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 negatively affecting patient adherence to self-management. Fragmented care coordination and inconsistent communication among healthcare professionals hinder real-time collaboration, leading to suboptimal diabetes management outcomes. To address these challenges, this assessment proposes an interdisciplinary care plan focused on improving communication, enhancing patient education, and strengthening overall diabetes care coordination.

Organizational Issue

SPRHC is experiencing significant delays in launching a structured diabetes education program, resulting in poor patient adherence and unfavorable clinical outcomes. These delays are primarily due to fragmented care coordination, inconsistent communication among interdisciplinary teams, and the absence of standardized workflows. The lack of real-time collaboration among primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists creates misaligned treatment plans, leading to inadequate glycemic control and increased hospital readmissions. Additionally, ineffective interdisciplinary coordination contributes to staff burnout, as unclear roles and inefficient workflows add to their workload. The hospital’s reputation is also at stake, as ineffective diabetes management may deter 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, highlighting significant improvements in clinical outcomes. These included reductions in systolic blood pressure (−5.88 mmHg), diastolic blood pressure (−3.23 mmHg), and HbA1C (−0.38%), particularly when interdisciplinary teamwork was emphasized. These findings underscore the need for a structured, interdisciplinary diabetes education program at SPRHC to improve collaboration, enhance patient outcomes, and reduce overall healthcare costs.

Importance of the Issue

Addressing the gaps in diabetes education and interdisciplinary collaboration at SPRHC is essential to delivering high-quality, patient-centered care. Implementing a formalized diabetes education program will establish standardized protocols, shared decision-making, and common electronic health record (EHR) templates to facilitate real-time treatment adjustments. Weekly interdisciplinary team meetings will enhance collaboration among primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists, ultimately improving patient outcomes and fostering a teamwork-oriented culture.

By improving communication and reducing treatment variability, healthcare professionals can provide more consistent, evidence-based care, leading to higher job satisfaction. This initiative aligns with SPRHC’s mission to offer comprehensive diabetes management, strengthen patient trust, and promote long-term engagement in care. Additionally, it will contribute to reduced hospital readmissions, lower healthcare costs, and enhanced organizational efficiency, ensuring the sustainability of high-quality diabetes care.

Table: Key Aspects of the Interdisciplinary Diabetes Care Plan

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

Implementation and Resource Management

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

• 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 improve communication and patient education.
• Doing Phase: A pilot group of patients will be enrolled in the diabetes education program. Staff will participate in simulation exercises and workshops to refine teamwork and engagement strategies.
• Study Phase: Performance indicators, including improved glycemic control (A1C levels), medication adherence, and reduced hospital readmissions, will be assessed. Staff and patient feedback will be used to refine the program.
• Act Phase: The program will be expanded hospital-wide, supported by ongoing training, quarterly interdisciplinary meetings, and continuous monitoring of patient outcomes.

Strategic Financial Planning

Sustaining the diabetes education program requires strategic financial planning. The estimated annual costs for training, technology, and patient education range from $250,000 to $450,000. However, this investment is expected to yield long-term savings by improving glycemic control, reducing hospital admissions, and minimizing diabetes-related complications (American Diabetes Association [ADA], 2024). Effective resource allocation, including optimized staffing and EHR integration, will further enhance care coordination and efficiency (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., 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