Running head: DIABETES EDUCATION 1

Promoting the Nurse Practitioner Role for Diabetes Education in the Primary Care

Setting

Elizabeth C. Cobb

Virginia Commonwealth University

DIABETES EDUCATION

Abstract

Diabetes type II (DMT2) is a chronic health condition with over 1.7 million new cases diagnosed

yearly in the US. Early and frequent diabetes self-management education (DSME) is

recommended as a primary way to improve patient outcomes and decrease long-term

complications. The aim of this quality improvement (QI) project is to develop a Nurse

Practitioner led educational program in the primary care setting targeting adults ages 18-64 with

a HbA1c > 8% and body mass index (BMI) > 30 kg/m2 over a three-month period to lower

HbA1c, BMI and improve patient self-efficacy managing DMT2. A structured educational

intervention based on the seven self-care behaviors outlined by the American Association of

Diabetes Educators will be utilized, along with the electronic health record (EHR) patient portal,

MyChart, to reinforce education throughout the three-month period. Program evaluation

includes pre- and post-HbA1c and BMI measurements as well as self-efficacy scoring with the

Diabetes Self-Management Questionnaire (DSMQ). Utilizing the NP as an education expert

aims to improve biomarkers of diabetes care and support patients’ acquisition of self-care skills,

leading to improved outcomes and increased patient satisfaction with care.

Keywords: Nurse Practitioner, diabetes self-management education, Hemoglobin A1c,

Body Mass Index, DSMQ, Diabetes type II

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Problem Statement

The United States (US) diabetes epidemic affects over 29 million people diagnosed with

the disease, with an additional nine million still undiagnosed (Centers for Disease Control

[CDC], 2014). Annually, new incident cases of type II diabetes (DMT2) exceed 1.7 million for

those aged 20 and older, with the largest burden of diabetes seen in the black and Hispanic

communities, accounting for 26% of the population (CDC, 2014). The incidence of DMT2 in

adults over 18 years of age in the Commonwealth of Virginia (VA) rose from 4.2% in 1995 to

8.3% in 2010 (Geiss et al., 2012). Diabetes rates are growing parallel with the rates of obesity,

with approximately 154 million adults classified as obese having a body mass index (BMI)

greater than 30 kg/m2 (Go et al., 2014). The obesity epidemic is closely associated with an

increased prevalence of diabetes and cardiovascular disease (Go et al., 2014). Cardiovascular

risk increases two to four fold in persons with diabetes (U.S. Department of Health and Human

Services [USDHHS], 2016). The complications related to diabetes include lower life expectancy,

along with increased risk of kidney failure and amputation (USDHHS, 2016).

The complications associated with diabetes directly impact the economic burden of

health care across the US. The direct medical cost of diabetes in the US increased from $174

billion in 2007 to $245 billion in 2012 for direct medical costs (American Diabetes Association

[ADA], 2015). These costs include inpatient care, medications, diabetic supplies, medical office

visits, as well as nursing home admissions (ADA, 2015).

Indirect costs of diabetes reach as high as $69 billion a year and correlate to loss of work

productivity, disability and mortality (ADA, 2015).

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Purpose and Rationale

Patient educational programs recognized by national and international guidelines are

recommended as part of comprehensive diabetes management (Lawal & Lawal, 2016). Healthy

People 2020 national health promotion initiative recommends diet modifications and exercise as

a way to control and prevent complications from diabetes (Campbell, Khan, Cone, & Raisch,

2011; Healthypeople.gov, 2016). Structured diabetes education programs improve patients’

perceived ability to self-manage their diabetes and lower HbA1c levels (Edsen & Nichols, 2013;

Kirby, Moore, McCarron, Perkins & Lyle, 2015; Lawal & Lawal, 2016; Peyrot, Peeples, Tomky,

Charron-Prochownik, & Weaver, 2007; Zgibor et al, 2007). Therefore, the aim of this project is

to develop a structured diabetes educational intervention among adults age 18-64 years, with

poorly controlled type II diabetes (defined as HbA1c > 8.0) and comorbid obesity (defined as

BMI > 30), in an ambulatory family practice population, to compare the effects of structured

diabetes education focusing on behavior change and lifestyle management with a traditional

office follow-up visit, in decreasing HbA1c and increasing patient perceived self-efficacy to

manage their diabetes within a six month time frame.

Literature Review

Healthy People 2020 identifies lifestyle change as the most substantial modifying factor

in diabetes prevention and treatment (Healthypeople.gov, 2016). The literature confirms dietary

changes and exercise improve blood sugar control and decrease obesity among people with type

2 diabetes (Boeing et al., 2012; Hall, 2015; Huntriss & White, 2016; McGloin, Timmins, Coates

& Boore, 2014; Radhakrishnan, 2011; Stroutenberg, Stanzilis, & Falcon, 2015). Lifestyle

interventions demonstrate positive health benefits for patients with diabetes, yet poor adherence

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to therapy leads to sub-optimal health outcomes and negative impact on healthcare costs (Capal

& Schub, 2016; Garcia-Perez, Alvarez, Dilla, Gil-Guillen & Orzoco-Beltran, 2013).

Successful interventions include multiple facets of encouraging self-management. Self-

management is defined as “the individual’s ability to manage the symptoms, treatment, physical

and psychological consequences and lifestyle changes inherent in living with a long term

disorder” (Radhakrishnan, 2011, p. 497). The American Association of Diabetes Educators

(AADE) and the ADA recommends diabetes self-management education (DSME) at the time of

diagnosis and at needed intervals using a structured program (Powers et al., 2015). Additionally,

the AADE strongly recommends patient satisfaction surveys of the curriculum for continuous

practice improvement (Martin et al., 2013). DSME incorporates information about the disease,

nutritional counseling and meal planning, physical activity, goal setting and progress review

(Huntriss & White, 2016). Radhakrishkan (2011) examined tailored individual education

interventions for persons with diabetes. The individual-specific interventions did not show any

significant gain over standardized interventions even when accounting for fidelity, cost

effectiveness, and patients receiving personal attention (Radhakrishkan, 2011). A written DSME

curriculum remains centrally important in development of behavior change goals for the patient

(Martin, Warren, & Lipman, 2013).

Teaching individuals the importance of adherence to their diabetes medications

significantly lowers HbA1c values during a three-month period (Garcia-Perez, et al., 2013).

Adherence also impacts the economic aspect of diabetes, reducing cost to the patient and the

health care system (Garcia-Perez et al., 2013). Three factors linked to improved adherence

include reduced treatment complexity, increased patient knowledge, and improved continuity of

care communicating with patients (Franklin, 2014; Garcia-Perez et al., 2013). Although some

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educational programs do not show a significant relationship between educational intervention

and lower HbA1c, the educational offerings do impact process measure outcomes of regular

office follow-ups with their primary care provider and foot and eye examination rates (Franklin,

2014). The National Diabetes Education Program (NDEP) recognizes routine provider follow-

up and monitoring for diabetes complications as glucose control outcome measures for

complication risk reduction (Gallivan, Greenberg, & Brown, 2008).

Adherence is linked to positive regard for self-care when developing programs for

persons with diabetes. Hall (2015) describes specific goal setting and behavior change

interventions as keys to improving health outcomes. The facets to this approach include healthy

lifestyle support, information about diabetes, and training to help increase patient comfort

dealing with the disease. Other important self-care tools include ensuring proper glucose

monitoring equipment and encouraging development of a support system (Hall, 2015). Laying

out a specific plan of information gathering and sharing, along with provider consultation and

joint decision making will lead to development of a sustainable diabetes self-care plan (Hall,

2015).

The educator and person with diabetes can work together to influence positive clinical

and behavioral outcomes (Peyrot et al, 2007; Zgibor et al., 2007). A diabetes education program

should include appropriate tools to support an individual’s educational needs and health

outcomes (Gallivan et al., 2008). The seven domains of diabetes care established by the AADE

provides the framework for a standardized diabetes education program (American Association of

Diabetes Educators [AADE], 2010).  

● being active,

● healthy eating,

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● taking medication,

● monitoring,

● problem solving,

● reducing risks, and

● healthy coping.

The seven self-care behaviors identify areas linked with increasing patient knowledge,

encouraging behavior change, and influencing health outcomes (AADE, 2014).  Materials

developed by the AADE are specifically designed for obtaining measurable outcomes for

continuous quality improvement of diabetes care and policy (AADE, 2014).  Providing an

educational program based on the seven self-care behaviors facilitates improved perceived health

status, quality of life, and HbA1c as three of the goals of diabetes care (AADE, 2014).

Background and Significance

In the Commonwealth of VA, diabetes prevalence approximates 10% of the total

population, with 35% of those being age 35-64, and over 10% located in the Shenandoah health

district (Virginia Department of Health [VDH], 2016d). Diabetes is the seventh leading cause of

death in VA; with ethnic minorities, low income and the poorly educated disproportionality

affected (VDH, 2016d). As the incidence of diabetes increases, so does the potential for

complications and increased health care service needs (Garfield, 2015). In 2010, overall health

care costs in the US for persons with diabetes were two to three times greater than average

healthcare expenditures, with $313 million spent in 2011 on inpatient hospitalizations related to

diabetes and it’s complications alone (Garfield, 2015, VDH, 2016d). The complexity of diabetes

coupled with comorbidities highlights the importance of education while promoting adherence to

self-care (Garfield, 2015; Martin, Warren & Lipman, 2013).

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There are an estimated 637,837 individuals living with diabetes in VA, with 95% of those

diagnosed with DMT2 (VDH, 2016d). The mean age of DMT2 diagnosis in VA is 47, with

equal distribution between genders. Ethnic minorities, persons with low education and incomes

all trend toward early age diagnosis between ages 43-44 (VDH, 2013a). While data on the new

incidence of DMT2 diagnosis is unclear, the established data on morbidity and mortality, as well

as hospitalizations reflects an ongoing public health issue, reinforcing the need for more widely

available DSME services.

DSME mitigates the costs of diabetes and associated complications by improving disease

self-management that prevents disease progression and reduces health services utilization.

Diabetes is notable for the complications of kidney failure, depression, cardiovascular events as

well as limb amputations (Garfield, 2015).

Needs Assessment

The VA population of interest is served by Carilion Clinic health care organization.

Carilion Clinic is centrally based in Roanoke, VA, serving upwards of 1 million people in

western VA. This coverage area includes the Shenandoah health district, including primary care

offices, specializing in family medicine, based in the cities of Staunton and Waynesboro

(Carilion Clinic, 2016e). Diabetes metrics for the Shenandoah health district varies from other

regions of the state. The Shenandoah district versus state averages differ for the age at diagnosis

(Shenandoah, 53 years versus State, 47 years), and diabetes screening rates (Shenandoah, 51%

versus State, 53%) (VDH, 2013a). Advanced age at diagnosis may be associated with lower

HbA1c screening levels among the Shenandoah population (VDH, 2013b).

The AADE and ADA’s position on diabetes education is to ensure access and define

barriers to DSME for all persons with diabetes (Powers et al., 2015). The diabetes educational

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program in the local Augusta County region is hospital-based through the Augusta Health

nutrition department and not directly affiliated with the Staunton and Waynesboro Carilion

family practices (Augusta Health, 2016). This creates a gap in services defining one local group

of diabetes educators responsible for the entire population of the Shenandoah health district, and

the local cities. Services outside the local region entail traveling anywhere from 45 minutes to

two hours for DSME. Carilion adopted the role of the care coordinator within office practices to

assist with providing basic diabetes educational needs. The education level of the care

coordinator is inconsistent, as a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) may

teach individuals. Utilization of a LPN is inconsistent with goals set forth by the American

Diabetes Association (ADA) and AADE to have all education programs led by a RN, Registered

Dietician (RD), or a Registered Pharmacist (RP) (AOA, 2015). While the office-based

educational offerings through Carilion are not AADE certified programs, utilizing a Nurse

Practitioner (NP) as the primary educator allows for a more holistic approach to DSME in

primary care (Robertson 2014).

The target goal for HbA1c, the gold standard for measuring diabetes control, is less than

7% or lower based on comorbidities (Butler, 2011). While the number of persons with DMT2 in

the Staunton and Waynesboro Carilion practices is approximated at over 1500, the number of

persons with DMT2 with a HbA1c evaluated in 2016 is 485 (Carilion Clinic, 2016c; Carilion

Clinic, 2016d). DSME improves HbA1c levels in persons with DMT2 by up to 1% and has

shown improved outcomes in many aspects of health (Powers et al., 2015). Within VA,

approximately half (56%) of the persons with DMT2 report having HbA1c checked within the

past 3 years, compared with only 51% of persons in the Shenandoah health district (VDH,

2013b).

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The development of DMT2 is strongly correlated with obesity, represented by a BMI >

30 kg/m2 (Butler, 2011). Excess weight increases insulin resistance making glycemic control

more challenging (Bell et al., 2014). Therefore even weight loss as minimal as 3% of total body

weight can decrease costs associated with diabetes medical care (Bell et al., 2014; Butler, 2011).

Additionally, although the ADA and AADE standards support DSME for all newly

diagnosed DMT2 at the time of diagnosis and follow-up DSME at timely intervals, DSME

referrals for VA, and the Staunton/Waynesboro Carilion are suboptimal. In VA between 2012-

2013, 58% of persons with known diabetes were referred for DSME, with the majority being

educated females between the ages 45-64 (VDH, 2013c). The Staunton and Waynesboro

Carilion offices have over 1,500 individuals with diabetes with an HbA1c on record (Carilion

Clinic, 2016c; Carilion Clinic, 2016d). The Waynesboro Carilion office logged 48 encounters

with patients in the last five months for DSME teaching, compared with 10 in the Staunton

Carilion (Carilion Clinic, 2016c; Carilion Clinic, 2016d). The encounters for DMSE in the

documented time frame reflect the need for innovative efforts to encourage increased diabetes

education for individuals. While DSME is traditionally based in specialized settings, it is

becoming more prevalent in office settings, offering the additional benefit of continuity of care

for patients (Franklin, 2014; Powers et al., 2015). Nurse Practitioners are specifically educated

and equipped to provide information on disease management to patients within the family

practice setting (Bartol, 2011; Edsen & Nicols, 2013; Franklin, 2014; Robertson, 2012). The NP

specializing in diabetes care provides an opportunity to improve self-management skills of

persons with DMT2 in the office setting while maintaining continuity of care (Franklin, 2014).

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Barriers

The complexity of diabetes and the numerous factors impeding proper self-care reinforce

the role of DSME in diabetes care (Powers et al., 2015). Diabetes is a chronic disease affecting

multiple organ systems (CDC, 2014). Multiple comorbidities complicate self-management

making delivery of DSME more challenging for the provider (Powers et al., 2015).

Hypertension, hyperlipidemia, retinopathy, kidney disease, and neuropathy are all complications

resulting from or compounded by diabetes (CDC, 2014). Persons with diabetes and other

comorbidities struggle with coping strategies, multiple medications, and often stress related to

emotional, psychological, and social factors (Powers et al., 2015).

The development of a primary care based diabetes education program relies on several

factors to help patients improve their diabetes self-management skills. The American

Association of Diabetes Educators (AADE) recognizes that only 50% of patients are referred to

diabetes education within the first six months of diagnosis, and approximately 30% of patients

completed 10 hours of DSME within their first year of diagnosis (Martin et al., 2013). In the US,

socioeconomic factors and ethnicity show disparity among those who receive services. Over

75% of persons receiving diabetes education have at least a high school education and 70% are

Caucasian (Martin et al., 2013). Since 25% of persons with diabetes are African American or

Hispanic, these statistics reinforce the need to deliver DSME to the underserved population,

(CDC, 2014). The delivery of diabetes education is limited by the availability of formal

education (Administration on Aging [AOA], 2015). Access to programs is cited as one of the

largest barriers (AOA, 2015).

Program costs deter many from participating in formal DSME (AOA, 2015). The costs

of DSME are linked to program development and utilization (Martin et al., 2013). Direct costs

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include insurance reimbursement concerns, with private insurance and Medicaid claims

accounting for 49% of DSME claims (Martin et al., 2013). While most insurances will pay for

up to 10 DSME visits a year, the visits are often underutilized. The reasons for that are unknown

and may be related to indirect costs of transportation and time off of work for patients and their

family.

The two local Carilion Clinic offices support a large diabetes population, but education

opportunity remains an area for improvement. Over 1,500 people within the Staunton and

Waynesboro Carilion offices are diagnosed with DMT2, and slightly over half show adequate

glucose control, with a HbA1c this year < 8% (Carilion Clinic, 2016a; Carilion Clinic, 2016b).

Office protocol of documentation regarding DSME referrals is not well established. The

Carilion diabetes registry allows for type of diabetes outreach and date to be added to an

individual’s medical record, but documentation is not currently updated (Carilion Clinic, 2016c;

Carilion Clinic, 2016d). Also, no formal process or tool within the EHR currently captures

whether a patients are offered or completed DSME. The gap in documentation is a systems

issue, with no certain individual responsible for tracking such information. Local providers refer

patients to the Augusta Health program for DSME or utilize the office based Care Coordinator

due to the high burden of patients with diabetes on the local office system. Despite scheduled

appointments, there is often poor patient follow-through, possibly linked to job conflicts,

transportation issues, or poor understanding of diabetes and it’s complications. Nationally, the

lack of emphasis to patients with diabetes on the importance of DSME by providers is cited as

one reason for patient indifference to participation (Martin et al., 2013).

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Stakeholders

The providers, office staff, clinic, and the patients are instrumental in successfully

implementing a new approach to DSME. The patients within the practice are identified as the

biggest beneficiary from implementation of a NP led diabetes education program. Patient self-

management relies on clinicians and services in place to assure comprehensive diabetes care.

The American Association of Diabetes Educators (AADE) reports that diabetes education is

underutilized particularly in individuals with diabetes showing poor control (Powers et al.,

2015). Individuals with a HgbA1c of 8% and higher will be targeted by this QI education

initiative to improve self-management skills.

The physicians are vested stakeholders in a successful office-based diabetes initiative.

There are four physicians within the Waynesboro Carilion office, and two within the Staunton

Carilion office. Each physician is monitored by a medical scorecard report tracking the

percentage of patients with HbA1c below 8%. The physicians receive a financial bonus at the

end of the fiscal year based on the percentage of patients with HbA1c < 8%. Both office

practices have high patient volumes, with billings averaging 1,300 relative value units (RVUs) a

month (Carilion Clinic, 2016f). Due to current high patient volumes, the physicians accept only

a limited number of new patients into the practices. Therefore, full daily schedules limit

physician time available for additional diabetes education. The goal of utilizing the NP in the

role of the diabetes clinical expert within the office setting will allow for decreased physician

burnout, improved office workflow and increased patient self-efficacy managing their chronic

disease.

The NP represents the critical stakeholder in development of an educational initiative.

The role of the NP in this office setting is to support the physicians through

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scheduling acute care patients as well as routine patient follow-up visits. Nurse Practitioners are

skilled at delivering patient education and make their role within an office setting more valuable

by delivering care as the clinical diabetes expert. (Robertson, 2012; Franklin, 2014).

Finally, Carilion Clinic benefits overall with successful implementation of an office

based education program. Providing individuals with diabetes education to improve disease

outcomes, not only keeps office visit revenues within the health system, it has potential to lower

overall patient cost. One of the long term outcome goals associated with DSME is to prevent

complications associated with diabetes, leading to reduced economic burden on the health care

system as a whole (Gallivan et al., 2008).

Project Benchmarks

Diabetes care is a major focus for quality improvement and performance measurements

(O’Connor et al., 2011). National agencies such as the Centers for Medicare and Medicaid

Services (CMS) and National Committee on Quality Assurance (NCQA) have identified control

of HbA1c as the most important measure of care; followed by blood pressure and LDL

cholesterol monitoring (O’Connor et al., 2011). Additional process measures include urine

microalbuminuria and yearly retinal exams (O’Connor et al., 2011). The NCQA stratifies

HbA1c levels as poor control > 9%, Adequate control < 8%, and HbA1c < 7% desired in patients

with multiple cardiac risk factors (National Committee on Quality Assurance [NCQA], 2015).

These biomarkers and process measures are included in physician payment programs (O’Connor

et al., 2011). Physicians with Carilion are monitored on quality diabetes care by HbA1c tracking

using the diabetes scorecard (Carilion Clinic, 2016a; Carilion Clinic, 2016b). While there are

many quality measures for diabetes, the proposed education program will focus on targeting

patients for diabetes education when HbA1c > 8%. This HbA1c goal is determined through risk

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factor assessment, based on cardiovascular events, microvascular complications and mortality

(O’Connor et al., 2011). The aim of this project is to use DSME to improve participants’ self-

efficacy in managing their diabetes, capturing that improvement through HbA1c level

monitoring.

Feasibility

A NP led DSME initiative allows the practice to bill for services and provides a feasible

alternative to outpatient education. Early diagnosis and effective treatment results in decreased

health care costs and utilization of the health care system. A NP focusing on education increases

the chances of enhancing diabetes care adherence within the office setting for person with

uncomplicated diabetes (Robertson, 2012). In addition, primary care office based diabetes

management allows not only for education, but medical management that is not standard in

diabetes education outside the medical office (Franklin, 2014). Improved patient outcomes result

from early diabetes diagnosis, treatment and education (Robertson, 2012; Gallivan et al., 2008).

The workflow of the office setting is structured to allow a smooth transition for

incorporating increased educational visits. The DSME visits will be scheduled as follow-up care

to routine office visits. The care coordinator medical office assistant (CCMOA) is responsible

for tracking data and patient visits which help the office meet the Affordable Care Act (ACA)

standards of care. The CCMOA will access the diabetes care registry enabling individuals to be

flagged who meet criteria of HbA1c > 8% and BMI > 30 kg/m2. Access to the diabetes registry

enables all persons with diabetes to be identified who meet criteria for the educational

intervention, rather than relying only on patients who schedule regular interval care visits. The

benchmark goal for HbA1c established by Carilion is 8% or lower (Carilion Clinic, 2016b). The

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physicians in the Staunton and Waynesboro practices range between 70-77% of their patients

reaching the goal of HbA1c < 8% (Carilion Clinic, 2016a; Carilion Clinic, 2016b).

Budget

Budgeting for a new DSME program in a family practice setting includes direct and

indirect costs associated with program preparation and implementation. Indirect costs include

fewer appointment slots in the NP schedule when factoring in the longer educational visits. The

program will occur within the family practice setting, therefore no additional administrative

overhead or additional labor expenses will be incurred. The program will create change within

the office workflow, but there are no budgeted labor changes to require additional cost. The

labor cost proposed (see Table 1) is assuming the educational initiative is not being absorbed

through current staff. The labor cost is variable and takes into account staff training and program

development time and salaries. Material costs include purchasing rights to use patient assessment

tools and educational literature, estimated at $500.00 for initial supplies. Overall, the cost to

begin the program is approximately $2,000.00.

The direct program cost reflects staff salary as well as ongoing material cost (See Table

2). The educational program is estimated to have a development cost of $2,000.00 with the

implementation over 24 weeks costing approximately $4,000.00, which is also the yearly cost to

continue the educational program. This cost will be recouped through the billings of the NP.

The complexity of the education, taking into account comorbidities visit will involve greater than

25 minutes of face-to-face counseling time allowing for follow-up visit code 99214, using ICD-9

diagnosis code 250.02 for Diabetes Type II, uncontrolled and 278.00 for Obesity, unspecified

(Centers for Medicare and Medicaid Services [CMS], 2014). The 99214 allows $157.00 charge

per visit. The estimation of five patients per week, at a chargeable rate of $157.00 a visit, for 24

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weeks total, allows for $18,840 billable revenue with this program. The literature supports that

office practices save money by offering DSME to patients. DSME can decrease direct medical

costs and hospital charges per patient with diabetes in the range of $783.00-$3,356 per year

(Garfield, 2015).

Theoretical Framework

The Health Belief Model (HBM) is a theoretical framework based on how individuals

perceive chronic illness. Successful diabetes care involves a holistic approach of not only

medication management and education, but also how the patient’s perception of their reality of

carrying the diagnosis of diabetes (Hurley, 1990). The model supports the individual’s perceived

threat arising from diagnosis of a chronic illness. The outcome of disease management is based

on each individual’s disease knowledge, educational level, and socio-economic status (Lo, Chair,

& Lee, 2014). The HBM assumes each patient has beliefs about their disease that can be

modified to improve treatment compliance and understanding (Hurley, 1990).

Acknowledging and targeting patient health beliefs to promote healthy behaviors is one

component of diabetes care. Self-efficacy is closely related to patients’ health beliefs and self-

care (Beckerle & Lavin, 2013). The self-efficacy theory defined by Bandura relates an

individual’s ability to regulate their internal motivation and behaviors as a means to improve

their health status (Beckerle & Lavin, 2013). The less a person feels competent managing the

challenges of chronic illness the positive outcomes of self-management decline (Beckerle &

Lavin, 2013). Aligning self-efficacy with patient health beliefs help the educator implement

strategies for behavior change (Beckerle & Lavin, 2013).

Diabetes education functions as a tool to support behavior change and influence

improved self-care management. The HBM and self-efficacy theory provide theoretical

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framework principles for health belief and self-care management in patients with DMT2

(Beckerle & Lavin, 2013; Campbell et al., 2011; Hurley, 1990; Peyrot, 2007; Skovlund &

Peyrot, 2005). The education program should have a foundation in assessment of an individual’s

perceived disease state, as well as the person’s ability to manage diabetes successfully. The NP

must be cognizant of each person’s perceived self-management skills to make an impact on the

outcomes of improving self-efficacy and diabetes biomarkers of HbA1c.

Project Implementation

Objectives

Education initiatives are part of quality comprehensive diabetes care.  Diabetes health

outcomes rely on DSME as a means to improve individuals’ self-management (Martin et al.,

2013).  The objectives of this quality improvement diabetes education project for adults age 18 –

64 years with HbA1c > 8 % and BMI > 30 kg/m2 conducted over six months in a primary care

setting are to:

● lower HbA1c,

● lower BMI, and

● improve self-efficacy scores using the Diabetes Self-Management Questionnaire

(DSMQ).

Population

The educational program targets adults, ages 18-64 years with DMT2 in a family practice

office setting.  The cohort will be derived from a pool of eligible participants from two family

practice groups, Carilion Family Medicine Staunton and Carilion Family Medicine Waynesboro,

owned by Carilion Clinic, headquartered in Roanoke, VA.  Adults diagnosed with DMT2 with a

HbA1c > 8% and a BMI > 30 kg/m2 will be recruited through EHR chart reviews, utilizing the

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diabetes registry.  Participants with at least one HbA1c collected between January 1, 2016 and

December 31, 2016 will be eligible for the education program, excluding those who have been

referred to endocrinology or outpatient diabetes education through Augusta Health.

Additionally, individuals in the registry representing nursing home residents or patients without

an office visit on file in 2016 will be excluded. Identified participants will have the option of

participating in office-based education or referral for certified DSME with a certified diabetes

educator through Augusta Health.  

Timeline

Enrollment in the educational program will begin January of 2017 after the VA

Commonwealth University and Carilion Clinic Institutional Review Boards grant approval of the

project proposal. Participants identified as eligible for inclusion in this project will be 1.)

Contacted by phone by the NP or the CCMOA to offer diabetes education for individuals who

are not currently scheduled to have an office visit, or 2.) Offered the opportunity to participate by

their primary care physician at an office based visit occurring between mid-January 2017-mid-

April 2017.  New participant enrollment will end three months after recruitment begins.

Participants will be followed for three months after enrollment, placing the end of the

educational project approximately July 31, 2017.

Measures

First, this project will use the HbA1c, the gold standard to assess the three-month average

of glycemic control (The International Expert Committee, 2009).  The HbA1c level strongly

correlates with macro- and microvascular complications.  Lowering this number decreases the

opportunity for complications to arise (Franklin, 2014). The HbA1c will be collected by the

Carilion nurses and laboratory technicians, and processed through the Carilion lab system.  Due

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to insurance requirements, it may be necessary to have the HbA1c drawn at the local hospital lab,

and results retrieved by the CCMOA.  When feasible, lab work will be collected at the

participant’s regularly scheduled follow-up visit with the primary physician, or by the Carilion

laboratory technicians during a visit for labs only.  The labs are filtered automatically into the

Epic EHR and will be flagged to the NP’s Epic desktop by the CCMOA for review.  The results

will be reviewed within 48 hours for meeting inclusion criteria of HbA1c.  Hemoglobin A1c

level drawn within the last 30 days will be accepted as a current acceptable result for initial

screening.  To meet the second inclusion criteria of BMI of 30 kg/m2 or greater, a height and

weight will be rechecked at the time of their office visit.

Three months after the initial education intervention, the participants will return to clinic for

a follow-up session to have a HbA1c redrawn as well as height and weight performed for BMI

recalculation. These visits will be scheduled by the front office staff immediately following the

initial session, with reminder calls made to the participant by the NP or front office staff three

days prior to their appointment date. In an effort to decrease attrition, participants who need to

cancel these pre-scheduled appointments will be offered another appointment within a two-week

time frame.

A tool linking self-management skills with glycemic control is the Diabetes Self-

Management Questionnaire (DSMQ) (Schmitt et al., 2016). The DSMQ measures the project

participant’s perception of how well they successfully manage their diabetes care (Schmitt et al.,

2016).  Successful management of diabetes as a chronic disease is reliant on people having the

knowledge and understanding to improve self-care behaviors (Fenwick, Xie, Rees, Finger, &

Lamoureux, 2013). The DSMQ is a 16-item Likert-type scale that is a reliable and validated tool

strongly correlating self-management behaviors to improved HbA1c control (Fenwick et al.,

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DIABETES EDUCATION

2013; Schmitt et al., 2016) (see Appendix A).  The DSMQ provides insight into medication

adherence, physical activity, diet choices as well as appropriate medical care follow-up, and will

be used to evaluate how well participants self manage their diabetes care, administered as a pre-

and post-intervention tool (Schmitt et al., 2016). Therefore, utilization of the DSMQ and HbA1c

testing will provide information on short-term outcomes in the cohort of family practice

participants. 

Preparation

The education project will be presented through an in-service format during both the

nursing and physician scheduled staff meetings. Discussion will include how the NP will be

utilized for these additional educational appointment slots, as these slots will be

scheduled on particular days agreed upon by the NP, collaborating physician and the office

manager.  Information regarding visit structure will be presented to the physicians and office

staff.  The NP visits will be educational in nature only, but can address insulin administration

teaching or any diabetes medication adjustments.  Any other health needs identified by the NP

during the visit will be directed by intra-office EHR messaging to the primary physician to be

addressed.

Methods  

Program Development

The educational program will utilize EHR data, survey collecting participant perceptions

of diabetes using a self-management survey questionnaire, and implementation of an educational

intervention. The new program will be evaluated using statistical methods examining pre- and

post-intervention data.  First, a presentation on the initiative and project timeline will be provided

for the physicians, as well as nursing and ancillary staff.  Both the Staunton and Waynesboro

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DIABETES EDUCATION

office physicians will receive instruction on the project purpose and methods.  The other NPs

within the office will receive a detailed educational session on prior to interaction with patients

on project objectives, goals and materials, should they choose to participate.  Prior to enrollment

in the program, consent will be obtained from the practice physicians to access their patient lists

and diabetes scorecards.  The diabetes registry will be accessed with assistance from the

CCMOA to receive an updated roster of patients meeting eligibility requirement.  Physicians will

provide an updated diabetes scorecard of their patient caseload documenting the starting

benchmark of HbA1c in their participant list.   

Participant Recruitment

Once the cohort of individuals meeting eligibility criteria of HbA1c > 8% and BMI > 30

has been established, the participants will be recruited by phone calls from the NP, CCMOA or

referral by primary physicians at routine office visits and informed consent will be obtained.  The

CCMOA or NP will contact participants by phone and arrange an appointment time.  The

CCMOA or other office support staff will log appointments into the EHR scheduling system.

Educational sessions will be offered at both Staunton and Waynesboro Carilion offices in up to

one-hour appointment blocks.

Program Delivery

For eligible consenting participants, each appointment will begin with a guided

discussion of topics by the NP related to the seven domains of diabetes care established by the

AADE (AADE, 2010).  The seven domains of diabetes care include being active, healthy eating,

taking medication, monitoring, problem solving, reducing risks, and healthy coping (AADE,

2010). A standardized office note template in the EHR will be utilized to document the

discussed information. Written handouts will be utilized for educational purposes during the

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DIABETES EDUCATION

visit and participants will be able to take these materials home for review (See Appendix B).

The initial visit will also involve the NP administering the DSMQ.  Based on literacy needs, the

NP to assist with survey administration at the patient’s request.  Literacy will be assessed with

the Single Item Literacy Screener, a tool with acceptable sensitivity for screening low-health

literacy (Cornet, 2009)(see Appendix C).  Documentation of assistance on the surveys will allow

for tracking any potential response bias by participants.  

As part of the formal education session, participants will be encouraged to sign up for

MyChart, an EHR based communication system available through Epic EHR.  MyChart allows

practitioners to send messages to patients and the educational participants in a confidential way

that is HIPPA approved.  Bi-weekly messages will be sent to educational participants by the NP

based on the seven domains of self-care set forth by the AADE. The messages will be

standardized, but at the request of the participant during the education session, information can

be individualized to a particular diabetes topic of interest. Utilization of MyChart will allow for

interaction with participants after the formal education session to provide ongoing health tips,

motivation, respond to any questions regarding self-care.  Participants will be encouraged to ask

questions related to their diabetes care, and will be answered by the NP. Participation is

voluntary and will be documented in the concluding statistical analysis.

Program Evaluation

The DSME intervention will be evaluated by comparing the pre- and post-HbA1c, and

DSMQ results, and from reviewing feedback regarding MyChart. First, follow-up educational

sessions will be scheduled three months after the first session. The HbA1c will be redrawn at

this visit. Lab results will be flagged to the NP and also shared with the primary care physician.

The DSMQ will be re-administered as a post-test for comparison to the original results. Also, a

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DIABETES EDUCATION

short likert-type scale will assess the participants’ perception of MyChart as a beneficial way of

augmenting the educational intervention (See Appendix D).  Gathering information on the

usefulness of utilizing MyChart for health reminders is important for ongoing quality

improvement of interactions with patients. Physicians will be requested to provide qualitative

input on the program at the conclusion of the six months (See Appendix E).  

Statistical Analysis

Statistical analysis by paired t-test will be utilized, assuming there are at least 30

participants in the intervention. Should there be less than 30 participants, a Wilcoxon matched

pairs test will be utilized. Data analysis will be conducted using JMP software comparing pre-

and post-assessment scores, with a significance level set at p < .05.  Hemoglobin A1c

comparisons pre- and post-intervention will be evaluated using a paired t-test or Wilcoxon

matched pairs test, with a significance level set at p < .05.  Demographical data will be extracted

as part of the data analysis. Results of the ordinal data collected by the MyChart survey will be

complied in an Excel file, and a bar graph will be constructed to display the results. A likert

scale seeking physician satisfaction with the educational program will be utilized at both Carilion

offices. Data will be compiled and results displayed in bar graph form.

Data extracted pre- and post-intervention will be stored in an Excel spreadsheet, with

written survey results scanned into Epic by front office staff and stored as a miscellaneous file.

All copies of information will be stored with the office managers at the Staunton and

Waynesboro offices for privacy and security purposes. Any documentation with patient

identifiers once electronically entered into Epic will be shredded for patient confidentiality. The

CCMOA will keep a master list of participants for future chart reviews and educational follow-

up.

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DIABETES EDUCATION

Nursing and Clinical Implications

The national standard of care for individuals with DMT2 according to the ADA is to

provide self-management education early in the diagnosis of diabetes and at any needed interval

(Powers et al., 2015). Certified health professionals should provide education opportunities,

which includes Nurse Practitioners, in convenient settings such as primary care offices (Powers

et al., 2015). The goal of DSME is for individuals with diabetes to become knowledgeable of

their condition to promote problem solving and coping strategies. This approach leads to short

and long term outcomes of lower HbA1c and complication prevention (Caple & Schub, 2016;

Gallivan et al., 2008; Powers et al., 2015).

The Doctor of Nursing Practice (DNP) degree prepares nurses for a variety of roles in the

health care landscape. As part of the ongoing need for diabetes education, the DNP essentials

highlight how nurses are prepared to participate in the healthcare landscape and add to the care

of people with diabetes. According to the NDEP, ADA and the AADE, all diabetes education

programs should be based on scientific evidence, utilizing an integrated approach to care

(Gallivan et al., 2008; Powers et al., 2015). The DNP essentials I and III prepares the NP with

extensive skills in synthesizing the research and determine how information, both scientific and

nursing theory based, can best be applied to clinical practice, specifically the development of a

diabetes educational program (American Association of Colleges of Nursing [AACN], 2006).

Second, the preparation of a diabetes educational program in a primary care office setting

requires many logistical considerations to be successful. Implementation of a change in

workflow to improve the delivery of care and improve outcomes of chronic disease states

requires understanding of policy and business practices. The DNP essential II prepares the NP to

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DIABETES EDUCATION

develop a quality improvement initiative considering factors such as budget, staffing, and

workflow concerns (AACN, 2006).

A unique part of this quality improvement initiative is the use of MyChart, an EHR based

email communication system. The use of technology with chronic conditions is becoming more

commonplace, including innovations in diabetes care (Devkota, Salas, Sayavong, & Scherrer,

2016; Wade-Vuturo, Mayberry, & Osborn, 2013). The DNP essential IV highlights the skills

acquired by the DNP graduate to incorporate new technology to influence patient care and

outcomes (AACN, 2006). The use of MyChart to help connect patients with the NP after the

educational visit aims to improve patient satisfaction and improved HbA1c control compared

with a one time educational session (Devkota et al., 2016; Wade-Vuturo et al., 2013).

Finally, the goal of DSME is to facilitate skills, confidence and better health outcomes in

individuals with DMT2, therefore improving health and lowering the overall burden on the

health care system (Powers et al., 2015). The AACN (2016) DNP essential VII prepares the

DNP graduate to improve the quality of care for populations, focusing on individuals’ health

behaviors and the multiple dimensions factors that affect health care. The development of an

educational program at the primary care level helps address the issues of access to care and

evaluation of delivery modes associated with improving local diabetes care.

Ethical Considerations

The purpose of this educational program is to improve the quality of the diabetes care

received on a local level. Patient safety, equality, and consent are considered with development

of the program. Institutional Review Boards through both Virginia Commonwealth University

and Carilion Clinic will review the quality initiative to ensure ethical standards for working with

patients are met. The program will be open to all individuals meeting the program criteria, and

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DIABETES EDUCATION

education will be provided equally to participants based on their motivation to learn. Individuals

who do not meet inclusion criteria will still receive referrals to outpatient diabetes education, as

well as the current available office visit education.

Sustainability

Diabetes education is not a new concept, yet a NP led educational initiative in the office

setting is a workflow change to help improve efficiency, cost, patient satisfaction and outcomes.

Educational visits require longer appointment time slots, but the loss of patient volume on the NP

schedule has potential to have a positive impact on the overall financial benefits on the office.

Diabetes education can reduce hospital admissions and lower overall health care costs (Powers et

al., 2015). Based on the success of this DNP quality improvement initiative impacting HbA1c

levels and participant self-efficacy, continuation of a NP lead initiative can be improved and

incorporated throughout Carilion Clinic primary care offices. NPs are credentialed to provide

diabetes education, yet development of a role for the NP as a certified diabetes educator (CDE)

can increase the outreach population. This role would allow for specific DMSE reimbursement

from Medicare and Medicaid, and also improve access to education opportunities in the office

setting for patients of all ages (Powers et al., 2015). Long-term evaluation of the program will be

achieved by continuous quality improvement (CQI) utilizing the Carilion Clinic CLEAR

research method (Carilion Clinic Nursing Research and Evidence Based Practice Group, 2015)

(see Appendix F). Ongoing CQI initiated by a NP led team will allow for changes to the

educational program to meet the needs of the office practice over time.

Another benefit to keeping DMSE in the office setting is the ability to incorporate

technology, with the use of MyChart. Utilization of the NP in the educator role allows

individuals to interact with a healthcare provider in an efficient manner, discussing educational

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DIABETES EDUCATION

and medical questions related to their diabetes care. This provides efficient and reduced

workflow for the front office staff, nurses and other providers when the NP manages diabetes

care. Therefore, with the shortage of primary care providers in the local Carilion Clinic region,

utilization of a NP to help handle chronic disease management should be explored as a method of

improving outcomes and controlling health care cost.

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Medical Informatics Association, 20(3), 519-525. doi:10.1136/amiajnl-2012-001253

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Wai, S. L., Sek, Y. C., & Fung, K. L. (2015). Factors associated with health-promoting behavior

of people with or at high risk of metabolic syndrome: Based on the health belief model.

Applied Nursing Research, 28(2), 197-201. doi:10.1016/j.apnr.2014.11.001

Welch, J. L., Fisher, M. L., & Dayhoff, N. E. (2002). A cost-effectiveness worksheet for patient-

education programs. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice,

16(4), 187-192.

Zgibor, J. C., Peyrot, M., Ruppert, K., Noullet, W., Siminerio, L. M., Peeples, M., . . .

Charron-Prochownik, D. (2007). Using the american association of diabetes

educators outcomes system to identify patient behavior change goals and diabetes

educator responses. Diabetes Educator, 33(5), 839-842. Retrieved from

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live&scope=site

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Table 1

Labor Cost

Personnel No. of Hours Hourly Rate Ext. Labor CostNurse Practitioner 1

24 $49.00 $1,176.00

Nurse Practitioner 2

4 $35.00 $140.00

Nurse Practitioner 3

4 $34.00 $136.00

Medical Office Assistant

4 $18.00 $72.00

Total 34 $1,524.00

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Table 2

Direct Cost—Salaries and Materials

Personnel No. of Hours Hourly Rate Extended Labor Cost

Total Cost

Nurse Practitioner 1

3 hours a week x 24 weeks

$49.00 $3,528

Nurse Practitioner 2

1 hour a week x 24 weeks

Salaried Fixed Cost

Nurse Practitioner 3

1 hour a week x 24 weeks

Salaried Fixed Cost

Medical Office Assistant

20 minutes a week x 24

weeks

Salaried Fixed Cost

Materials $500.00Total 184 hours $3.528.00 $500.00

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Appendix A

Diabetes Self-Management Questionnaire (DSMQ)

The following statements describe self-care activities related to your diabetes. Thinking about your self-care over the last 8 weeks, please specify the extent to which each statement applies to you.

Applies to me very much

Applies to me to a consider-able degree

Applies to me to some degree

Does not apply to me

1.

I check my blood sugar levels with care and attention.

☐ Blood sugar measurement is not required as a part of my treatment.

3☐ 2☐ 1☐ 0☐

2. The food I choose to eat makes it easy to achieve optimal blood sugar levels. 3☐ 2☐ 1☐ 0☐

3. I keep all doctors’ appointments recommended for my diabetes treatment. 3☐ 2☐ 1☐ 0☐

4.

I take my diabetes medication (e. g. insulin, tablets) as prescribed.

☐ Diabetes medication / insulin is not required as a part of my treatment.

3☐ 2☐ 1☐ 0☐

5. Occasionally I eat lots of sweets or other foods rich in carbohydrates. 3☐ 2☐ 1☐ 0☐

6.

I record my blood sugar levels regularly (or analyse the value chart with my blood glucose meter).

☐ Blood sugar measurement is not required as a part of my treatment.

3☐ 2☐ 1☐ 0☐

7. I tend to avoid diabetes-related doctors’ appointments. 3☐ 2☐ 1☐ 0☐

8. I do regular physical activity to achieve optimal blood sugar levels. 3☐ 2☐ 1☐ 0☐

9.I strictly follow the dietary recommendations given by my doctor or diabetes specialist.

3☐ 2☐ 1☐ 0☐

10.

I do not check my blood sugar levels frequently enough as would be required for achieving good blood glucose control.

☐ Blood sugar measurement is not required as a part of my treatment.

3☐ 2☐ 1☐ 0☐

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The following statements describe self-care activities related to your diabetes. Thinking about your self-care over the last 8 weeks, please specify the extent to which each statement applies to you.

Applies to me very much

Applies to me to a consider-able degree

Applies to me to some degree

Does not apply to me

11. I avoid physical activity, although it would improve my diabetes. 3☐ 2☐ 1☐ 0☐

12.

I tend to forget to take or skip my diabetes medication (e. g. insulin, tablets).

☐ Diabetes medication / insulin is not required as a part of my treatment.

3☐ 2☐ 1☐ 0☐

13. Sometimes I have real ‘food binges’ (not triggered by hypoglycaemia). 3☐ 2☐ 1☐ 0☐

14. Regarding my diabetes care, I should see my medical practitioner(s) more often. 3☐ 2☐ 1☐ 0☐

15. I tend to skip planned physical activity. 3☐ 2☐ 1☐ 0☐16. My diabetes self-care is poor. 3☐ 2☐ 1☐ 0☐

Schmitt et al., 2013

Appendix B

American Association of Diabetes Educator’s Seven Self-Care Behaviors Educational Materials

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*Please see Attached PDF File for the educational materials

Appendix C

Single Item Literacy Screener

Never Rarely Sometimes Often Always

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How often do you need to have

someone help you when you read instructions,

pamphlets, or other written material

from your doctor or pharmacy?

1 2 3 4 5

Scores greater than 2 were considered positive, indicating some difficulty with reading printed health related material (Cornet, 2009).

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Appendix D

MyChart Evaluation Scale

Please circle the number best describing your feelings about using MyChart for diabetes education

Strongly Agree

Agree No Opinion Disagree Strongly Disagree

MyChart emails increased my

understanding of diabetes care

1 2 3 4 5

MyChart emails covered diabetes topics I wanted to learn about 1 2 3 4 5

The NP responded to the MyChart email I

would send in a timely fashion

1 2 3 4 5

I wish I could have received more emails

each week about diabetes

1 2 3 4 5

I wish I would have received less emails

each week about diabetes

1 2 3 4 5

The number of emails I received each week

about diabetes was just right

1 2 3 4 5

I would continue using MyChart emails for

diabetes education in the future if offered

1 2 3 4 5

Additional thoughts about using MyChart as part of diabetes education: ____________________________________________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________________________________________________________

Appendix E

Physician DSME Quality Improvement Project Evaluation Scale

Strongly Agree

Agree No opinion Disagree Strongly Disagree

Utilizing the NP for DSME improved quarterly patient satisfaction with

their care

1 2 3 4 5

Arranging appointments for the

NP education sessions was flexible

1 2 3 4 5

The NP utilized provider

collaboration for potential patient

diabetes complications in a

timely manner

1 2 3 4 5

Long-term evaluation of the NP in the educator role

would be worthwhile to the practice for

diabetes care

1 2 3 4 5

Additional thoughts regarding the NP led quality improvement DSME initiative: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Key

DSME = Diabetes Self-Management Education

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Appendix F

CLEAR Research Model

*Please see attached CLEAR Research Model handout

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