NURS FPX 4005 Assessment 4

NURS FPX 4005 Assessment 4

Student Name

Capella University

NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations

Prof. Name:

Date

Stakeholder Presentation

The delays in implementing an integrated diabetes education program at St. Paul Regional Health Center (SPRHC) are significantly affecting patient adherence to self-management. The fragmentation of care coordination and inconsistent communication between healthcare teams hinder real-time collaboration, negatively impacting diabetes management outcomes. This assessment proposes an interdisciplinary care plan to improve communication, enhance patient education, and optimize diabetes care coordination at SPRHC.

Organizational Issue

SPRHC is experiencing notable delays in the implementation of a comprehensive diabetes education program, which is adversely affecting patient adherence and clinical outcomes. These delays are primarily caused by fragmented care coordination, inconsistent communication among interdisciplinary teams, and a lack of standardized workflows. Without real-time collaboration between primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists, treatment plans become misaligned, leading to poor glycemic control and higher rates of hospital readmissions. Furthermore, ineffective interdisciplinary coordination contributes to staff burnout due to unclear roles and inefficient workflows. These issues not only affect patient health but also risk SPRHC’s reputation, as poor diabetes management may discourage potential patients and hinder the recruitment of top healthcare professionals.

A systematic review by Tandan et al. (2024) examined 54 studies on team-based interventions for chronic disease management in primary care. The review revealed significant improvements in outcomes, including reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%), especially when multiple teamwork components were integrated. These findings underscore the importance of a structured, interdisciplinary approach to diabetes education at SPRHC, which could enhance collaboration, improve patient outcomes, and reduce healthcare costs.

Importance of the Issue

Addressing the gaps in diabetes education and interdisciplinary practice at SPRHC is vital for delivering high-quality, patient-centered care. A formalized diabetes education program would establish standardized protocols, promote shared decision-making, and incorporate common electronic health record (EHR) templates to allow real-time treatment adjustments. Weekly interdisciplinary rounds will be implemented to enhance coordination among primary care providers, nurses, dietitians, pharmacists, and behavioral health professionals, thus improving patient outcomes while fostering a collaborative environment.

By improving communication and reducing variability in treatment plans, healthcare providers can deliver evidence-based care more effectively, thereby increasing job satisfaction. This initiative aligns with SPRHC’s mission to provide comprehensive diabetes management, strengthen patient trust, and encourage long-term engagement in care. Additionally, it will help reduce hospital readmissions, lower healthcare costs, and improve organizational efficiency, ensuring long-term sustainability and excellence in diabetes care.

Table: Key Aspects of the Interdisciplinary Diabetes Care Plan

Implementation and Resource Management

The successful implementation of the interdisciplinary diabetes education program at SPRHC requires a well-structured approach and careful resource allocation. The Plan-Do-Study-Act (PDSA) cycle will be employed to ensure continuous improvement and sustainability.

• Planning Phase: Identify key challenges such as low patient compliance, inadequate diabetes education, and inefficient care coordination. Develop training programs for primary care teams, nurses, dietitians, pharmacists, and behavioral health professionals to enhance communication and patient education.
• Doing Phase: Enroll a pilot group of patients in the diabetes education program. Staff will participate in simulation exercises and workshops to refine teamwork and engagement strategies.
• Study Phase: Analyze performance indicators such as improved glycemic control (A1C levels), medication adherence, and reduced hospital readmissions. Use feedback from staff and patients to guide program refinements.
• Act Phase: Expand the program hospital-wide, supported by ongoing training, quarterly interdisciplinary meetings, and continuous monitoring of patient outcomes.

Financial Planning and Resource Allocation

Strategic financial planning is critical to the program’s long-term success. Initial costs for training, technology, and patient education are estimated to range from $250,000 to $450,000 annually. However, this investment is projected to reduce long-term healthcare costs by improving glucose control, reducing hospitalization rates, and minimizing diabetes-related complications (ADA, 2024). Effective resource allocation, including optimized staffing and EHR integration, will further enhance care coordination (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/

NURS FPX 4005 Assessment 4

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

Tamunobarafiri, G., Aderonke, J., Cosmos, C., Ajegbile, M. D., & Abdul, S. (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