Table 3 Summary of Work Plan for Year 1 of the Diabetes Navigation Program
GOAL: We will establish a Comprehensive Diabetes Patient Navigation Program for Rural Appalachians to improve health outcomes and lower health care expenditures for individuals with diabetes through the development and coordinated implementation of the Diabetes Patient Navigator Program to impact the health care delivery system, individual patients, and inform policy. | ||||
Objective One: Establish a Diabetes Patient Navigator Program that serves individuals with diabetes to improve health measures in diabetes clients by addressing barriers to health care and self-care activities Evaluate Annually: # provider/staff trained to identify and refer patients with diabetes due to poor glycemic control; number of referrals received, % of referred individual who engage navigation services; number and type of barriers identified; number of barriers targeted for interventions; number of barriers resolved; repeated measures of patient health metrics including haemaglobin, blood pressure control (all available), depression symptoms, distress symptoms, self-care (intake, 6Â m, 12Â m); provider and patient satisfaction (annual). Patient admissions, readmissions and emergency department utilization, annual expenditures; patient improvement measures tracked. Healthy People 2020: Improve glycemic control; improve blood pressure control; complete dental, eye, foot exams; increase number performing daily self-monitoring of glucose and getting formal diabetes education. | ||||
Activities Year One: October 2015–October 2016 | Dates | Outcome/Results | Evaluation/Measurement | Partner Responsible |
Year 1, Activity 1: Design intake, referral procedures, HIPAA compliant releases at Diabetes Endocrine Center (SYSTEM CHANGE) | May 2015–July 2015 | • Intake and referral processes in place; staff trained • Navigator to serve Diabetes Endocrine Center • Obtain access EHR at both | • Workflow within health care practice is reformed to screen and refer patients to Diabetes Navigator • Number staff trained • Referrals made | Diabetes Navigators; Medical practice managers |
Year 1, Activity 2: Submit protocol to IRB for approval; consent process established (EVALUATION) | August 2015–September 2015 | • Consent forms and measurement tools selected • Data collection processes set | • IRB approval received | Principal Investigator |
Year 1, Activity 3: Direct services provided to individuals referred to Diabetes Navigator. (INDIVIDUAL CHANGE) | October 2015–October 2016 | • 80% of patient referred are successfully engaged in Navigation services • 90% barriers targeted for intervention that the consumer agreed to address with the Navigator are resolved. | • Process: number and types barriers identified and resolved. Goal to see 50 patients. • Health Outcomes: haemoglobin A1C, blood pressure, exams depression, distress, self-efficacy, satisfaction metrics 3 times year • Cost Outcomes: admissions, readmissions, and ED utilization rates tracked; annual expenditures | Diabetes Navigators |
Year 1, Activity 4: Manager of Navigator Program facilitates the coordination of all navigation programs (SYSTEM CHANGE) | October 2015–October 2016 | • Protocols and policies in place to differentiate types of navigation services and access • Best linkages of care for patients | • System integration increases the capacity and efficiency of service delivery; Single point of referral established | Diabetes Navigators |
Years 1,2,3, Activity 5: Diabetes nurse navigators initiate clinical activity to become Certified Diabetes Educator | Jan 2015-April 2018 | • Clinical hours accrued | • Certified Diabetes Educator earned at end of Year 3 | Diabetes Navigators |
Year 1, 2, 3; Activity 6: Diabetes Navigator and manager participate in consortium members meeting to discuss integration efforts, monitor challenges, improve practices; facilitate integration into Diabetes Institute; develop five year strategic plan. | October 2015–April 2018 | • Consortium meetings held quarterly • Strategic planning sessions held • Integration of consortium into larger delivery system and Diabetes Institute | • 100% attendance • Steps identified to integrate with Diabetes Institute • Five year strategic plan written such that it situates to strategic initiatives of consortium partners; and adopted by consortium | Diabetes Navigators, Principal Investigator |