NURS FPX 4905 Assessment 4 Intervention Proposal
Student name
Capella University
NURS- FPX4905
Professor Name
Submission Date
Narration
Hi, I am _______. Today, I’m going to tell you about one intervention to improve care coordination and the use of technology in the management of Type 2 Diabetes at our outpatient clinic. My practicum site in Farmington Hills, Michigan, has identified Patient follow-up gaps/poor care coordination as inefficiencies to optimal results. The ideas that focus on organized, care coordination, interprofessional collaboration, and technology integration that will enhance patient engagement, patient quality and safety, reduce health care costs, and pave the way for sustainable, patient-centered care.
The Need for Change
At my practicum, the focal key practice issue is that clients have not been completing follow-ups, and clients’ care coordination is lacking with adults with type 2 diabetes, leading to less than optimal glycemic control and increased complications. The use of patient self-scheduling, combined with ongoing provider follow-up (but not frequently), and with limited use of regular reminders or interprofessional communication, is the approach being used for practicing now. To promote this, I recommend a nurse-coordinated care program, in addition to TeleHealth and automatic reminders using the Electronic Health Record (EHR). It helps nurses provide healthcare services through technology means, such as phone and video calls, to bridge the gap between providers and patients. Process changes include standardized processes for tracking appointments, documenting the data, and educating patients; including being culturally responsive and tailoring care plans to the individual.
Assumption
The assumption is that improving communication, empowering patients’ use of the system, and ongoing monitoring will produce better patient outcomes. These strategies have been effective in lowering HbA1c and preventing diabetes complications. Coordinated workflow, together with technology integration, helps to enhance quality and keep patients safe. Besides, this approach leads to more cost-efficient care by lowering the fragmentation of care and avoiding the need to use emergency services.
Strategy to Improve Current Practice
Care Coordination program implemented by the nurse, with the inclusion of the Telehealth results in an improvement in quality, safety, and cost-effectiveness of type 2 diabetic patients. Regular review, tailored training, and timely re-planning of the care plan lead to better control of blood glucose levels and fewer complications, improving quality. Telecare can conduct checks and provide education to the participants while nurses monitor them and call them about managing their blood sugar, taking their medicine, and providing diabetes education. This translates to cost savings, as patients visit the emergency room less, are readmitted fewer times, and have fewer long-term complications, all to the benefit of the health care system. Challenges can be the upfront cost of the technology, employee training, and the change of workflow. For other patients, it is difficult to adapt to telehealth due to limited access to digital tools or lower digital literacy. Despite the challenges, the benefits are not outweighed by the drawbacks in that there is a possibility for sustainable development of care improvement in terms of chronic diseases by using technology and organized coordination. The study shows that the results of the HTCC intervention are an impressive reduction in HbA1c and patients’ adherence with treatment. These outcomes confirm the validity of the strategy and its success in improving patient care outcomes and the organization of resources in an efficient way.in an efficient way.
Government Agency Practice Guidelines
There is a number of government and regulatory bodies that propose suggestions that can directly be correlated to the issue of inconsistent follow-up and limited care coordinated for patients with type 2 diabetes in my practicum site. Chronic care management (CCM), which enables follow-up care, medication reconciliation, and care management for patients with complicated chronic conditions. It is supposed that frequent communication within the group will reduce visiting the emergency room and long-term costs by preventing avoidable complications. The use of these standards in the clinic could increase the possibility of nurse-managed follow-up programs and financially sustain the clinic.
The Joint Commission has standards that focus on patient safety, communication of clinical issues, and accurate documentation. The standards focus on the following key patient, individual, or resident care and organizational functions that are vital for the provision of safe and high-quality care. This is based on the premise that, with better documentation and the streamlining of communications, continuity of care is strengthened, and mistakes are minimised. For diabetes, this means that a reminder, laboratory test results, and diabetes care plan are consistently documented in the electronic health record (EHR) and that this information is accessible for all providers. The implementation of these guidelines could be used to overcome current follow-up/coordination of care deficits. The National Database of Nursing Quality Indicators (NDNQI) offers benchmarks for various patient satisfaction, readmission, and nurse-sensitive indicators. The NDNQI is nurse-sensitive patient outcomes and RN workforce participation measure tracking and benchmarking tool that is based on evidence. The reasoning behind this is that measurement and reporting regularly help to ensure accountability and stimulate organizations to improve their performance. Monitoring the impact of diabetes intervention by outcomes, including diabetes control (HbA1c), no-shows, and patient satisfaction, can help demonstrate impact. Having the clinic meet the NDNQI standards would allow it to monitor progress in real time, identify areas for improvement, and improve its quality improvement system.
Application of Technology
There are new technologies – electronic health records (EHRs), telehealth, mobile health (mHealth) applications – that enable the proposed strategy to improve care coordination for the type 2 diabetes patient. Smooth documentation, tracking of laboratory results, and proper communication and organization are all easier with EHRs, which help ensure continuity of care. 87.2% of the nurses in a survey said that EHRs helped them to document more effectively.
With fewer missed appointments with patients and less of a hindrance for them in traveling to appointments, follow-ups, education, and remote monitoring can be provided through telehealth services. It allows patients to upload glucose data, medications, diet, and exercise data – thus helping to keep patients more self-managed and activated.
This holistic approach is ideal, since it brings together provider monitoring and patient-focused monitoring, and offers information to help make timely interventions. It assumes that the patients have basic computer access and that the employees can easily use the computers. The mHealth apps designed to be used by diabetes patients were proven to improve glycemic control, with a significant reduction in the level of HbA1c in both T1DM and T2DM. The integration of these technologies into the process can help the clinic improve the quality, safety, efficiency, and reduce the gap in chronic disease care. Avoid using a term that has different meanings. Don’t use an alternative term if it means different things.
To implement the strategy for care coordination at the Farmington Hills outpatient clinic, staff would need to be trained on how to use the EHR documentation, how to use the telehealth processes, and how to utilize the mHealth app. A phased implementation is proposed, starting with a test group of patients that will be used to work out the processes and get patient feedback. Geese and Schmitt. Based on a review of the literature, (2023) found evidence that interprofessional collaboration (IPC) was a successful intervention to improve transitions of care for complex patients in health care. The site-specific barriers include time limitations for staff, patients’ digital ability, and limitations of the technology budget.
These can be addressed through formal training sessions, through individual patient education, and by partnering with community groups to provide devices and/or affordable Internet access. AI can automate pre-visit reminders and educational materials to ensure patients are prepared and go through the check-in process before their appointments, reducing delays and omissions in the process. For example, if a patient has a transportation problem, she can be virtually nutrition counseled through a secure website, and glucose records can be checked with nurses using mHealth apps. This encourages continuity of care, patient engagement, and the overall efficiency of the organization through proactive action and technology that goes beyond traditional workflows.
Interprofessional Collaboration
For the care coordination approach to type 2 diabetes to work there needs to be effective interprofessional collaboration. Collaboration between the nurse practitioners, registered nurses, dietitians, pharmacists, behavioral health providers, and community health workers (CHWs) in the Farmington Hills outpatient clinic includes the creation of individual care plans. An interprofessional collaboration between physicians, nurses, dietitians, social workers, and CHWs was researched as a model to support patients in navigating the healthcare system. Nurses act as a link between the provider and the patient within the hub and are able to communicate quickly and effectively. Counselling by dietitians for nutritional care is provided in a culturally sensitive manner, whilst pharmacists ensure that there are no issues around the compliance of medications through medication reconciliation and medication counselling.
Behavioral health professionals address stress or depression that might affect self-management and community health workers address social determinants of transportation, food, and being able to get to appointments. So collaborations with health workers with a specific knowledge of the patient’s history will be important in delivering good quality health care and narrowing health gaps. The partnership improves patient involvement, decreases duplication of services, and improves resource use while at the same time increasing patient safety. Embedding interprofessional working into everyday practice ensures that the care provided is coordinated, patient-centred, and will help to embed a practice change in the future.
Conclusion
Care coordination programme by organizing and integrating the use of Telehealth and EHR can improve follow-up and glycemic control in type 2 diabetes patients. It’s a quality control measure that not only helps to keep patients safe, but also can save health care dollars. Holistic and coordinated care is done in an interprofessional manner and has the patient as its focus. In general, the use of technology, professional protocols, and collaboration between members of the interprofessional team are all tools that allow for sustainable improvement of the population diversity in the clinic.
References
Bandiera, C., Ng, R., Mistry, S. K., Harris, E., Harris, M. F., & Aslani, P. (2025). The impact of interprofessional collaboration between pharmacists and community health workers on medication adherence: A systematic review. International Journal for Equity in Health, 24(1). https://doi.org/10.1186/s12939-025-02415-4
Bulto, L. N. (2024). The role of nurse‐led telehealth interventions in bridging healthcare gaps and expanding access. Nursing Open, 11(1), 1–3. https://doi.org/10.1002/nop2.2092
Dailah, H. G. (2024). The influence of nurse-led interventions on diseases management in patients with diabetes mellitus: A narrative review. Healthcare, 12(3), 352. https://doi.org/10.3390/healthcare12030352
De-Groot, J., Wu, D., Flynn, D., Robertson, D., Grant, G., & Sun, J. (2021). Efficacy of
telemedicine on glycaemic control in patients with type 2 diabetes: A meta-analysis.
World Journal of Diabetes, 12(2), 170–197. https://doi.org/10.4239/wjd.v12.i2.170
Eberle, C., Löhnert, M., & Stichling, S. (2020). Effectiveness of disease-specific mhealth apps in patients with diabetes mellitus: Scoping review. Journal of Medical Internet Research(JMIR) MHealth and UHealth, 9(2). https://doi.org/10.2196/23477
Geese, F., & Schmitt, K.-U. (2023). Interprofessional collaboration in complex patient care transition: A qualitative multi-perspective analysis. Healthcare, 11(3), 1–14. https://doi.org/10.3390/healthcare11030359
Khashu, K. (2025). Optimizing patient check-in process for telehealth visits: A data-driven perspective. Frontiers in Digital Health, 7. https://doi.org/10.3389/fdgth.2025.1554762
Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 1–27. https://doi.org/10.3390/life10120327