NURS FPX 4005 Assessment 4

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 impacting patient adherence to self-management. Fragmented care coordination and inconsistent communication hinder real-time collaboration among healthcare teams, affecting diabetes management outcomes. This assessment proposes an interdisciplinary care plan aimed at enhancing communication, patient education, and overall diabetes care coordination.

Organizational Issue

SPRHC faces significant delays in implementing a structured diabetes education program, negatively impacting patient adherence and clinical outcomes. These delays stem from fragmented care coordination, inconsistent communication among interdisciplinary teams, and a lack of standardized workflows. The absence of real-time collaboration between primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists results in misaligned treatment plans, leading to poor glycemic control and increased hospital readmissions. Beyond patient health, ineffective interdisciplinary coordination contributes to staff burnout due to unclear roles and inefficient workflows. Additionally, SPRHC’s reputation is at risk, as ineffective diabetes management may deter potential patients and hinder 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. The findings demonstrated significant improvements, including reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%), particularly when multiple teamwork components were integrated. These results highlight the importance of a structured, interdisciplinary approach in diabetes education at SPRHC to enhance collaboration, improve patient outcomes, and reduce healthcare costs.

Importance of the Issue

Addressing gaps in diabetes education and interdisciplinary practice at SPRHC is crucial for delivering high-quality, patient-centered care. A formalized diabetes education program will establish standardized protocols, shared decision-making, and common electronic health record (EHR) templates to enable real-time treatment adjustments. Weekly interdisciplinary rounds will improve coordination among primary care providers, nurses, dietitians, pharmacists, and behavioral health professionals, optimizing patient outcomes while fostering a teamwork-oriented environment.

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

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Table: Key Aspects of the Interdisciplinary Diabetes Care Plan

Category	Details
Interdisciplinary Team Approach	Enhances care coordination among primary care providers, endocrinologists, diabetes educators, dietitians, pharmacists, and behavioral health professionals.
Standardized Communication Protocols	SBAR (Situation, Background, Assessment, and Recommendation) will be used for patient handoffs to ensure consistent and effective 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 improve collaboration and patient education.

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Implementation and Resource Management

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

1. Planning Phase: Identifying major 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 enhance communication and patient education.
2. Doing Phase: A pilot group of patients will be enrolled in the diabetes education program. Staff will undergo simulation exercises and workshops to refine teamwork and engagement strategies.
3. Study Phase: Performance indicators such as improved glycemic control (A1C levels), medication adherence, and reduced hospital readmissions will be analyzed. Staff and patient feedback will guide refinements.
4. Act Phase: The program will be expanded hospital-wide, supported by ongoing training, quarterly interdisciplinary meetings, and continuous monitoring of patient outcomes.

NURS FPX 4005 Assessment 4

Strategic financial planning is essential to sustain the program. Initial costs for training, technology, and patient education are estimated between $250,000 and $450,000 annually. However, this investment is expected to reduce long-term healthcare expenses through improved glucose control, lower hospitalization rates, and fewer diabetes-related complications (ADA, 2024). Effective resource allocation, including optimized staffing and EHR integration, will further enhance care coordination (Tamunobarafiri et al., 2024).

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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., 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