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

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

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Student name

Capella University

NURS-FPX6011 Evidence-Based Practice for Patient-Centered Care and Population Health

Professor Name

Submission Date

Slide 1

• Evidence-Based Population Health Improvement Plan

Hi, my name is ________. The suggested evidence-based population health improvement program as presented in this presentation would aim at improving the self-management of diabetes and health literacy of adults with Type 2 Diabetes Mellitus (T2DM). The practice promotes the enhancement of technology-based, culturally competent approach to increasing patient engagement and glucose control.

Slide 2

Diabetes Mellitus type 2 (T2DM) is one of the chronic and lifestyle diseases that is on the rise among adults in the global world. It is primarily prevalent among individuals of age between 4565 years and also among ethnically poor South Asians and African Americans. Physical activities and unhealthy diets, as well as the diminishing digital literacy are complicating the inability to control diabetes.

The outcome, which is compliant with the Healthy People 2030 objective D-06, is the reduced number of complications and deaths with the assistance of improved education, engagement, and self-care technology. Shared decision-making (SDM), motivational interviewing (MI), and digital technologies are the evidence-based approaches that the plan will engage in empowering patients to make better health choices, increase health literacy, and accept long-term self-management.

Slide 3

• Environmental and Epidemiological Data

Type 2 diabetes is gaining momentum in the majority of societies. As the data given by the CDC (2024) shows, the number of people with diabetes grew among adults, and low-income citizens, and city residents appear to be the most vulnerable population groups. Some of the causes of this trend include poor diets, inactivity, and low access to fresh food.

Some of the obstacles that most adults must face include income, overworking, and the unavailability of preventive healthcare. Individuals are also not digitally literate, and, therefore, they cannot monitor themselves through mobile health applications. Poor neighborhood design and the absence of safe walk areas are some examples of environmental hazards that influence healthy living.

The peer-reviewed studies and the conflicting facts of the CDC and ADA suggest that self-care is highly dependent on social and cultural factors. These findings prove that diabetes requires education, assistance in the utilization of technology, and community engagement. Recent literature has provided evidence to justify this assessment, whereby research studies indicate that better diabetes self-management is vital towards decreasing complications and mortality rates among T2DM patients. As an illustration, the studies have shown that digital health interventions and culturally specific education enhance patient interaction and health literacy, especially in underserved groups.

Table 1: Identifying Relevant Data

Factor	Prevalence	Population Most Affected	Environmental/Epidemiological Factors	Mode of Transmission
Type 2 Diabetes	13% of U.S. adults; 19% in low-income urban areas	Adults aged 45–65, South Asian and African American communities	Low health literacy, food deserts, sedentary jobs, and limited access to preventive care	Non-communicable
Poor Glycemic Control	~50% of diagnosed adults have HbA1c >7%	Low-income and minority populations	Economic stress, poor adherence, and limited digital literacy	Non-communicable

Slide 4

Health Improvement Plan

• Health Improvement Plan

The Community Diabetes Self-management Education (DSME) Program aims to empower individuals with Type 2 Diabetes to live through a simple, ethical, and culturally sensitive program. The program will focus on improving the self-care skills, health literacy, and blood sugar control, which will make adults (45 to 65 years) healthier. It includes Shared Decision-Making (SDM) through participation of the patients in the process of setting individual diet, medication, and exercise goals. Patients will be helped by nurses by means of Motivational Interviewing (MI), which will help them gain motivation to adopt and follow the healthy habits.

The family involvement will ease the home’s emotional control, diet planning, and medication adherence. Monitoring glucose will also be more convenient because of the telehealth and mobile applications like MySugr or a Glucose Buddy, which will provide feedback to a patient in real time (Kesavadev & Mohan, 2023). Education sessions will be culturally oriented by the use of bilingual materials and interpreters to cover students. The proposal aligns with the goals of the American Diabetes Association (ADA) and the objectives of the Healthy People 2030 program to decrease the complications of diabetes through self-management and education of patients.

• Potential Barriers

Some problems have the potential to affect the attendance and outcomes of the DSME program. One of the main concerns of many older adults and low-income earners is digital literacy; thus, they are not able to apply mobile health applications in an easy manner. Money problems could limit the right to healthy food, access to the internet, or cameras. The cultural preferences of food may be opposite to the food needs and affect compliance (Jayasinghe et al., 2025).

Online education cannot be convenient in places where a poor internet connection exists. In addition, work schedule and family responsibility may play out as a hindrance to regular attendance. The challenges will be overcome by the program through the implementation of flexible schedules in classes, free training of digital literacy, installation of Wi-Fi and computer stations in other local libraries and community facilities to enable these participants to access the program.

• Outcome Criteria

Short-term outcomes are

• Personally participate in DSME sessions at least 25% more often in six months.

Make sure that 90 percent of the participants exhibit the capacity to utilize mobile self-monitoring devices, e.g., MySugr and Glucose Buddy.

Long-term outcomes are

• Attain a greater than 0.5% decrease in the level of HbA1c among participants in 12 months.
• Cut emergency department visits of uncontrolled diabetes by 20 percent in a year.

Rationale for Criteria

These outcome measures were chosen because they showed significant enhancement in self-management, health literacy, and patient outcomes. This is in line with the concerns of Healthy People 2030 that focus on the minimization of complications and patient education. The study by Nkhoma et al. (2021) contributes to the supposition that DMSE intervention lowers the level of HbA1c and positively influences adherence to treatment.

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The measures are moral, quantifiable, and holistic, and they make sure that the progress is monitored fairly. The causes that were covered in the plan, such as poor engagement and digital illiteracy, are provided and tackled with the integration of technology, cultural awareness, and education. Such empowerment and access would come in handy in ensuring the sustainability of the plan and assist in changing the lives of adults with Type 2 Diabetes.

Slide 5

• Plan for Collaboration with Community Organization

Partners

The most important stakeholders that would be involved in this project would be the Local Public Health Department and the American Diabetes Association (ADA). These organizations will collaborate in order to generate awareness, education, and access to diabetes in the community. Health sessions and screening services will be conducted at the local clinics, pharmacies, and cultural associations; the necessary support of the project will be provided (Taylor et al., 2021).

Digital literacy training and the workshop will be implemented in community centers, which will be conveniently situated. This type of partnership will provide the program with an opportunity to have a favorable interaction with the available existing community networks and resources.

Role

The ADA will be useful in offering evidence-based education materials and professional training of health workers, as well as providing guidance on the topic of culturally competent diabetes education. The Public Health Department will organize Community-wide screenings and telehealth access and collect local health data to help in tracking the outcomes.

The local clinics and pharmacies will have an opportunity to minimize the cost of medications and lifetime support, yet the community volunteers will provide the possibility of translation and peer mentorship, and outreach services. These roles will combine to establish a long-term trend of cooperation that will result in the participation of patients and equality of care.

There will be a clear communication plan with the aim of creating trust and transparency without discriminating against cultural and ethical issues, especially when it comes to data privacy. This plan will include the gain of informed consent, making sure that the community members are informed about the way their data will be utilized, and focusing on confidentiality by referring to the regulations and ethical principles in the local territory.

The strategy will involve the use of culturally relevant language, illustrations, and other alternative formats like audio or video presentations to people with disabilities to enable them to understand complex medical terms and concepts. The language barriers will also be surpassed by using interpreters and multilingual materials so that all the members of the community can understand the information, despite their level of education.

• Rationale for Collaboration

Partnerships with the community organizations that have already been established result in increased cultural inclusiveness, increased level of confidence by the populations, and a waste of resources. The ADA has the experience that is aligned with the nationally developed objectives of diabetes reduction, which will ensure the program will be both clinical and ethical (Abukhalil et al., 2024).

The cooperation with the local health agencies provides an opportunity to arrange screenings and training. The privacy of the data and the ethical communication of this partnership are also easier with the use of HIPAA-compliant systems and informed consent practices. Lastly, the partnership will lead to communal accountability, which would help the community to maintain a lasting change in the prevention and management of diabetes.

Slide 6

• Relevance and Value of Evidence and Technology

Evidence

The evidence and technology resources utilized in the population health improvement plan are useful and applicable since they are informed by the latest and peer-reviewed research that specifically responds to the needs of adults with T2DM in various community settings. The latest research demonstrates that SDM, MI, and family-based education can be used to facilitate positive patient outcomes and self-management in diabetes.

Religioni et al. (2025) have discovered that the methods increase engagement, treatment adherence, and satisfaction. Diabetes Self-management Education (DSME) also has a better regulation of HbA1c level and self-confidence to cope with the disease. One can discover peer-reviewed literature, ADA guidelines, and reports issued by the CDC that were all published within the past 5 years and can back these findings. Altogether, this fact demonstrates that the educational and family-based care is an effective, ethical, and patient-focused way of managing diabetes.

Technology Value

Technology helps and supports patients with diabetes to track their illnesses with less effort and stay determined towards treatment. MySugr and Glucose Buddy are remote health and mHealth apps that allow patients to monitor their blood sugar and get immediate feedback, and communicate with the healthcare provider remotely (Religioni et al., 2025). Electronic Health Records (EHR) portals are used to improve communication and follow-ups on medications, not to mention lab results. Continuous Glucose monitoring (CGM) is a real-time data used to prevent high or low blood sugar levels. These devices are used ethically, requiring the privacy of the data, patient approval, and templates that are clear-cut, multilingual, and easily interpretable by anyone.

New technologies are being used to revolutionize diabetes. AI-based health coaching apps offer personal tips and reminders depending on patient data (Li et al., 2020). The VR technologies teach insulin administration, nutrition, and exercise in a virtual environment that increases education and confidence. With multilingual telehealth, patients with language barriers are able to access care and are given equal opportunities and accessibility to care. The combination of these technologies helps not only in learning but also overcomes the issue of literacy and supports ethical and patient-centered delivery of diabetes care.

Slide 7

• Specific Actions for Community Stakeholders

The community stakeholders could contribute to the sustainability of the efforts to combat diabetes. They will be able to support the program with local diabetes education meetings where they will train on how to self-care, dietary planning, and glucose monitoring. Adults will be empowered to be conversant with telehealth and mHealth devices, which will be provided at a reasonable cost (Rasekaba et al., 2022).

Online consultation will be made easier since telehealth access points will be established within community libraries or clinics where people have limited resources. The other manner in which the leaders can promote culturally appropriate nutritional campaigns would be by acting in a respectful manner towards the culture, without ignoring healthier eating. The financial impediments must be eradicated by making the equipment used to monitor glucose levels subsidized and internet access affordable to available to the local policy makers.

Permanent and participatory change is achieved through community ownership. According to the Change Theory developed by Lewin, the changes begin with the creation of awareness (unfreezing), the process is further supported by the introduction of novelties through education (change), and the continuity of the activity of the communities (refreezing). Peer support groups are community-based groups that can enhance motivation, trust, and accountability in self-care. The involvement of the local voices will make the initiative more powerful, fairer, and long-lasting to improve the results of diabetes.

Slide 8

• Conclusion

Diabetes Type 2 is among the significant social health issues that demand effective interventions that are attentive to both culture and patient-centered. The community partnerships are proper, and the population health improvement plan is self-management-based on education and technology. Work collaboration with the local health organizations and the American Diabetes Association (ADA) will provide ethical, inclusive, and sustainable outcomes.

The embrace of technology will help in the engagement, improve health literacy, and provide equal access to care. All these strategies are meeting their moral obligations to the nursing profession, which allows us to be fair and patient-centered, and reminds us that we can change the situation in the diabetes care state of affairs across the board, with the help of empathy, evidence, and empowerment.

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Slide 9

• References

Abukhalil, A. D., Muhanna, S. A., Madi, M. N., Ni’meh Al-Shami, Naseef, H. A., & Rabba, A. K. (2024). Patient Preference and Adherence, Volume 18, 2667–2680. https://doi.org/10.2147/ppa.s494951

CDC. (2024, May 15). National diabetes statistics report. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/php/data-research/index.html

Li, J., Huang, J., Zheng, L., & Li, X. (2020). Application of Artificial Intelligence in diabetes education and management: Present status and promising prospects. Frontiers in Public Health, 8. https://doi.org/10.3389/fpubh.2020.00173

Jayasinghe, S., Byrne, N. M., & Hills, A. P. (2025). Cultural influences on dietary choices. Progress in Cardiovascular Diseases, 90(1), 22–26. https://doi.org/10.1016/j.pcad.2025.02.003

Kesavadev, J., & Mohan, V. (2023). Reducing the cost of diabetes care with telemedicine, smartphones, and home monitoring. Journal of the Indian Institute of Sciences, 103(1). 231-242. https://doi.org/10.1007/s41745-023-00363-y

Nkhoma, D., Jenya Soko, C., Joseph Banda, K., Greenfield, D., Li, Y.-C. (Jack), & Iqbal, U. (2021). Impact of DSMES app interventions on medication adherence in type 2 diabetes mellitus: Systematic review and meta-analysis. BMJ Health & Care Informatics, 28(1). https://doi.org/10.1136/bmjhci-2020-100291

Geriatrics, 7(2), 28. https://doi.org/10.3390/geriatrics7020028

Religioni, U., Barrios-Rodríguez, R., Requena, P., Borowska, M., & Ostrowski, J. (2025). Medicina, 61(1), 153–153. https://doi.org/10.3390/medicina61010153

Taylor, S., Cairns, A., & Glass, B. (2021). International Journal of Environmental Research and Public Health, 18(12), 6456. https://doi.org/10.3390/ijerph18126456

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