Running head: SELF-CARE IN DM2 1 Assessment of Self-Care and Education in Patients with Type 2 Diabetes Mellitus Kristen M. Monroe and Adrianne M. Wilkerson Michigan State University College of Nursing April 10, 2022 SELF-CARE IN DM2 2 Table of Contents Abstract ........................................................................................................................................... 4 Background and Significance ......................................................................................................... 5 Problem Statement and Clinical Question ...................................................................................... 7 Description of Clinic ....................................................................................................................... 8 Organizational Assessment “Gap Analysis” of Project Site ........................................................... 9 Strengths, Weaknesses, Opportunities, and Threats ................................................................... 9 Purpose of the Project ................................................................................................................... 10 Evidence-Based Practice and Quality Improvement Models ....................................................... 10 Review of the Literature ............................................................................................................... 11 SDSCA Utilization .................................................................................................................... 12 Educational Interventions .......................................................................................................... 13 Theory Utilization ..................................................................................................................... 15 Summary of the Literature ........................................................................................................ 15 Methods......................................................................................................................................... 16 Ethical Considerations and Protection of Human Subjects....................................................... 16 Project Site and Population ....................................................................................................... 17 Setting Facilitators and Barriers ................................................................................................ 18 The Intervention and Data Collection Procedure ...................................................................... 19 PDSA Cycle .............................................................................................................................. 21 Measurement Instruments and Tools ........................................................................................ 23 Cost-Benefit Analysis and Budget ............................................................................................ 24 Evaluation and Outcome Measures ........................................................................................... 24 Data Analysis ............................................................................................................................ 25 Sustainability Plan ........................................................................................................................ 26 Discussion and Implications for Nursing ...................................................................................... 26 Conclusion .................................................................................................................................... 27 References ..................................................................................................................................... 28 Appendix A ................................................................................................................................... 33 Appendix B ................................................................................................................................... 34 Appendix C ................................................................................................................................... 35 Appendix D ................................................................................................................................... 36 Appendix E ................................................................................................................................... 38 SELF-CARE IN DM2 3 Appendix F.................................................................................................................................... 39 Appendix G ................................................................................................................................... 41 Appendix H ................................................................................................................................... 42 Appendix I .................................................................................................................................... 43 Appendix J .................................................................................................................................... 46 Appendix K ................................................................................................................................... 47 Appendix L ................................................................................................................................... 48 SELF-CARE IN DM2 4 Abstract Background and Significance: The annual cost of diagnosed type 2 diabetes mellitus (DM2) in the United States is $327 billion, with individuals with DM2 spending 2.3 times more on health care than individuals without DM2. Education, such as Diabetes Self-Management Education and Support (DSMES) programs, and self-care support, utilizing tools such as the Summary of Diabetes Self-Care Activities (SDSCA) Measure, are the cornerstones of improving care and outcomes for patients with DM2. Purpose: The purpose of this quality improvement project was to implement a standardized self-care assessment and educational intervention for a mid- Michigan internal medicine clinic’s adult patient population over 18 years of age with DM2 and hemoglobin A1c (HbA1c) greater than 9% and improve patient self-care. Methods: The Plan, Do, Act, Study (PDSA) Cycle and the Chronic Care Model were used as a framework to guide the project. Eligible participants were identified by clinic staff and received self-care education. Evaluation: The validated SDSCA tool was utilized to assess self-care pre- and post- educational intervention. A two-tailed paired t-test was then performed to compare pre- and post- intervention scores. Outcomes: Of 25 eligible patients in the clinic, 13 patients participated in the initial phase with 3 patients lost to follow-up, leaving 10 patients included in data analysis. A statistically significant improvement was seen in DM2 self-care with mean scores increasing from 4.1 days/week to 4.8 days/week (t = -6.5, p < 0.01). Implications/Conclusion: Identification of specific areas of patient educational needs can improve self-care in patients with DM2 and improve their overall health outcomes. Keywords: type two diabetes mellitus, type 2 diabetes, t2dm, DM2, education, self-care, Summary of Diabetes Self-Care Activities Measure, SDSCA SELF-CARE IN DM2 5 Assessment of Self-Care and Education in Patients with Type 2 Diabetes Mellitus Patients with uncontrolled Type 2 Diabetes Mellitus (DM2) are at risk for poor healthcare outcomes (American Diabetes Association [ADA], 2021a), and have significantly higher healthcare costs than individuals without DM2 (ADA, 2021b). Healthy People 2030 (U.S. Department of Health and Human Services [USDHHS], 2020) has a goal of reducing the number of individuals with elevated hemoglobin A1c (HbA1c) as a means to improving patient health and outcomes. Self-care self-efficacy and education are key interventions to create positive change toward achieving this goal. Healthcare providers and practices are the facilitators of direct care and treatment for diabetes, as well as delivery of education and monitoring of patient self-care. The purpose of this project is to develop a workflow pathway to improving education and self-care for adult patients with DM2 and elevated HbA1c in a primary care setting. Background and Significance In the United States (U.S.), over 34 million people have diabetes, with approximately 90- 95% of those having DM2 (Centers for Disease Control and Prevention [CDC], 2019). In 2016, the diabetes prevalence median in the U.S. was 9.5%, while the diabetes prevalence median in the state of Michigan was 9.8% (Michigan Department of Health and Human Services [MDHSS], 2019). The estimated diabetes prevalence broken down by age in Michigan is 2.9% among adults 18-44 years, 13.5% among adults 45-64 years, and 22.6% among adults 65 years and older (MDHSS, 2019). Data shows males have a higher diabetes prevalence than females (MDHSS, 2019). Additionally, diabetes prevalence is 1.4 times higher in non-Hispanic Black adults than non-Hispanic White adults and two times higher in adults with disability than those without disability (MDHSS, 2019). More specifically, in Ingham County from 2011-2013, diabetes prevalence was 8.24% (Ingham County Health Department, 2018). Rates per 10,000 SELF-CARE IN DM2 6 adults for preventable hospitalizations due to diabetes in 2016 in Michigan were 34.4%, and in Ingham County were 30.9% (Healthy! Capital Counties, 2018). According to the American Diabetes Association (2021b), the annual cost of diagnosed diabetes in the United States is $327 billion, with 30% being spent for hospitalizations, 30% being spent for diabetic complications and treatments, and 15% on anti-diabetic agents and supplies (ADA, 2021b). Individuals with diabetes spend 2.3 times more on health care than individuals without diabetes (ADA, 2021b). Overall, 1 in 7 healthcare dollars is spent to treat diabetes and diabetic complications (ADA, 2021b). Additionally, indirect costs of diabetes include increased absenteeism, decreased work productivity, inability to work due to disease- related disability, and early mortality (ADA, 2021b). Education and self-care support are the cornerstones of improving care and outcomes for patients with DM2. Under ideal circumstances, Diabetes Self-Management Education and Support (DSMES) is utilized, as it is the recommended standard of care across many professional organizations (Beck et al., 2017; Powers et al., 2020). However, these programs can be lengthy and intensive and there are often many barriers to patients attending these specialized programs such as lack of access, financial or transportation limitations, and even lack of willingness or desire by the patient (K. Richardson-Aubrey, personal communication, June 16, 2021). At the core of this educational program is support for self-care as patients are their own best advocate and caregiver. Eller, Lev, Yuan, and Watkins (2018) assert that interventions targeting self-care self-efficacy can grow patients’ skills in this area, reduce health care costs, and improve overall patient outcomes. As such, educational interventions that do not utilize DSMES certified programs should still focus on evaluating and supporting patient self-care abilities. SELF-CARE IN DM2 7 Additionally, when determining the best patient population on which to focus, HbA1c cutoffs can be a useful consideration. HbA1c, an indicator of how well an DM2 is being managed over the course of a three-month period, should be maintained at or below 6.5% (ADA, 2021d). Individuals whose HbA1c is chronically over 6.5% are at risk for DM2 a variety of complications such as diabetic ketoacidosis, neuropathy, kidney disease, cardiovascular disease, hypertension, stroke, and skin, eye, and foot complications (ADA, 2021a). Clinical trials have shown that individuals with a HbA1c of greater than 9% may require more treatment and have an increased risk from complications than individuals whose HbA1c is less than 9% (USDHHS, 2020). As such, Healthy People 2030 has identified the goal of reducing the percentage of adults who have a HbA1c greater than 9% (USDHHS, 2020). Problem Statement and Clinical Question A mid-Michigan internal medicine clinic identified a need to improve self-care and education in their adult patient population with DM2 (K. Richardson-Aubrey, personal communication, June 4, 2021). Current educational practices within the clinic are inconsistent across providers, and there is a lack of specific, consistent education provided to patients (K. Richardson-Aubrey, personal communication, June 4, 2021). Clinic staff feel that patients with DM2 would have improved outcomes in areas such as medication adherence, exercise, nutrition, and foot assessment, if specific, consistent education was provided (K. Richardson-Aubrey, personal communication, June 4, 2021). In addition to providing specific, consistent education, utilization of a validated self- care focused self-efficacy tool, such as the Summary of Diabetes Self-Care Activities Measure (SDSCA), would be useful in determining areas in which patients need additional education (Toobert, Hampson, & Glasgow, 2000). SELF-CARE IN DM2 8 Description of Clinic The clinic identifies its purpose through their mission “to offer cost effective, quality patient care and other services to the people of the Capital city and the mid-Michigan area” (Capital Internal Medicine Associates [CIMA], n.d.). Their main office is centrally located in Lansing, Michigan, with satellite offices that cover a range of specialties around central Michigan. Their outreach is vast, actively treating a population of almost 40,000 patients across all offices. Approximately 14,000 of those patients are seen at the clinic’s main location, which is the planned site of intervention (A. Ryal, personal communication, August 2, 2021). They care for a diverse subset of patients who represent male and female sexes almost equally, with ages ranging across the lifespan. Insurance breakdowns for this group include approximately 1% uninsured, 15% Medicaid, 39% commercial plans, and 45% Medicare (A. Ryal, personal communication, August 2, 2021). More specifically, the identified population of adult patients with DM2 with HbA1c >9% in the past year includes 174 patients (A. Ryal, personal communication, August 2, 2021), which provides a scope of estimated patients who could possibly participate in the proposed intervention depending on the timing of their next appointment. Over the course of the project intervention period, project leads estimate one quarter, or approximately 45, patients will be seen in the clinic for a diabetes follow-up appointment. Within the main clinic office, a wide variety of professionals ensure access to the best care possible. Providers represent a variety of backgrounds including eight doctors of osteopathic medicine, five doctors of human medicine, three physician assistants, and two nurse practitioners (A. Ryal, personal communication, June 16, 2021). Additional office staff include one registered nurse, one licensed practical nurse, two nurse care managers (CMs), twelve medical assistants (MAs), seven receptionists, four schedulers, five quality control specialists, and three referral SELF-CARE IN DM2 9 specialists (A. Ryal, personal communication, June 16, 2021). Together, these providers and staff develop and implement processes to achieve high quality, cost-effective care through competitive pricing, enforcement of high care standards, and close monitoring of performance metrics and patient outcomes (A. Ryal, personal communication, June 16, 2021). More specifically, the quality control specialists, led by the Director of Clinical Operations, strive to streamline processes and monitor patterns of care implementation and outcomes (A. Ryal, personal communication, June 16, 2021). They meet monthly to discuss goals, progress, and planning and are looking to standardize point of care diabetes education within their main office beginning with the development of this new intervention (A. Ryal, personal communication, June 16, 2021). Organizational Assessment “Gap Analysis” of Project Site Utilizing information provided by the community partner and assessment completed during a clinic site visit, a gap analysis in the form of a fishbone diagram (Appendix A) was completed to determine where process barriers were occurring within the clinic. A standardized approach to providing in-clinic assessment of patient self-care in relation to management of DM2, patient education, and post-interventional clinic initiated patient contact may improve current barriers. Strengths, Weaknesses, Opportunities, and Threats A strengths, weakness, opportunities, and threats (SWOT) assessment was performed to determine areas within the clinic that may contribute to the success of this project, as well as areas within the clinic that may cause setbacks to this project. Appendix B provides the SWOT analysis for this project. SELF-CARE IN DM2 10 Strengths identified for the clinic include seasoned and knowledgeable clinic staff, adequate staffing, and resources for implementation. Weaknesses identified for the clinic include many practice locations causing inconsistencies across clinic sites, no synchronous process across sites or providers, resistance to change by providers and staff, difficulty in process change roll out due to large staff buy-in, providers wanting control over education given to patients, short provider appointments, and lack of additional staff to help implement and maintain educational process changes. Opportunities supporting this process change include multiple certified diabetic education programs in area for referral and public transportation available within city. Threats include staff turnover and ongoing COVID-19 pandemic. Slow acceptance and hesitancy to accept change may also be a threat to success. Purpose of the Project Support of self-care behaviors through a standardized educational process maximizes patient adherence to a diabetes plan of care, which subsequently improves diabetic health outcomes. Therefore, the purpose of this quality improvement project was to implement a standardized self-care assessment and educational intervention for the clinic’s adult patients over 18 years of age with DM2 and HbA1c greater than 9%. This process change also developed consistency across providers of diabetes follow-up visits, as well as a standardized office workflow. Evidence-Based Practice and Quality Improvement Models Plan, Do, Study, Act (PDSA) cycle is an evidence based, scientific method for making change (Institute for Healthcare Improvement [IHI], 2020a). PDSA provides a model for making change within a healthcare environment, asking questions such as “what are we trying to accomplish?” (IHI, 2020a) or “what change can we make that will result in improvement?” (IHI, SELF-CARE IN DM2 11 2020a). The Chronic Care Model exemplifies the PDSA cycle by identifying six fundamental areas that create a system to manage chronic disease (IHI, 2020b). These six fundamental areas are self-management support, delivery system design, decision support, clinical information systems, organization of health care, and community (IHI, 2020b). Additionally, it is important that development of productive interactions occurs between patients with chronic disease and providers assisting these patients through education and support (IHI, 2020b). Review of the Literature Several searches were performed using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed of the U.S. National Library of Medicine National Institutes of Health (Appendix C). The first search completed was to determine what self- efficacy tools were available. CINAHL search #1 utilized the Boolean/Phrases self-efficacy AND type 2 diabetes OR type 2 diabetes mellitus OR t2dm AND assessment tools OR assessment method OR assessing with additional limiters of English Language, Research Article, Peer Reviewed, 2016-2021, and All adult, finding 21 total results. PUBMED search #1 used the terms self-efficacy AND type 2 diabetes OR type 2 diabetes mellitus OR t2dm AND assessment tools OR assessment method OR assessing in the query box with additional filters of Last 5 years, English Language, Adults: 19+ years, and Free Full Text, finding 95 total results. Based on the clinic needs and review of the tools identified in CINAHL search #1 and PUBMED search #1, the Summary of Diabetes Self-Care Activities (Toobert, et al., 2000) tool was identified as a validated, reading level appropriate assessment tool which would provide insight into diabetic indicator areas on which the clinic’s patients need additional education. Following selection of the SDSCA tool, a second search was completed to synthesize the literature on use of this tool and its efficacy in relation to an educational intervention. CINAHL search #2 utilized the Boolean/Phrases Summary of Diabetes Self-Care Activities AND SELF-CARE IN DM2 12 education with additional limiters of English Language, Research Article, Peer Reviewed, 2016- 2021, and All adult, finding 13 total results. PUBMED search #2 used the search terms Summary of Diabetes Self-Care Activities AND education in the query box with additional filters of Last 5 years, English Language, Adults: 19+ years, and Free Full Text, finding 13 total results. Articles included in the literature review were narrowed from 26 articles to 8 articles based on elimination of duplicate articles between the CINAHL and PUBMED searches, and content in the abstract, such as focus on type 1 diabetes mellitus, use of a different self-efficacy tool, or lack of educational intervention. In reviewing the literature found in this search, a few themes emerged that hold relevancy to this intervention. A literature synthesis table can be found in Appendix D. SDSCA Utilization All articles selected for review utilized the SDSCA to varying degrees. Of the eight articles reviewed, six articles, Bauer et al. (2018), Formosa & Muscat (2016), GB & Premkumar (2016), Jiang et al. (2019), Marques et al. (2019), and Zheng et al. (2019) used the SDSCA tool in its entirety to assess patient behaviors with two of those using the subscales individually as well. Those using the entire SDSCA tool, such as GB & Premkumar (2016) and Marques et al. (2019), typically utilized the SDSCA as a pre-intervention and post-intervention test to determine overall changes in self-care. Bauer et al. (2018) and Formosa & Muscat (2016) used the SDSCA in its entirety to assess patient self-care behaviors then used the subscale scores to develop appropriate interventions. Only one of the eight articles, Afaya et al. (2020), used the subscales of the SDSCA to assess patient self-care behaviors, excluding the smoking subscale as the authors did not feel smoking was a self-care behavior (Afaya et al., 2020). The last of the eight articles, the systematic review by Nogueira, Otuyama, Rocha, & Pinto (2020), found four SELF-CARE IN DM2 13 articles (Jahangard-Rafsanjani et al., 2015; Jarab et al., 2012; Korcegez, Sancar, & Demirkan, 2017; Wishah, Al-Khawaldeh, & Albsoul, 2014) that used the SDSCA as a whole to assess patient self-care behaviors at intervals, such as baseline, three months, and 6 months, through their research. Overall, the literature shows the SDSCA is a flexible tool for self-care assessment and can be utilized in its entirety or as subscales to provide a more focused intervention. Educational Interventions The next theme found in the literature was that a variety of educational interventions can successfully be used to teach patients about diabetes self-care and facilitate changes in outcomes. Individually based interventions were the most common approach across the literature and included a range of tools and methods to target specific weaknesses (Afaya et al., 2020; Bauer et al., 2018; Formosa & Muscat, 2016; GB & Premkumar, 2016; Nogueira et al., 2020; Zheng et al., 2019). Some of these interventions were truly individualized, such as those reviewed by Nogueira et al. (2020) wherein pharmacists provided medication guidance to fit patients’ needs. Whereas Bauer et al. (2018), used an individual approach with a universal intervention, as they sent standardized text messages to each patient with ongoing educational guidance. Alternatively, group-based interventions were also represented in the literature. Group based classes were beneficial in that they incorporated peer support and reached a broader patient base for consistent and universal education (Marques et al., 2019; Zheng et al., 2019). This option also provides flexibility in designing an intervention plan, as it can be used independently or in conjunction with individual education. For example, Marques et al. (2019) implemented a fully group-based educational program for older adults with resultant improvements in diet and foot care scores on the SDSCA. Zheng et al. (2019) utilized a combination of group didactic courses along with individualized exercise programs to improve SDSCA self-care scores. SELF-CARE IN DM2 14 Another finding within the literature was that successful interventions could be implemented by a variety of healthcare professionals. Some of the research did not overtly specify who the purveyor of education was but indicated a standard of care that appears to be referring to a provider such as a physician (Afaya et al., 2020; Bauer et al., 2018; Formosa & Muscat, 2016; Zheng et al., 2019). Nurses have also demonstrated teaching to successful outcomes, as illustrated by GB & Premkumar (2016), while Marques et al. (2019) even utilized nursing students alongside registered nurses and researchers to improve outcomes in their elderly population. Jiang et al. (2019) benefited from a combination of physicians and nurses to guide patient education. Finally, Nogueira et al. (2020) reviewed various studies that utilized pharmacists as providers of education. In each instance, valuable outcomes, self-care changes, and benefits were realized as various healthcare professionals demonstrated an ability to educate and influence patient knowledge and behaviors. Education delivery was successful in many forms. The most common format for education delivery was by providers during treatment in healthcare settings (Afaya et al., 2020; Formosa & Muscat, 2016; GB & Premkumar, 2016; Jiang et al., 2019; Zheng et al., 2019). This is often the baseline care and source of education for most patients. Formal and structured education classes were also beneficial for some patients, but typically lasted longer in duration and required greater commitment from the patient to attend and actively participate (Marques et al., 2019; Zheng et al., 2019). In the systematic review by Nogueira et al. (2020), some successful educational delivery methods included providing educational handouts with relevant information to supplement the verbal educational process, as well as follow-up phone calls to answer additional questions and clarify points of confusion. Finally, Bauer et al. (2018) scheduled text messages to reinforce teaching from in-person appointments. SELF-CARE IN DM2 15 Theory Utilization The final theme found in the literature highlights the benefits and necessity of grounding any intervention in supportive theory. Of the eight articles reviewed, two were found to support the use of behavior change theory, in addition to the SDSCA tool to make positive behavior changes in patients with DM2. Jiang et al. (2019) utilized the Social Cognitive Theory to support the idea that changes in self-care self-efficacy and behavior require knowledge of DM2 to occur (Jiang et al., 2019). Formosa & Muscat (2016) did not use a behavior change theory in their article, however stated that use of behavior theories while developing education interventions in the primary care setting may translate into “improved care, reducing long-term complications, and better quality of life” (Formosa & Muscat, 2016, p352). Summary of the Literature To initiate any self-care self-efficacy change, it is important to determine the best strategies supporting change prior to implementation of any intervention. Research shows that the SDSCA tool can be utilized in its entirety (Bauer et al., 2018; Formosa & Muscat, 2016; GB & Premkumar, 2016; Jiang et al., 2019; Marques et al., 2019; Zheng et al., 2019) to assess a patient’s overall self-care self-efficacy behaviors, as well as broken into subscales to provide a specialized intervention (Bauer et al., 2018; Formosa & Muscat, 2016; Afaya et al., 2020). Educational interventions can range from individualized education, group-based education programs, and can be performed by a variety of healthcare professionals, such as providers, nurses, and pharmacists. Additionally, education can take many forms, such as during provider appointments, formal group education, educational flyers, and text messages (Afaya et al., 2020; Bauer et al., 2018; Formosa & Muscat, 2016; GB & Premkumar, 2016; Jiang et al., 2019; Marques et al., 2019; Nogueira et al., 2020; Zheng et al., 2019). Finally, use of a behavior SELF-CARE IN DM2 16 change theory when developing any intervention can improve the overall outcomes of said intervention (Jiang et al., 2019; Formosa & Muscat, 2016). Methods The overall goals of this project were twofold. The first goal was to improve diabetes knowledge and relevant self-care through evidence-based assessment and education during diabetic follow-up appointments with the patients’ primary care providers (PCPs). This was achieved by utilizing the Summary of Diabetes Self-Care Activities (SDSCA) tool to assess educational needs for the highest risk patients with HbA1c greater than 9%, followed by a standardized educational handout that was reviewed by the provider with the patient. The second goal was to create a standardized process for educating patients with DM2, as the clinic had identified that there was no consistent process for identifying or providing DM2 education across their providers or patients (K. Richardson-Aubrey, personal communication, June 4, 2021). An implementation timeline (Appendix E) shows a tentative start date for data collection of mid- September 2021 with completion of data collection in mid-December 2021. Ethical Considerations and Protection of Human Subjects Michigan State University Internal Review Board (IRB) approval was obtained prior to initiating the Doctor of Nursing Practice (DNP) Project. Approval verification can be found in Appendix F. The following statement was included on the SDSCA tool, providing participants with informed consent, “By completing this assessment tool, I give my consent to participate in the ‘Assessment of Self-Care and Education in Patients with Type 2 Diabetes Mellitus’ project performed by Michigan State University Doctor of Nursing Practice students.” Project leads do not have access to E-Clinical Works, the EHR system used by the clinic, and all data provided by the clinic to DNP students was deidentified prior to performance of data synthesis. SELF-CARE IN DM2 17 Project Site and Population The clinic’s main is located in southeast Lansing, Michigan. The estimated population of Lansing in July 2019 was 118,210, with 48.1% male and 51.9% female (United States Census Bureau [USCB], 2019). The age breakdown estimates 22.6% of the population is under 18 years, 65.5% of the population is 19 to 64 years, and 11.9% of the population is 65+ years (USCB, 2019). Demographic breakdowns show 61% of the population identifies themselves as White alone, 23.3% identifies as Black alone, 12.4% as Hispanic alone, 4.4% as Asian alone, 0.7% as American Indian/Alaskan Native alone, and 8.1% as two or more races (USCB, 2019). The median household income in Lansing from 2015-2019 was $41,674, with 24.6% of the population falling below the poverty line (USCB, 2019). In the last 24 months, the clinic has provided primary care to 13,089 patients, 6,332 male and 6,757 female (A. Ryal, personal communication, August 2, 2021). The clinic patient population further breaks down into the following groups: 981 ages 0-18, 1,510 ages 19-29, 1,767 ages 30-39, 1,824 ages 40-49, 2,288 ages 50-59, and 4,107 ages 65+ (A. Ryal, personal communication, August 2, 2021). In the past 12 months, the clinic has seen 2,234 patients with DM2 with 325 having an HbA1c 7.0-7.9, with 157 having an HbA1c 8.0-8.9, with 84 having an HbA1c 9.0-9.9, and with 90 having an HbA1c over 10.0 (A. Ryal, personal communication, August 2, 2021). A total of 147 referrals were made to McLaren DSMES programs in the past year, while only 35 referrals were made to Sparrow DSMES programs (A. Ryal, personal communication, August 2, 2021). The clinic is affiliated with McLaren Health Care Corporation – Greater Lansing campus, where the clinic providers run the admission and discharge service (A. Ryal, personal communications June 16, 2021). Additionally, the clinic participates with the McLaren High Performance Network’s Accountable Care Organizations (ACO) and Physician Group Incentive SELF-CARE IN DM2 18 Program (PGIP) group (McLaren, 2021), which is comprised of health care providers who voluntarily work together to provide coordinated, high quality patient care (Centers for Medicare and Medicaid Services [CMS], 2021). The clinic patients participating in this project were comprised of individuals from four willing providers with an HbA1c above 9%, with exclusion criteria based only on the patient’s unwillingness to participate. Stakeholders include the clinic, Michigan State University, McLaren Health Care Corporation – Greater Lansing campus, insurance companies, and patients (K. Richardson-Aubrey, personal communication, August 13, 2021). Setting Facilitators and Barriers The clinic currently staffs 18 providers, each working with an MA assigned to assist them daily (A. Ryal, personal communication, June 16, 2021). Care Managers and quality specialists work together to ensure patient follow-ups and transitions of care occur based on provider order and/or patient needs. Clinic resources and services are extensive and demonstrate the willingness of the clinic to facilitate best care for their patients. For example, the clinic provides the following services on-site: • Preventative Care Including Wellness and Physical Exams • Gynecological Exams and Procedures • Minor Office Surgical Procedures • Immunizations • Family Medicine and Pediatrics • Well Child Physicals including Newborn • Pediatric Sports/School physicals • Pediatric Immunizations • Wart Removal • Asthma and Allergy Care • Vision Screening • Nutrition and Childhood Obesity • Minor Wound and Burn Care • Behavior and Developmental Care • Conners Scale for Assessing ADHD SELF-CARE IN DM2 19 • Bone Mineral Density Testing • X-Ray • Osteopathic Manipulation Testing (OMT) • Onsite Ultrasound • Onsite Laboratory Services by Sparrow Hospital • Onsite Pharmacy Services by Central Pharmacy • Aesthetic Services (CIMA, n.d.) A letter of support was obtained from the clinics Director of Clinical Operations, as well as the Incentive Management and Quality Control lead (Appendix G) prior to initiation of the intervention. The support of these clinic members, as well as the support of CMs and quality specialists, helped facilitate this intervention and process change. As stated above, barriers were addressed utilizing the PDSA cycle and included staff buy-in, implementation limitations due to ongoing outbreaks related to the Covid-19 pandemic, and transition of deidentified data from the clinic staff to project leads. Further explanation of the PDSA cycle for this project is described in greater detail within the PDSA cycle section below. The Intervention and Data Collection Procedure The intervention and data collection process are outlined in Appendix H. The first step in the process was to provide education on the SDSCA scale and new patient education process to the clinic staff. Education was provided via review of the SDSCA scale and ADA educational tools which patients were to receive. Education on scoring of the SDSCA scale along with how the MA selects the ADA educational handout was provided via zoom calls in August and September 2021. Following completion of staff education, patients whose HbA1c was greater than 9% were identified and clinic staff determined if they had a diabetes follow-up appointment scheduled during the three-month intervention period. Most of these patients had an appointment already scheduled, as patients with uncontrolled DM2 should see their PCPs every three to six SELF-CARE IN DM2 20 months until their HbA1c is better controlled (ADA, 2021c). The clinic’s quality specialists ran a report from E-Clinical Work, the electronic health record (EHR) system used by the clinic, and cross checked the list with the scheduling system. Any patients who were not scheduled within the intervention period were contacted by the quality specialists to determine if an appointment could be moved or created to fit within the designated timeframe. The next step in the process was to facilitate the intervention at patient appointments. The quality specialists set up an alert within the EHR that signaled the MAs to incoming patients who met the criteria for the intervention. Upon patient arrival for an appointment, the MA gave the patient the abbreviated SDSCA assessment tool (Appendix I) with consent statement to complete, along with several additional questions to assess previous participation in formal diabetes education or referral to endocrinologist for DM2 education (Appendix J). After the questionnaire was filled out, the MA calculated the scores and determined which subscale was the weakest area of knowledge for the patient. The subscales assess self-care in the areas of diet, exercise, blood glucose testing, foot care, smoking, and medication adherence (Toobert et al., 2000). After determining the greatest area of need, the MA provided the patient with the corresponding pre-printed ADA educational handout and alerted the provider to the topic. Although not originally planned, some patients received education for multiple subscales as determined by staff. The provider then facilitated education during the appointment in accordance with these handouts. Following completion of the appointment and the educational intervention, the provider placed all paperwork collected from the patient in a collective bin, located in a secure, employee only area, to be scanned and uploaded into the EHR. This practice was already in place and is consistently used throughout the clinic practice (A. Ryal, personal communication, August 13, 2021). Project leads did not have access to the bin. SELF-CARE IN DM2 21 The final step in the intervention process was to complete follow-up phone calls with the patients to assess any change in self-care behaviors. Again, the quality specialists created an alert within the EHR that signaled to the CMs and quality specialists that a phone call was warranted. The CMs and quality specialists rotated responsibility for these calls so that the work was distributed evenly and did not create undue burden on any single group within the clinic practice. This process occurred 7-14 days after the patient’s appointment and included a repeat delivery of the full SDSCA tool via phone. Additional questions that were covered during this phone call assessed patient opinion of the new educational process and any suggestions or needs they may have to improve self-care related to their diabetes. These additional questions, developed by the project leads and clinic staff, determined the extent of diabetes education the patient has received in the past and what direction patient education might need to go in the future, as well as patient feedback on the flow of this new education process. After the intervention period was complete, the quality specialists downloaded the deidentified data that was collected and sent it to the project leads for analysis. PDSA Cycle The Plan, Do, Study, Act (PDSA) cycle (IHI, 2020a) was utilized in this project as an evidence-based, scientific method for enacting change. The initial Plan and Do stages of this project are described above as the project design process and implementation phases were outlined. During implementation, project leads enacted the Study and Act stages as they monitored for unanticipated problems and developed solutions as needed. The first modifications came as a result of the Covid-19 pandemic as project initiation was delayed and limitations were placed on project leads’ ability to be present at the clinic on the first day of project implementation. While the anticipated start date was planned for mid-September, the first patient SELF-CARE IN DM2 22 to receive the intervention was actually seen on October 21st, 2021 (A. Ryal, personal communication, October 28, 2021). Throughout the implementation phase, delays continued as patient appointments were rescheduled due to ongoing illness among the clinic staff and patients. Upon initiation of the intervention with patients, a few issues arose directly with patients not completing the full questionnaire. In one instance, the MA gave the patient the full packet of educational material and in another the patient simply received the smoking cessation education material (A. Ryal, personal communication, October 28, 2021). Another solution that was developed included the CMs completing the questionnaire with patients upon the two-week follow-up call. Additionally, some patients chose not to participate at all and indicated feeling overwhelmed by having to manage their chronic disease or simply needing more time before feeling ready to commit to change (A. Ryal, personal communication, November 18, 2021). Further assessment determined that language barriers did not play a role in any of the uncompleted questionnaires. Aside from these instances, the intervention went smoothly, and patient data was collected as expected. Workflow unfolded as anticipated, with staff indicating that the intervention fit smoothly within processes they already had in place (A. Ryal, personal communication, November 18, 2021). An unanticipated benefit of this new process was an increase in referrals to endocrinology specialists and formal diabetes education programs resulting from the guided discussions occurring between patients and providers (A. Ryal, personal communication, November 18, 2021). This news was encouraging and determined no loss or detriment to project integrity was incurred by virtue of project leads being limited in ability to be onsite during outbreaks of illness among clinic staff. SELF-CARE IN DM2 23 Measurement Instruments and Tools The SDSCA assesses elements of self-care related to DM2 including diet, exercise, blood glucose testing, foot care, medication adherence, and smoking (Toobert et al., 2000). The extended tool offers 25 questions for gathering data; however, the authors support the utilization of subscales separately to support the needs of the project (Oregon Research Institute, n.d.; Toobert et al., 2000). Individualized use of the desired subscales for intervention development is evident within the literature as well, as described in the literature synthesis above (Bauer et al., 2018; Formosa & Muscat, 2016). Toobert et al. (2000) summarizes test and subscale validity and reliability across seven studies that utilized progressive versions of the SDSCA across a variety of settings and participants. Of note, the final version of the SDSCA tool was developed to maximize outcomes found across the seven studies including internal consistency, variability across subscales, stability of scales over time, predictive validity, sensitivity to behavior change, scoring simplicity, and utility for investigators and clinicians (Toobert et al., 2000). For the purposes of this project, 10 questions covering six subscales were utilized to assess educational needs. These subscales were chosen by project leads and clinic staff, as the clinic tracks these metrics on all patients with DM2 in their clinic. Permission to use the SDSCA assessment was obtained (Appendix K). The educational tools correlated with the area of need found by the SDSCA assessment. The ADA offers free patient education handouts (Appendix L) to help guide conversations between providers and patients and can be utilized as an ongoing reference for the patient. Separate handouts were chosen from the ADA website to correlate with each subscale of the SDSCA such that a low score on diet would necessitate use of the diet related handout and facilitate discussion on diet education, needs, and plans moving forward. Additional questions SELF-CARE IN DM2 24 were determined by the project leads and the clinic to gauge possible educational needs in the future. Cost-Benefit Analysis and Budget Minimal cost was incurred for the clinic in relation to this project. The Incentive Management and Quality Control lead created a notification process within the EHR based on HbA1c >9% and a template utilized by the CMs and other quality specialists during follow-up phone calls. Following approval from the IRB, project leads provided education to staff involved in the intervention over zoom. No additional cost related to staff wages were incurred for this activity as it was incorporated into preplanned work hours. Approximately 1 hour of education was provided by the project leads. Although both are registered nurses, no additional cost was charged for this time as it is attributed to course project hours as graduate students. The SDSCA and educational materials provided to patients occurred during an already scheduled DM2 follow-up appointment. The SDSCA is free to use for educational purposes, incurring no additional cost to this project. Printing of the SDSCA tool and educational materials, which are free online from the ADA, occurred in the clinic at a cost of approximately $0.04 per color page (A. Ryal, personal communication, August 13, 2021). Evaluation and Outcome Measures The success of this project was evaluated by comparing the initial and follow-up SDSCA overall scores. Improvement in the scores indicate that the education that occurred was successful in improving patient diabetes related self-care. Additionally, the process change was assessed by determining if there was an increase in the percentage of the clinic’s patients with DM2 that are receiving a standardized educational process. The additional questions after the SELF-CARE IN DM2 25 SDSCA as asked by CMs or quality specialists were designed to help the clinic determine future directions on types of education they may want to provide. Data Analysis Deidentified data was collected from the clinic in bulk at the end of the implementation phase. Although initial plans were to collect data on a biweekly basis, this was not feasible due to the manpower burdens placed on the clinic related to the Covid-19 pandemic, as described in our PDSA cycle above. There was a slight modification to the goal regarding comparison of subscale scores. Initial plans considered an increase in subscale scores across 15% of patients to indicate success of the intervention. However, fewer patients participated than expected, and there was more overlap in education across subscales than anticipated. As such, comparison of means across the pre- and post-intervention groups by use of a two-tailed paired t-test was deemed to be a more appropriate analysis. Regarding the desired outcome of increasing diabetic education via workflow changes, determination of success remained at a goal of 50% of patient interactions utilizing of the new procedure to increase in patient education compared to no intervention or consistent education procedure. Data showed that 25 patients were eligible to participate during the designated timeframe, while only 13 patients chose to participate in the initial phase of the intervention. As such, 52% of eligible patients participated in the new procedure, just exceeding the 50% target. Three of the participants were then lost to follow-up upon post-intervention phone call by CMs, resulting in n=10 for final pre- and post-intervention score analyses. The group pre-intervention mean was 4.1 days per week, while post-intervention was 4.8 days per week. Data indicated a statistically significant improvement in days per week that patients engaged in self-care behavior (t = -6.5, p < 0.01). These results met the two primary goals of the project, indicating a successful outcome SELF-CARE IN DM2 26 of the overall plan and intervention. Additionally, the supplementary questions developed to ascertain patient experience and readiness for formal diabetes education showed that only two of the 13 (15%) participants had previously attended a DSMES program. Subsequently, involvement in this intervention led to six patient referrals total, five to DSMES and one to an endocrinology specialist. This finding, although not a predetermined goal, was certainly considered a positive outcome of the intervention. Sustainability Plan This intervention provided the clinic with information regarding the self-care behaviors of their patients with DM2 and standardized a DM2 educational process among participating providers at the clinic. This information can readily be utilized to continue with the changes standardized within this project and by expanding the process to the remaining providers at the clinic and its satellite offices. At this time, however, the clinic providers as a group do not wish to sustain this intervention due to provider preferences and limitations on staff and physical resources. Alternatively, the case managers have expressed appreciation for the utility of the SDSCA tool and do wish to continue using it within their role in patient care. As such, transfer of permission to use the SDSCA tool from the project leads to the clinic Incentive Management and Quality Control lead is underway. Discussion and Implications for Nursing This project focused on standardizing a self-care assessment and educational procedure for patients with DM2 within the clinic. Identification of specific areas of patient educational needs can improve self-care in patients with DM2 and improve their overall health outcomes (Afaya et al., 2020; Bauer et al., 2018; GB & Premkum, 2016; Jiang et al., 2019; Nogueria et al., 2020; Zheng et al., 2019). The information collected in the additional questions asked in the initial and follow-up assessments provided the clinic with valuable information upon which they SELF-CARE IN DM2 27 could enhance the in-clinic diabetic educational program or develop a plan for increasing referrals to outside formal diabetes education programs. The success of this program offers the clinic a standardized diabetes education process, which can be expanded to providers across the clinic network and patients with HbA1c below 9% to be used universally across the population of patients with DM2. Additionally, patients who benefited from this intervention demonstrated an improvement in self-care behaviors which will ultimately improve diabetes related outcomes and reduce subsequent complications. Conclusion While DSMES education remains the gold standard for DM2 education in the U.S. (Beck et al., 2017; Powers et al., 2020), it is not always feasible for patients with DM2 to participate in this type of education. Self-care support is at the core of DSMES education (Beck et al., 2017; Powers et al., 2020) and interventions that focus on improving self-care self-efficacy can improve patient outcomes (Eller et al., 2018). Healthy People 2030 has an identified goal of reducing the percentage of adults who have a HbA1c greater than 9% (USDHHS, 2020), however it is important to focus on the self-care self-efficacy of all patients with DM2. By focusing on assessing self-care self-efficacy and providing standardized education to patients with DM2, we can reduce further complications for these patients (ADA, 2021a) and improve their control of chronic disease. SELF-CARE IN DM2 28 References Afaya, R. A., Bam, V., Azongo, T. B., Afaya, A., Kusi-Amponsah, A., Ajusiyine, J. 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The Diabetes Educator, 44(3), 237-248. doi: 10.1177/0145721718767400 Beck, J., Greenwood, D. A., Blanton, L., Bollinger, S. T., Butcher, M. K., Condon, J. E., …, & Wang, J. (2017). 2017 national standards for diabetes self-management education and support. The Diabetes Educator, 43(5), 449-464. doi: 10.1177/0145721717722968 Capital Internal Medicine Associates, P.C. (n.d.). Welcome to CIMA. Retrieved from https://cimamed.com/ Centers for Disease Control and Prevention. (2019). Diabetes. Retrieved from https://www.cdc.gov/diabetes/basics/type2.html SELF-CARE IN DM2 29 Centers for Medicare and Medicaid Services. (2021). Accountable care organizations (ACOs). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO Eller, L. S., Lev, E. L., Yuan, C., & Watkins, A. V. (2018). Describing self-care self-efficacy: Definition, measurement, outcomes, and implications. International Journal of Nursing Knowledge, 29(1), 38-48. doi: 10.111/2047-3095.12143 Formosa, C., & Muscat, R. (2016). Improving diabetes knowledge and self-care practices. Journal of the American Podiatric Medical Association, 106(5), 352-356. GB, M., & Premkum, J. (2016). Effects of a behavioral intervention on self-efficacy, self-care behavior and HbA1c values among patients with type 2 diabetes mellitus. International Journal of Nursing Education, 8(3), 1-5. doi: 10.5958/0974-9357.2016.00082.9 Healthy! Capital Counties. (December 31, 2018). Community health profile & health needs assessment. Retrieved from https://www.healthycapitalcounties.org/uploads/9/1/6/3/9163210/healthycapitalcounties_ 2018_community_health_needs_assessment_final_01072019_compressed.pdf Ingham County Health Department. (2018). Health equity data highlights. Retrieved from https://hd.ingham.org/Portals/HD/Home/Documents/hesj/HESJ%20Data%20Highlights% 20Spring%202018.pdf Institute for Healthcare Improvement (2020a). Science of improvement: Testing changes. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChang es.aspx Institute for Healthcare Improvement (2020b). Changes to improve chronic care. Retrieved from http://www.ihi.org/resources/Pages/Changes/ChangestoImproveChronicCare.aspx SELF-CARE IN DM2 30 Jahangard-Rafsanjani, Z., Sarayani, A., Nosrati, M., Saadat, N., Rashidian, A., Hadjibabaie, M., …, Gholami, K. (2015). Effect of a Community Pharmacist–Delivered Diabetes Support Program for Patients Receiving Specialty Medical Care: A Randomized Controlled Trial. The Diabetes Educator, 41(1), 127-135. doi: 10.1177/0145721714559132 Jarab, A. S., Alqudah, S. G., Mukattash, T. L., Shattat, G., Al-Qirim, T. (2012). Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. J Manag Care Pharm, 18(7), 516-526. doi: 10.18553/jmcp.2012.18.7.516. Jiang, X., Jiang, H., Li, M., Lu, Y., Liu, K., & Sun, X. (2019). The mediating role of self‐ efficacy in shaping self‐management behaviors among adults with type 2 diabetes. Worldviews on Evidence-Based Nursing, 16(2), 151-160. doi: 10.111/wvn.12354 Korcegez E. I., Sancar, M., Demirkan, K. (2017). Effect of a pharmacist-led program on improving outcomes in patients with type 2 diabetes mellitus from Northern Cyprus: A randomized controlled trial. J Manag Care Spec Pharm, 23(5), 573-582. doi: 10.18553/jmcp.2017.23.5.573 Marques, M. B., Coutinho, J. F. V., Martins, M. C., Lopes, M. V. O., Maia, J. C., & Silva, M. J. (2019). Educational intervention to promote self-care in older adults with diabetes mellitus. Revista da Escola de Enfermagem da USP, 53, e03517. doi: 10.1590/S1980-220X2018026703517 McLaren. (2021). McLaren high performance network, LLC. Retrieved from https://www.mclaren.org/aco/aco-home Michigan Department of Health and Human Services. (2019). Diabetes in Michigan update. Retrieved from https://www.michigan.gov/documents/mdhhs/diabetes-in-Michigan- SELF-CARE IN DM2 31 update-2019_658300_7.pdf Michigan Quality Improvement Consortium. (2020). Management of type 2 diabetes mellitus [pdf]. Retrieved from http://www.mqic.org/pdf/mqic_management_of_diabetes_mellitus_cpg.pdf Nogueira, M., Otuyama, L. J., Rocha, P. A., & Pinto, V. B. (2020). Pharmaceutical care-based interventions in type 2 diabetes mellitus: A systematic review and meta-analysis of randomized clinical trials. einstein (São Paulo), 18, 1-14 doi: 10.31744/einstein_journal/2020RW4686 Oregon Research Institute. (n.d.). SDSCA – FAQs. Retrieved from http://www.ori.org/sdsca/faqs Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., . . . 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, 1636-1649. doi: 10.2337/dci20-0023 Toobert, D. J., Hampson, S. E., & Glasgow, R. E. (2000). The summary of diabetes self-care activities measure: Results from 7 studies and a revised scale. Diabetes Care, 23(7), 943- 950. Retrieved from https://care.diabetesjournals.org/content/diacare/23/7/943.full.pdf U.S. Department of Health and Human Services. (2020). Health people 2030: Diabetes - Reduce the proportion of adults with diabetes who have an A1c value above 9 percent — D‑03. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse- SELF-CARE IN DM2 32 objectives/diabetes/reduce-proportion-adults-diabetes-who-have-a1c-value-above-9- percent-d-03 United States Census Bureau. (2019). QuickFacts Lansing city, Michigan. Retrieved from https://www.census.gov/quickfacts/lansingcitymichigan Wishah R. A., Al-Khawaldeh O. A., & Albsoul, A. M. (2014). Impact of pharmaceutical care interventions on glycemic control and other health-related clinical outcomes in patients with type 2 diabetes: Randomized controlled trial. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 9(4), 271-276. doi: 10.1016/j.dsx.2014.09.001. Zheng, F., Liu, S., Liu, Y., & Deng, L. (2019). Effects of an outpatient diabetes self-management education on patients with type 2 diabetes in China: A randomized controlled trial. Journal of Diabetes Research, 2019, 1-7. doi: 10.1155/2019/1073131 SELF-CARE IN DM2 33 Appendix A Gap Analysis: Fishbone Diagram People Process Providers unsure of where referral for DM education go No standard DM education in clinic Most providers want to provider No follow-up from clinic to their own education Lack of ensure patient understanding additional of education qualified staff to help provide Providers education unsure if patient attends education Lack of self- efficacy in No standard Providers only managing have 15-minute patient appointments type 2 DM educational material in clinic Fast paced clinic environment Materials Environment SELF-CARE IN DM2 34 Appendix B Gap Analysis: SWOT Strengths (Internal Factors) Weaknesses (Internal Factors) What are you good at? What areas do you struggle with? What do you do better than anyone else? What areas have fewer resources? What is your team good at? What will help you get there? Seasoned and knowledgeable staff Many practice locations leads to Good staffing and resources for inconsistencies across sites. implementation No synchronous process across sites or providers Resistance to change Difficulty in process roll due to large staff needing buy-in Providers want control over education given to patients Short provider appointments Lack of additional staff to help implement and maintain educational processes Opportunities (External Factors) Threats (External Factors) What areas can you take advantage of? What are areas you should be wary of? What are places you can grow? What could derail your project? Where are things you can do to What could negatively affect your accomplish the task? project? Where are opportunities for growth? Multiple certified diabetic education Staff turnover programs in area for referral Ongoing COVID-19 pandemic Public transportation available within city SELF-CARE IN DM2 35 Appendix C Literary Search Methods Database Keywords Limitations Number of Searched Results CINAHL #1 self-efficacy AND English Language 21 type 2 diabetes or Research Article type 2 diabetes Peer Reviewed mellitus or t2dm 2016-2021 AND assessment All adult tools or assessment method or assessing PUBMED #1 self-efficacy AND Last 5 years 95 type 2 diabetes or English Language type 2 diabetes Adults: 19+ years mellitus or t2dm Free Full Text AND assessment tools or assessment method or assessing CINAHL #2 Summary of English Language 13 Diabetes Self-Care Research Article Activities AND Peer Reviewed education 2016-2021 All adult PUBMED #2 Summary of Last 5 years 13 Diabetes Self-Care English Language Activities AND Adults: 19+ years education Free Full Text SELF-CARE IN DM2 36 Appendix D Literature Synthesis Table Author/ Level of Purpose of the Frame Results How does this relate Implications for Title Evidence project/research work to your project? Practice Afaya et Analytical Evaluate DM2 patients for None Higher age and education Utilization of SDSCA Identifying targeted al. (2020) Descriptive diabetes related medication increased medication helps providers identify educational needs can Cross- adherence, self-care adherence. Increased areas of weakness for improve patient Sectional behaviors, and knowledge knowledge equated to increased patients and intervene education, thereby self-management. with strategies that improving self-care promote adherence. and outcomes Bauer et RCT Determine impact of None Neuropathy pain was not Utilization of an Educational activities al. (2018) education text messages on reduced. Scores improved for educational intervention that correlate to diabetes self-management all SDSCA subscales and via text messaging that SDSCA content can activities and outcomes in health beliefs. HbA1c declined was relevant to SDSCA improve self-care patients with painful diabetic but not significantly. subscales improved behaviors and scale peripheral neuropathy scores. scores. Formosa Non- Assess for correlation None No correlation between overall There are limitations to Supporting behavioral et al. Experimental between knowledge and self- diabetes knowledge and correlating knowledge change to enhance (2016) Prospective care behaviors in patients SDSCA. Significant correlation with self-care behaviors. self-care through Study with DM2 between knowledge and diet Utilizing behavior education should subscale. change theories to incorporate behavior enhance self-care may change help. theories/models. GB et al. True Evaluate the effectiveness of None The experimental group, who The SDSCA was utilized Providing a structured (2016) Experimental a behavioral intervention on received both routine as a pre- and post-test educational Study self-efficacy, self-care clinic treatment, and an with both the control and intervention improves behavior educational intervention, the experimental groups. self-care behavior and and HbA1c values among saw enhanced confidence in HbA1c values. patients with type 2 diabetes self-management mellitus. of the DM2, which in turn improves their self-care behavior and HbA1c values, over the control group who only received routine clinic treatment. SELF-CARE IN DM2 37 Jiang et Cross- Test a model of self-efficacy, Social Self-efficacy had the strongest Knowledge based Focusing on self- al. (2019) Sectional diabetes distress, knowledge, Cognitive direct effect on DSM behaviors interventions can affect efficacy can enhance and education level and Theory and mediated the effects of the self-care but should be diabetes education diabetes self-management other variables as well. enhanced by theories efforts being done in (DSM) behaviors. Knowledge had a direct effect that support self- the office. on DSM behaviors. efficacy. Marques Quasi- Implement group education None SDSCA scores demonstrated The SDSCA can be Group educational et al. Experimental for older adults focusing on that self-care increased in the effectively used to interventions are (2019) Study diabetic self-care. areas of diet and foot care. measure elements of useful for improving self-care for pre- and diabetes self-care. post- education intervention. Nogueira, Systematic Investigate the impact of None Pharmaceutical care and Utilization of the Educational et al. review and pharmaceutical care and educational SDSCA scores in RCT interventions and the (2020) meta-analysis educational interventions on interventions have significant analyzed in this review use of the SDSCA of randomized DM2. positive impact on type 2 showed improvement in improve outcomes for clinical trials diabetes mellitus. The tools key areas of diabetic patient with diabetes. SDSCA and the Morisky education such as Medication Adherence Scale HbA1c and fasting blood may be useful to monitor glucose. patients. Zheng et RCT Develop an outpatient None Compared with the control SDSCA scores in the Standardized al. (2019) interactive educational group, scores of the SDSCA group that received the educational program and evaluate its measure and problem areas in standardized educational interventions improve effects utilizing the SDSCA the diabetes scale, fasting blood intervention were higher the level of self- prior to the education glucose, postprandial 2-hour than those that did not reported self- program and after the blood glucose, and HbA1c were receive the standardized management, educational program. An significantly improved in the educational intervention. psychological outpatient diabetes self- intervention group after the distress, and glycemic management education was intervention (P < 0 01). control in patients with subsequently conducted to type 2 diabetes guide these subjects in an mellitus. appropriate, targeted, self- management manner and to improve the self-management level. SELF-CARE IN DM2 38 Appendix E DNP Project Timeline: GANTT Chart Task Task 6/21 7/21 8/21 9/21 10/21 11/21 12/21 1/22 2/22 3/22 4/22 5/22 Description 1 Faculty advisor x x x meetings 2 Community x x x partner meetings 3 Literature x x x Review 4 Completed x x x proposal presentation 5 Committee x review and approval 6 Development x x x of in clinic process implementation 7 Implementation x x x x of intervention 8 Collection of x x x x outcome data 9 Evaluation of x x x x x x x outcome data 10 Completion of x x x x x final report SELF-CARE IN DM2 39 Appendix F IRB Approval SELF-CARE IN DM2 40 SELF-CARE IN DM2 41 Appendix G CIMA Letter of Support SELF-CARE IN DM2 42 Appendix H Intervention and Data Collection Process Patient Arrival: Complete Survey Follow-Up: MA Task: CMs and QI Specialists Score Survey, ID Call Patient to Complete Education, Communicate Follow-Up Questions to Provider EHR Function: Provider Appointment: Survey Uploaded to Educate Patient on Topic Patient EMR, Alert Staff ID'ed by Survey Score for Follow-Up Call SELF-CARE IN DM2 43 Appendix I Abbreviated SDSCA Scale Statement of Consent: By completing this assessment tool, I give my consent to participate in the “Assessment of Self-Care and Education in Patients with Type 2 Diabetes Mellitus” project performed by Michigan State University Doctor of Nursing Practice students. Summary of Diabetes Self-Care Activities Questionnaire (SDSCA)© (Toobert, et al., 2000) The questions below ask you about your diabetes self-care activities during the past 7 days. If you were sick during the past 7 days, please think back to the last 7 days that you were not sick. Diet Number of Days 1. How many of the last SEVEN DAYS have you followed a healthful eating plan?  0  1  2  3  4  5  6  7 2. On average, over the past month, how many DAYS PER WEEK have you followed your eating plan?  0  1  2  3  4  5  6  7 Physical Activity 3. On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activity?  0  1  2  3  4  5  6  7 (Total minutes of continuous activity, including walking). 4. On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?  0  1  2  3  4  5  6  7 Blood Sugar Testing (skip this section if your provider has not instructed you to test your blood sugar) 5. On how many of the last SEVEN DAYS did you test your blood sugar?  0  1  2  3  4  5  6  7 SELF-CARE IN DM2 44 6. On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health- care provider? 0 1 2 3 4 5 6 7 Foot Care 7. On how many of the last SEVEN DAYS did you check your feet? 0 1 2 3 4 5 6 7 8. On how many of the last SEVEN DAYS did you inspect the inside of your shoes? 0 1 2 3 4 5 6 7 Medications 9. On how many of the last SEVEN DAYS, did you take your recommended diabetes medication? 0 1 2 3 4 5 6 7 Smoking 10. Have you smoked a cigarette, even a puff, in the past SEVEN DAYS? 0 No 1 Yes 10a. If yes, how many cigarettes did you smoke on an average day? Number of cigarettes: _____________ SELF-CARE IN DM2 45 Scoring Instructions for the Summary of Diabetes Self-Care Activities (SDSCA)© Scores are calculated for each of the five regimen areas assessed by the SDSCA: Diet, Exercise, Blood-Glucose Testing, Foot Care, and Smoking Status. Step 1 For items 1–10, use the number of days per week on a scale of 0–7. Note that this response scale will not allow for direct comparison with the percentages provided in Table 1. Step 2: Scoring Scales General Diet = Mean number of days for items 1 and 2. Exercise = Mean number of days for items 3 and 4. Blood-Glucose Testing = Mean number of days for items 5 and 6. Foot Care = Mean number of days for items 7 and 8. Medications = Use total number of days for item 9. Smoking Status = Item 10 (0 = nonsmoker, 1 = smoker) and item 10a number of cigarettes smoked per day. SELF-CARE IN DM2 46 Appendix J Additional Questions Initial Additional Questions: 1. Have you ever talked to your provider about any of these topics (circle all that apply): diet, exercise, blood sugar testing, foot care, medication adherence, smoking 2. Have you ever participated in a formal diabetes education program? Yes No 3. Are you interested in participating in a formal diabetes education program? Yes No 4. If you are interested in participating in formal diabetes education, where would you prefer to attend (circle all that apply): Sparrow, McLaren, or in the CIMA clinic 5. Have you seen an endocrinologist for your DM in the past or are you currently seeing one? Yes No If yes, who was/is the endocrinologist? Post Intervention Follow-Up Questions: 1. Repeat the questions from the subscale that required education. 2. Do you feel you learned something from your appointment with your provider? Yes No 3. Did you find the educational handout useful? Yes No 4. Do you feel you’ve made improvements in self-care in the area of education you covered? Yes No 5. What else would help you improve your self-care or support your DM care? SELF-CARE IN DM2 47 Appendix K SDSCA Tool Authorization SELF-CARE IN DM2 48 Appendix L ADA Educational Handouts Standards of Care https://professional.diabetes.org/sites/professional.diabetes.org/files/media/Standards_of_Care.p df Diet: https://professional.diabetes.org/sites/professional.diabetes.org/files/pel/source/wcie_2019_porti on_control_flyer_en_8_5x11_draft03_lowres.pdf Physical Activity: https://professional.diabetes.org/sites/professional.diabetes.org/files/media/15_advisor_physical- activity_eng_med-res.pdf Blood Glucose Testing: https://professional.diabetes.org/sites/professional.diabetes.org/files/pel/source/sci- advisor_2018_blood_glucose-newb-final_v2.pdf https://professional.diabetes.org/sites/professional.diabetes.org/files/pel/source/sci- advisor_2018_blood_glucose_log.pdf Foot Care: https://professional.diabetes.org/sites/professional.diabetes.org/files/pel/source/sci- advisor_2018_taking_care_of_your_feet-newa_0.pdf Smoking: https://professional.diabetes.org/sites/professional.diabetes.org/files/pel/source/sci- advisor_2018_all_about_quitting_smoking_v3.pdf Medications: https://professional.diabetes.org/sites/professional.diabetes.org/files/pel/source/medications.pdf https://professional.diabetes.org/sites/professional.diabetes.org/files/media/Managing_Your_Me dicines.pdf