Provide one example, with supporting evidence, of an interprofessional patient education activity that was associated with an improved patient outcome. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Problem/Background
Diabetes is a chronic disease that if left untreated leads to multisystem and multi-organ failure. People with diabetes require constant self-care and vigilance by health care providers. Diabetes self-management education/support (DSME/S) provides patients the necessary tools to manage their diabetes. DSME/S is a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully manage the disease and its related conditions.
To be recognized as a provider of DSME/S, a facility must adhere to the ten national standards for Diabetes Self-Management Education and Support outlined by the Task Force convened by the American Diabetes Association and American Association of Diabetes Educators (AADE)(Exhibit EP13EO.1).
Exhibit EP13EO.1 National Standards for Diabetes
Exhibit EP13EO.1 National standards for Diabetes Self.pdf
The Diabetes and Outpatient Medical Nutrition Therapy Center (Center) at FF Thompson Hospital was established in 2007 and received its first American Diabetes Association recognition in 2008. Jane Hallstead, MSN, RN, CDE, Diabetes Educator for FF Thompson Hospital is an active participant with the AADE, and ensures that the above standards are addressed throughout the system with the use of evidence-based practice presented by AADE.
Patients referred for DSME/S are either seen on an individual basis by a registered dietitian and/or registered nurse. Each initial visit lasts an hour and includes an extensive patient medical history, self-assessment, and education. Additionally, levels of patient engagement on several behaviors that include glucose monitoring, nutrition and exercise/physical activity, are assessed and mutually agreed upon individual target goals are established. Standard #7 calls for individualization of patient care and states that the diabetes self-management, education, and support needs of each participant will be assessed by one or more of the instructors. The participant and instructor(s) will then together develop an individualized education and support plan focused on behavior change. The instructors consult with each other on a regular basis and participants are given contact numbers for both instructors.In order to reassess patients and follow-up on their progress, the coordinator began working with the interprofessional team of nursing and the registered dietitian in 2012 to conduct follow-up phone calls using a scripted interview. This mode of follow-up enables the Center to reach out to more participants and the information gathered better represents most of the population served. Ideally, patients will come back for a follow-up appointment at 2-4 months and 8-12 months. However, most patients decline to schedule a follow-up appointment often citing financial and work schedule as reasons for not making the appointment. Tracking behavioral goals and weight changes can occur with face-to-face visits or telephone follow-up and A1c tracking can be obtained electronically if patients have their blood work done within FF Thompson Hospital.
Per standard #9, monitoring will occur whether participants are achieving their personal diabetes self-management goals and other outcomes as a way to evaluate the effectiveness of the educational interventions, using appropriate measurement techniques.
The Center chose to measure the following goals: 1) nutrition management/healthy eating; 2) physical activity/being active; 3) monitoring; 4) A1c; and 5) weight.
Goal Statements:
Description of Interventions:
Participants:
Jane Hallstead, RN, MSN, CDE – Diabetes Educator, Program Coordinator and instructional staff, Nursing Administration
Linda Rowsick, RD, CD-N – Instructional staff, Dietitian. Patient Care Services
Outcomes: