NURS FPX 6011 Assessment 2 Evidence-Based Population Health Improvement Plan

Student name

Capella University

NURS-FPX 6011

Professor Name

Submission Date 

Slide 1

Evidence-Based Population Health Improvement Plan

Hello, I will now explain what type 2 diabetes is and some of its pros and cons.

Slide 2

Introduction

Diabetes is a condition that requires daily input from the patient and daily report submission from the patient to the healthcare practitioner. The World Health Organization (2024) shows that in 2022, 14 percent of individuals aged 18 and above were recorded to have diabetes, a worrying percentage. Statistics on diabetes in the USA are similar. It is also important to note that diabetes distribution is not uniform throughout the country. There are some segments of the population that have excessively high rates of the disease. This disease predominantly affects the same population residing in the geographical area of the target community. There are multiple challenges in managing the disease.

Slide 3

Environmental and Epidemiological Data

The results of the research done on poor and Hispanic communities and Type 2 Diabetes Mellitus (T2DM) are of great concern. The World Health Organization (2024) has documented new cases of diabetes in populations for whom diabetes was hitherto of relatively low prevalence, such as poor communities. The rate of diabetes increased from 7 percent in 1990 to 14 percent in 2022, according to previously noted reports. As noted by Baumblatt et al. (2024), in 2024, the prevalence of diabetes was 14.3 percent. Difficulties of controlling the condition were also on the rise at the same time. Of particular concern is the 2017-2023 cohort of younger individuals in which HbA1c was reportedly increased and alarmingly high at 7.6 percent, as indicated by the NHANES study. During that period, it was reported that environmental factors were of prime importance.

The poor have added financial burdens because of the increased costs associated with eating healthy, going to the doctor, and purchasing diabetes monitoring equipment. Without access to healthy food in a food desert, and without ways to get there, the impoverished community is unable to stick to a diabetes diet and is completely without the ability to control their T2DM.

Slide 4

Health Improvement Plan

The plan has three main components. The first is the incorporation of Continuous Glucose Monitoring (CGM) technology. The second is the incorporation of telemedicine consultations. The third is the incorporation of a diabetes education program. It is anticipated that, in combination, these programs will potentially help address the challenges that residents of the area who have diabetes are currently facing. CGM helps solve the problem of the hundreds of blood sugar level tests that are done by way of a painful blood draw. The use of telemedicine solves the problem of being able to access diabetes specialty care without the burden of having to travel to that care. Finally, the health care improvement plan’s educational program is designed to teach patients how to manage their diabetes.

Potential Barriers

There exist numerous daunting challenges to composing efficient health care systems. Funding is a good example. Some events related to this barrier exist today. Since most health care insurance companies have not started to integrate telehealth and glucose monitoring services, most users of these services are financially burdened (Presley et al. 2023). The aim of this project is to motivate health care insurance companies to earmark resources for this service. Lack of skills among the target population to use the technology is another challenge. The target population, which has never used telehealth, will be provided with the necessary technology, coupled with training on how to use the technology. The target population also has a considerable level of mistrust of health technology.

Outcome Criteria

Expected outcomes for the first 6-12 months of implementation include a decrease in the average HbA1c level by 0.5% (Alomar et al. 2024), an increase in the rate of clinic visits for diabetes testing by 25%, and 70% of study participants using a glucose monitoring device to engage in self-management of diabetes.

Rationale for Criteria

Choosing the most relevant outcome measures involves several considerations. The first consideration relates to the importance of outcome measures in both the clinical and the social domains. HbA1c levels correlate with the degree of control of blood glucose and the risk of developing complications (Alomar et al., 2024). An indicator that health professionals are available to patients following an intervention suggests that health services are operational. Another consideration is that the use of patient-completed or patient-recorded measures will indicate the efficiency of program expenditures.

Slide 5

Plan for Collaboration with Community Organization

Partners

The primary partner for the program is a government-run health center that specializes in serving the underserved, more specifically, the Spanish-speaking community (Bender et al., 2025). It is worth noting that during the initiatives, health centers demonstrate a lot of capacity, especially the ability to offer health services to the community and employ personnel that span the services to the Spanish-speaking population. Other partners in the area will include health centers that serve the Spanish-speaking population and Spanish-speaking churches that are trusted in the local community.

Role of Community Partners

Additional project support and implementation help will come from Community Partners. They will provide CGM devices and offer telehealth consultations to the community. In addition, community health workers will provide home visits. During CGM device education, Community Health workers will use patients’ native languages. Lastly, the churches will host diabetes education using community-appropriate spaces, while the school’s wellness program will host diabetes education to provide children and their families with this education.

Rationale for Collaboration

Adaptability is needed because of the changing landscape in all aspects of healthcare and the shift in population health needs. Combined resources and continued partnerships among agencies, practitioners, and community stakeholders who operate within the community will help address the health concerns of this population. It has been documented that the most beneficial and effective approach in positively impacting the health of an individual suffering from a chronic illness is utilizing a collaborative approach and working with both the community member and health practitioner from the population’s geographical vicinity (Ozana-Andreea-Măriuț et al., 2025). In addition, this approach maintains integrity to the values and ethics of practice, as well as privacy.

Communication Strategy

Project execution relies on effective communication. All instruction and assent documents will be in English and Spanish, at a reading level of sixth grade. Communication matters, and having visual aids will improve it. The community meetings will be organized with simple communication and will be interpreted (Alomar et al., 2024). The materials will be made with and for the disabled. The project will aim for compliance with HIPAA. This will include the protection of personal information obtained through the use of CGM and telemedicine.

Slide 6

Relevance and Value of Evidence and Technology

Evidence

The evidence employed in this approach is derived from real-world situations relevant to the study population and is up to date (within the last five years). Maita et al. (2024) published a study where T2DM patients had a reduction in HbA1c levels and a decrease in hospitalization rates as a result of increased patient education, which improved adherence to medication recommendations. Latif et al. (2025) performed a systematic review on digital diabetes care and found that adding CGM to telehealth services improves glycemic control. Maita et al. (2024) focused on the health equity concerns in rural populations and stated that using digital health services would equitably address the lack of access to health care for those in need the most. Alomar et al. (2024) state that a health care technological ethics framework and the essential principles of protecting the privacy of health care clients in AI technology in health care were formulated. It is supported that the evidence is strong.

Technology Value

One of many values technology offers is its ability to solve real-world social problems while demonstrating imagination and ingenuity. An example is technology to monitor glucose continuously. Finger pricking is one of the major reasons people avoid glucose monitoring. With the technology, there is no longer the need to prick fingers, and therefore no pain is associated with blood glucose level monitoring. The technology enables real-time and useful data such that the impact of consumption of certain foods, exercise, and medication on glucose levels can be monitored. This can be further addressed during the annual consultation (Bender et al., 2025). Telemedicine provides a solution to the decades-old challenge of access, granting people living in remote areas the ability to see a doctor from their home. With regard to the EHR system, all healthcare professionals will have the ability to access a patient’s most recent medical history from any location, thus eliminating avoidable mistakes or unsafe acts that may adversely affect a patient.

Cited Technologies

This project involves using CGM technology to monitor blood sugar levels. This technology connects to an app on the user’s phone and has a low learning curve (Bender et al., 2025). Additionally, this project will use a Telehealth technology built to HIPAA policy standards. This technology offers a doctor the ability to converse with the patient via text and/or voice messages outside of the traditional clinic visits, and conforms to the HIPAA regulations (Alomar et al., 2024). Furthermore, this project utilizes a mobile application that offers both English and Spanish versions, thus offering the patient an educational resource and reminder to aid the patient in maintaining adherence to their prescribed medication regimen (Latif et al., 2025). Lastly, the project incorporates EHR technology to simplify the documentation and information transfer process for the doctors and medical personnel attending to the patient (Alomar et al., 2024).

Slide 7

Specific Actions for Community Stakeholders

There are many ways the local community can collaborate with community stakeholders to ensure the community not only takes part in the process, but also becomes the main driver and is accountable for the outcome of the process. One of those approaches is peer education. Community health workers should facilitate significant health campaigns and health education to the communities about the health challenges that members of the community face.

In this regard, community health workers should integrate local community values, beliefs, and customs (Maita et al., 2024). Furthermore, the implementation of a monthly diabetes testing framework can be facilitated by religious leaders within the community (Maita et al., 2024). Individuals with Type 2 Diabetes can play an important role as peer educators and mentors to those who have recently been diagnosed and do not know how to cope (Maita et al., 2024). The local food vendors and business people will sell healthy and safe food that meets the demand of people suffering from diabetes (Maita et al., 2024). Lastly, the local schools and communities will host family health evenings to give education to the families on how to prevent diabetes.

Slide 8

Conclusion

Type 2 Diabetes Mellitus can affect everyone in our community and is a manageable problem. The obstacles can be identified, and solutions developed with provided data and evidence. Typical barriers to the implementation of diabetes prevention measures can be resolved by picking the right solutions with the help of the best-known diabetes management organizations. Data on diabetes prevention programs indicate that in the case of failure, it is possible to evaluate all outcomes and restructure the program. This initiative gives the community the chance to be part of the program implementation, rather than being a passive recipient of health and related services.