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: