In this assignment, you will continue to develop the Methods section of your proposed proposal. The focus of the current assignment is continued to refine previously submitted sections of the proposal

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In this assignment, you will continue to develop the Methods section of your proposed proposal. The focus of the current assignment is continued to refine previously submitted sections of the proposal and to describe a plan to evaluate the impact of the project.  You will provide a description of measures and procedures you will use to collect data including descriptions of valid/reliable tools from the literature (if indicated), drafts of data collection forms such as survey instruments, drafts of data management tools such as coded Excel spreadsheets, and the proposed data analysis plan. If you plan to use an established instrument, you will also need to show proof of permission to use the form from the author and incorporated this permission in the Appendix of proposal document.

The current submission will include the following:

  • Working draft of the proposal that incorporates Faculty Project Advisor recommendations for previously submitted work. Ensure reference lists and appendices are updated.
  • Outcome measures selected to evaluated the process and outcomes of the interventions (How you will evaluate the impact of the intervention on processes, individuals, clinical outcomes, system delivery, etc… This may include economic analyses.)

    • Description of each measure and rationale for selecting the measure which may include economic indicators such as cost savings, personnel outcomes such as retention, or patient care outcomes such as length of stay or customer experience.
    • Operational definition of each measure in this project
    • Validity and reliability information of measures if known.
    • Include any tools or surveys you will used to gather outcome data. Make mention of the tools in the text description of the outcome measures and make mention of availability of the survey or other instrument in the Appendices. Add copies of the outcome measures to the Appendices. Also, don’t forget to cite the tool in text and references and to add any citations to your reference list. Again, if an established tool, show proof of permission to use the instrument.
  • Data collection procedures

    • Description of the specific process you will use to collect data (who, what, when, where, how)
    • Include spreadsheets you will use to aggregate and manage data in the Appendices. Refer the reader to the availability of the data collection form in the text.
  • Data Analysis Plan
    • Description of processes you will use to analyze data (frequency counts, percentages, statistical tests, cost/benefit ratio, cost savings). You may want to consult your Faculty Project Advisor for guidance in developing this section.  The clinical analytics and data management text also will be useful in developing this section of the proposal.

In this assignment, you will continue to develop the Methods section of your proposed proposal. The focus of the current assignment is continued to refine previously submitted sections of the proposal
Outline for Leonne’s proposal Introduction Background (This all needs to come from published literature – cite everything) – How is the lack of follow-up of T2D patients among low-income patients described in the literature (you can also discuss lack of accessibility to care)? How specifically does accessibility to times that allow patients to work influence follow-up rates? You want to include any stats you find (for example, what is the percentage of low-income populations that have T2D? – Can you find any specific numbers about what follow-up rates are for this population?) How does the lack of follow-up of these patients affect their health outcomes? In this section you are making a case that the problem you have identified (lack of follow-up for T2D care management) exists on a broader level. Here are a couple of articles/books you can start with (please also do a literature search to find more articles, this was a quick search and didn’t read these in depth, you need to find more literature about the lack of accessible care for minority/migrant/impoverished communities): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535449/ https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05421-0 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475839/ Take a look at this book: https://link.springer.com/content/pdf/10.1007/978-3-319-73630-3.pdf On page 104: “Migrants were less likely to have a medical appointment in the previous 3 months compared to nationals” & “Migrants may be more affected by financial hardship, which leads to a decrease in their use of preventive and non-urgent medical care” On page 105: “Another important barrier identified is linked with employment patterns and f inancial situation. The prevalence of insecure employment (illegal work, lack of contract, agency work) or even unemployment among migrants is high. This places migrants in a very fragile situation in case of illness. Also, the schedules in PHC units are frequently limited to that of “traditional” working hours. For a migrant, attending a medical appointment during work time, even if for pregnancy follow-up or children care, might mean losing a job. This leaves the migrant with either one of two solutions: (1) not attending and thus not accessing appropriate and timely care; or (2) misuse by accessing emergency departments in hospitals (and again failing to have a good follow-up after the illness episode)” Organizational Needs Assessment Describe the organization – what type of clinic is it? What type of providers provider care at this clinic? What care model is used at this clinic? What is the mission/vision of the organization? What type of population is served at this clinic? (You are talking generally, if you are a mobile unit you need to mention that, you need to mention how the mobile unit is funded, staffed, etc.) Include stakeholder analysis – for you, stakeholders will include the clinic providers, medical director, office manager, nurses, multidisciplinary team, and patients and their families). Project Management Tools (look at these from the lens of your problem rather than from the perspective of education as seen before). This includes your SWOT analysis, Fishbone, Driver diagram, etc. Local Problem Statement – Here you want to specifically state the problem you and the stakeholders have identified as a problem, your problem poor compliance to follow-ups for T2D patients. You will discuss how often you observe that patients aren’t showing up for their follow-ups, you don’t need specific numbers necessarily, but you need to be able to state that clinic stakeholders have identified that patients do not seem to be keeping follow-up appointments. You can also speak to the fact that although you have increased accessibility to care by providing care at the apartment complex, current office hours prevent accessibility to care during times that these patients might be more available due to working in the field. Literature Review & Synthesis (You are likely going to need to redo most of your literature review) You will need to do a new literature looking specifically to answer this PICO question: “In low-income patients with T2D, how does improving accessibility to care (i.e., use of an after hours care model) influence continuity of care or chronic care management follow-up rates?” Your search strategy should include keywords and synonyms of these words: Type 2 diabetes, low income/impoverished/migrant, accessibility, after hours care, continuity of care, follow-up/follow-up non-adherence (FUNA) – Take a look at the first article I mentioned above to see how they used some of their key terms. Please try to use around 7-10 articles for synthesis Your literature review will include all the ways that you find that improves accessibility and follow-up of these patients. Headings you may be able to use include: Barriers to accessibility, Improving accessibility – here you can have subheadings of all ways to improve accessibility including offering after hours care, and Effects of Improving Accessibility (then talk about improving follow-up rates, which in turn improves continuity of care, which in turn improves patient outcomes – this should be found from the literature, write whatever you find, I am just thinking these are things you will be able to find). Purpose – The purpose of your project is to improve patient attendance at follow-up T2D care appointments. Your specific aims are to: By the end of the project, follow-up rates will increase to 80% among patients with T2D at Clinic Name (or whatever percentage you think is reasonable – you want a measurable goal here) By the end of the project, 100% of patients will bring their blood glucose logs with them to their follow-up appointments (or again, whatever is reasonable). Conceptual framework – I think you will be using a quality improvement framework, and you can choose which one you want to use, but the PDSA model is always a popular choice. I also think you need to use the chronic care management model as a guide to this project: “For example, for patients to engage in proactive care (delivery system design)” Take a look at this article: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.28.1.75 Methods Project Design – quality improvement Setting – describe your clinic in detail, describe the apartment complex area Population – describe the patients that are seen at this clinic Intervention – describe in detail what you will do, and how you will do it; include how feasible it is at your organization. You will also want to talk about how you are going to inform patients about after hours offerings, you will discuss when you will offer after hours visits, you will talk about you will discuss that you will provide chronic care management and diabetes education at these visits, any detail that you can think of that will allow someone else to replicate this intervention. But you intervention is implementing a pilot with one provider to offer after hours office visits. You will also want to consider what you are going to do to encourage that they bring their logs with them to all follow-up visits, do you currently have a process for this? If you are measuring this outcome you want to make sure you have some kind of intervention to affect this. Budget and Resources – you will want to talk about any considerations of budget resources, will the after hours visits be provided voluntarily? Will you utilize any additional resources that you don’t usually utilize? Take a look at this CDC resource: https://www.cdc.gov/policy/polaris/economics/program-cost/index.html Cost-Benefit analysis – you want to develop your cost benefit analysis, if you start implementing these after hours, how does the benefit outweigh the cost. You can google “cost benefit analysis” for more info on how to do this, but here is the CDC site: https://www.cdc.gov/policy/polaris/economics/cost-benefit/index.html Outcome measures – you will describe the outcomes you will measure in your project. These will include the follow-up rate of patients with T2D and the rate of compliance of brining their glucose log to follow-up with them. Data collection: How are you going to collect this data? Likely you will collect preintervention (baseline) data using a retrospective chart review. You will identify all patients that are diagnosed with T2D using the EHR, you will then collect information on when their last visit was, when their follow-up was scheduled, and if they attended their follow-up. If you can get baseline data on the logs you will describe how you will collect that. You also want to mention that you will collect demographic data from the EHR. Then to collect project data, you will do a retrospective chart review after 2-3 months of implementing your project and collect the same outcome data for postintervention period. Data Analysis Plan – You will use descriptive statistics to describe the demographics of your patients, you will also use percentages to report follow-up rates and compliance rates of brining glucose log. Ethical Considerations – see the exemplars, but you want to discuss that all data will be aggregated, and no patient identifiers will be collected during data collection. You will obtain IRB approval, and will keep data on a secure, password-protected computer. Timeline – your timeline should be something like this, but you can change it based on your thoughts: Activity Dec Jan Feb Mar Apr Complete proposal Feasibility discussion with chair and sponsor Submit IRB paperwork Collect baseline data Implement Intervention Collect postintervention data Analyze data Write final report Disseminate project findings
In this assignment, you will continue to develop the Methods section of your proposed proposal. The focus of the current assignment is continued to refine previously submitted sections of the proposal
Outline for Leonne’s proposal Introduction Background (This all needs to come from published literature – cite everything) – How is the lack of follow-up of T2D patients among low-income patients described in the literature (you can also discuss lack of accessibility to care)? LOOK UP NUMBERS TO SUPPORT How specifically does accessibility to times that allow patients to work influence follow-up rates? The patient will have access to the be seen from 1x a month to 2x a month You want to include any stats you find (for example, what is the percentage of low-income populations that have T2D? –I found an article on the ADA /CDC and see the population OR IF YOU CAN FIND AN ARTICLE Can you find any specific numbers about what follow-up rates are for this population?) How does the lack of follow-up of these patients affect their health outcomes? IF THE PATIENT MISS FOLLOW UP APPOINTMENTS, THEN WE ARE NOT ABLE TO TRACK THE PROGRESS OR CATCH ANY MISTAKES THAT THEY ARE MAKING AND NOT REALIZE IT. In this section you are making a case that the problem you have identified (lack of follow-up for T2D care management) exists on a broader level. Here are a couple of articles/books you can start with (please also do a literature search to find more articles, this was a quick search and didn’t read these in depth, you need to find more literature about the lack of accessible care for minority/migrant/impoverished communities): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535449/ https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05421-0 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475839/ Take a look at this book: https://link.springer.com/content/pdf/10.1007/978-3-319-73630-3.pdf On page 104: “Migrants were less likely to have a medical appointment in the previous 3 months compared to nationals” & “Migrants may be more affected by financial hardship, which leads to a decrease in their use of preventive and non-urgent medical care” MISSING A DAY OF WORK WILL AFFECT THE FAMILY/HOUSEHOLD On page 105: “Another important barrier identified is linked with employment patterns and financial situation. The prevalence of insecure employment (illegal work, lack of contract, agency work) or even unemployment among migrants is high. This places migrants in a very fragile situation in case of illness. Also, the schedules in PHC units are frequently limited to that of “traditional” working hours. For a migrant, attending a medical appointment during work time, even if for pregnancy follow-up or children care, might mean losing a job. This leaves the migrant with either one of two solutions: (1) not attending and thus not accessing appropriate and timely care; or (2) misuse by accessing emergency departments in hospitals (and again failing to have a good follow-up after the illness episode)” THIS SECTION ABOVE IS VERY RELEVENT TO MY TOPIC AND IS VERY TRUE CAN YOU FIND A WAY TO INCORPORATE IT IN THE PAPER Organizational Needs Assessment Describe the organization – what type of clinic is it? PRIMARY CARE /GERIATRICS CLINIC What type of providers provider care at this clinic? INTERNIST, GERIATRICANS, ADULT APRN, AND LOCAL PRIMARY VOULTEERS What care model is used at this clinic? TO PROVIDE QUAILTY CARE TO SOME OF SOCIETES MOST VULNERABLE, THE ELDERLY, DISABLED AND THE INDIGENT. What is the mission/vision of the organization? TO IMPROVE QUALITY OF LIFE OF THOSE WE TREAT. What type of population is served at this clinic? ELDERLY OVER 65, DISABLED, POOR AND UNFUNDED (You are talking generally, if you are a mobile unit you need to mention that you need to mention how the mobile unit is funded, staffed, etc.) WE ARE A MOBIL UNIT THAT GOES TO THE APARTMENT COMPLEX 1X A MONTH AND AS NEEDED TO PROVIDE CARE AND TEACHING AND FOLLOW UP. WE ARE FUNDED THROUGH MEDICARE AND OTHER REFERENCES. Include stakeholder analysis – for you, stakeholders will include the clinic providers 3 PROVIDERS medical director (1), office manager (1), nurses 1, multidisciplinary team NUTRITIONIST, AND A DIETITIAN, and patients and their families). Project Management Tools (look at these from the lens of your problem rather than from the perspective of education as seen before). The lens is trying to meet the patients on their level keeping it simple for example telling them that we are here every second Monday of the month and there are more likely to make the appointment versus saying come on the 4th of the month This includes your SWOT analysis, Fishbone, Driver diagram, etc. Local Problem Statement – Here you want to specifically state the problem you and the stakeholders have identified as a problem, your problem poor compliance to follow-ups for T2D patients. You will discuss how often you observe that patients aren’t showing up for their follow-ups, you don’t need specific numbers necessarily, but you need to be able to state that clinic stakeholders have identified that patients do not seem to be keeping follow-up appointments. You can also speak to the fact that although you have increased accessibility to care by providing care at the apartment complex, current office hours prevent accessibility to care during times that these patients might be more available due to working in the field. We are looking to change the availability of the clinic from 4:00 to 8:00 PM two times a month and we are going to have a signup sheet so that the patients can sign up and have a slotted time and they can show up at 15 minutes before. Having them come during the work hours is sometimes difficult and they are only coming in once every 60 days if that. Literature Review & Synthesis (You are likely going to need to redo most of your literature review) You will need to do a new literature looking specifically to answer this PICO question: “In low-income patients with T2D, how does improving accessibility to care 2X A MONTH AT THE CLINIC BETWEEN 4PM-8PM (i.e., use of an afterhours care model) influence continuity of care or chronic care management follow-up rates?” Your search strategy should include keywords and synonyms of these words: Type 2 diabetes, low income/impoverished/migrant, accessibility, after hours care, continuity of care, follow-up/follow-up non-adherence (FUNA) – Take a look at the first article I mentioned above to see how they used some of their key terms. Please try to use around 7-10 articles for synthesis Your literature review will include all the ways that you find that improves accessibility and follow-up of these patients. Headings you may be able to use include: Barriers to accessibility INCLUDES LACK OF TRANSPORTATION, HANDICAP ACCESSIBILTY HAVING WHEELCHAIR RAMPS BEING THAT WE HAVE SOME PATIENTS THAT ARE AMPUTEES, Improving accessibility – here you can have subheadings of all ways to improve accessibility including offering after hours care, and Effects of Improving Accessibility (then talk about improving follow-up rates, which in turn improves continuity of care, which in turn improves patient outcomes – this should be found from the literature, write whatever you find, I am just thinking these are things you will be able to find). During the initial visit I would give them a list of things they can do about to help them feel better and I would want them to return within 30 days and if they are feeling better then there will be excited to show up and show us their improvement and how they feel. Purpose – The purpose of your project is to improve patient attendance at follow-up T2D care appointments 2 X A MONTH. Your specific aims are to: By the end of the project, follow-up rates will increase to 80% among patients with T2D at Clinic Name (or whatever percentage you think is reasonable – you want a measurable goal here) CONFERENCE TO THE SCHEDULER AND REVIEWING THE EMR AND OBTAIN THE LIST OF PATIENTS WITH T2D IN THE PAST YEAR AND SEE THE TREND OF MISSED/KEPT APPOINTMENT FOR THE PAST SIX MONTHS. By the end of the project, 100% of patients will bring their blood glucose logs with them to their follow-up appointments (or again, whatever is reasonable) …HOPING 80% OF THE PATIENTS WILL HAVE IT ON PAPGRAPH LOG OR COPY ON HIS CELL PHONE INCLUDING NAME, DAILY BLOOD GLUCOSE WITH TIME/ FASTING. Conceptual framework – I think you will be using a quality improvement framework, and you can choose which one you want to use, but the PDSA model is always a popular choice (WE NEED TO CREATE THIS). I also think you need to use the chronic care management model as a guide to this project: “For example, for patients to engage in proactive care (delivery system design)” Take a look at this article: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.28.1.75 Methods Project Design – quality improvement DECREASE MISSED APPOINTMENTS AND HAVING THE PATIENT BRING THE BLOOD GLUCOSE LOG IN PERSON OR ON THEIR PHONE. Setting – describe your clinic in detail, describe the apartment complex area 5 STORY APARTMENT BUILDING WITH 10 UNITS ON THE TOP 4 FLOORS AND AMENITIES ON THE 1ST FLOOR THAT INCLUDES THE LEASING OFFICE, MAIL ROOM, LAUNDRY ROOM AND THE CLINIC. THE CLINIC IS A 2 BEDROOM APARTMENT THT HAS BEEN REMODELED TO IMMULATE A TYPICAL DOCTORS OFFICE. THE LIVING ROOM IS THE WAITING ROOM WITH A DESK AND 10 CHAIRS, 1 BEDROOM IS THE EXAM ROOM AND 2ND BEDROOM IS THE CLINICAL ROOM FOR VITALS, THE KITCHEN IS USED TO STORE LAB SUPPLIES, MEDICATIONS, STATIONARY PAPERWORK AND URINE IS STORED IN THE FRIDGE. Population – describe the patients that are seen at this clinic ELDERLY, DISABLED AND LOW-INCOME PATIENTS. Intervention – describe in detail what you will do, and how you will do it; include how feasible it is at your organization. You will also want to talk about how you are going to inform patients about after-hours offerings, you will discuss when you offer after hours visits, you will talk about you will discuss that you will provide chronic care management and diabetes education at these visits, any detail that you can think of that will allow someone else to replicate this intervention. But you intervention is implementing a pilot with one provider to offer after hours office visits. You will also want to consider what you are going to do to encourage that they bring their logs with them to all follow-up visits, do you currently have a process for this? If you are measuring this outcome you want to make sure you have some kind of intervention to affect this. The staff and I will put together some Flyers indicating the hours and through word of mouth that will be available two times a month the 2nd and 4th Monday from 4:00 PM to 8:00 PM. The sign-up sheet with fifteen 30-minute intervals to sign up located outside the door of the clinic. They are required to bring in a physical blood sugar log with their weight and time of day that they’re checking their blood sugar, or they can keep a log on their phone cause some of them are technology savvy. During the visit we will go over there eating habits we will go over their blood sugars and when they are testing and looking at the trend to see how the blood sugars are going down. On the third visit we will have him scheduled to see a nutritionist who will go overeating styles and what they’re eating and how much and when they’re eating. TO MEASURE THE OUTCOME The patients WILL COME IN two times a month and after them coming consistently for four months the patients will be enrolled in a program that provides free medication for up to one year. During this time, we were doing medication review and we will go to the meds and try to find inexpensive scripts that we can give them all of these will be encouragement for the patient to follow up you see because they are receiving more benefits. The caveat is they must be consistent coming in twice a month for four months. When they check in at the front desk with the volunteer or medical assistant upon signing in, they will provide the blood sugar records and then during their visit we will monitor their blood work making sure that their labs are done every three months to check the A1C and monitor the descending trend . *** PLEASE FEEL FREE TO MAKE CORRECTIONS OR CHANGEOR ADD**** Budget and Resources – you will want to talk about any considerations of budget resources, will the after-hours visits be provided voluntarily? To keep the overhead down we will be utilizing myself volunteering my time, we will use pre-Med/APRN students for internship in return they will get clinical hours. We will ask staff to volunteer at least once a month. Also, we will reach out to local ADULT primary care providers and asked them to work to commit to one time a month for a return of 4 CME hours. Will you utilize any additional resources that you don’t usually utilize? Take a look at this CDC resource: https://www.cdc.gov/policy/polaris/economics/program-cost/index.html Cost-Benefit analysis – you want to develop your cost benefit analysis, if you start implementing these after hours, how does the benefit outweigh the cost. The benefit of implementing the after-hour clinic will help decrease the uncontrollable diabetes number overall in Hillsborough county. Which will help provide less core morbidities and patients living longer, in return less trips to the emergency room. The cost will be kept down by partnering with the local universities to get a list of students that need clinical hours to complete their program. You can google “cost benefit analysis” for more info on how to do this, but here is the CDC site: https://www.cdc.gov/policy/polaris/economics/cost-benefit/index.html Outcome measures – you will describe the outcomes you will measure in your project. These will include the follow-up rate of patients with T2D will increase and the schedule will be full and the rate of compliance of brining their glucose log to follow-up with them will also. WE WILL COMPARE THE SCHEDULE IN THE EHR FROM A YEAR AGO, SIX MONTHS AGO AND 6 MONTHS FROM NOW. We will create a bulletin board “Keeping It Under Control” demonstrating improvements and one patient will be recognized every month (with their permission). The incentive will be a free glucose monitor, donated from Lilly and/or Sanofi and if they are not on insulin a gift card donated from the local Publix or Walmart. Data collection: How are you going to collect this data? Likely you will collect preintervention (baseline) data using a retrospective chart review. You will identify all patients that are diagnosed with T2D using the EHR, you will then collect information on when their last visit was, when their follow-up was scheduled, and if they attended their follow-up. If you can get baseline data on the logs you will describe how you will collect that. You also want to mention that you will collect demographic data from the EHR. Then to collect project data, you will do a retrospective chart review after 2-3 months of implementing your project and collect the same outcome data for postintervention period. If we are successful at this location and having a larger turn out of more than 15 people, then we can get funding from Medicare or other grants and donations to help us add more days and hours and eventually open other locations to provide care. Data Analysis Plan – You will use descriptive statistics to describe the demographics of your patients, you will also use percentages to report follow-up rates and compliance rates of brining glucose log. Demographics Age Group: 18-35, 36-59, 60 and up. Sex: M OR F. RACE: AFRICAN AMERICAN/CAUCASIAN /HISPANIC/AMERICAN INDIAN/ASIAN Ethical Considerations – see the exemplars, but you want to discuss that all data will be aggregated, and no patient identifiers will be collected during data collection. You will obtain IRB approval, and will keep data on a secure, password-protected computer. Timeline – your timeline should be something like this, but you can change it based on your thoughts: SEE BELOW Activity Dec Jan Feb Mar Apr Complete proposal Feasibility discussion with chair and sponsor Submit IRB paperwork Collect baseline data Implement Intervention Collect postintervention data Analyze data Write final report Disseminate project findings

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