Evidence-Based Population Health Improvement Plan

Evidence-Based Population Health Improvement Plan

The Population Health Improvement Plan (PHII) incorporates all healthcare stakeholders to implement evidence-based strategies to improve population health. The Institute of Healthcare Improvement developed the Triple Aim Framework to improve patient experience, reduce healthcare costs and improve population health (Obucina et al., 2018). This framework can be applied in the implementation of population health improvement initiatives. Different populations have different healthcare needs. It is thus critical for healthcare professionals such as nurses to implement evidence-based strategies that consider the unique needs of the population of interest.

Data Evaluation

Establishing a geographical area where the population health improvement plan will be encountered is critical. The utilization of epidemiological data is essential in identifying population healthcare needs, and it can also help in monitoring and evaluating healthcare outcomes. Type 2 diabetes is prevalent in the United States, and it is associated with morbidity, mortality, and high healthcare costs. The geographical area of interest will be New York. Two million individuals in New York have diabetes, with 517,00 unaware (American Diabetes Association(ADA), 2022). Annually, approximately 66,000 individuals in New York are diagnosed with diabetes (ADA, 2022). Of individuals diagnosed with diabetes,31% are African Americans (ADA, 2022). It is thus essential to implement a PHII among African Americans in New York.

Behavioral risk factors for diabetes include excessive alcohol use, physical inactivity, and sedentary lifestyles (Bellou et al., 2018). These are the environmental risk factors present in African Americans in New York. Besides, a family history of diabetes is also a risk factor for developing diabetes (Bellou et al., 2018). After evaluating the environmental and epidemiological data in African American communities, several knowledge gaps were identified. There is more data on behavioral risk factors but little data on the role of environmental pollutants. It is also essential to evaluate the social and cultural factors that prevent African Americans in New York from accessing healthcare services.

Meeting Community Needs

The Chronic Care Model model (CCM) will be used to help in diabetes management. CCM has six essential models: clinical information systems, health systems, decision support, delivery system design, self-management support, and community resources and policies (Boehmer et al., 2018). This model will be utilized to improve the population health of African Americans in New York. Accordingly, this plan will have five basic principles: long-term sustainability, compliance with evidence-based strategies in patient care, patient education and lifestyle modifications, provision of affordable healthcare services, and culturally sensitive care.

Moreover, this model will promote proactive community participation in their healthcare. CCM will guide the establishment of a data collection system and operational leadership to provide culturally sensitive care (Boehmer et al., 2018). Healthcare professionals will be educated on linguistic and cultural competence. Finally, local community resources such as community health centers will help connect with diabetic patients. Some of the barriers that this plan may face are community resistance and cultural barriers that may impede the implementation of culturally competent care.

Value & Relevance of Evidence

Since its establishment, CCM has been utilized in many healthcare organizations in diabetes management with positive outcomes (Bongaerts et al., 2017). A lot of evidence supporting CCM is from meta-analyses, systematic reviews, and randomized controlled trials. Study results indicated that CCM utilization has proved effective in better diabetes management. Healthcare leaders implemented CCM by initiating changes in their organizations that improved diabetes management. These changes included the introduction of disease registries, the establishment of patient-centered goals, patient education on self-management, and the training of healthcare workers on evidence-based care (Bongaerts et al., 2017). CCM model can be effective since it incorporates system-level interventions, patients, and healthcare professionals.

Evaluation of Achievement

The outcome measures that will be used to evaluate the achievement of this plan are optimal clinical indicators, patient satisfaction and experience, quality of life, and impact on healthcare disparities. These measures are measurable and can effectively help determine the success of PHII. Another evaluation criterion that can be used is the diabetes evaluation criteria. This criterion will aid in determining whether the objectives of the plan were met and provide details of performance indicators that were achieved (Huber, 2017). In addition, this criterion will offer a well-rounded analysis that considers the plan’s different components. Patients will be evaluated on their knowledge of diabetes risk factors and their adherence to medications and treatment plans.

Culturally Sensitive Communication

Communication is vital in a population health improvement plan. However, several barriers may be present to hinder effective communication. They include distrust and misunderstanding due to linguistic differences, inappropriate teaching methods, and cultural incompetence. One strategy to ensure effective communication is training healthcare professionals on cultural competence. This may also involve hiring staff from the African American background who will help achieve cultural concordance. Peer specialist-led interventions are critical in communication since they connect with patients. Peer specialists are people with personal experiences with health problems such as diabetes and may belong to the same community as the patients (Debussche et al., 2018). The resources and facilities should be tailored to be culturally sensitive. Further, the educational material should have graphic content that will capture the patients’ attention; plain text may result in ambiguity.

Conclusion

Chronic diseases like diabetes are prevalent globally. Healthcare workers and communities must collaborate to create patient-centered interventions. Subsequently, these interventions should be culturally sensitive and consider the population’s unique needs of interest. CCM can help customize care for different ethnicities. The communication plan should be culturally and racially sensitive to improve the population’s buy-in of the health improvement plan.

References

American Diabetes Association(ADA). (2022). Greater NYC/NJ | ADA. American Diabetes Association | Research, Education, Advocacy. https://www.diabetes.org/get-involved/community/local-offices/greater-nycnj

Bellou, V., Belbasis, L., Tzoulaki, I., & Evangelou, E. (2018). Risk factors for type 2 diabetes mellitus: An exposure-wide umbrella review of meta-analyses. PLOS ONE, 13(3), e0194127. https://doi.org/10.1371/journal.pone.0194127

Boehmer, K. R., Abu Dabrh, A. M., Gionfriddo, M. R., Erwin, P., & Montori, V. M. (2018). Does the chronic care model meet the emerging needs of people living with multimorbidity? A systematic review and thematic synthesis. PLOS ONE, 13(2), e0190852. https://doi.org/10.1371/journal.pone.0190852

Bongaerts, B. W., Müssig, K., Wens, J., Lang, C., Schwarz, P., Roden, M., & Rathmann, W. (2017). Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: A systematic review and meta-analysis. BMJ Open, 7(3), e013076. https://doi.org/10.1136/bmjopen-2016-013076

Debussche, X., Besançon, S., Balcou-Debussche, M., Ferdynus, C., Delisle, H., Huiart, L., & Sidibe, A. T. (2018). Structured peer-led diabetes self-management and support in a low-income country: The ST2EP randomized controlled trial in Mali. PLOS ONE, 13(1), e0191262. https://doi.org/10.1371/journal.pone.0191262

Huber, D. (2017). Leadership and nursing care management (6th ed.). Saunders.

Obucina, M., Harris, N., Fitzgerald, J., Chai, A., Radford, K., Ross, A., Carr, L., & Vecchio, N. (2018). The application of Triple Aim framework in the context of primary healthcare: A systematic literature review. Health Policy, 122(8), 900-907. https://doi.org/10.1016/

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Assessment 3 Instructions: Evidence-Based Population Health Improvement Plan
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Create a 3-5 page paper identifying the health concern you think is most appropriate for the community in your practice environment. Your choice should be based on evaluating the relevant data you have gathered for your chosen issue.

Evidence-Based Population Health Improvement Plan

Master’s-level nurses need to be able to think beyond the bedside. It is important to be able to research, synthesize, and apply evidence that will result in improved health outcomes for the communities and populations that are part of your care setting. Improving outcomes at a community or population level, even incrementally, can create noticeable and significant aggregate health improvements across all of a care setting’s patients.

Scenario
Your organization has created an initiative to improve one of the pervasive and chronic health concerns in the community. Some examples of possibilities for health improvement initiatives are nationwide concerns, such as type 2 diabetes, HIV, obesity, and the Zika virus. However, your organization wants you to identify the health concern that is most appropriate to address for the community in your practice environment. You will need to do your own research to gather and evaluate the relevant data for your chosen issue.

Instructions
The bullet points below correspond to the grading criteria in the scoring guide. Be sure that your population health improvement plan addresses all of the bullets below, at minimum. You may also want to read the Evidence-Based Population Health Improvement Plan Scoring Guide and Guiding Questions: Evidence-Based Population Health Improvement Plan [DOCX] to better understand how each criterion will be assessed:

Evaluate the environmental and epidemiological data about your community so that you can illustrate and diagnose widespread population health issues.
Develop an ethical health improvement plan that addresses the population health issue you have identified in your evaluation. The plan should be based on the best available evidence and meet the cultural and environmental needs of your community.
Justify the value and relevance of the evidence you used as the basis for your population health improvement plan.
Propose criteria that can be used to evaluate the achievement of your health improvement plan’s outcomes.
Explain how you plan to apply strategies for communicating with community members and colleagues in the health care profession in an ethical, culturally sensitive, and inclusive way about the development and implementation of your health improvement plan.
Integrate relevant sources to support assertions, correctly formatting citations and references using APA style.
Example assessment: You may use the Evidence-Based Population Health Improvement Plan Example [PPTX] to give you an idea of what a Proficient or higher rating on the scoring guide would look like.