the policies in accordance with guidelines of the ANA and other regulatory authorities, may address the enhancement of patients’ self-management of diabetes. Because of this, nurses can be able to manage community health activities and other social determinants that influence health, like providing customized medication regimen, proper diet and education for the patients. Thus the role of nurses in light of the policies aligns well with the capstone project to increase the improve the management of diabetes and improve the health of patients.
Comparison of Outcomes with Initial Predictions for Capstone Project
The capstone project has provided me the chance to meet the initial predictions regarding the management of diabetes. The criteria were a significant improvement in the symptoms for Mr. Mathew and the frequency of medical crisis. Therefore, all the set goals and objectives of enhancing the quality of healthcare, patient safety and cost efficiency were achieved by the implementation of care plan to Mr. Mathew. Based on the benchmark parameters, the severity of the symptoms, quality of life, physical health, social interaction and adherence to the prescribed treatment plan significantly improved. It also helped to increase my confidence as a health care practitioner. To improve the quality of life of Mr. James, the intervention plan focused on the enhancing communication between the patient and the healthcare providers. Community awareness and public resources also played an important role.
Insight into the Generalizability of the Intervention
As for the generalization of the capstone project, it is possible to state that it can be generalized for larger set of population with some modifications. As the individualized approach was used in the intervention, the study can be regarded as the pilot study for diabetes management. The patient’s centered care, awareness, education, therapeutic plans and lifestyle can be extended to other patients and the community. Despite the fact that the intervention and
treatment plan has been customized for Mr. Mathew, it is possible to apply it with other people with necessary changes.
The above task helped me to advance my professionalism, especially the nursing skills through academic and practical skills improvement. This project and the RN-to-BSN program has been very useful to my career. It enhanced my knowledge and competencies that I need to offer to my patient.
Practicum Hours
During my 3-hour practicum, I interviewed Mr. Mathew regarding diabetes, the risks and its complications and intervention plan for the management of this disease. The current therapeutic plans were also assessed to enhance the existing plans to develop the plan for improving the patient care and safety. The assessment of the plan depending on the feedback of the patient and the healthcare team, helped improve the quality of the care provided, patient satisfaction level and the cost effectiveness point of the plan formulated for Mr. Mathew.
Due to the extensive literature and groundwork that is needed for the effective development and implementation of the project, I was able to enhance my theoretical as well as the practical knowledge in nursing.
Analyzing the Personal and Professional Growth During the Capstone Project
The RN-to-BSN capstone project was academically very useful to me as helped develop my abilities both personally and professionally. The practicum hours with Mr. Mathew helped me to gain an understanding of some of the issues related to diabetes. I have also learnt to be sensitive with the different communities of people. I realized and applied better use of communication and cultural skills through this project. Thus I am in a better position to attend to patients’ diverse needs (Yao et al., 2021). At the conclusion of this project, I can confess I realize it as an opportunity to better understand diabetes, its causes, complications, and available
Participation in the capstone project has expanded my knowledge of the healthcare issues and solutions, particularly the application of evidence-based practices. This gave me a chance to interact with the healthcare professionals. Exploratory literature review enabled me to develop my research and project management skills which are vital in nursing practice.
Conclusion
In this assessment, it is concluded that the outcomes of the patients can be enhanced for diabetes with the help of the care plan and the intervention. The intervention program can have potential positive effects on patients’ satisfaction and recovery while being cost effective. It was general in its approach to the medical requirements of the community aimed at enhancing the wellbeing of the patient. This program shows that cultural sensitivity, moral behavior, and patient-centered care as key components for the improvement of the community. However, More research is required to determine the longevity of such programs and their ability to grow to include other people.
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