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Capella 4900 Assessment 4

Capella 4900 Assessment 4 Patient, Family, or Population Health Problem Solution

Student Name

Capella University

NURS-FPX 4900 Capstone Project for Nursing

Prof. Name


Patient Health Problem

Michael who is a 67-year-old male presented to our hospital named Southern California Hospital at Hollywood, has been suffering from type 2 diabetes for the last 4 years. His blood glucose levels reaching 315 mg/dL were the reason he got admitted to our hospital as his condition required prompt care treatment and management. His lifestyle showed that he required education on his condition so I worked with Michael and his family. Through active collaboration and care coordination, I developed an intervention plan for Michael that included providing diabetes self-management education and support (DSMES) along with remote monitoring of his medication adherence behavior as Michael was inconsistent in taking his medication.

The reason I selected Diabetes as the focus of this project is that millions of people suffer from diabetes and the ill management of this disease leads to millions of deaths. Moreover, diabetes is relevant to my professional practice and in my community as pools of people with diabetes are coming for clinical visits at my hospital who happen to have various health complications due to poor management.

Role of Leadership and Change Management in Diabetes

Diabetes management requires appropriate knowledge and awareness among healthcare professionals and patients. Healthcare professionals with certifications e.g. diabetes educators can play a leadership role in raising awareness and knowledge about diabetes among team members and patients. This education can include ways to monitor blood glucose levels, diabetes management strategies, and knowledge of risk factors and symptoms to provide effective care treatment to patients.

Furthermore, nurses can play leadership roles such as head nurses with advanced nursing practice certification who can ensure that all junior nurses are providing care treatment to patients with effective collaboration and coordination with other healthcare professionals. They can foster a culture of collaboration, communication, and continuous learning within healthcare systems (Lipscomb et al., 2023). Change management in healthcare setups plays an important role in providing updated and effective care treatment to patients.

For this purpose, healthcare professionals with leadership roles can collaborate with management department personnel to communicate with them about the need for changes in the healthcare work environment (Milella et al., 2021). For example, change management is required to implement healthcare technologies for diabetes management in hospitals where such novel health information technologies have never been implemented. The nurses can play such roles in implementing change management strategies to build a technology-oriented environment in the hospital to provide care treatment to diabetic patients.

Influence of Leadership and Change Management Strategies on Intervention Development

Transformational leadership strategy and change management strategies such as the ADKAR model of Awareness, Desire, Knowledge, Ability, and Reinforcement influenced the development of remote monitoring of medication adherence for Michael and the DSMES program for him. With the help of transformation leadership, I was provided with the decision-making ability where I could decide an intervention plan as my patient’s condition required. For this purpose, I collaborated with my health professional team and shared my intervention plan along with the patient’s condition that was approved by them.

The ADKAR model helped me develop this intervention for Michael as I raised awareness about the proposed intervention to my healthcare staff and patient and presented the potential benefits of these interventions which created a desire and knowledge in hospital administrators and authorities to bring change in management and reinforced the establishment of this technology by providing ongoing support and guidance to healthcare staff which enabled this technology in our hospital for Michael.

Influence of Nursing Ethics on Intervention Development 

Nursing ethics also informed the development of my proposed intervention which included patient autonomy, beneficence, and confidentiality. Through my collaboration with Michael, I discussed the potential benefits of this technology-based intervention and DSMES and acquired his decision which he approved and was willing to coordinate with me. Moreover, following the nursing ethical principle of beneficence, I developed this intervention to enhance Michael’s quality of life so that his family does not suffer from their loved one loss through diabetes. Through this intervention, the patient’s confidentiality can be maintained and his rights of privacy can be fulfilled.

Communication and Collaboration Strategies with Patient

Communication and collaboration with patients are necessary to provide patient-centered care in diabetes. Therefore, effective strategies promote communication and collaboration with patients in providing required care treatment. One of the evidence-based strategies that improve communication and collaboration with patients in healthcare systems includes engaging patients in shared-decision making (SDM) of their care treatment plans. Patients will feel valued and preferred and this can enhance their collaboration and improve communication in deciding on a care treatment plan (Roodbeen et al., 2020).

Another strategy to improve communication and patient collaboration is to use clear and culturally competent language and style so that patients’ cultural beliefs are not affected. As culturally sensitive patients often become barriers to effective care treatment when their cultural beliefs of particular norms and traditions are not valued (Brooks et al., 2019). These strategies can improve the outcomes associated with Michael’s case of diabetes by improving the quality of care and coordination of care.

The benefits of gathering patient input through communication and collaboration include providing better ideas to health professionals in developing care treatment plans for diabetes according to patients’ needs and preferences that promote patient-centered care. Moreover, the patient can be educated and guided on his condition to promote self-management of diabetes which can improve care treatment efficacy.

State Board Nursing Practice Standards and/or Governmental or Organizational Policies on Guiding the Development of Proposed Intervention

The American Nursing Association has provided several standards for nursing practices that guided me in the development of the proposed interventions for Michael. The primary ANA-provided standards that acted as guiding tools for me in developing this intervention plan for Michael are standards of care coordination and utilization of community resources (Brunt & Russell, 2019). The care coordination and community resources used can be practiced in providing the DSMES program to Michael where he will be educated on various skills to manage diabetes such as medication management, healthy diet intake, and engaging in physical activity.

In providing the DSMES program, a multidisciplinary team will be involved such as diabetes educators, dieticians, and exercise specialists. Care coordination in DSMES program will be practiced to provide adequate and proper education to Michael. Moreover, Michael will be connected to various community resources such as community groups that provide support to diabetes through motivation and success stories.

The HITECH Act of 2009 has provided a policy on the adoption and use of health information technologies that can improve the quality of care and quality of life of patients (HIPAA Journal, 2023). The HITECH Act policy of promoting the use of health information technologies guided me in developing the proposed intervention where technology can be utilized for the effective management of diabetes. Therefore, I selected remote monitoring for Michael to monitor his medication adherence behaviors. 

Capella 4900 Assessment 4

Care coordination and community resource utilization have improved outcomes in diabetes. According to Northwood and colleagues (2022), care coordination has been effective in managing diabetes in older people as it promotes a patient-centered approach to care treatment and it results in positive outcomes. Another study by Samudera and colleagues (2021) stated that using community health workers or peer support as community sources to promote healthy lifestyle programs and manage diabetes has been more effective than traditional care methods for diabetes.

The effectiveness of the HITECH Act policy on using health information technologies is described in a research study by Morelli and coauthors (2023) where they implemented digital health to promote quality of care in diabetes programs. Their study resulted in improvement in quality indicators relevant to the diabetes care process. These research-based data show that these standards and policies play an effective role in improving diabetes care outcomes.

Role of Proposed Intervention in Improving Quality of Care, Enhancing Patient Safety, and Reducing Costs

DSMES and remote monitoring of medication adherence improve the quality of care in a number of ways. DSMES programs are meant to increase the knowledge of patients related to diabetes management and empower them to self-manage their condition. This leads to improved self-management behaviors and maintains blood glucose levels. For this purpose, healthcare professionals actively collaborate with patients to provide patient-centered DSMES care treatment which improves the quality of care. Furthermore, the use of DSMES apps to monitor medication adherence remotely has also been effective in improving the quality of care (Enricho Nkhoma et al., 2021).

DSMES and remote monitoring of medication adherence have the potential to enhance patient safety as patients are empowered to self-manage their diabetes, and risks of complications are reduced which enhances patient safety. Furthermore, remote monitoring of medication adherence will reduce the chances of missing doses and regular medication administration will regulate blood glucose levels normally leading to effective management of diabetes. The complications of hyperglycemia will be lessened and patient safety will be enhanced (Munshi et al., 2021).

The proposed intervention has the potential to reduce costs to both the individuals and the health care system as the DSMES program provides patients with information on self-management behaviors, which leads to improved diabetes management. Improved management of diabetes leads to reduced hospital revisit and readmission rates ultimately reducing costs by saving resources and traveling costs which are also saved by remote monitoring technology (Kesavadev & Mohan, 2023).

The specific, relevant, and available sources of benchmark data for diabetes include standards of medical care provided by the American Diabetes Association. These standards of care for diabetes include benchmark data on diagnosis, treatment, and management of diabetes which nurses and other healthcare professionals can implement in the care treatment of patients with diabetes (ADA, 2023).

Role of Technology, Care Coordination, and Utilization of Community Resources in Diabetes

Healthcare information technology (HIT), care coordination, and community resources use can be applied in addressing diabetes in terms of improving outcomes and helping healthcare professionals provide patient-centered treatment to diabetic patients. The use of HIT such as telemonitoring and remote monitoring plays a vital role in managing diabetes as patients are remotely in contact with healthcare professionals and their treatment is monitored continuously. This improves the quality of care and enhances patient safety by managing blood glucose levels under normal limits (Munshi et al., 2021).

Care coordination is a prerequisite in the effective management of diabetes to provide patient-centered care through effective collaboration among multi-professional team members. For example, a patient with diabetes requires medication management by physicians, pharmacists, and nurses; a healthy diet chart by dieticians; guidance on physical activity by exercise specialists or physical therapists. This multifaceted care treatment can be employed when care coordination is applied in managing diabetes (Northwood et al., 2022).

Utilizing community resources such as community organizations on diabetes and community groups can improve care treatment. Implementing community-based healthy lifestyle programs for diabetics is more effective in diabetes management than traditional care as peer support enhances patient motivation and improves self-management behaviors (Samudera et al., 2021). Therefore, community resources can be effectively utilized in diabetes management.


In this assessment, the proposed interventions of DSMES and remote monitoring of medication adherence for Michael who suffers from diabetes mellitus are analyzed. First, the role of the transformational leadership strategy and change management strategy of the ADKAR model on developing the proposed interventions are analyzed. Furthermore, communication and collaboration strategies such as SDM and using culturally competent language are discussed that can improve diabetes care treatment outcomes and gain patient input to develop patient-centered care treatment.

The ANA standards of care coordination, community resource utilization, and HITECH policy of adopting health information technologies together guided me in developing the proposed intervention. The proposed interventions of the DSMES program and remote monitoring of medication adherence have the potential to improve the quality of care, enhance patient safety, and reduce costs to the system and individuals. Lastly, the role of technology, care coordination, and community resource utilization in diabetes management has been described.


ADA. (2023). American diabetes association releases 2023 standards of care in diabetes to guide prevention, diagnosis, and treatment for people living with diabetes | ADA. 

Brooks, L. A., Manias, E., & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383–391. 

Brunt, B. A., & Russell, J. (2019, January 8). Nursing Professional Development (NPD) Standards. StatPearls Publishing. /

Enricho Nkhoma, D., Jenya Soko, C., Joseph Banda, K., Greenfield, D., Li, Y.-C. (Jack), & Iqbal, U. (2021). Impact of DSMES app interventions on medication adherence in type 2 diabetes mellitus: Systematic review and meta-analysis. BMJ Health & Care Informatics, 28(1). 

HIPAA Journal. (2023). What is the HITECH act. 

Kesavadev, J., & Mohan, V. (2023). Reducing the cost of diabetes care with telemedicine, smartphone, and home monitoring. Journal of the Indian Institute of Sciences. 

Lipscomb, D., Rezazadeh, E., & Rowney, J. (2023). Diabetes care for you: Leadership, followership, partnership. Practical Diabetes, 40(1), 25–29. 

Milella, F., Minelli, E. A., Strozzi, F., & Croce, D. (2021). Change and innovation in healthcare: Findings from literature. ClinicoEconomics and Outcomes Research, 13(13), 395–408. 

Capella 4900 Assessment 4

Morelli, D. M., Rubinstein, F., Santero, M., Gibbons, L., Moyano, D., Nejamis, A., & Beratarrechea, A. (2023). Effectiveness of a diabetes program based on digital health on capacity building and quality of care in type 2 diabetes: A pragmatic quasi-experimental study. BMC Health Services Research, 23(1). 

Munshi, K. D., Amelung, K., Carter, C. S., James, R., Shah, B. R., & Henderson, R. R. (2021). Impact of a diabetes remote monitoring program on medication adherence. Journal of Managed Care & Specialty Pharmacy, 27(6), 724–731. 

Northwood, M., Shah, A. Q., Abeygunawardena, C., Garnett, A., & Schumacher, C. (2022). Care coordination of older adults with diabetes: A scoping review. Canadian Journal of Diabetes. 

Roodbeen, R., Vreke, A., Boland, G., Rademakers, J., Muijsenbergh, M. van den , Noordman, J., & van Dulmen, S. (2020). Communication and shared decision-making with patients with limited health literacy; helpful strategies, barriers and suggestions for improvement reported by hospital-based palliative care providers. PLOS ONE, 15(6), e0234926. 

Samudera, W. S., Efendi, F., & Indarwati, R. (2021). Effect of community and peer support based healthy lifestyle program (CP-HELP) on self care behavior and fasting blood glucose in patient with type 2 diabetes mellitus. Journal of Diabetes & Metabolic Disorders, 20(1), 193–199. 

Capella 4900 Assessment 4