NUR 653 Module 5 Milestone Two Example

Milestone Two: A Population Program for Diabetes Prevention and Management

[Student Name]

Southern New Hampshire University

NUR 653: Population Care Management

Module Five Milestone Two

[Instructor Name]

[Date]

Milestone Two: A Population Program for Diabetes Prevention and Management

A population program for diabetes must do two things at once: keep people with prediabetes from developing the disease and help people who have it reach safe control. Most practices focus on the second and only for patients who come in. Mesa Valley's Milestone One assessment identified four priorities: re-engage the quarter of patients unseen in a year, close gaps in kidney and eye screening and statin use, improve control where A1c exceeds 9%, especially Spanish-speaking and Medicaid patients, and strengthen practice systems. A laboratory search also found 2,900 adults with prediabetes. This milestone designs a program with a prevention arm and a management arm, each built from trial evidence and assigned to specific roles. It argues that pairing a proven lifestyle program for prediabetes with nurse-led case management, well-timed self-management education and standing orders can address all four priorities within the organization's resources.

Prevention Arm: Lifestyle Change for Prediabetes

The Diabetes Prevention Program Research Group (2002) enrolled 3,234 adults whose glucose was high but not yet diabetic and assigned them at random to intensive lifestyle coaching, metformin or placebo. Coaching aimed at shedding at least 7% of body weight and reaching two and a half hours of brisk activity each week, delivered through a sixteen-session core curriculum with follow-up support. Participants were followed for close to three years on average. New cases of diabetes were 58% lower with coaching than with placebo and 31% lower with metformin, and the lifestyle benefit held across age and ethnic groups.

Mesa Valley will identify patients whose A1c fell in the prediabetes range, 5.7% through 6.4%, or whose fasting glucose was between 100 and 125 mg/dL in the past two years and invite them to a year-long lifestyle program delivered by a partner that uses the national curriculum derived from the trial, with sessions offered in English and Spanish, in person at two community sites and online. Primary care clinicians will discuss metformin with patients at highest risk, such as those with a body mass index of 35 or more or a history of gestational diabetes, consistent with the trial's findings. The registry will track enrollment, session attendance, weight change and annual A1c.

Management Arm: Nurse Case Management

Not all quality improvement strategies are equally effective. Shojania et al. (2006) conducted a meta-regression of randomized and quasi-experimental trials of quality improvement strategies for type 2 diabetes. Strategies overall produced modest reductions in A1c, but those that changed team roles and those using case management produced the largest effects, particularly when case managers could adjust medications without waiting for physician approval. Strategies relying mainly on clinician education or reminders had smaller effects.

Mesa Valley will therefore assign each of its three population nurse case managers a panel of patients with an A1c above 9%, beginning with the two rural practices and with Spanish-speaking and Medicaid patients prioritized. Under protocols approved by the organization's medical director, case managers will titrate metformin, basal insulin and selected other agents according to home glucose readings, order laboratory tests and refer to pharmacy for complex regimens. Contact will be at least every two weeks by phone or video until the A1c is below 9%, then monthly. Community health workers from the social needs program will work alongside case managers for patients with positive screens.

Self-Management Education at the Right Moments

Powers et al. (2020), in a consensus report from diabetes, nursing, pharmacy and primary care organizations, described diabetes self-management education and support as a critical element of care and identified four times when it should be provided or reviewed: at diagnosis, annually or when treatment goals are not met, when new complicating factors arise and during transitions in life or care. They noted that such education improves clinical outcomes, quality of life and self-care behaviors, yet few patients receive it. Mesa Valley will build these four moments into the registry as triggers, so that a new diagnosis, an A1c rising above goal, a new complication or a hospital discharge automatically prompts a referral to a certified diabetes educator, with group classes in English and Spanish and individual sessions for patients who prefer them.

Closing Process Gaps and Re-engaging Patients

Standing orders approved by the medical director will allow medical assistants to order urine albumin tests and schedule retinal imaging for any registry patient who is due, and will prompt clinicians about statin therapy for eligible patients aged 40 to 75. Retinal cameras will be placed in the two rural practices so patients do not need a separate optometry visit. To re-engage the quarter of patients unseen in a year, medical assistants will call each patient using a script, offer a planned visit and send a text or letter in the patient's preferred language when calls fail. Patients found to have left the organization will be removed from the registry, which will improve its accuracy.

Roles, Costs and Measures

The program requires three nurse case managers, already funded, one additional certified diabetes educator at 0.8 full-time equivalent, two retinal cameras, the lifestyle program contract and medical assistant time for outreach. First-year incremental costs are estimated at $410,000. Measures follow the assessment: proportion of registry patients with an A1c test, proportion with an A1c above 9% counting untested patients as uncontrolled, blood pressure control, kidney and eye screening, statin use, visit gaps and the same measures by practice, language and insurance. For the prevention arm, measures include enrollment, attendance, the proportion achieving 5% weight loss and progression to diabetes. First-year targets include reducing poor control from 42% to 32% and raising kidney screening from 38% to 65%.

Clinician engagement will determine whether the program works. Each practice will name a physician or nurse practitioner champion who reviews the practice's registry dashboard monthly with the case manager, and practice meetings will open with a five-minute review of progress. Clinicians will receive their own panel's results compared with peers, presented privately and without penalties, since the goal is learning rather than ranking.

Conclusion

Mesa Valley's program addresses the full spectrum of diabetes risk. A lifestyle program modeled on the trial that cut progression by 58% serves patients with prediabetes. Nurse case managers who can adjust medications, the strategy that meta-regression found most effective, serve those with poor control, prioritized by need. Self-management education is triggered at the moments that matter, and standing orders and outreach close gaps in screening and engagement. Each element answers a priority from the assessment.

References

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. https://doi.org/10.1056/NEJMoa012512

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care, 43(7), 1636-1649. https://doi.org/10.2337/dci20-0023

Shojania, K. G., Ranji, S. R., McDonald, K. M., Grimshaw, J. M., Sundaram, V., Rushakoff, R. J., & Owens, D. K. (2006). Effects of quality improvement strategies for type 2 diabetes on glycemic control: A meta-regression analysis. JAMA, 296(4), 427-440. https://doi.org/10.1001/jama.296.4.427