Background

Even with the many efforts to promote healthy living and awareness of the dangers of diabetes, the disease I still a major health issue in the United States as it continues to prevail.   In most cases, diabetes is accompanied by other conditions that lead to a lot of burdens for the patient. This includes financial burden, disability, and reduced quality of life. Older patients with geriatric conditions suffer the most and undergo a lot of trauma especially given that they will need to be under a lot of care (Awoyemi, Trøseid, Solheim, Arnesen, & Seljeflot, 2018).  Patient education and health promotion may not promote the occurrence of various diseases related to geriatric patients. However, with better support, promotion of adherence to doctor’s appointment and self-management interventions for diabetic patients including better screening can aid in the prevention of worsening of their conditions some of which might to would development and inevitable amputations. Of the many aspects of diabetes treatment, the issue of self-management and adherence has been found to be efficient in the healing of many conditions and reducing the worsening of the current patient situation (GUO & XU, 2018).  Implementation of a self-management program in both the clinical and home care setting can allow for patient assessment, more detail screening and promote early intervention to reduce or prevent more complications of a geriatric patient with diabetes.  

Problem Statement

Geriatric patients with diabetes 2 most often will suffer other impediments which comprise but are not restricted to peripheral nerve damage, kidney diseases, foot ulcers, circulatory system disorder, hyperglycemia which is one of the leading causes of delayed foot healing. I most cases these patients will undergo a lot of pain and discomfort, they will not be active, unable to move and experience a diminished quality of life.  The treatment of these geriatric conditions can be expensive, time-consuming, and when all the remedies are not successful, patients will have to make difficult choices that include inevitable amputation.

Purpose of Change Proposal

The purpose of this change proposal is to establish mechanisms for early intervention for these patients through the promotion of self-management education for patients coming to the clinic and ensure that they understand and practice the importance of adherence to treatment schedules which can bring about hope to many geriatric patients.  If this is done well, more lives for people living with diabetes will be prolonged; there will be a reduction of would development leading to amputations and increased quality of life for these patients.  

PICOT

For geriatric patients with Type 2 diabetes at DaVita Medical Groups Fountain Oaks (P), does lifestyle modification coupled with medication compliance (I) compared to only medication compliance (C) lead to decreased hgb A1C and increased self-reported diabetes control (O) over a three-month timeframe (T)? 

Literature Search Strategy Employed

The strategy employed for searching literature entailed going through various medical journal platforms like NCBI, CINALH PLUS and PubMed where keywords like prevention and promotion, Diabetes Self-Management, Geriatric wounds, hyperbaric oxygen, diabetes treatment adherence were used to research studies from 2014-2019.  This project was able to find some recent studies pertaining to geriatric diabetes management. However 8 articles were reviewed to provide the effects of diabetes Type 2 on geriatric patients, the impact of non-adherence to treatment, the importance, and strategies for self-management education (Abbatecola, Paolisso, & Sinclair, 2015). Also, 2 articles were reviewed to examine the impact of self-management and adherence tools in the promotion of wound healing among geriatric patients and avoiding amputation. Other articles also offered information on geriatric complications and mechanisms to promote healing. 

Evaluation of the Literature

From the literature, Abbatecola, Paolisso, & Sinclair, (2015) defined ‘geriatric patients' as people with diabetes with several conditions in which ischemia, neuropathy, and infection will lead to injury, cause skin problems and potential surgeries or amputations.  Onofrei & Smith, (2019) looks at the importance of self-management education for both the health care providers and the patients in addition to adherence to treatment which is required for assessment of the healing as a way of reducing various geriatric conditions.  Also Nyambuya, Dludla, & Nkambule, (2018) argued that diabetes prevention is better than cure since, with the increase of patients not adhering to treatment, this leads to renal failure, wound infections and development calling for nurses and medical doctors to find better ways to prevent worsening of the condition and avoid chances of surgery. Migdal & Abrahamson, (2016) calls for the implementation of a diabetes self-management program in the clinics, which must also focus on wound care and general self-management of patients with diabetes. 

Applicable Change or Nursing Theory Utilized

This project will apply the Diffusion of innovation theory which multiplies the number of people that are subject to or are going to be affected by any intervention by reinforcing their influence in public health.  It may always not be enough to come up with innovative programs; this is because in any case, programs need to be extensively publicized and broadcasted.  The diffusion and innovation theory thus will take a deep look at how new products, concepts, and social practices are incorporated in organizations, society, or a community (Migdal & Abrahamson, 2016).  According to this theory, thus, when a community, organization, or society work together, then it becomes possible for the intended intervention to succeed.  

In this project thus, the intended population is geriatric patients with diabetes 22 who are at risk of not adhering to doctor appointments and self-care ( this includes lifestyle change, taking medications the right way and personal exercise) that may lead to the worsening of their geriatric conditions.  The proposed solution thus focuses on self-management and adherence to appointments to encourage screening and identify whether they are at high risk of developing serious conditions like foot ulcers to intervene through self-management education, attendance to clinics, following prescriptions and personal hygiene and care for other related conditions (Rodriguez-Saldana, 2019).  At this, the diffusion of innovations theory will work with the proposed solution as a way of promoting all levels of care and healing with the patient and the individual, clinical, community, and organizational level.  On the patient level, diffusion will provide education and change of lifestyle. At the clinical level, this will require adjustment of regulations and starting new patient programs like the implementation of new screening and assessment tools (Migdal & Abrahamson, 2016). At the community level, this will entail publicity, best practice exchange forums, and advancement of policies.

Proposed Implementation Plan

After the proposed solution is approved, it will go straight to implementation which will begin by hiring an assistant nurse and a specialist and self-management therapy who will assist in the development of self-management and patient adherence to appointment toolkit.  The nurse will have to be knowledgeable and experienced inpatient training, including staff regarding diabetes self-management and adherence issues.  In the implementation plan, this nurse is also going to work in collaboration with other fellow nurses and the medical doctors to incorporate sufficient material required for training and therapy and to also understand the patients being seen at the clinic.  Together, there will be a team formed where resources will be pulled together and networks to invite specialist’s speakers for patient self-management, care workshops, and training.  There will also be a budgeting committee that will ensure all the necessary supplies like tuning forks, demonstration medicines, and training materials and publics are availed (Komkova, Brandt, Hansen Pedersen, Emneus, & Sortsø, 2018).  Also, the team will work with the IT team in coming up with an electronic version of the diabetes self-management video and adherence to the appointment and medication tool, which will be distributed to all patients.  There will also be a pre and post-test to determine the knowledge of patients and staff regarding self-management and adherence issues as identified in the clinic. 

Identification of Potential Barriers to Plan Implementation and a discussion of this could be overcome

Among the barriers anticipated during the implementation of the project includes; stigma from the geriatric patients with diabetes 2  of which might prevent them from participating in the project, there could also be social and cultural issues which may see patients not attending the seminars.  Also, other patients could be in worse conditions that would prevent them from reaching the clinic during the training and demonstration.  Lack of funding to support the training process could also be a barrier (Komkova, Brandt, Hansen Pedersen, Emneus, & Sortsø, 2018). To overcome these barriers, all the training process will be explained to each patient in person so they can understand the health benefit of the training. Their medical records will not be used during the training, and there will also be electronic materials developed for patients that might not attend all the sessions. There will also be a local fundraiser from diabetes institutions to support the training needs. 

Conclusion

This project insists on self-management and adherence to treatment and doctor’s appointments; this is because when geriatric patients with diabetes Type 2 do not know how to manage their conditions, they are bound to worsen their conditions resulting in pain, reduced quality of life, including disability.  The goal of this project is to provide geriatric patients with diabetes 2 early intervention mechanisms that support the need to manage and combat the disease through self-care and to form partnerships with healthcare professionals.  

References

Abbatecola, A., Paolisso, G., & Sinclair, A. (2015). Treating Diabetes Mellitus in Older and Oldest Old Patients. Current Pharmaceutical Design, 21(13), 1665-1671. Doi: 10.2174/1381612821666150130120747

Awoyemi, A., Trøseid, M., Solheim, S., Arnesen, H., & Seljeflot, I. (2018). Metabolic endotoxemia as related to metabolic syndrome in an elderly male population at high cardiovascular risk. Atherosclerosis, 275, e55-e56. doi:10.1016/j.atherosclerosis.2018.06.149

GUO, M., & Xu, Y. (2018). SGLT2 Inhibitors and Stroke Risk in Patients with Type 2 Diabetes—A Systematic Review and Meta-analysis. Diabetes, 67(Supplement 1), 165-OR. Doi: 10.2337/db18-165-or

Komkova, A., Brandt, C. J., Hansen Pedersen, D., Emneus, M., & Sortsø, C. (2018). Electronic Health Lifestyle Coaching Among Diabetes Patients in a Real-Life Municipality Setting: Observational Study (Preprint). doi:10.2196/preprints.12140

Migdal, A. L., & Abrahamson, M. J. (2016). Treating Type 2 Diabetes Mellitus. Principles of Diabetes Mellitus, 1-24. Doi: 10.1007/978-3-319-20797-1_44-1

Nyambuya, T. M., Dludla, P. V., & Nkambule, B. B. (2018). T cell activation and cardiovascular risk in type 2 diabetes mellitus: a protocol for a systematic review and meta-analysis. Systematic Reviews, 7(1). Doi: 10.1186/s13643-018-0835-1

Onofrei, L., & Smith, A. G. (2019). Advocacy for patients with neuropathic pain. Advocacy in Neurology, 347-360. doi:10.1093/med/9780198796039.003.0030

Rodriguez-Saldana, J. (2019). Clinical Practice Guidelines, Evidence-Based Medicine, and Diabetes. The Diabetes Textbook, 333-355. Doi: 10.1007/978-3-030-11815-0_21


Appendix 1

Appendix 2

Diabetes Self-Management Evaluation Form



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