Student name

Capella University

NURS-FPX9000

Professor Name

Submission Date

Project, Preceptor, and Practicum Interest Form (PPPIF)

Description of Project Site

This project location is an outpatient primary care facility. The project area is in Rock Hill, a mid-sized city in York County, South Carolina that represents a wide range of patients, most of which are uninsured and underinsured with lower socioeconomic status. The clinic does offer full-service facilities, including preventive services, chronic disease management, urgent care, women health, telehealth, and aesthetic services. The site is a direct primary care facility which means the majority of the services are provided to the uninsured and underinsured people who pay out of pocket (Nurse executive, personal communication, July 10, 2025). The clinic operates on a Monday-Friday schedule and it takes care of pediatric patients as well as adult patients. The direct clinic employees include about six to eight workers including nurse practitioners, medical assistants, administrative workers, and support ancillary workers (Nurse executive, personal communication, July 10, 2025). The clinic is getting an average of 80 to 100 patients every week and this is a steady flow of acute visits, follow-up visits and regular health maintenance visits. The facility has a number of examination rooms, a designated room where the procedures and chronic diseases are counseled, and telehealth technology to communicate with their patients virtually (Nurse executive, personal communication, July 10, 2025). The environment offers the ideal context of putting into practice a quality improvement initiative.

Gap in Practice

The project location is one of the high patient volume sites of chronic conditions, which has about 80-100 patients per week, and diabetes, high blood pressure, and other chronic illnesses that need continuous management and interactions with patients. The practice gap within the project site is the absence of an evidence-based self-management of chronic disease program, which is organized. The chronic illnesses, especially type 2 diabetes and high blood pressure, are common in the patient population of the clinic and need a long-term patient engagement that goes beyond the usual clinical visits to deliver the best results (Bellary et al., 2021). The need to improve the self-management support is critical, as the outcomes of the clinical activities at the facility are poor. According to the data provided by this internal clinic, 58 percent of patients with type 2 diabetes had a HbA1c over 9 in the past 12 months, and 62 percent of hypertension patients enrolled in mean blood pressures over 150/95 mmHg (Nurse executive, personal communication, July 10, 2025). The literature shows that insufficient self-management habits, such as poor medication adherence, inadequate lifestyle changes, and ineffective monitoring habits are the direct causes of poor chronic disease outcomes (Silva et al., 2021). It has been found in literature that self-management interventions, such as Stanford chronic disease self-management program (CDSMP), can be linked to the significant improvement of clinical outcomes (Kerari et al., 2024). The CDSMP is a peer-led educational intervention that is structured to equip patients with skills necessary in the management of chronic conditions.

Clients are now receiving standard medical attention when visiting clinics and the environment does not have a consistent education, goal-setting, or follow-up system to continue self-management practices. In turn, evidence-based recommendations highlight the importance of designed self-management interventions, such as patient education, goal-setting, peer support, and frequent follow-up as a way of improving the outcomes of chronic diseases (Aghdaei et al., 2022). Comparing the clinic results to the national standards, the difference is apparent: The percentages are much lower nationally, and the CDC reports that in patients with known diabetes and uncontrolled hypertension, HbA1c exceeding 7 percent are seen in approximately 47 percent of patients (CDC, 2024; Martin et al., 2024). Cases of uncontrolled blood pressure and glucose levels among patients who are uninsured in the clinic have been recurrent (Nurse executive, personal communication, July 10, 2025). Leadership has expressed the intention to enhance the metrics within the next 6-12 months in order to enhance the quality of care and patient satisfaction.

Quality Improvement Initiative

Quality improvement (QI) is an essential and ongoing process that can enhance the treatment, safety, and patient outcomes within any healthcare setting. In the project site, the implementation of a structured self-management support program aligns perfectly with the identified needs. A program that will be implemented to bridge the gap is the Stanford Chronic Disease Self-Management Program (CDSMP), which is a guideline-based intervention (New York State Department of Health, n.d.). The Stanford Patient Education Research Center developed the nationally recognized intervention. The intervention includes six weeks of peer-based workshops, which teach patients how to adhere to medication, how to cope with symptoms, how to establish goals and how to communicate with health care professionals.

Application of CDSMP to practice will help close this gap by providing a methodical way of patient education and follow-up. The Stanford chronic disease self-management program is particularly relevant to underserved groups that are not educated and resource-deficient (Fracso et al., 2022). The integration of the program will not only improve the clinical outcomes, i.e., the glucose level and blood pressure but also nurse-patient relationships and patient self-confidence (Kerari et al., 2024). Good QI requires proper planning, ongoing observation, and ability to adapt to patient requirements. All in all, quality improvement is a great opportunity to establish long-term, positive change in healthcare delivery.

Helpful Information for the Mentor and Site-Based Learning

Additional data that may be helpful is a detailed account of the current processes of chronic disease care, such as how follow-up appointments are made, what information is provided to the patient, and whether current tools assess patient progress between visits. The awareness of staff positions and their availability will also play a crucial role in order to plan training and distribute tasks effectively (Ruttenberg et al., 2020). Measurable goals can be created by using baseline measures of average blood glucose levels and blood pressure in the patients of the clinic. It would also be useful to know whether the clinic has a record of group education sessions or telehealth follow-ups as the forms of delivery may be complementary to the intervention. Understanding the problem of culture or language would help to create materials that are responsive to patients (Latif, 2020). Finally, the background information about the expectations of leadership, reporting, and any quality improvements underway will keep everyone on track and not make them repeat themselves. The background collection will help to make the implementation smooth and maximize the benefit of the project.

Population Description

The project population consists of the registered nurses of the project site who directly provide care to the adults with such chronic conditions as diabetes and hypertension. The registered nurses collaborate to offer patient evaluation, drug administration, patient education, and follow-up. The experience and training of the nurses in chronic disease management are mixed, and most of them work on several tasks, including urgent care visits, preventive care, and administrative work. Nurses can be short of time and have high volumes of patients, which do not leave time to provide formal self-management education (Otter et al., 2022). In addition, nurses tend to encounter low health literacy and resource-limited patients, and it is important to be creative in how to engage and motivate the patient. The program will be aimed at equipping the group with evidence-based tools, education, and resources to support nurses in their performance and confidence in coaching patients to manage chronic diseases more effectively and achieve better health outcomes.

1. You will be scheduling a Virtual Check-In with you, your mentor, and your preceptor in the upcoming weeks. Please provide a list of dates and blocks of time when you and your preceptor are available. Your mentor will use this to send out a Zoom meeting link.