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NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

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    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    Student Name

    Capella University

    NURS FPX 4900 Capstone Project for Nursing

    Prof. Name

    Date

    Patient, Family, or Population Health Problem Solution

    Type 2 diabetes are widespread health issues with significant consequences for individuals and healthcare systems alike. In John’s case, these co-occurring conditions necessitate a holistic, evidence-based intervention tailored to effectively manage his health and minimize the risk of complications. This assessment will delve into the importance of understanding the patient’s needs, preferences, and financial situation. We will explore strategies for patient-centered care, communication and collaboration, adherence to nursing practice standards and policies, the application of technology, care coordination, and utilization of community resources. By considering John’s unique circumstances, including his financial constraints, our goal is to develop a comprehensive approach that incorporates self-management strategies, government policies, and telehealth services to optimize his diabetes management and overall health.

    Role of Leadership and Change Management in Addressing the Health Problem

    Leadership and change management are critical components in addressing Type 2 diabetes. Effective leadership strategies involve creating a shared vision, empowering team members, and building a culture of learning and innovation. By developing a clear vision for diabetes management that aligns with organizational goals and patient needs, leaders can ensure that all team members understand and work towards that vision (Khodyakov et al., 2021). Empowering healthcare professionals to make decisions, share ideas, and implement evidence-based practices is crucial for developing a culture of continuous improvement (Worum et al., 2020).

    Change management strategies are essential for adapting to new practices and overcoming barriers to change. Strategies include assessing readiness for change, engaging stakeholders, and piloting and evaluating changes (Kho et al., 2020). Involving patients, families, healthcare professionals, and other stakeholders in the change process is critical for building buy-in and ensuring their needs and concerns are addressed (Ritchey et al., 2020).

    Nursing ethics, such as patient autonomy, beneficence, non-maleficence, and justice also influenced the development of the intervention (Cheraghi et al., 2023). The proposed intervention involves a multidisciplinary approach, which includes patient education, self-care, technology, care coordination, and the utilization of community resources. Providing culturally sensitive, tailored education on diabetes management, nutrition, and physical activity empowers patients to make informed decisions about their care (Singh et al., 2022). Encouraging patients to take an active role in their care, including self-monitoring of blood glucose, medication adherence, and lifestyle modifications is essential (Ritchey et al., 2020).

    Communication and Collaboration Strategies to Improve Outcomes

    The care team will work collaboratively with John and his family to implement the following strategies to improve his health outcomes:

    • Providing John with culturally sensitive, tailored education on diabetes management, nutrition, and physical activity empowers him to make informed decisions about his care. Healthcare professionals should deliver clear, concise, and accessible information that addresses John’s specific needs and learning preferences (Singh et al., 2022). This comprehensive education can help John gain a better understanding of his condition, develop self-management skills, and adopt healthy lifestyle choices to improve his health outcomes. This will also develop a sense of trust between the patient and the medical team. John will be able to communicate his concerns and needs with openness. This approach can lead to better treatment adherence, reduced diabetes-related complications, and improved overall health outcomes . 
    • Encouraging John to take an active role in his care, including self-monitoring of blood glucose, medication adherence, and lifestyle modifications is essential. Healthcare professionals can provide ongoing support, education, and resources to facilitate John’s self-management efforts. This approach can John can better manage his diabetes, leading to better glycemic control, fewer hospitalizations, and reduced healthcare costs  (Ritchey et al., 2020).
    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution
    • Introducing continuous glucose monitoring (CGM) systems, telehealth, and digital apps can enhance diabetes management and facilitate communication between John and healthcare professionals. The use of technology can provide real-time feedback on blood glucose levels, enable remote consultations, and offer personalized recommendations and support (Ritchey et al., 2020). By integrating technology into John’s care, the care team can effectively monitor his progress, promptly address any concerns, and optimize his treatment plan leading to better diabetes management.
    • Ensuring a seamless, patient-centered approach to care involves collaboration among healthcare professionals, including primary care providers, endocrinologists, nutritionists, and mental health specialists. Effective care coordination can lead to better health outcomes, increased patient satisfaction, and reduced healthcare costs (Eze et al., 2020). For John, a coordinated care team can develop a comprehensive and individualized care plan, addressing his unique needs and working together to achieve his health goals. This can help in increased patient satisfaction, and reduced healthcare costs 
    • Connecting John with support groups, educational programs, and other community resources can further enhance diabetes management and promote patient self-management. These resources can provide John with additional support, guidance, and motivation to maintain his self-care efforts (Worum et al., 2020). By leveraging community resources, John can build a strong support network and gain access to valuable tools and information to help him manage his Type 2 diabetes effectively. 

    Influence of State Board Nursing Practice Standards and Policies on the Proposed Intervention

    The devised intervention for John’s situation is built upon nursing practice standards set by the state board, organizational directives, and government regulations that prioritize evidence-based, patient-focused care. These guiding principles were instrumental in forming the intervention and ensuring its alignment with up-to-date best practices. The practice standards underscore the significance of nursing assessments, care planning, personalized patient education, and routine patient monitoring for those with diabetes. Adhering to these standards guarantees that nurses deliver uniform, top-notch care while following ethical nursing principles such as patient autonomy, beneficence, non-maleficence, and justice.

    The suggested intervention takes into account the ADA’s extensive guidelines concerning diabetes management. These guidelines address numerous care aspects, including blood glucose monitoring, pharmacological interventions, lifestyle changes, and care coordination (Buse et al., 2019). By following these recommendations, the care team can offer John the most suitable care, customized to his unique needs and preferences. A study discovered that diabetes self-management education (DSME) and support, in accordance with ADA guidelines, resulted in significant enhancements in glycemic control, self-care habits, and diabetes-related quality of life (Sukkarieh-Haraty et al., 2022).

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    The intervention also complies with organizational and governmental policies that advocate for patient safety, care quality, and cost-effective healthcare delivery. For example, the Centers for Medicare & Medicaid Services (CMS) have introduced initiatives to enhance diabetes care, such as the Diabetes Self-Management Training (DSMT) program, which bolsters patient education and self-management efforts (Puckrein et al., 2022). Research indicated that technology-supported diabetes self-management solutions, in line with nursing practice standards set by the state board and governmental policies, positively impacted patients’ clinical outcomes and satisfaction levels (Brew-Sam et al., 2020). 

    By ensuring that nursing care is evidence-based, patient-focused, and in line with the most recent best practices, the policies indicated in the supplied text can be successful in raising outcomes and standards. It is possible to guarantee that care is provided in a standardized and efficient manner by adhering to nursing practice standards established by the state board and by following directives from professional organizations like the ADA. Consistency can improve patient outcomes, including glucose control, self-care routines, and quality of life for people with diabetes.

    Additionally, adhering to corporate and governmental rules can advance patient safety, high-quality care, and efficient healthcare delivery. Healthcare professionals can improve patient education and self-management efforts by implementing programs like the Diabetes Self-Management Training (DSMT) program. 

    Effects of proposed intervention on Quality of Care, Patient Safety, and Reducing Costs

    The proposed intervention for John is designed to improve the quality of care, enhance patient safety, and reduce costs for both the healthcare system and the individual. By implementing evidence-based strategies, the intervention can potentially lead to better health outcomes, fewer complications, and decreased healthcare expenditures. The intervention’s focus on personalized patient education and self-care encourages John to actively participate in his diabetes management, leading to better adherence to treatment plans and improved health outcomes.

    Additionally, the multidisciplinary approach ensures that John receives comprehensive care tailored to his needs, ultimately improving the overall quality of care (O’Hara et al., 2020). The American Diabetes Association (ADA) Standards of Medical Care in Diabetes support these conclusions, emphasizing the effectiveness of comprehensive diabetes management in enhancing patient outcomes and lowering healthcare costs (Doyle-Delgado et al., 2020). 

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    For John, the use of continuous glucose monitoring (CGM) systems, telehealth services, and digital apps enhances patient safety by providing real-time data and immediate access to healthcare professionals for timely interventions and adjustments to treatment plans. This proactive approach helps prevent complications, such as hypoglycemia and hyperglycemia, and supports John in effectively managing his condition (Jothydev Kesavadev & Mohan, 2023).

    Improved diabetes management for John through the proposed intervention can lead to decreased healthcare costs by reducing the number of hospitalizations, emergency room visits, and long-term complications associated with Type 2 diabetes. A study demonstrated that diabetes self-management education programs could save the healthcare system up to $4,274 per person over a lifetime (Sharma et al., 2022).

    Application of Technology, Care Coordination, and Community Resources

    In John’s case, the intervention employs technology to enhance his diabetes management. Continuous glucose monitoring (CGM) systems allow for real-time tracking of blood glucose levels, enabling healthcare providers to make timely adjustments to his treatment (Beck et al., 2017). Telehealth services facilitate remote consultations, reducing the need for in-person visits, while digital apps assist John in monitoring lifestyle changes, glucose readings, and medication adherence, empowering him to take control of his diabetes management. To ensure a patient-centered approach for John, the intervention fosters collaboration among healthcare professionals, such as primary care providers, endocrinologists, nutritionists, and mental health specialists. This coordination allows for the development of a tailored treatment plan, ongoing monitoring of John’s progress, and adjustments to his care as needed. By receiving comprehensive, well-coordinated care, John can expect improved health outcomes (Sharma et al., 2022).

    Affordable Care Act (ACA) also provides care -cordination. ACA includes provisions for preventive care services, such as diabetes screening and education, without out-of-pocket costs, which can help John manage his condition before it becomes more severe. The ACA also supports the development of accountable care organizations (ACOs) and medical homes, which are models of care that focus on care coordination and patient-centered care (Millenson et al., 2019). These models involve healthcare providers working together to manage a patient’s care across different settings and can help ensure that John’s care is coordinated and comprehensive. 

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    In John’s intervention, community resources such as support groups and educational programs are integrated to enhance his diabetes management and promote self-management. For example, the National Diabetes Prevention Programme (NDPP) is a community-based initiative with the goal of delaying or preventing the onset of T2D by promoting good eating, exercise, and weight loss (Desai et al., 2020). Community-based organizations can help John manage his condition better and stop the disease from progressing by offering this program and supplying him with the tools and resources he needs to make lasting lifestyle changes.

    Programs for diabetes self-management education and support (DSMES) are essential for giving diabetic patients assistance and resources. These programs provide instruction on self-care techniques like managing medications, monitoring blood sugar, eating a nutritious diet, and exercising (Powers et al., 2020). DSMES programs help diabetic patients understand the importance of self-management and provide them with the necessary tools and resources to manage their condition effectively. By empowering patients to take an active role in their care, DSMES programs can improve treatment adherence, reduce diabetes-related complications, and enhance overall health outcomes.

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    Connecting John with these resources helps him build a supportive network, acquire essential knowledge and skills, and develop confidence in making informed decisions about his care. A study demonstrated that patients participating in diabetes self-management education programs had improved glycemic control and self-management skills (Buse et al., 2019). By integrating community resources into John’s care, the intervention provides additional tools and support, ultimately improving his overall health and well-being.

    Conclusion

    The assessment has highlighted the pressing necessity for a comprehensive, patient-centric, and evidence-driven approach to tackling Type 2 diabetes. The suggested intervention prioritizes strategies such as patient education, self-care, technology, care coordination, and community resource utilization to optimize diabetes management and enhance health outcomes. Effective leadership and change management techniques are imperative for implementing these interventions and surmounting obstacles to change.

    The intervention aligns with state board nursing practice standards, organizational directives, and governmental regulations that prioritize patient-focused, evidence-based care. By enhancing the quality of care, boosting patient safety, and reducing costs, the proposed intervention holds the potential to significantly impact the well-being of individuals and healthcare systems.

    References

    Brew-Sam, N., Chib, A., & Rossmann, C. (2020). Differential influences of social support on app use for diabetes self-management – A mixed methods approach. BMC Medical Informatics and Decision Making, 20(1), 151. https://doi.org/10.1186/s12911-020-01173-3 

    Buse, J. B., Wexler, D. J., Tsapas, A., Rossing, P., Mingrone, G., Mathieu, C., D’Alessio, D. A., & Davies, M. J. (2019). 2019 Update to: Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 43(2), 487–493. https://doi.org/10.2337/dci19-0066 

    Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing, 22(1). https://doi.org/10.1186/s12912-023-01246-4 

    Desai, J. R., Vazquez-Benitez, G., Taylor, G., Johnson, S., Anderson, J., Garrett, J. E., … & O’Connor, P. J. (2020). The effects of financial incentives on diabetes prevention program attendance and weight loss among low-income patients: the We Can Prevent Diabetes cluster-randomized controlled trial. BMC Public Health, 20(1), 1-11. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09683-5 

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    Doyle-Delgado, K., Chamberlain, J. J., Shubrook, J. H., Skolnik, N., & Trujillo, J. (2020). Pharmacologic approaches to glycemic treatment of type 2 diabetes: Synopsis of the 2020 american diabetes association’s standards of medical care in diabetes clinical guideline. Annals of Internal Medicine. https://doi.org/10.7326/m20-2470 

    Eze, N. D., Mateus, C., & Cravo Oliveira Hashiguchi, T. (2020). Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLOS ONE, 15(8), e0237585. https://doi.org/10.1371/journal.pone.0237585 

    Jothydev Kesavadev, & Mohan, V. (2023). Reducing the cost of diabetes care with telemedicine, smartphone, and home monitoring. Journal of the Indian Institute of Sciences. https://doi.org/10.1007/s41745-023-00363-y 

    Kho, J., Gillespie, N., & Martin-Khan, M. (2020). A systematic scoping review of change management practices used for telemedicine service implementations. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05657-w 

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    Khodyakov, D., Buttorff, C., Xenakis, L., Damberg, C. L., & Ridgely, M. S. (2021). Alignment between objective and subjective assessments of health system performance: Findings from a mixed-methods study. Journal of Healthcare Management, 66(5), 380–394. https://doi.org/10.1097/jhm-d-20-00249 

    Millenson, M. L., Muhlestein, D. B., O’Donnell, E. M., Jones, D. A. N., Haring, R. S., Merrill, T., & Weissman, J. S. (2019, December). Patient-centered care innovations by accountable care organizations: Lessons from leaders. In Healthcare (Vol. 7, No. 4). Elsevier. https://doi.org/10.1016/j.hjdsi.2018.10.002 

    O’Hara, V. M., Johnston, S. V., & Browne, N. T. (2020). The paediatric weight management office visit via telemedicine: pre‐ to post‐ COVID ‐19 pandemic. Pediatric Obesity, 15(8). https://doi.org/10.1111/ijpo.12694 

    Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., … & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care, 43(7), 1636-1649. https://doi.org/10.2337/dci20-0023  

    Puckrein, G., Hirsch, I. B., Parkin, C. G., Taylor, B. T., Norman, G., Xu, L., & Marerro, D. G. (2022). Assessment of glucose monitoring adherence in medicare beneficiaries with insulin-treated diabetes. Diabetes Technology & Therapeutics, 25(1), 31–38. https://doi.org/10.1089/dia.2022.0377 

    NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

    Ritchey, K. C., Foy, A., McArdel, E., & Gruenewald, D. A. (2020). Reinventing palliative care delivery in the era of covid-19: How telemedicine can support end of life care. American Journal of Hospice and Palliative Medicine®, 37(11), 992–997. https://doi.org/10.1177/1049909120948235 

    Sharma, V., Feldman, M., & Sharma, R. (2022). Telehealth technologies in diabetes self-management and education. Journal of Diabetes Science and Technology, 193229682210930. https://doi.org/10.1177/19322968221093078 

    Singh, H., Fulton, J., Mirzazada, S., Saragosa, M., Uleryk, E. M., & Nelson, M. L. A. (2022). Community-based culturally tailored education programs for black communities with cardiovascular disease, diabetes, hypertension, and stroke: systematic review findings. Journal of Racial and Ethnic Health Disparities. https://doi.org/10.1007/s40615-022-01474-5 

    Sukkarieh-Haraty, O., Egede, L. E., Khazen, G., Abi Kharma, J., Farran, N., & Bassil, M. (2022). Results from the first culturally tailored, multidisciplinary diabetes education in Lebanese adults with type 2 diabetes: Effects on self-care and metabolic outcomes. BMC Research Notes, 15(1). https://doi.org/10.1186/s13104-022-05937-0 

    Worum, H., Lillekroken, D., Roaldsen, K. S., Ahlsen, B., & Bergland, A. (2020). Physiotherapists’ perceptions of challenges facing evidence-based practice and the importance of environmental empowerment in fall prevention in the municipality – a qualitative study. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01846-8