Purpose: The purpose of this project was is to test whether an enhanced role of nursing in primary care could improve diabetes care and outcomes.

Goal: The goal of the project was to enhance the role of the care team RN, allowing them to work to the highest of their licensure and improve the health of patients with diabetes, develop sustainable workflows and practices that would improve our quality metrics. All tools and processes developed were to be translatable to other chronic diseases in the future. This approach is proactive and longitudinal where nurses engage patients in their care and collaborate with the multidisciplinary teams.

Description: A literature review was completed, and working with a multidisciplinary team, interventions and workflows were developed to address each element of optimal diabetes control. Understanding the elements of optimal diabetes care resulted in complex workflows. To ensure the patient-centered workflows were followed consistently, a decision support tool was developed to result in consistent actions and best practice recommendations to assist in improving patient outcomes.

Utilizing the decision support tool, the nurses review the patient’s medical record, determine opportunities for improvement, make referrals to supporting departments, and recommend actions to providers. In addition, the nursing staff reaches out to patients to discuss healthy lifestyle changes, collaborate on ways to improve the patient’s health, and address barriers that prevent the patient from taking an active role in self-management of their chronic condition.

A resource guide, toolkit, and webpage were developed to support teams. Electronic health record (EHR) tools were enhanced to optimize documentation to include patient activities and outreach which allows the teams to follow-up with patients on a routine basis.

Initial education was provided to nursing staff. In follow-up, a diabetes bootcamp for nursing was developed as an on-demand program that will be used to refresh current nursing teams on workflows and orient new nurses to the established processes. The bootcamp includes information on understanding diabetes, medication therapy management (MTM) pharmacy and nutrition resources, viewing quality data, motivational interviewing, setting smart goals, and examples of how nurses changed their practice and patient outcomes.

Evaluation/outcome: 30 primary care teams across multiple sites initiated this nurse led intervention with staggered start dates. The average percent of patients meeting optimal diabetes care prior to implementation was 37%, with no teams meeting the 50% goal. Challenges included differing team compositions, resources, and COVID-19. Despite the challenges, as of June 2021, this transformational nurse-led intervention has resulted in 13 out of the 30 teams now meeting the 50% goal of optimal diabetes care, with many more teams approaching the 50% mark.

Future implication and learnings: This project has demonstrated that improving diabetes control is highly impacted by nursing interventions. Optimal outcomes are achieved through prioritization of quality outcomes across all levels of the organization. This can be accomplished by having formal and informal conversations related to quality, establishing accountability mechanisms, sharing data regularly, developing a collaborative work environment, and encouraging a team-based approach to improvement.

Emily Bauer ME-PD

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