DNP project

Lifestyle change participation program

Lifestyle change with special interest in nutrition and diet is a critical aspect in the management of diabetes. The lifestyle change program is to ensure that the transition of care is not jeopardized by a change in diet likely to worsen the situation. dietary restrictions are vital for management of diabetic conditions and the different types of diabetes will necessitate an individualized program. The program participants are the care givers, the patient, and the medical care giver. The ADA also recommends a lifestyle change program for prediabetes patients. A lifestyle change has proven effective for the prevention of advancement of the diabetes and also leads to better life quality of life for patients with reduced morbidities (complications from DM condition) and also reduced risks of comorbidity (CDC, 2016). The program is proposed as a four-week program.

Physical activity and exercise is also an instrumental intervention plan to improve the blood glucose control, overall health, reduce weight loss, and reduced heart disease risk factors. The DNP aims to integrate around two to three days per week of two-hour exercises. The intensity of the exercises however, will vary with the patients with factors to consider as age and fitness.

Telemedicine

Health information systems prove vital for the success of care transition and discharge of patients from hospital and to prevent readmissions which have serious implications on costs. In the era of health information technology, the telehealth systems serve to connect the patients and the health care providers. Communication is among the principles of the transition theory and the telehealth systems are an efficient way to close the communication gap in the transition of care.

These systems are patient-centered and entail a multifaceted intervention with wide range of care services to improve the care quality after discharge from health facilities or in the transition of care. The DNP project will involve the use of telehealth as an intervention model. This model involves the daily monitoring of patient’s vitals and creation of electronic medical records for patients (Noel, 2018). The electronic health data from patients is used in the evaluation and identification of risk factors, which helps to risk management for patients.

Diabetes self-management education

Safety post-hospitalization is perhaps the most critical aspect that determines the risk of readmission. The DNP project will initiate the patient self-care management program 4 weeks before discharge to ensure the patient is conversant with self-care and maintains a safe practice aimed at reducing risks of readmission. Nurses will be tasked with education, they will have three days training at two hours each, and monitoring of the patients about self-care whenever the patient is ready to learn (Seley, 2014). The education approach will be an individualized model to ensure that each patient learns as per their personal needs or as is sufficient for their condition. Caregivers are also instrumental in the transition of care and they will also be involved in the education of patient self-management and care provision to patients.

Patient education will be focused on teaching the patients balance between the use of insulin, exercise, and carbohydrate intake to ensure a maximum benefit and good quality health. Patients will also be educated on medical emergencies related to DM like hypoglycemia and how to identify the symptoms and the risk factors that may lead to the emergencies (Lim et al., 2018). The self-care education in the project will be continuous, ensuring continuity of care, until the transition of care is over and the length depends on patient adaptability to new care environments.

Caregiver assessment and intervention

Transition of care also largely depends on the caregivers. There still exists gaps in caregiving with frustrations from the caregiver view point. Caregiver burden is also an issue of concern when it comes to patient care. Most of the interventions are patient-based models which effectively leave out the vital factor of caregiving which is very instrumental in the transition. The DNP project will factor in the needs and burden of caregivers. Provision of needs and resources to caregivers reduce caregiver burnouts and provide morale for the caregivers to perform their duties well (Mitchell, 2018). Caregiver stress will also be assessed and an appropriate caregiver intervention model applied as per the situation presented.

Follow up

A follow up on the interventions will be conducted in the DNP protocol. The follow-up will include an audit of the compliance with the rolled-out protocols in DM management. It will also help to determine the efficiency of the intervention models. The efficiency will be determined by the rate of DM patient readmissions comparing four weeks before the project implementation and four weeks after the implementation of the project. Comparison of the rates will help to determine the efficiency of the protocols.

Tools

The intervention plan comes along with the need for various resources and tools. Tools to be used are comprised of existing and new ones to be developed by the DNP team. The intervention will also utilize hospital resources to ensure that the transition is well executed. A policy governing the TOC protocol will be established and validated in consultation with experts in the medical field.

Here is the instruction for this section. Describe each tool that will be necessary for achieving your objectives and carrying out interventions of the QI project. Include the following information:

1. Who will develop the tool (will you use an existing/established tool or develop your own)?

1. 2) How will the tool be validated (was it validated by a previous study, or will you seek expert consultation through stakeholders and the project team)?

1. 3) If using an established tool, do you need to seek permission to use the tool? From who?

Note that every project will have different tools. Examples are provided below.

1. Protocol/Policy

1. Pre-Post Education Test/Questionnaires

1. Educational Presentation/handouts

1. Published Tools (Obtain Permission)

1. Chart Audit Tool

Here are the tools I chose, and I noted I will be creating them. You can find already existing tools and cite the source instead of creating them. A good resource will be American Diabetic Association)

Tools (Below are the tools you need to create for the appendices)

Tool will be Self-developed and validated by expert consultation through stakeholders and the project team will be sought for validation.

· Transition of care protocol

Tool will be Self-developed and validated by expert consultation through stakeholders and the project team will be sought for validation

· PowerPoint presentation and theoretical framework graphics for staff training

A pre-post education test questionnaire will also be utilized to gauge providers attitudes and knowledge of the TOC protocol.

Tool will be Self-developed and validated by expert consultation through stakeholders and the project team will be sought for validation.

.

Educational material

The intervention model includes the need for education provision to the patients and the caregivers which gives need for the provision of education materials. Other educational materials instrumental for self-care includes the insulin pen training supplies, glucose meter manuals which are available in the market and come with the instruments. A simpler version of the manuals will also be developed as per the original instrument manual for easier education. However, the most vital tools are the human resource and include the nurses in the DNP project and diabetes champions who will appropriately guide the patients and their caregivers on DM management. Educational handouts available on diabetes management will be availed in multiple languages for the patients and caregivers for private learning also with permission obtained from the publishers. The handouts will be supplemented by PowerPoint presentations to be developed by the DN team and validated by expert consultations.

Practice pens and free meters will also be issued in support of self-care education during the start-up of the DNP project. A questionnaire will also be used to gauge the knowledge and attitude of the involved individuals on the TOC protocols. The questionnaire will be self-developed and will be validated through expert consultation.

Data management systems (not part of the tool) Only above listed tools should be discussed in this section.

The telehealth intervention necessitates for the use of health information systems and it is in the best interest of project success that a proper system is used. The system considerations will include patient confidentiality as an ethical practice in the project. The systems will only be accessible to the patients and the caregivers as a data protection step. The telehealth system will be a hospital-based system where there will be virtual patient visits and video conferencing. The organization’s electronic health records system will also be used to store the patient data.

Caregiver needs assessment questionnaire (This should speak specifically to pre and post-test or questionnaire)

The CNA questionnaire will be used to assess the caregiver needs. The CNA questionnaire has been developed and its efficiency validated in other projects. It is also easy to compile and will provide the basis for personalization of programs to offer the psychological and other necessary support that the caregiver may need for the smooth roll out of the TOC protocols (Moroni et al., 2008). A self-assessment questionnaire will also be developed and validated through expert consultation as an additional care giver assessment model (Lefranc, 2017).

AIC- This goes better with Transition of care protocol and the provide assessment tool creation) Can be one of the questions asked and documented during assessment. Also, part of the protocol can be to check AIC level and outline needed actions if high.

The A1c test is vital for the follow-up program and to determine the risk factors and to determine the efficiency of the diabetes treatment. This test is recommended by the ADA identifying the necessity in using the test to identify risks that may lead to DM complications. This test is recommended to be taken at least twice a year as a follow up plan post-hospitalization and on diagnosis of prediabetes.

1. Chart audit (Provider assessment and documentation template is the tool that will be used for chart audit. The DNP student will look for this tool when auditing charts to make sure it was 1). Utilized and 2) completed thoroughly).

A chart audit will also be used during the TOC protocol roll-out and will be a self-developed tool as per the DNP project. This tool will be used to assess the caregivers’ and nurses’ performance pertaining to the TOC protocol. The chart will therefore provide basis for the closing of gaps and improvement of practice related to the TOC protocol.

Instruction for this section (Appendix)

All tools need to be completed and placed in the appendices by the final due date for this section. Appendices should be listed in the order they appear in your paper. Use this section to plan out the order that you will list your appendices in your paper.

Additional appendices that should be included:

1. Permission to complete project at the site

1. IRB materials where applicable from the project site

Below tools need to be create and added to the appendix

1. Letter from project site (No affiliation agreement needed)

1. Theoretical Framework graphic

1. Transition of care protocol

1. PowerPoint presentation

1. A pre-post education test

1. Provider assessment and documentation template

Great Job on the Appendix arrangement but the rest of tools need to be created. Also, see theoretical framework on my paper to help you modify the one you have attached

Appendix A

*attach letter from project site

Appendix B

[photo credits: Penney et al., 2018]

Appendix C

· Assessment of patient and caregiver needs.

· Initiation of the care transition period.

· Implementation of self-care plan and medication reconciliation.

· Updating of the patient medical records in the electronic health record system.

· Development of a medication follow up plan detailing tests to be done and appointments.

· Provision of caregiver and patient education

· Communication of the summary care findings to the organization’s IRB.

· Referral of the patient to community support programs and services.

· Follow up by the DNP nurses to ensure the patients obtain the relevant post-hospitalization care.

Appendix D

*powerpoint presentation

Appendix E

*Attach pre-post education test

Appendix F

*Attach assessment documentation and template

References

Mitchell, S. E., Laurens, V., Weigel, G. M., Hirschman, K. B., Scott, A. M., Nguyen, H. Q., ... & Jack, B. W. (2018). Care transitions from patient and caregiver perspectives. The Annals of Family Medicine, 16(3), 225-231.

Noel, K., Yagudayev, S., Messina, C., Schoenfeld, E., Hou, W., & Kelly, G. (2018). Tele-transitions of care. A 12-month, parallel-group, superiority randomized controlled trial protocol, evaluating the use of telehealth versus standard transitions of care in the prevention of avoidable hospital readmissions. Contemporary clinical trials communications, 12, 9-16.