DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

1. Individual Success Plan signed off by mentor.
2. Case log of actual clock hours applied to doctoral level learning outcomes.
3. Learner evaluations: one by faculty (final).
4. Current and updated CV. (Update each course as necessary.)
5. Faculty approvals of the Individual Success Plan and documented practice immersion hours. (Learner is responsible for obtaining approvals.)
6. Practice mentors’ approval of the Individual Success Plan and documented practice immersion hours. (Learner is responsible for obtaining approvals.)

Improving Medication Adherence among Type II Home Healthcare Diabetic Patients

Submitted by

Bola Odusola-Stephen

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

May 12, 2021

GRAND CANYON UNIVERSITY

Improving Medication Adherence among Type II Home Healthcare Diabetic Patients

by

Bola Odusola-Stephen

Proposed

May 12, 2021

DPI PROJECT COMMITTEE:

Maria Thomas, DNP, Manuscript Chair

Bamidele Jokodola, DNP, Committee Member

Abstract

Home healthcare programs are often effective since these programs offer techniques for improving health outcomes among diabetes patients. At the project site, although staff consistently assesses for patient medication adherence (MA), there is no standardized process for identifying and addressing MA. Medication Adherence Project (MAP) resources have been utilized in chronic disease management to improve MA. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of Medication Adherence Project (MAP) resources, which include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List, will impact medication adherence among type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas over a period of four weeks. The theoretical frameworks that will guide this direct practice improvement (DPI) project include the social cognitive theory and the attachment theory. MA rates will be abstracted from the project site’s EHR, based on documentation provided by home health personnel, and will be compared to baseline MA rates.

Keywords: home-based care, MAP resources, quantitative approach, medication adherence, diabetes mellitus type II

Table of Contents

Chapter 1: Introduction to the Project 8 Background of the Project 9 Problem Statement 10 Purpose of the Project 14 Clinical Question 15 Advancing Scientific Knowledge 16 Significance of the Project 18 Rationale for Methodology 19 Nature of the Project Design 20 Definition of Terms 22 Assumptions, Limitations, Delimitations 23 Summary and Organization of the Remainder of the Project 25 Chapter 2: Literature Review 27 Theoretical Foundations 28 Review of the Literature 33 Strengthening the Relationships with Patients 35 Importance of Adhering to Medication Regimen 36 Tools/Support Strategies for Improving Self-Efficacy and Medication Adherence 39 Diabetes Care Concepts 40 Patient-Centeredness 40 Diabetes Across the Life Span 41 Advocacy for Individuals with Diabetes. 42 Summary 42 Chapter 3: Methodology 45 Statement of the Problem 46 Clinical Question 47 Project Methodology 49 Project Design 50 Population and Sample Selection 51 Sources of Data 53 Validity 55 Reliability 56 Data Collection Procedures 56 Data Analysis Procedures 58 Potential Bias and Mitigation 59 Ethical Considerations 60 Limitations 61 Summary 62 References 64 Appendix A 73 Appendix B 80

5

Chapter 1: Introduction to the Project

According to the Centers for Disease Control and Prevention (2020), diabetes impacts one in ten Americans. Furthermore, the prevalence of diabetes continues to rise and is projected to increase by 0.3% per year until 2030 (Lin et al., 2018). Two types of diabetes plague a large proportion of Americans: Type I diabetes and Type II diabetes. Type I diabetes is dependent on insulin, whereby the pancreas produces minimal amounts of insulin (Bellouet al., 2018). Type II diabetes is an impairment related to the body’s ability to regulate glucose (Bellou et al., 2018). There are ways to curtail the onset of Type II diabetes; however, once individuals are diagnosed with diabetes, there is no cure (Kvarnström et al., 2017).

Among individuals with Type II diabetes, proper and effective medication adherence is critical (Kvarnström et al., 2017). According to the World Health Organization (WHO, 2003), “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvements in specific medication treatment” (Brown & Bussell, 2011, para. 1). Furthermore, Kvarnström et al. (2017) stated that more than half of the population does not adhere to prescribed medication regimens, resulting in various health-related challenges. Health-related challenges associated with poor medication adherence include limited knowledge of health-related benefits, lack of proper technique for providing dosage, lack of patient self-management, and lifestyle constraints (Kvarnström et al., 2017). For individuals with Type II diabetes, lacking medication adherence can mean the difference between life and death (Rathish et al., 2019).

Various researchers have denoted the critical role that home healthcare providers play in promoting enhanced medication adherence (Bussell et al., 2017). Furthermore, the WHO, as cited by Brown and Bussell (2011), explained that five factors impact medication adherence, which include: (1) patient-related factors, (2) socioeconomic factors, (3) therapy-related factors, (4) condition-related factors, and (5) the health system/health care team-related factors. For this project’s purpose, the primary investigator (PI) will examine the impact/role that healthcare team members play in addressing patient-related factors that affect medication adherence among home healthcare diabetic patients. The health system/health care team-related factors.

The project was conducted to improve the patient’s adherence to medication to increase their overall health and wellbeing as it relates to diabetes mellitus. The primary investigator (PI) will also examine the impact/role that healthcare team members play in addressing patient-related factors that affect medication adherence among home healthcare diabetic patients. When diabetic patients do not adhere to their prescribed medication regime, they tend to have poor outcomes (Kvarnström et al., 2017).

Background of the Project Comment by Author: This heading is tagged with APA Style Level 2 heading.

Home-based healthcare has existed since 1909 (Choi et al., 2019). Since its inception, home-based healthcare has been perceived as a more costly method of patient care than expenses associated with hospitalization (Singletary, 2019). In the early 20th century, home-based healthcare was mainly practiced due to financial disparities, specifically since many individuals could not afford hospitalized care. Furthermore, home-based healthcare was also practiced due to medical inaccessibility, which often existed in African American communities due to limited access to resources (Choi et al., 2019).

Present-day, home-based healthcare is often selected due to an individual’s personal preferences. There are some situations in which individuals prefer the comforts of their own home compared to that of a hospital or group home (Bryant, 2018). As older generations continue to age, they often prefer to remain in their home for as long as possible. Given the needs of older generations and the impact of advances in healthcare and technology, the prevalence of home-based healthcare has exponentially grown (Wong et al., 2020). While home-based healthcare is not appropriate for all patients, Szanton et al. (2016) noted that this care option is best when an individual’s condition can be managed without admission to a hospital. Patients who have diabetes or hypertension are often recipients of home-based healthcare (Wong et al., 2020).

Home healthcare providers often visit patients and assess their blood pressure, cognitive functioning, and adherence to treatment proposals. During patient visits, home healthcare providers are responsible for biological assessments of patients (Wong et al., 2020). One of the vital functions of home healthcare providers is to ensure that patients are adhering to their medication regimen (Wong et al., 2020). According to Wong et al. (2020), medication adherence is predicated on medication understanding and education, which home healthcare providers should convey.

Adhering to diabetes medication regimen requirements can be complex. In fact, in a study by Raoufi et al. (2018), the researchers noted that 10% of diabetic patients did not correctly monitor their glucose levels, nor did they adhere to medication requirements. Dr. Goldbach, who is the Chief Medical Officer for Health Dialogue, stated, “There are programs that can be based on things like texting people, but what we’re highlighting is the fact that – especially for people with chronic illness that are facing challenges like depression, or transportation, or complexity of medication regimens – that these interpersonal, trusted interactions with a nurse tend to be very effective” (Heath, 2018, para. 8). Patients with diabetes often express difficulties in adhering to medication regimens, thereby reinforcing the critical role of receiving education from home healthcare providers (Wong et al., 2020). Comment by Author: Paraphrase please, there should only be on quote per chapter

In a study by Wong et al. (2020), home healthcare patients expressed that they did not have sufficient knowledge about the requirements associated with diabetes treatment. Often, diabetic home healthcare patients fail to practice medication adherence, thereby resulting in health complications due to unmanaged health conditions. Comment by Author: Need another sentence to equal a paragraph

Problem Statement

It is not known if or to what degree the implementation of the Medication Adherence Project (MAP) resources, which include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List, will impact medication adherence among type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas over a period of four weeks. At the selected project site, a home healthcare organization located in urban Texas, the stakeholders have cited that medication adherence among diabetic patients is lacking. In fact, according to data obtained from the site’s electronic health record (EHR), home healthcare providers have documented that 10% of diabetic home healthcare patients are not adhering to their medication regimen. Although this percentage is under 10 percent lower than other percentages cited in the literature for medication non-adherence, in terms of chronic disease management, various researchers have noted the implications associated with lacking adherence to medication regimens (Brown & Bussell, 2011; Camacho et al., 2020; Hamrahian, 2020; Misquitta, 2020; Wood, 2012). Lacking medication adherence is especially troubling among diabetic patients. It can be due to inadequate drug-related knowledge, medication costs, poor understanding of medication regimen, etc., thereby reinforcing the need for this direct practice improvement (DPI) project (Heath, 2019; Sharma et al., 2020).

Kvarnström et al. (2017) emphasized healthcare providers play a critical role in ensuring medication adherence. While there are many reasons for lacking adherence among patients, for this project, the WHO’s (2019) focus on the role of healthcare team members in enhancing medication adherence will be addressed. To promote medication adherence among patients of a home healthcare facility, the primary investigator will use MAP resources.

As previously noted, among diabetic patients at the project site, medication non-adherence is 10%. While this level of medication non-adherence seems exceptionally low, it is essential to note that false reporting among patients may occur (Tedla & Bautista, 2017). Tedla and Bautista (2017) explained that “self-reported medication adherence is known to overestimate true adherence.” Choo et al. (2001) demonstrated that 21% of patients expressed non-adherence when in fact, after measuring adherence with electronic cap bottles, non-adherence rates were 42%. In-home healthcare settings, lacking adherence to diabetic regimens is 14% (Ong et al., 2018). It is important to note that the project site’s non-adherence rates might be similar to that of the national average; however, often, patients are wary about disclosing true non-adherence due to embarrassment, forgetfulness, and lacking knowledge about the importance of medication adherence. Comment by Author: Divide into two sentences for clarity 44 words, a sentence has 24 to 30 words

To improve patient-related outcomes and reduce preventable issues, home healthcare nursing staff members will utilize MAP tools, which were created by Starr and Sacks (2010). The tools utilized in this study, which are from Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List. Before implementing these tools, the PI will provide a 30-minute information session on this project’s purpose and significance and provide detailed information about utilizing the MAP resources.

During the onset of this project, once home healthcare nursing staff members have attended the educational training session, the project will be implemented. Nursing staff members will first provide patients with the Questions to Ask Poster. The purpose of offering this poster to patients is to address the six questions about medication, thereby improving patients’ knowledge regarding their medication regimen and reasons for the regimen prescribed.

After addressing the six critical questions on the Questions to Ask Poster, patients will be provided with the Adherence Assessment Pad. The purpose of the Adherence Assessment Pad is to explore barriers that impact one’s adherence to the prescribed medication regimen. There are several factors, listed on the pad, that affect one’s medication adherence (e.g., [1] Makes me feel sick, [2] I cannot remember, [3] Too many pills, [4] Costs, [5] Nothing, and [6] Other). To further understand what might be preventing patients from adhering to their medication regimen, this resource is necessary to utilize.

Once barriers associated with medication adherence are identified, the nursing staff member will provide patients with the My Medications List. This list is essential to give the patients, as it allows providers and patients to converse about a schedule for taking one’s medication and details, in a sheet, when medication must be taken. According to Starr and Sacks (2010), “Filling out the Medication List may seem time-consuming. However, your initial investment will pay off, as patients better understand their regimens and adherence increases” (p. 17). In addition to the time-consuming nature of filling out the My Medications List, nursing staff members and patients might feel overwhelmed during this first session. However, it is important to note that subsequent nurse-patient home healthcare meetings will seem less intense after the first session because the My Medications List is the only MAP resource that will be consistently reviewed over the four weeks.

To evaluate the impact of the intervention, the PI will compare pre-project implementation medication non-adherence rates to post-project implementation medication non-adherence rates after implementing the MAP resources. Project participants will include Type II diabetes patients, ages 35-64, who are receiving home health services at the project site. Medication adherence data will be available through the project site’s EHR. This project will take place over four weeks. 

Purpose of the Project

The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the MAP resources, which will be delivered by home healthcare nursing staff members, will impact medication adherence when compared to current practice among type II diabetic patients, ages 35 to 64 of a home healthcare setting in urban Texas. Medication adherence is the dependent variable explored in this project and will be measured using data attained through the project site’s EHR. The MAP resources, which serve as the independent variables explored in this project, include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List. Comment by Author: Spell out 1st time using

Each month, the selected project site, which is located in urban Texas, serves an average of 100 patients. Of the total number of patients, approximately 30 patients have Type II diabetes. Patients with Type II diabetes, who are between the ages of 35 and 64 and are without cognitive or language deficits, will be the target population for this project. Exclusion criteria consists of age, gender, race, ethnicity, type of disease, treatment history, and other medical conditions. The project is significant since home-based healthcare services can enhance treatment initiative outcomes. Wong et al. (2020) stated that physicians visit patients to ensure proper status of patient’s blood pressure, cognitive functioning, and adherence to treatment proposals. Comment by Author: Complete this please

Starr and Sacks (2010) explained that engagement with healthcare providers is imperative, as these encounters can enhance patient-related health outcomes. Physical and cognitive assessments are conducted to ensure that patient-related home-based treatment approaches are effectively implemented. The project is vital as it may enhance positive healthcare outcomes, through improving medication adherence among Type II diabetic patients, using the MAP resources.

Clinical Question

The problem described above was used to create a clinical question. The problem was it was unknown if or to what degree the implementation of the MAP resources, which will be delivered by home healthcare nursing staff members, will impact medication adherence when compared to current practice among type II diabetic patients, ages 35 to 64 of a home healthcare setting in urban Texas. The clinical question results will be determined using data collected on the diabetic patient self-reported documentation on their adherence to medication administration as prescribed by their clinician. A clinical question should be relevant to the problem being investigated and formed to facilitate an answer (Leedy & Ormrod, 2013).

A well-developed clinical question must be related and relevant to patient care. This helps the primary investigator search for evidence-based answers. The clinical question that will direct this quality improvement project is: To what degree does the implementation of Medication Adherence Project resources, which include the Questions to Ask Pad, the Questions to Ask Poster, an Adherence Assessment Pad, and the My Medications List impact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas over a period of four weeks?

This project’s independent variable was implementing the Medication Adherence Project resources, which include the Questions to Ask Pad, the Questions to Ask Poster, an Adherence Assessment Pad, and the My Medications List impact medication adherence. The dependent variable was the Medication adherence attained through the project site’s EHR. Medication adherence has the potential to decrease the likelihood of complications related to diabetes. The adherence to medication attained via the EHR will be counted and the use of the MAP resource will be documented.

Chapter 2: Literature Review

Diabetes is a medical condition that is characterized by high blood sugar levels, and is managed with drugs and insulin. Blood sugar serves as the major producer of energy in the body, therefore conditions/factors interfering with blood sugar levels and mechanisms disrupt normal body activities. Optimal diabetes control requires patient engagement in various types of self-care activities, including adhering to the identified medication regimens, adjusting to various lifestyle changes, and monitoring blood glucose levels (Jajarmi, Ghanbari, & Baleanu, 2019).

Diabetes is a lifestyle disease, which can be prevented or avoided by making lifestyle changes. Disease management can also occur through adhering to one’s prescribed medication regimen(s). Medication adherence is important since it can help to reduce the likelihood of diabetes-related challenges and complications.

One of the most problematic issues associated with home care for diabetes patients is adherence to medications. According to Bonney (2016), patients take their medication as prescribed only 50% of the time. Furthermore, patients are often reluctant to share medication compliance details, thereby resulting in health-related complications. This project hopes to enhance medication adherence, at the project site, which offers home-based care to diabetes patients. This project will also analyze the role of educating patients on medication adherence in improving their medication adherence.

Chapter 2 provides a theoretical framework and an empirical framework. Medication taking behaviors among home-based healthcare diabetes patients is investigated. The chapter is divided into theoretical and empirical sections. The theoretical section reviews the two theories that will guide this project, which include the attachment theory and social cognitive behavior theory. In the empirical section, literature from peer-reviewed studies and projects is explored. Furthermore, literature gaps are identified.

The primary investigator (PI) utilized various databases to conduct a thorough review of the literature. Specifically, the PI systematically searched for reviews that reported various aspects associated with medication adherence among diabetic patients. Eighteen systematic reviews, scoping reviews, and narratives were analyzed and are included in this chapter. Overall, the literature review revealed six main sub-themes and other sub-themes that promote the importance of this direct practice improvement (DPI) project. Each of the key sub-themes is comprehensively discussed and details about the importance of these sub-themes, in terms of the project’s focus, are explored.

Theoretical Foundations

According to Liu and Butler (2016), medication adherence is considered to be the largest challenge that healthcare workers and patients encounter. Medication adherence is a critical issue that requires more attention. Two key theories are explored during this project, which attempts to explain the relationship between medical non-adherence among patients and how medication adherence can be enhanced among diabetic patients through improved interventions.

Attachment theory. The first theory that will guide this project is the attachment theory. Bowlby (1958) proposed that attachment is adaptive as it improves the infant’s chance of survival. The attachment theory is defined as being a psychological, evolutionary, and ethological associated theory concerning the aspects of relationships between individuals. The attachment theory is famous and has been used in healthcare practices for many years. The most vital tenet of the attachment theory is that young children usually need to develop a relationship with, at minimum, a single primary caregiver. The child’s caregiver assists in offering social and emotional support. Within this theory, the term “attachment” is usually utilized to refer to an affection bond or tie that is between a person and their attachment figure, who in this case is considered to be the child’s caregiver (Liu & Butler, 2016). In this project, the attachment figure is the patient’s home healthcare provider, as providers can assist in creating the best interventions for enhancing medication adherence among diabetic patients.

The biological purpose for the use of attachment theory is the facilitation of survival, while the psychological purpose of the theory is to offer security, thus making it a suitable theory to use. Attachment theory does not provide an exhaustive description of human relationships. Furthermore, this theory is not synonymous with feelings of love or affection. In child-adult relationships, the child is usually referred to as the attachment while the caregiver is usually defined as being the reciprocal equivalent, who in this case is called to provide the caregiving bond (Hunter & Maunder, 2016). 

The modern attachment theory focuses on bonding, which is an intrinsic human need that can assist in regulating emotions, such as fear, which can result in improve vitality and can promote development. Common attachment behaviors and emotions are usually displayed in most social primates, including humans, and are considered to be adaptive. The long-term evolution of social primates has aided in identifying social behaviors that enable people and groups to survive. The commonly observed types of attachment behavior in toddlers, such as staying near familiar individuals, are based on safety advantages. According to Bretherton (1992), Bowlby and Ainsworth perceived the environment associated with early adaptation as similar to hunter-gatherer communities. There is a survival advantage in the capacity to effectively sense dangerous conditions, like the issue of unfamiliarity, loneliness, and rapid approach, through guidance and support.

The advancement of attachment is considered to be a transactional process. Particular attachment behaviors start as predictable innate behaviors in the infancy stage of life. The behaviors are altered with age in various ways that are determined partly by experience, as well as the various sit-upon elements. As the various attachments are altered throughout life, they are shaped by relationships.

According to Hunter and Maunder (2016), there are two key reasons why the attachment theory is considered effective for the following DPI. First, the theory acts as a solid foundation for the enhanced comprehension regarding the identified development of ineffective coping techniques, as well as the underlying dynamics associated with the emotional difficulties of the person. Clinicians can help people who have attachment anxiety and fail to comprehend past experiences. Through the involvement of caregivers and/or significant others, individuals can help to reshape their coping patterns.

Clinicians can help people who have attachment anxiety and avoidance to find the best alternative way to meet their various needs. Most of the individuals who seek help want to learn how they can employ different strategies for coping with the dysfunction in their daily lives. Furthermore, individuals often express the desire to modify their dysfunctional and/or inappropriate coping techniques. The desire to change/modify techniques is an essential aspect needed to encourage medication adherence. Before delivering appropriate and patient-specific advice and interventions, to diabetic patients of the selected project site, individuals may express that they would like to adhere to their medication regimens. It is important to note that for effective outcomes to be realized, it is critical to ensure that all of a patient’s basic needs are effectively met. Therefore, through understanding barriers and challenges associated with medication adherence, strategies can be created, which can result in effective patient-related outcomes (Hunter & Maunder, 2016). 

Social cognitive theory (SCT). The social cognitive theory (SCT) is a critical theory that will be utilized during this DPI project. The SCT is utilized to explain how human behavior is associated with dynamic, reciprocal, and progressive types of interactions that exist between the person and his/her given surrounding (Bosworth, 2015). Therefore, the SCT is famous because it often proposes that identified behavior aspects are an outcome of the cognitive processes that individuals usually develop. Cognitive processes are developed through social knowledge acquisition.

According to Bosworth (2015), the SCT bases its focus on the concept of behavioral capability, which states that before any individual acting in a certain situation, the individual needs to have knowledge on what they need to do and the manner in which they need to do it. Bandura’s (1986) conceptual model regarding reciprocal determinism is often utilized in addressing all the personal determinants associated with health. Bandura (1986) postulated people often engage in cognitive, vicarious, self-reflective, and self-regulatory processes in hopes of attaining a given goal. Individuals can often change by identifying their actions and proactively engaging in their change-related behaviors. When people exercise individual control over their behaviors, thoughts, procedures, and motivations, enhanced outcomes can be achieved (Bosworth, 2015).

Bandura (1986) asserted without having any kind of aspirations, individuals usually course through life unmotivated and uncertain regarding their specific capabilities. Nonetheless, Bandura also stated that people who take part in health-promoting behavior have self-belief, which enables them to fully take control over their thoughts, feelings, and actions (Badura, 1986). Bosworth (2015) explained that self-control should get promoted since it improves the ability of individuals to adopt healthy habits. According to Bandura (1986), although the SCT acknowledges that patients must understand health-associated risks and the benefits of treatment to effectively perform health-associated behaviors, understanding, in itself, is not adequate.

Self-influences can help an individual to achieve various changes that will result in desired health-associated outcomes. An individual’s belief in his/her ability to achieve certain outcomes is a concept that is referred to as self-efficacy. The two types of cognitive processes that are involved in influencing behavior in the SCT are self-efficacy and outcome expectations (Bosworth, 2015).

According to Hadler, Sutton, and Osterberg’s (2020) findings, SCT is essential to encourage patient change. Healthcare workers who counsel patients with chronic medical illnesses, like HIV or diabetes, found that providing patients with vital knowledge can enhance their likelihood of adhering to health/lifestyle changes. Support groups can utilize the SCT to empower patients to effectively approach and address various issues associated with medication adherence. In addition, supportive types of relationships can be established to effectively strengthen the patient’s ability to adhere to his/her prescribed medication regimen.

The two theories (i.e., the attachment theory and the SCT) are associated with improved health-related adherence and enhanced clinical results. Through education and support, medication adherence can improve. The attachment theory and the SCT will be used during this project to aid in improving medication adherence among patients. Patients often need to be educated, by a trusted medical provider, about the benefits of medication adherence. Therefore, through using the MAP resources, which encourage patient-provider conversation and discussion, special interventions can occur, thereby improving medication adherence. Healthcare providers, of the selected project site, will encourage patients to make behavioral changes and will offer support/rationale for these changes, thereby likely improving medication adherence.

Review of the Literature

Medication adherence is a major healthcare challenge that impacts a patient’s quality of life. Researchers are constantly exploring ways to minimize medication non-adherence and continue to develop evidence-based strategies to improve medication adherence among patients. Medication non-adherence is a critical issue that deserves a higher level of attention. Understanding medication adherence-related barriers, addressing those barriers, and inspiring patients to change their actions/beliefs is an important step in improving health among patients.

At the selected project site, healthcare workers, who work directly with diabetic patients, believe it is critical to ensure medication adherence. Patients present with unique health-related challenges, thereby reinforcing the importance of minimizing health-related threats. Lacking medication adherence can mean the difference between life and death (Rathish et al., 2019). Adherence to antiretroviral therapy is considered a predictor of effective clinical outcomes among diabetic patients, which is one of the reasons why medication adherence is essential.

Medication adherence. The term medication adherence refers to the art of taking medication as prescribed by a patient’s healthcare practitioners (Ahmed et al., 2018). Healthcare practitioners must ensure that the prescriptions that are provided to patients are suitable to the patient’s unique condition(s). Ahmed et al. (2018) stated that the quality of healthcare can be influenced by the ability of the body to respond to treatment. It is important to conduct physical assessments of patients so high-quality care is offered.

While medication adherence is important, there is a plethora of literature available that expresses the prevalence of medication non-adherence among patients. Various factors continue to impact medication adherence, which includes, but are not limited to, fear, costs, misunderstanding, too many medications, lack of symptoms, mistrust, worry, and depression (American Medical Association [AMA], 2020). To prevent medication non-adherence, providers can seek to understand the needs of patients and provide them with resources that can aid in overcoming non-adherence.

Enhancing medication adherence. To handle the issue of medication adherence among the diabetic patients who have had an issue with adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere to the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as costly public health-associated challenge especially for the healthcare system in the US.

Since the aspect and issue of inappropriate as well as inefficient medication adherence are considered to be a complex change with a variety of contributing causes, there is no universal solution (Rodriguez-Saldana, 2019). The following theme breaks down into three subcategories that form the basis of the sub-themes associated with this theme. The sub-themes are used to offer a comprehensive analysis of all the vital types of interventions that are considered to be effective in enhancing medication adherence among diabetic patients but are also considered to be potentially scalable, that is they are easy to implement in any given scenario and population (Bosworth, 2015). Key traits that make these interventions effective are discussed throughout the DPI. The information offered under each sub-theme is vital to explain, as it can result in enhanced medication adherence through the implementation of documented and cost-effective solutions.

Strengthening the Relationships with Patients

Patients usually consider their healthcare providers (HCPs) as the most dependable source of data regarding their health condition and treatment. Patients are highly likely to effectively follow the treatment plan when they are involved in having a good relationship with their HCP due to the confidence and trust that has been built over time. Relationship building in healthcare is considered to be a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job, which necessitates that they maintain long-term relationships with their patients for enhanced medication and treatment outcomes (Heston, 2018).

Trust is critical to developing, specifically since patients can experience improve health-related outcomes when they value relationships with their HCPs. Patients who have trust in their HCP often believe that their provider has a high level of competence and truly cares about their health-related outcomes (Heston, 2018). Mistrust develops when the patients attain unrealistic, inconsiderate, or insensitive advice from their HCPs, as well as feel some kind of emotional distance from them.

Importance of Adhering to Medication Regimen

Literacy is the ability to read and understand the different information that is provided to a person. Researchers have and continue to explore the impact of low literacy rates on patient compliance with medication regimens and other health-related advice (Glanz, Rimer, & Viswanath, 2015). An estimated 35% of American adults are considered to possess basic or below basic health literacy. Lacking literacy rates are a global concern and impact an individual’s ability to comprehend and read what is indicated on prescribed medicines or treatment sheets. Health literacy has been considered to be a vital aspect in receiving any kind of service. Health literacy helps diabetic patients comprehend the details of their care or seek further clarification if they do not understand the information (Glanz et al., 2015).

Given inadequate literacy rates, among members of the general population, world practitioners continue to create unique strategies that can be used to reduce lacking health adherence among patients with diabetes. Improved literacy is a theme that should be of the utmost priority, specifically since it creates the foundation for long-term sustained profitability. Furthermore, as patients can understand the importance of medication compliance, adherence to medication regimens improves (Glanz et al., 2015).

Using universally implemented and published resources that can improve medication adherence is important. Tools and resources can be utilized by HCPs to identify patients who are not taking their prescribed medications. Prescriptions need to be taken seriously for exceptional results and for the continued well-being of patients who have critical illnesses like diabetes.

The use of simple language by HCPs, as well as by medication manufacturers, can encourage providers to meet patients where they are and utilize teach-back techniques to ensure a patient’s understanding of his/her prescribed medication regimen. Teach-back methods have been utilized to enhance medication adherence among many types of non-adhering patients. Most of the time people opt to not take their medication as they cannot read all the instructions written on the medicine and are afraid that they will die, especially in the cases that they mistake those drugs for poison or some drug that may look like a famous poison causing death. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine, 2018). 

Reading instructions and making a patient understand what is written on a medicine bottle or package should never be taken for granted as it is key for determining how patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. For the medical practitioner to be aware and sure that what they have explained to the patients has been delivered safely and appropriately, there is the need for a verification test. The patients as well as their identified support individuals need to be asked to explain in their own words stating what they have understood from everything the practitioner has told them regarding their health, along with drug management and intake. This teaching back method is vital in offering additional data on the key topic of interest; thus it should be used often.

Concerns associated with the issues of side effects can be challenges to medication regimen adherence, especially when the given advantages associated with taking the medication are not properly comprehended. To minimize the potential concerns that are associated with the side effects of drugs, since this can be identified as one of the reasons why patients may opt to not adhere to medications in fear that they will experience the side effects and be greatly inconvenienced, there is the need for HCPs to offer the relevant data regarding the common types of side effects when they are in the prescription process.

There have been issues of people and patients dying or experiencing very negative and disturbing side effects when it comes to them taking the medication prescribed by their doctors. These cases have always been used as examples to explain the reason why people have been reluctant to take medications for prolonged periods. When an individual has a critical illness, it is not uncommon that he/she needs to take the prescribed medication for a long period, as this can result in improved medication efficiency. Lacking understanding of medication-related details has caused patients to withdraw from their prescribed medication regimen, which is due to lacking knowledge and prolonged side effect issues that are associated with their medication (Institute of Medicine [IOM], 2016). For example, when offering metformin, to enable adherence to the drug there is a need to inform patients that are suffering from diarrhea during their time of prescription to anticipate that the loose bowel issues will be over in about a week if the drug is continued. It is also vital to offer brief explanations about medication side effects and benefits due to time limitations. If a patient cannot have additional time with his/her provider, then other members of the health care team should aid in answering their questions and provide additional education. Education can be in the form of printed handouts, websites, or a teaching module that should be readily available for use with the identified patient.

In summary, among Americans, the level of medication illiteracy is assumed to be high. This significantly contributes to the difficulties faced by patients when they are required to follow instructions. There is a need for practitioners to take time and educate patients on the right measures to take. Educated patients will have a better understanding of the actions to take, which can positively impact their health-related outcomes.

Tools/Support Strategies for Improving Self-Efficacy and Medication Adherence

Using tools and instruments that are considered effective and appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family and social support are considered to be vital aspects associated with adherence to the issue of diabetes management (Rodríguez-Saldana, 2019). The engagement of family members can enhance self-care activities for patients suffering from diabetes, including eating effective and healthy foods, keeping fit, monitoring blood glucose, and adhering to medication.

A web-based portal is an innovative resource that can be used to assist patients. This web-based portal can improve medication reconciliation processes among patients and providers. The web-based portal can help patients with various regimens navigate challenges. Furthermore, this medication information, available through the portal can help individuals understand medication requirements, as the portal often helps to clarify and verify inaccuracies. The web portal aims to enhance medication adherence and prevent the improved use of the medication (Forman & Shahidullah, 2018). 

When patients can verify information in their electronic medical records to ensure proper medication adherence, this can enhance patient well-being. The EMR provides an accurate list of a patient’s medications and provides detailed medication information (e.g., type of drug, what the drug is used to treat, frequency of drug use, etc.). Also, the use of screening tests is vital in understanding how well patients are taking their drugs. If there is no consistency in medication-taking then motivation aspects should be utilized to enhance adherence (Eskola, Waisanen, Viik, & Hyttinen, 2018).

In summary, the simultaneous utilization of tools and instruments plays an essential role in upholding medication adherence. Having a supportive and positive-minded family also plays an essential role in supporting the self-efficacy of the patients. Innovation should be incorporated in searching for medications. This will be advantageous because of the contemporary rapid advancement in technology.

Diabetes Care Concepts

When dealing with patients who are reluctant to take their medications, various care concepts must be understood. Through improving one’s literacy, knowledge about the medication, and offering patient-specific details, enhanced outcomes can occur. Improved medication adherence can result in enhanced patient outcomes, thereby reinforcing positive long-term health-related outcomes. The following themes noted below, provided comprehensive knowledge, as well as in-depth illustrations, about the distinct components associated with clinical control for patients who have been diagnosed with diabetes. The review offers effective clinical practice guidelines, which must be considered, to enhance population health. It is important to note that to ensure identified optimal outcomes (discussed below), individualized patient care is critical.

Patient-Centeredness. Patient-centeredness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped to effectively adhere to the given medication during home care settings. Patients who have been diagnosed with various critical illnesses and have been asked to go home for home-based care have been associated with poor adherence to the medications they are given when they are discharged from the hospital (Steinberg & Miller, 2015).

Practice recommendations, whether they are focused on evidence or expert opinion, are intended to offer the desired guidance on an overall approach to care (da Costa, van Mil, & Alvarez-Risco, 2018). The science, as well as the art associated with medicine, usually come together when the identified clinician is experiencing or has experienced some sort of situation whereby, they have to make treatment recommendations for any patient who would be considered to not have effectively met the eligibility criteria for the studies on which the given guidelines were based.

Diabetes Across the Life Span. An increment in the identified proportion associated with patients that suffer from diabetes is usually considered to be mostly adults (Balogh, Miller, & Ball, 2015). For the less salutary reasons, the identified incidences associated with type II diabetes are considered to be highly increasing in the creating in the children as well as the young adults. Patients that possess type II diabetes as well as those that have type I diabetes are considered to have good lives even in their older age, which is regarded as a stage of life whereby there is minimal evidence from the identified clinical traits to be used in the guidance of therapy (Bonney, 2016). All these toes of demographic alterations are usually involved in highlighting another key challenge to high-quality diabetic patient care. In this case, the identified need is usually considered to be the enhancement of the coordination between clinical teams as well as patients in the effective transitioning via the dysfunction phases enticed in life span (Corcora & Roberts, 2015). 

Advocacy for Individuals with Diabetes. Advocacy is a vital aspect in healthcare since it addresses the needs of the patient who need the utmost help and care, thereby allowing them to go back to their previous health state (D’Onofrio, Sancarlo, & Greco, 2018). Advocacy is an aspect that can be referred to as active support, as well as engagement, that aims to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the lives of individuals suffering from diabetes. The various issues that diabetic patients experience, such as obesity, physical inactivity, and societal challenges reinforce the need for advocacy (Firstenberg & Stanislaw, 2017). 

Summary

The existence of chronic illnesses such as diabetes requires studying affected persons to limit negative events. The proposed intervention techniques should be studied to limit the occurrence of diabetes-related issues like frequent urination, fatigue, and thirst. The issues affect an individual’s capability to function in life. Optimal adherence to prescribed medications can be entailed in the decrement of complications, also enhancing clinical outcomes and saving healthcare-associated costs.

The DPI project has been constructed using careful techniques that promote the development of patient initiatives. The purpose of the project is to ensure that diabetic patient care techniques get applied to enhance the validity of treatment proposals. There are practical solutions to limiting the effects of diabetes, which require careful adherence (Nunes, 2015).

Medication adherence is considered to be the largest challenge that healthcare workers, as well as their patients, are facing in their daily lives. It is often considered to be a critical issue that deserves a higher level of attention. Inspiration along with the act of supporting patients to take their identified medications as prescribed can be a great issue, however, it is considered to possess the capability to possess the highest effect on their identified long term associated health as the well as on the economic well-being regarding the healthcare system of the nation.

Two theories will be used to guide this direct practice improvement project, which includes: the attachment theory and the SCT. The identified theories point to the possibility of solving the problem of poor medication taking behaviors through the use of attachment and social learning. The theories reveal that medication taking is learned and can be enhanced through the use of cognitive behavior change.

The empirical review points to the complications caused by lack of medication adherence in diabetes patients. It also highlights possible ways in which health care providers can help patients better adhere to medication through strategies such as advocacy and patient-centeredness. Overall, medication adherence is important to the treatment and effective management of diabetes in patients, and health care providers can play a vital role in ensuring that diabetes patients learn the importance of adherence.

Chapter 3: Methodology

Medication adherence is a critical aspect in minimizing the impact of negative patient-related outcomes among those with chronic illnesses. According to Ahmed et al. (2018), medication adherence, for the purpose of this practice improvement project, refers to the extent to which a home-based care patient can correctly take his/her medication in the absence of health practitioners. Medication adherence requires the patient to adhere and comply with all the medical instructions given (Bellou et al., 2018). Ahmed et al. (2018) noted that diabetes impacts one in ten Americans. Furthermore, the prevalence of diabetes continues to rise and is projected to increase each year by 0.3% by 2030 (Lin et al., 2018). There are two types of diabetes that plague a large proportion of Americans: type I diabetes, which is insulin-dependent, and type II diabetes, which is glucose related (Bellou et al., 2018). There are ways to curtail the onset of type II diabetes; however, once individuals are diagnosed with diabetes, there is no cure (Bellou et al., 2018).

This chapter’s purpose aims to determine if the implementation of the MAP resources, which will be delivered by home healthcare nursing staff members, will impact medication adherence.

The chapter is organized into sections. Chapter 3 details information about the methodology that will be used during this project. Information about the project’s design, selection of the sample, instrumentation, validity, and reliability are presented. Additionally, data collection procedures, data analysis procedures, ethical considerations, and limitations are included in this chapter.

Statement of the Problem

It is not known if or to what degree the implementation of the Medication Adherence Project (MAP) resources, which include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List, will impact medication adherence among type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas over a period of four weeks. At the selected project site, which is a home healthcare organization located in urban Texas, the stakeholders have cited that medication adherence among diabetic patients is lacking. In fact, according to data obtained from the site’s EHR, home healthcare providers have documented that 10% of diabetic home healthcare patients are not adhering to their medication regimen. At the project site, failure to adhere to the prescribed medication regimen has resulted in the limited capability to deal with diabetes related issues. Various researchers have noted the implications associated with lacking adherence to medication regimens, specifically among diabetic patients, thereby reinforcing the need for this practice improvement project (Ahmed et al., 2018).

Clinical Question

Prior studies have demonstrated that medication adherence among home-based care patients is lacking. Researchers have explained that medication non-adherence is often due to a variety of factors, which include lack of knowledge, trust, fear, and inadequate monitoring. Wolff-Baker and Ordona (2019) noted that there is usually nobody to remind patients to take medication the right way. Furthermore, many patients do not understand the importance of medication adherence, which is another issue that healthcare providers can aid patients in overcoming. The clinical question that will guide this direct practice improvement project is:

Q1: Does using the MAP resources improve medication adherence among home health diabetic patients?

Many researchers have explored ways to improve medication adherence among patients. To enhance medication adherence among home healthcare diabetic patients, a quantitative, quasi-experimental design approach will be utilized. Specifically, the PI will utilize the MAP Toolkit and Training Guide resources, which include: (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List.

The PI will evaluate how the use of the newly implemented MAP protocol contributes to medication adherence among patients over four weeks. Using the project site’s EHR, pre-project data will be analyzed from April 1, 2021 to April 30, 2021. The purpose of examining this pre-implementation project data is to determine if or to what degree the implementation of Medication Adherence Project resources may enhance medication adherence. Medication adherence among type II diabetic home healthcare patients, ages 35 to 64, will be explored by comparing pre-project implementation data to post-project implementation data. Currently, nursing staff members, of the selected project site, assess medication adherence by conducting interviews.

Unfortunately, the method of assessing medication adherence differs among nursing staff members. Furthermore, no tools or resources that are highly cited and/or evidence-based are utilized to assess medication adherence. Since there is no site-specific patient protocol developed or utilized to encourage medication adherence among patients, this project is necessary to ensure process standardization and to ensure that any patient-specific medication adherence barriers are properly addressed.

Medication adherence, which is the dependent variable explored in this project, will be measured using data attained through the project site’s EHR. The MAP resources, which serve as the independent variables explored in this project, include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List.

Table 1

Characteristics of Variables

Project Methodology

A quantitative methodology is appropriate for this project because of the clinical question being answered. According to Fain (2017), this research methodology focuses on objective measurements and analyzes the data collected through statistical, numerical, or mathematical analyses. Quantitative methodology also uses computational techniques to manipulate pre-existing statistical data. Usually, it is applied to test if certain theories and assumptions are true or false. According to Zaccagnini and Pechacek (2019), the two important foundational aspects of projects that use quantitative methodology are that they build on results and evidence from past research and that they usually form the basis for future research.

Specifically, the PI plans to analyze the impact of the change initiative pre-and post-project implementation, in which data from the project site’s EHR will be obtained. The project site data, about medication adherence, is quantifiable and objective data that is related to the clinical question and PICO question being explored during this project. To assess the impact of the intervention, numerical data will be analyzed using statistical analyses.

A quantitative methodology is the preferred methodology to utilize for this project, as compared to a qualitative methodology because compliance with medication adherence will be analyzed. If the PI wanted to learn more about common themes or issues impacting medication non-adherence, then a qualitative methodology, using interviews or focus groups, may have been utilized. Qualitative methods do not allow for numerical data to be compared. For this project, numerical data will be collected pre-and post-project implementation. All numerical results will be analyzed using statistical methods to explore the impact of the MAP resources. Based upon the data results, project-related conclusions will be made.

Project Design

This quality improvement project will use a quasi-experimental design as the principal evaluation method (Handley, Lyles, McCulloch, & Cattamanchi, 2018). The purpose of a quasi-experimental design is to compare data pre-and post-project implementation to explore the impact of a specific intervention. For this project, the impact of MAP resources as compared to current practice at the project site will be assessed. The PI will determine if the implementation of the intervention improved medication adherence among diabetic patients.

Since this project aims are to compare current practice versus the implementation of this project on enhancing medication adherence, numerical data will be collected and analyzed. Demographic data will also be collected during this project, which will be extracted from the project site’s EHR. Specifically, information about the gender and age of each participant will be attained. At the project site, there are 100 patients of which 30 have been diagnosed with type II diabetes. Using a G*power analysis, helps to determine the sample size for the study, which will help with the probability of detecting a “true” effect of comparing two different diets, A and B, for diabetic patients. Therefore, a minimum sample of 20 participants will involve in this project to ensure constancy of program design, implementation, and evaluation. It is important to note that although 30 of the patients, at the project site, have been diagnosed with type II diabetes, not all potential participants will meet the eligibility criteria. As previously noted, type II diabetes home healthcare patients must be between the ages of 35 to 64 and must not have any cognitive issues that would impair them from partaking in this project.

Pre-project implementation data and post-project implementation data, which will be reported in the EHR, by nursing staff members of the selected project site, will be analyzed. SPSS version 25 will be utilized to determine the impact of the intervention in improving medication adherence among patients. Given the benefits of the MAP resources, in enhancing medication adherence, it is the hope of the PI that medication adherence will be improved at the selected project site.

Population and Sample Selection

The term population reflects that main group of focus that possesses similar characteristics or traits. Therefore, the population for this project is type II diabetes patients who receive care through home healthcare organizations. Since the PI cannot incorporate the involvement of all type II diabetes patients who receive care through home healthcare organizations, throughout the world, the PI is therefore relying on a select sample. A sample refers to a subset of the population. The sample is type II diabetes patients of a home healthcare organization that is located in urban Texas.

The PI will use a non-probability sampling technique to carry out this project. Specifically, a convenience sample will be used because of ease of access to this particular group of individuals. The purpose of convenience sampling is to obtain information about the population of interest through accessing individuals who are easy to reach. Home healthcare patients, of the selected project site, will comprise the project’s sample.

Individuals who are eligible to participate in this project must meet the following criteria: (1) have a type II diabetes diagnosis, (2) be between the ages of 35 to 64, (3) be cognitively capable of engaging in this project (i.e., no mental impairments), and (4) be a home healthcare patient of the selected project site. According to a Texas Medicaid and Texas Diabetes Council report (2020), which provides the most up-to-date information about hospital claims from diabetes patients in 2019, 82,708 outpatient hospital claims were made by diabetes patients. Furthermore, 193,551 professional claims were made by Medicaid clients in 2019 (Texas Diabetes Council, 2020). The information reported by the Texas Diabetes Council (2020) is significant because it reinforces the prevalence of diabetes in the state of Texas where this project is to be carried out.

According to a study by the United Health Foundation (2019), the prevalence of diabetes among residents of Texas continues to increase. In the United States, according to the CDC (2019), approximately 10.7% of adult females have diabetes. In the state of Texas, 11.5% of females have diabetes. Furthermore, the prevalence of diabetes among U.S. males is 11.4%, while the prevalence of diabetes among Texan males is 13.0% (CDC, 2019). These findings reinforce the higher prevalence of diabetes among Texas residents.

At the selected project site, which provides home healthcare to 100 individuals, approximately 30% have a type II diabetes diagnosis. Of those individuals with a type II diabetes diagnosis 66% likely meet the inclusion criteria for participating in this project. As noted above, to determine the estimated sample size needed to encourage statistical significance, a power analysis was conducted. Based upon the effect size, the sample size, and the variability, it was determined that the ideal sample size for this project is 20, this relates to the G*power participants.

Sources of Data

The tools utilized in this project, which are from Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List. The first MAP tool that will be utilized is the Questions to Ask Poster. The Questions to Ask Poster is a tool that encourages patients to ask providers about their medication(s). The Questions to Ask Poster will be presented by home health nursing staff members and will be reviewed with type II diabetes patients. Home health nursing staff members will address all of the six questions on this poster, which include: (1) “Why do I need to take this medicine?,” (2) “Is there a less expensive medicine that would work as well?,” (3) “What are the side-effects and how can I deal with them?,” (4) “Can I stop taking any of my other medicines?,” (5) “Is it okay to take my medicine with over-the-counter drugs, herbs, or vitamins?,” and (6) “How can I remember to take my medicine?”

When barriers associated with medication adherence are addressed, in terms of knowledge, expenses, side effects, etc., patients typically feel more empowered. Furthermore, according to Starr and Sacks (2010), it is not uncommon for patients to feel surprised that they can ask these questions. The researchers noted that the Questions to Ask Poster aided individuals in feeling empowered, provided them with a list of questions that they normally would not ask, gave patients an idea of how to ask certain questions and what questions would be meaningful to them, and provided patient relief (Staff & Sack, 2010).

After discussing information and addressing all of the questions on the Questions to Ask Poster, the Adherence Assessment Pad will be given to all patients. The Adherence Assessment Pad explores answers to the following question, “What gets in the way of taking your medicine(s)?” The questions on the Adherence Assessment Pad include: (1) Makes me feel sick, (2) I cannot remember, (3) Too many pills, (4) Costs, (5) Nothing, and (6) Other. Nursing staff members will be asked to assume that individuals are not properly taking their medication. Through making this assumption, nurses can gain stronger insight into barriers that impact patients. For example, if cost-related concerns were denoted by the patient, then the nurse would likely go back to the patient’s primary care provider (PCP) and discuss why costs are impacting medication adherence. The process of exploring individual concerns with the patient’s care team can result in collaboration and enhanced patient-related outcomes.

It is important to note that if individuals cannot remember to take their medication, appropriate resources will be provided. According to Starr and Sacks (2010), “The question encourages truthful discourse, validates a positive response” (p. 16). Through encouraging truthfulness, individuals will feel empowered to express their concerns, which will allow for resources to be offered as appropriate based upon the patient’s concerns.

The final tool that will be utilized is the My Medications List. The My Medications List details information, in chart form, which will be discussed by the nursing staff member and patients. The purpose of the My Medications List is to encourage medication adherence among patients. The nursing staff provider and patients will discuss all of the categories in the chart, which include: (1) Name and Doses of My Medicine, (2) This Medication is for My Diabetes, (3) When Do I Take and How Much [options include: morning, noon, evening, and bedtime], and (4) I Will Remember to Take My Medicine _____ [note: the blank will be filled in]. It can be time-consuming to fill out this list, but it’s important to note that likely, once the patient and the provider work on the list together, patients will buy into the chart requirements and, therefore, improve their medication adherence. After filling out this chart, unless modifications are needed, subsequent visits will not require the chart to be filled out again.

In addition to the aforementioned instruments that will be utilized, it is important to note that information from the project site’s EHR will be collected. As mentioned above, pre-and post-project implementation data will be collected and analyze to determine the impact of the MAP intervention. Specifically, the PI will examine medication adherence rates from April 1, 2021 to April 30, 2021 to determine adherence rates before the project was implemented and four weeks after the project’s implementation.

Validity

There are various types of validity which include face validity, content validity, criterion validity, and discriminant validity. In terms of the MAP toolkit, the resources that are utilized, at face value, explore the topic of interest. For example, the researchers noted the instrument had strong validity in terms of attaining detailed feedback from participants regarding their lacking adherence to their prescribed medication regimen. The statements that were asked of participants, using the MAP resources, had good face validity and seek to encourage adherence to one’s medication regimen.

It is important to note that from 2007 to 2009, the MAP project was developed and included a group of professionals from the Fund for Public Health in New York and the New York City Department of Public Health and Mental Hygiene. The professionals developed and implemented a training course and toolkit, based upon years of experience. Professionals who were involved in this effort included physicians, pharmacists, nurses, medical assistance, nutritionist, social workers, and health workers (Starr & Sacks, 2010). In addition to making improvements from 2008 to 2010, when the study was published, about ways to strengthen the toolkit’s content, expert guidance and support were offered from key stakeholders who are knowledgeable in their field. Based upon expert feedback, modifications to the MAP toolkit were made (Starr & Sacks, 2010). The recommendation set forth, in terms of toolkit improvements, are aligned with best practices noted by the CDC and other healthcare governing bodies.

Reliability

The reliability of the instrument refers to its consistency of a measure. Often times three different types of consistency are explored, which include inter-rater reliability, internal consistency, and test-retest reliability. For the purpose of the MAP toolkit, inter-rater reliability was confirmed (Starr & Sacks, 2010). Observers noted the same benefits associated with utilizing the instrument, which was aligned with the findings in the literature about the processes associated with collecting information concerning medication adherence.

Over time, researchers have utilized the MAP toolkit and noted its benefits. In fact, in a study published by Harrell (2017), which was conducted over 90 days, weekly medication adherence rates were assessed. Before the implementation of the study, Harrell (2017) cited that 78% of patients did not adhere to their prescribed medication regimen. After the three-month implementation of this project, 56% of patients (those who originally cited lacking adherence rates) noted improved medication adherence, thereby reinforcing the benefits of this toolkit.

Data Collection Procedures

After obtaining approval from Grand Canyon University’s Institutional Review Board, the PI will reach out to the administrator and the Director of Nursing at the project site who will assist in scheduling a time for the educational training sessions to take place. Ideally, these training sessions will be offered twice, so nursing staff members who work on weekends will be able to participate. Once ideal times are determined, two face-to-face training sessions will be conducted. During these training sessions, the PI will provide information about current medication adherence rates at the selected project site and will compare these rates to the national average. Then, the PI will explain details about the MAP resources. The PI will use a PowerPoint presentation to conduct this training, which will be provided to participants. In addition to providing participants with the PowerPoint slides, the PI will also insert all relevant MAP resource information into a binder. All training participants, upon the completion of the training, will have a binder to take with them.

The PI will also work with the Information Technology Department, at the project site, to ensure that the three MAP resources, which will be utilized during this project, are input into the site’s EHR. Over four weeks, nursing staff members, who engaged in the educational training session, will be required to utilize the MAP resources. As noted above, the MAP resources, at first, will take a bit longer to complete, specifically since the following resources need to be explored during Week 1: (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List. Furthermore, since providers will be educating individuals about their medication adherence (i.e., using the Questions to Ask Poster) and will be exploring barriers associated with medication adherence (i.e., using an Adherence Assessment Pad), this initial phase, during Week 1, will be time-consuming. In subsequent weeks (Weeks 2-4), unless a huge revision is made to one’s My Medications List, then the process of examining medication adherence and answer questions will take no longer than ten minutes.

Each week, nursing staff members will record medication adherence information in the patient’s EHR. If the patient expresses that he/she has not adhered to the medication regiment, during the previous week, lacking adherence information will be recorded in the system. Upon the completion of the four-week project, all information, input by nursing staff members into the EHR, will be assessed. The PI will compare pre-project implementation medication adherence rates to post-project implementation medication adherence rates. In addition to exploring medication adherence rates after the implementation of this project, pre-project implementation adherence rates will be explored over four weeks from April 1, 2021 to April 30, 2021.

Once pre-project implementation data and post-project implementation data are obtained, the results will be statistically analyzed. The PI will work with a statistician, who will assist in the data analysis process. Data will be compared analyze using various statistical techniques. For more about data analysis procedures, explore the heading below.

Data Analysis Procedures

For this project, data will be analyzed to explore if medication adherence improved among type II diabetic patients after the implementation of the MAP resources. The collected data, pre-and post-project implementation, will be inserted into a Microsoft Excel document, which will be provided to the PI by ___who____. Once information is inserted into the Microsoft Excel spreadsheet, missing data, if applicable, will be coded or excluded, depending on the recommendation set forth by the PI’s statistician. The Microsoft Excel spreadsheet will then be imported into SPSS version 28.

For this project, data will be analyzed to explore if medication adherence improved among type II diabetic patients after the implementation of the MAP resources. The collected data, pre-and post-project implementation, will be inserted into a Microsoft Excel document, which will be provided to the PI by the secretary. Once information is inserted into the Microsoft Excel spreadsheet, missing data, if applicable, will be coded or excluded, depending on the recommendation set forth by the PI’s statistician. The Microsoft Excel spreadsheet will then be imported into SPSS version 28.

To explore the impact of the MAP resources on improving medication adherence, a t-test will be used. For this project, data will be provided in written format, as well as in tables and figures. It is important to note that descriptive statistics will be used to measure central tendency and standard deviations across the variable groups. T-test will be used to compare the means between the two groups. The two groups that will be explored in this project are the pre-project implementation group and the post-project implementation group. It is important to note that demographic data will also be explored to determine if certain demographic variables impact medication adherence rates. A p-value of 0.05 will be used to determine statistical significance.

Potential Bias and Mitigation

There is a number of sources of potential bias that may exist throughout this project. While biases are present in most projects, it is important to formulate a proactive solution about how to mitigate biases. One potential source of bias is recall bias, which references what happens when a person self-reports information. Sometimes, self-reporting surveys are inaccurate, as patients do not feel comfortable reporting the truth or forget valuable details.

For the purpose of this project, diabetic patients will be required to respond to MAP resources, which address information about medication adherence. Based on the patient’s memory, the information may or may not be accurate. To improve the accuracy of the data obtained, the nursing staff members will encourage patients to fill out documents (as appropriate) daily and to determine a set time to report information in these documents.

Ethical Considerations

An authorization letter has been obtained from the project site (Appendix B). The project has also been submitted to the project site for Institutional Review Board (IRB) exemption approval (Appendix B). The project will be submitted to Grand Canyon University’s IRB for review (Appendix B).

Before this project is conducted, the PI will attain permission from the project site’s IRB and GCU’s IRB. Once permission is obtained, the project will begin. There are two groups of project participants who will engage in this project. The first group of participants is home healthcare nurses of the selected project site. Considering the support by the project site, for this initiative, all nursing staff members will be asked to implement the newly implemented processes when interacting with eligible participants. Therefore, participation among nursing staff members is not voluntary as this is a sitewide effort, which is supported by organizational stakeholders. The other group involved in this project includes patient participants. Nursing staff members will provide patient participants with information about all aspects of the project.

Three MAP resources will be used during this project. The purpose of using these three resources is to provide patient-specific training and details about medication adherence. All attained data will be gathered by nursing staff members, whether in written or verbal then transcribed form, and will be entered into the patient’s EHR. Considering that the EHR is only available to individuals of the selected project site, who have an account and password, no unique identifiers will be used. Paper-based questionnaire information and verbal notes, from patient-provider interactions, will be input into the EHR by the end of the provider’s shift.

Data will be extracted from the EHR, after the four-week project timeline, by the PI. It is important to note that the data files, which will be presented to the PI pre-and post-project implementation, will not include any patient identifiers. For example, only relevant project-related data will be attained, which is related to the patient’s age, race, and gender. Furthermore, data regarding medication adherence among type II patients will be obtained. The data files, which will be sent to the PI via email, will be encrypted. Furthermore, the data files will only be accessible to the PI using her work computer. Aggregate data will only be shared, as needed, with individuals who are directly impacted by the project’s implementation (e.g., organizational stakeholders and nursing staff members).

All project-related data will be maintained by the PI for a period of three years, which is aligned with the requirements set forth by GCU’s IRB. After the three-year timeframe is over, the PI will dispose of project-related data. The PI’s work computer will be scrubbed of these data files.

Limitations

There are several limitations to this project, which must be explored. First, it is important to note that the project’s timeframe is short. Due to this four-week timeframe, it might be difficult to assess the true impact of the intervention. The second limitation is that the sample size set for this research project is also relatively small. In March of 2021, the home healthcare system serviced approximately 100 patients of which 30 were diagnosed with type II diabetes. While the sample size as relevant to the project site’s patient population is large, given the overall sample size (n = 30), it may be difficult to generalize the results of this project.

It is important to note the only patients who will engage in this project are those who have been diagnosed with type II diabetes and are between the ages of 34 to 65, thereby further limiting the project’s sample. While there is much merit in utilizing the MAP tools, the overarching effectiveness of this tool might be difficult to determine given eligibility requirements

This project is also limited by the data collection technique that will be used. For example, since a lot of the data gathered is self-reported, patients may overinflate information about medication adherence. If incorrect information is provided by patients the project’s overall results will be impacted (Brown, Kaiser, & Allison, 2018).

Delimitations

The study had the following Delimitations:

1. Due to convenience and university policies, there will be a small sample size of 20 participants. The consequence is that, it might negatively influence the transferability of study findings because of limited participants (Hesse et al., 2019). To minimize the impact of the small sample size I will attempt to reach saturation when no new topics are arising in new interviews.

2. The participants that will be included in this study were healthcare providers at the project site. As a result, this study did not involve healthcare providers from other parts of the city. The consequence is that it might not be transferable. To minimize this the participants, their work environment will be described to allow readers to assess if the findings transfer to their context.

Summary

Medication adherence among patients with diabetes remains a crucial determiner of their well-being. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of MAP resources, which include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List impact MA among type II diabetic home healthcare patients, ages 35 to 64, at a home healthcare organization located in urban Texas over four weeks. The project’s design will explore the impact of the MAP resources on improving medication adherence among type II patients. As noted above, the validity and reliability of the MAP resources have been established.

Medication adherence rates will be collected before the implementation of the intervention and after the implementation of the intervention. An analysis of the two sets of data will be used to determine the impact of the independent variables on the dependent variable. The data gathered will be compiled in an Excel spreadsheet and transferred to SPSS for analysis.

To ensure that ethical research standards are upheld, the PI will comply with the standards set forth by GCU’s IRB. Participant anonymity and privacy will be maintained. This project is limited by several factors, which include a small sample size, the short project timeframe, and the use of self-reporting data regarding medication adherence.

In Chapter 4, project results will be presented. Information in Chapter 4 will be presented in a written and visual format. Chapter 5 will provide project-related recommendations based upon the data analyzed and will offer details about limitations.

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Appendix A

10 Strategic Points

71

Appendix B

Site Authorization Letter

Nations Pioneer

Health Services Inc.

11224 Southwest Freeway, Suite 240, Houston, Texas 77031

Phone: (281) 498-6203. Fax: (281) 498-6206

www.nationspioneer.com

Office of Academic Research

Grand Canyon University

College of Doctoral Studies

3300 W. Camelback Road

Phoenix, AZ 85017

Phone: 602-639-7804

Dear IRB Members,

After reviewing the proposed study, Improving Medication Adherence in Diabetic Patients in Home Health Care Settings, presented by Bola Odusola-Stephen, I have granted authorization for Bola Odusola-Stephen to conduct her quality improvement project at Nations Pioneer Health Services, Inc. and Pioneer School of Health, Houston, Texas.

I understand the purpose of this Quality Improvement Project is to determine if or to what degree the implementation of Medication Adherence Project resources (MAP) that include the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Pad impact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64, in home healthcare in urban Texas

I have indicated to Bola Odusola-Stephen that the Nations Pioneer Health Services, Inc. and Pioneer School of Health, Houston, Texas will allow the following Direct Practice Improvement Project

· Provide staff an information session on the project and MAP project resources.

· Collect pre and post implementation medication adherence rates

The participants that will be in this Quality Improvement Project must meet the following criteria:

Registered nurses from single department that will participate in the informational session as well as diabetic patients ages 35-64 receiving home health services and are identified as having diabetes type II.

Bola Odusola-Stephen has agreed to provide a copy of the project results, in aggregate, to Nations Pioneer Health Services, Inc. and Pioneer School of Health

If the IRB has any concerns about the permission being granted by this letter, please contact me by (phone or email preference of site granting permission).

Sincerely,

________________________________________

Bamidele Jokodola MSNEd, RN (Administrator) Date

Office: (281) 498-6203 Cell: (281) 685-7280

Email: Daleyrn@sbcglobal.com

Bamidele Jokodola MSNEd, RN

Nations Pioneer Health Services, Inc.

Pioneer School of Health

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Submitted by

Bola Odusola-Stephen

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

December 10, 2020

GRAND CANYON UNIVERSITY

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings

by

Bola Odusola-Stephen

Proposed

December 10, 2020

DPI PROJECT COMMITTEE:

Mary Guhwe, DNP, Manuscript Chair

Bamidele Jokodola, RN, MSN, FNP, CMSRN, DNP, Committee Member

Full Legal Name, EdD, DBA, or PhD, Committee Member Comment by Author: Need to remove this as well as the footer

Abstract

Home-based healthcare is useful in managing some conditions as it is cost-effective and is known to improve the quality of life and longevity of patients. Home-based care is known to improve the mortality of patients due to the mental well-being associated with home-based care such as independence, mobility and the comfort of family and home. While beneficial, it can also be detrimental to patients if mishandled resulting in fatalities and complications in patients. Even though home-based care is popular and cost-effective, the adherence to medication by patients is unknown thus this project hopes to find out if educating patients undergoing home-based care improves their medication adherence. The project also aims to find out if family-led strategies lead to better medication adherence in home-based diabetes patients. Attachment and social cognitive theories will be used as the theoretical framework for this study. The project will be conducted in Urban Texas and will include 50 patients undergoing home-based care. Medical records of diabetes patients undergoing hospital-based care will also be reviewed for comparison. A standard questionnaire as well as the Morisky Medication Adherence scale (MMAS-8) will be used to collect data from patients. Data will be analyzed using excel and SPSS. Descriptive statistics and inferential statistics will both be used in analyzing data, Factor analysis will be used to analyze the data from the MMAS-8 tool. Comment by Author: The DPI template has the correct format for the abstract. Please refer to that and adjust your abstract. For the proposal you obviously will not have the results yet but you can complete the rest of the abstract requirements using the correct format Comment by Author: Make sure you have a change theory as part of your theories. As I mentioned previously, you do not need both the attachment and social cognitive theories but it is difficult to pin point which as you have not yet clearly identified what your intervention is for the project

Table of Contents Table of Contents Chapter 1: Introduction to the Project 1 Background of the Project 5 Problem Statement 6 Purpose of the Project 7 Clinical Question(s) 9 Advancing Scientific Knowledge 11 Significance of the Project 13 Rationale for Methodology 14 Nature of the Project Design 15 Definition of Terms 17 Assumptions, Limitations, Delimitations 20 Summary and Organization of the Remainder of the Project 23 Chapter 2: Literature Review 25 Theoretical Foundations 27 Review of the Literature 29 Theme 1 31 Theme 2 32 Summary 36 Chapter 3: Methodology 40 Statement of the Problem 41 Clinical Question 42 Project Methodology 44 Project Design 46 Population and Sample Selection 48 Instrumentation or Sources of Data 51 Validity 52 Reliability 53 Data Collection Procedures 54 Data Analysis Procedures 56 Potential Bias and Mitigation 59 Ethical Considerations 62 Limitations 64 Summary 66 References 68 Appendix A 70 Appendix B 72 Appendix C 74

2

Revised 4/21/2020 by: Dr. Suzette Scheuermann (Please remove this footer)

Chapter 1: Introduction to the Project

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Comment by Author: You have numerous formatting issues throughout the proposal that need to get fixed. My advise is to use a new template and re-enter your information in the new template as the template is already formatted for you in APA format

It is important that there should be proper and effective medication to the patients that are living with diabetes especially those that are under home -based care. More than half of the population does not take the medicine as it has been prescribed and this in most cases is resulting in costly health care challenge. The poor medication taking habits and the lack of adherence to the medicine creates complex problems. It is important that those who are under home care based should work hard to ensure that the patients are taking medications as they are supposed to be so that they do not develop more complications as a result of not adhering to medication. There are key interventions that should be identified, and effective measures made from this. Comment by Author: Why? Comment by Author: Citation? This whole section has numerous sections that need citations. I have given you feedback previously that you need some assistance with writing/editing. Please see DC network for resources. Comment by Author: The healthcare workers? Probably better to name the group you are referring to avoid confusion with the patients

Some medical situations inevitably require home healthcare services, this is important since it can help especially a person who is aging manage diabetes. Home –based care is also important in managing health issues, which are chronic in nature and also important in assisting people to live independently. Home-based care is also helpful in a person who is recovering from medical setback. Some patients that are under home care based may be unable to recover as well because in some instances they may not get the correct guidance as compared to when they are in the hospital. Comment by Author: See comments about citations above

The project is about the strategies and the methods that home-based care patients should follow to improve their health especially in adhering to medication to ensure that they get maximum benefits of their home-based care. This is because it has proven to be a challenge to follow the right medication strategies when the person is under home-based care. Comment by Author: This is not correct. Please see previous feedback about this. Your DPI project should be translating evidence into practice and not generating new knowledge/research. Please also refer to the DPI template for all the components you need in your various sections of the proposal. It is important to avoid missing any items but also so you can stay focused in your writing and be clear

Background of the Project

Home-based healthcare has been around since 1909 (Choi et al., 2019). It was perceived as a cheaper way to take care of patients who would have the benefit of enjoying the comfort of home and save money that would be have used up in paying hospital bills. In the early 20th century, home-based healthcare was mainly practiced due to adversities, in that the patients practiced it due to insufficient funds to afford proper health care. It was also practiced due to hardships in accessing medical care (Choi et al., 2019). In the present times, however, it is practiced out of choice, after a patient has weighed their options. Some of the situations where a patient can choose to practice home-based healthcare are when a patient is elderly and prefers to get home-based care instead of hospital care since at home, they would be more independent than they would be in a hospital. Home-based care is ideal when the condition can be managed without admission to a hospital such as in patients who have diabetes or those with hypertension (Szanton, et al.., 2016).

There is also a high rise of lifestyle diseases and conditions, such as diabetes. These chronic disease conditions require that a person engages in self-care behaviours at home to keep the situation controlled and prevent complications. Diabetes, for example, requires a patient to keep checking their glucose level. Many patients who are under home-based care do not have sufficient knowledge of the requirements that diabetes treatment entails. They do not practice medication adherence, causing more health complications due to unmanaged health conditions. Home-based care can increase the mortality and morbidity of diabetic patients if it is handled correctly by ensuring that diabetes patients have sufficient knowledge of what is required of them in terms of adherence (Neupane, et al, 2017). Comment by Author: This statement is incorrect. How does home correctly rendered home based care increase mortality and morbidity?

This proposed project is looking to tackle an increase in the fatality rate of diabetic patients practicing home-based healthcare. Most of the fatalities are caused by medical non-adherence, caused by a lack of sufficient knowledge of home-based care related to diabetes and other conditions. Patients at home are unaware of the requirements for medication, dosages, and required follow-up. Comment by Author: Citation? Also, I gave you feedback on this. This is not the aim or purpose of your project. Need to really adjust this and edit for clarity and scholarly writing

Problem Statement Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.

Even though home-based care has certain advantages such as increasing the mortality of patients and the mental well-being of patients, it also has challenges in its implementation and successful outcomes. The adherence rate of home-based care patients is unknown and the implementation of strategies to aid in adherence is also unknown. It is important to measure these strategies and also to evaluate the adherence success rate of home-based care patients as this could make the difference between life and death for the home-based care patients.

The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions. The intervention for this problem can be done before a person is given a go ahead of having home-based care. Patients should first be given knowledge and the tips that are required on adherence to medication so that their health can continue improving and not to deteriorate as happens in many people who undergo home-based care. The nutritionists will be in charge of the diet education while nurses and practitioners will be responsible in offering general healthcare education regarding diabetes and the right lifestyle changes have to be taken into account. Nutrition education will examine the types of foods to be consumed, amount and frequency with which they should be taken. Lifestyle education changes will examine the healthy life activities that diabetic patients ought to be involved with. Medication adherence will be measured using self-report questionnaires that will be given to patients and health care providers during data collection. The tool will involve asking patients questions about the missed doses within a specific period of time. For accuracy purposes, the patients will be asked about medication adherence in the last three days because asking for more than three last days will be difficult for the patients to recall.

Purpose of the Project Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.

The purpose of the project will be to determine medication adherence amongst home-based diabetes patients in Urban Texas. The project aims at determining the level of knowledge about diabetes and home healthcare requirements in 50 diabetes patients in Urban Texas. The project will focus on ways to reduce fatalities in diabetes patients under home-based healthcare. Many diabetes patients suffer due to medication non-adherence. This means that they do not follow the guidelines in managing their condition at home by the physician.

The main reason for medical non-adherence is the lack of knowledge of what they should do at home as healthcare measures to ensure they continue to improve their health. This could be due to home nurses’ failure to sensitize the patients on proper medication adherence or lack of proper follow-up through home visits.

The main aim of the project is to evaluate the implementations of some strategies which are important when it comes to defining clearly impacts that are present in case a person is on home-based care and the implications of not adhering to set times of taking medication

By conducting this project, the medical field can devise ways of ensuring that the useful information on diabetes management at home reaches everybody in Texas and other parts of the country. This should be incorporated in all systems like schools, workplaces, hospitals, and homes.

Clinical Questions Comment by Author: Put your PICOT question in this section and use that as your clinical question. Then add all the other information needed in the section based on guidance from the DPI template

Does Medication Adherence Education Increase Medication Adherence?

The project will focus on medication adherence of diabetes patients who are undergoing home-based care. The variables measured in this project will be adherence to medication and the outcomes of adherence or the lack of adherence in the patients and how this impacts home-based care. The project also hopes to understand the differences that are present in adherence to medication in diabetes patients undergoing home-based care as compared to those undergoing hospital-based care.

The data will be collected from both patients and health care providers engaged in home-based care programs. The aim is to find out to what extent medication adherence is utilised and what strategies are in place to ensure that patients adhere to their medication. The project will also seek to understand if the patients have sufficient knowledge on medication adherence. The following questions will guide this quantitative project: Comment by Author: This is research. Remember only limit your project to translating evidence into practice. Be very clear about what your problem is , what your intervention is and what your outcome is. Then you can be a good position to edit your manuscript. If you continue to edit the manuscript without clarity on those things it will be difficult for you

1. Does education on diabetes increase medication adherence in diabetic patients in home healthcare?

2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?

Advancing Scientific Knowledge

This quality improvement project will help ensure that there is sufficient information available for the public regarding diabetes and the recommended home healthcare requirements to manage the condition. Seeing that there are so many patients without the necessary information regarding diabetes and how to manage it, there is a need to diversify the sources of information on diabetes and manage it. Comment by Author: Citation?

Sensitizing the population on the importance of adherence to medical recommendations and finding alternatives for expensive home healthcare facilities will solve problems even in the future, ensuring that the fatality rate in-home healthcare drops significantly. Adherence to medication by diabetes patients has been shown to improve their lives and reduce the development of more complications and premature death of patients (Delameter, 2006). This project will improve the overall quality of life for both the patients and their caregivers. This quality improvement project is also a gateway to more sensitization to people. The information can be shared in institutions. Future generations will also benefit from the knowledge on how to implement effective home-based care strategies to improve medication adherence and reduce diabetes related fatality rates. Comment by Author: How is this related to your project since these patients are home health patients?

The project will fill the literature gap on adherence to medication by diabetes patients undergoing home-based care. This project aims to provide all the necessary information to all Texas people to people all around the world. This information should be accurate and certified medically so that it will help reduce fatalities among diabetic patients in home healthcare settings.

Significance of the Project

This project is significant in current times. With the rise in chronic diseases, many people are opting for home-based care and not getting their treatment from a healthcare facility and thus they must know the importance of medication adherence even at home. Also, with the COVID-19, many people are undergoing more home-based due to congestion in hospitals and to also reduce the risk of spreading COVID-19 to other patients (Choi, Choi, & Shon, 2019). This DPI project provides a scope upon the general level of knowledge about diabetes and home healthcare. By focusing on medication adherence, the fatalities in home-based management can be reduced thus making the project very important to the management of diabetes at home. Though the project focuses on diabetes patients, it gives insight into the gap in a lack of knowledge on medication adherence for home-based care for other conditions as well including hypertension, heart disease and presently COVID-19. Other scholars interested in projects of this nature regarding other conditions will know the factors to consider and what to expect. Comment by Author: You need to make more of an argument for this as this is not the focus of your project so need to develop this argument further. You immediate impact for the project is improve medication adherence which improves control of the condition and prevents complications

After following through with content on the different ways of adhering to medical recommendations, other researchers can come up with ways to provide more information on current conditions to ensure that there is enough information guiding patients on the care measures required for a healthy life. Some situations that need looking into in the future are hypertension, and COVID-19, which are very urgent currently. Comment by Author: This is not what your project is about so need to edit

Rationale for Methodology

The DPI project employs quantitative methodology. This is where I will employ questionnaire as a way of collecting information. The data collected will be quantitative in nature to establish the medication taking behaviours of the patients under home-based care. In addition to the questionnaire developed, the Morisky Medication Adherence Scale (MMAS-8) will be used to determine how effectively the patients are adhering to medication. The MMAS-8 is a tool developed and widely used to determine patients’ adherence to medication in different conditions. It is a tool that eliminates bias from the patients and health care providers by asking questions in a method that avoids ‘yes-saying’ by patients. Numerical data is important as it focuses on trying to reduce the number of diabetes fatalities in home-based healthcare. Comment by Author: Can not use first person in scholarly writing. Pleas edit Comment by Author: You can not develop your own questionnaire/instruments for your project. You will need t utilize an already evidence-based instrument/questionnaire Comment by Author: Citation?

According to Creswell &Creswell (2017), a quantitative methodology is best suited for projects that require data in numerical form. This is to know the interventions that are happening to those who are under home based care to ensure that the strategies are working, and mortality rate of such people are reduced.

The information is then analyzed using quantitative methods and represented in charts and graphs. The conclusion on the findings is then drawn from the analysis of data, after which recommendations are thought of and implemented to curb the problems in scope.

Nature of the Project Design

This project will adopt the quasi-experimental design in that it deals with a random population that will be targeted will be all the stakeholders that have interacted with those patients that are in health care basis, and the DPI research project does not happen in a controlled environment. This design is more cost-effective than the actual experiment project design. In this project, the sample population is diabetes patients in Texas. The questionnaires, both the MMAS-8 scale and the questionnaire developed by the researcher, provide insights into the information intended for collection, thus providing accurate findings. Another mode of data collection used in this project surveys involves the diabetic patient or their caregiver to answer some questions related to diabetes, medical adherence, and home healthcare. Comment by Author: This is not really true. There is no requirement for randomization in quasi experimental design Comment by Author: The writing here needs editing for grammar and flow. Also please see prior feedback about removing any references of research a it pertains to the project. Comment by Author: Citation? Comment by Author: Only use evidence based instrument which you have provided as the MMAS so do not include caregiver interview etc that pertain to research

The project will use the data collected through the course time allocated. A detailed analysis of the data will be done, the date represented for interpretation, after which solutions to the research problem will be solved and tackled. It is a very descriptive project aimed at unravelling some of the truths that are not too obvious to develop solutions that are well needed in the current times. Comment by Author: If you are going to discuss data analysis then you need to just state what specific statistical tests you will run and what specific data you will analyze. This section is very vague and unclear as there are lot of research related statements

The research designs will help in the smooth process of data collection, analysis, and conclusions, which will help draft the recommendations for a healthy life for diabetic patients in Texas and possibly in the world who practice home-based healthcare.

Definition of Terms

Medication adherence:

This is the extent to which a patient, caregiver, or home nurse follows the recommended guidelines on managing a medical condition.

Home-based healthcare

Refers to the medical care given to a patient in the comfort of their home instead of going to the hospital.

Facilities

A thing, place, or person necessary to make the home healthcare process for a person with diabetes easier for both the patient and the caregiver.

Diabetes

A medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin.

Assumptions, Limitations, Delimitations

This project assumes that medical non-adherence by diabetes patients’ is caused by a lack of sufficient knowledge on the matter. Education in the area as well as providing information on managing diabetes from home will solve the problem. It is also assumed that after education, the patients will automatically practice medical adherence because the knowledge will be easy to understand and the benefits of adhering to medication will be outlined to patients thus, they should be able to implement the knowledge. It also assumes that many people practicing diabetes home healthcare cannot afford the required facilities and equipment for treatment and care which is why they chose home-based care in the first place. Additionally, this project assumes that all patients and their caregivers are literate. Therefore, they can understand the physician’s diabetes and home healthcare recommendations for a long healthy life. Comment by Author: This is not correct as home health is not based on financial limitations bur rather other factors Comment by Author: Why are you assuming literacy when there is literature evidence that the average patient education material needs to be at the 5th grade level?

The project is limited because it focuses on only diabetes home-based care and does not consider patients undergoing home-based care who have different conditions. The project is also limited to an urban location and thus Texas state only and further limited to Urban Texas thus excludes rural Texas patients who may have different needs or challenges related to medication adherence. The project will also be limited to medication adherence of home-based care patients and does not cover other aspects such as mental health and health related quality of life of the patients. The project also includes all diabetes home patients, even those who are not necessarily ill and who are only practicing home-based care due to old age. In this case, the data may be a little imbalanced since it may record diabetes fatalities of patients who succumb to old age as a medical non-adherence fatality. Comment by Author: This is not a limitation as your population is diabetic patients in home health

Delimitations in this project include the project areas namely adherence and diabetes patients. The project will only collect data from diabetes patients and will only be interested in their medication adherence. The project study area is also only being conducted in an urban Texas area in the South East Unites State thus it will exclude patients from other states as well as rural rural locationsTexas.

The findings of the project will be applicable to medication adherence in patients with other conditions who are undergoing home-based care. They will also be applicable to all patients with diabetes throughout the country who are in the home-based care program to help them better adhere to medication and reduce the number of fatalities associated with the home-based health care programs.

Summary and Organization of the Remainder of the Project

Chapter one provides support for the assessing of interventions and their effectiveness especially those that are in home-based care, (Creswell & Creswell, 2017). This will bring about changes in the quality of life for people practicing diabetes home-based care not just currently during the COVID-19 pandemic but also in the years to come. People need to know the importance of medical adherence since it provides a chance to improve a patient’s quality of life. Chapter two will review literature both theoretical and empirical on the variables home-based healthcare, diabetes and also medication adherence to give the project a literary and empirical framework on which it will be based.

Chapter three will discuss the research methodology employed in the project. This will include research design, the target population, sample size, data collection tools, data analysis, reliability and validity of research instruments and ethical considerations when collecting data. Chapter four will present research findings and discussion of the findings. This will include both descriptive and inferential data analysis as well as discussions of the findings. Chapter five will present conclusions and recommendations drawn from the project.

Diabetes patients should also be enlightened on maintaining a healthy lifestyle and managing the condition at home (Choi et al., 2019). The data collected will make it easier to spot the problem and the gap, and therefore come up with ways to bridge it. One way to bridge the gap and reduce home-based healthcare fatalities of patients with diabetes is by providing adequate information on the management of diabetes at home. All the people involved in the home healthcare provision process should be sensitized to the significance of medical adherence. Comment by Author: See previous feedback on this

The projects also include data collection, where the data is presented and analyzed. The data gives insight into the situation, enabling ease of discussion of solutions and recommendations to increase medication adherence in home-based healthcare, which will reduce fatality rates of diabetic patients in home-based healthcare.

Chapter 2: Literature Review

Diabetes is a medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin. Blood sugar serves as the major producer of energy in the body. Any condition interfering with blood sugar levels and mechanisms would bring about disruptions to the normal body activities. Optimal diabetes control usually needs patient associated engagement in various types of self-care associated activities, including the adherence of patients to the identified medication associated regimens along with adjustments to various lifestyle associated modifications and even the monitoring of the blood glucose associated levels, (Jajarmi, et al, 2019).

Since diabetes is a lifestyle disease, it can be easily prevented and avoided by making lifestyle changes. Managing the disease can also be made easier by making lifestyle changes as well as adhering to medication. This is important since it will help in avoiding of many challenges and complications that may arise from diabetes. one of the most problematic issues associated with home care for the patients suffering from Diabetes is Adherence to medications. According to Bonney (2016), patients usually take their identified medication as is prescribed solely 50% of the time. This along with the reluctance to be involved in the sharing of the details associated with medication taking behavior have been identified as less than optimal by healthcare providers. This project hopes to shed light on medication adherence and how it affects the quality of home-based care in diabetes patients. It hopes to understand the role of educating patients on medication adherence in improving their adherence to medication and also understand the impact of improved adherence on the patients.

This chapter provides both a theoretical and empirical framework through which the medication taking behaviors of diabetes patients undergoing home-based healthcare is investigated. The chapter is divided into theoretical and empirical sections. The theoretical section reviews two theories namely attachment theory and social cognitive behavior theory. In the empirical section, literature from previous studies and projects is reviewed and study gaps are identified in them which differentiate the reviewed projects from this project. The DPI project utilized databases as well as literature sources which have been systemically searched for the identified systematic reviews that report various aspects associated with diabetic adherence. A total of eighteen18 systematic reviews were realized as well as utilized in the advancement of the DPI conceptual framework. In overall, there was a total of six key sub-themes and many other subthemes for the project and that emerged which are all focused on thoroughly to enhance the comprehension of the DPI. Each of these key sub themes are discussed comprehensively along with in in-depth study. Most of the identified interactions were considered to be within the patient associated elements which usually not only interact with other kinds of theses but are also within the same theme. Comment by Author: I gave you feedback on this previously, you can not only have systematic reviews in your literature review. You need to revisit this Comment by Author: The writing is unclear here and needs editing for grammar and flow

Background

Non-adherence to diabetic medications in patients that are being treated from home usually leads to poor recovery along with ineffective treatment associated outcomes and even an increment in the healthcare associated costs is usually reported (Bosworth, 2015). A variety of elements that are usually related with the identified medication associated adherence have also been highly studied. However, it is vital to understand that a comprehensive framework along with a clear disease specific conceptual framework associated model which is involved in the capturing of all the probable elements has not been fully established. The main aim of the project is to assess the effectiveness of the interventions that have been put into place so as to ensure that there is improved home based care.

The demographics along with the cultural beliefs of the patients were considered to be the most notable elements of the given interactions with other types of categories as well as themes. The intricate network as well as the various interactions regarding the elements that have been identified between the distinct themes as well as within the individual types of themes usually reveal the identified complexity associated with the issue of adherence of medication especially those that are diabetic.

Theoretical Framework Comment by Author: One of your theories needs to be a change theory. As previously indicated, it is difficult to see the link between attachment theory and medication adherence. Not yet clear on your intervention so hard to say if it aligns with that or not. The social cognitive theory I can see how it aligns with your project.

According to Liu & Butler (2017), medication adherence is considered to be the largest challenge that healthcare workers and patients are facing in their daily lives. It is often considered to be a critical issue, which usually deserves higher level of attention. Inspiration along with the act of supporting patients to take their identified medications as prescribed can be a great issue. The Direct Practice Improvement (DPI) project utilizes two key theories to explain the relationship between medical non-adherence to patients and how medical adherence can be enhanced among the diabetic patients through improved interventions. Comment by Author: The writing here needs editing for flow and clarity

Attachment theory

The first theory is the attachment theory. This is defined as being a psychological, evolutionary, and ethological associated theory in relation to the aspects of relationships between individuals. This is a famous theory that had been used in the healthcare practices for a long time thus will be a suitable framework to be used in this case that entails creating the best interventions made for enhancing medical adherence with the diabetic patients.

The most vital tenet concerning the attachment theory is usually considered to be that young children usually need to advance a relationship with at least a single primary caregiver for the identified normal social and emotional advancement. The theory was designed by the prominent psychiatrist and psychoanalyst John Bowlby. Within this theory, the term attachment is usually utilized to refer to an affection bond or tie that is between a person and their attachment figure who in this case is usually considered to be the caregiver (Liu & Butler, 2017).

Some types of bonds may be considered to be reciprocal such as those occurring between two adults, however, the bond between a child and a caregiver are usually on the basis of the need of the child for safety, security and even protection. This is usually considered to be essential in both infancy and childhood phases of life. This given theory usually proposes that children are involved in the creation of attachment to their careers instinctively for the key associated purpose regarding survival along with the untimely as well as genetic replication.

The biological purpose for the use of this theory is the facilitation of survival while the psychological aim about the theory is to offer security thus making it a suitable theory to use. Attachment theory is considered to not be an exhaustive description associated with human relationships nor is it considered to be synonymous with love or affection, however these can be utilized in indication of the fact that bonds still exist. In the child to adult types of relationships, the child is usually referred to as the attachment while the caregiver is usually defined as being the reciprocal equivalent who in this case is called to be the care giving bond (In Hunter & In Maunder, 2016). 

The modern attachment theory is usually focused on three key principles which entail bonding as an intrinsic human need along with regulation associated with emotion as well as fear to improve vitality and in the promotion of addictiveness along with development. Common attachment behaviors as well as emotions are usually displayed in most of the social primates including humans and are considered to be adaptive. The long-term associated evolution possessed by these types of species usually involves selection for the identified social behaviors which enable people and group survival more likely.

The commonly observed types of attachment behavior in toddlers staying near the familiar individuals are based on safety advantages in the identified environment both in early adaptation and our current world. Bowlby perceived the identified environment associated with the early adaptation as being the same to the current and also similar to the hunter-gatherer communities. There is a survival advantage in the identified capacity to effectively sense possibly dangerous conditions like the issue of unfamiliarity, loneliness, and rapid approach. In the identified internal models is entailed the regulation, interpretation and the prediction of attachment associated behavior in the identified self and the attachment figure.

The advancement of attachment is considered to be a transactional process. Particular attachment associated behavior usually starts with the predictable apparently innate behaviors in the infancy stage of life. They usually alter with age in various ways that are usually determined partly by the identified experience as well as partly by the various sit-upon elements. As the various attachments get altered throughout life, they do so in techniques that are shaped by the identified relationships.

In accordance with Hunter & Maunder (2016), there are two key reasons why the attachment theory is considered as being effective to be utilized in the following DPI. First and foremost, the theory acts as a solid foundation for the enhanced comprehension regarding the identified development of ineffective coping techniques as well as the underlying dynamics associated with the emotional difficulties of the person. Clinicians can help those people that have attachment anxiety and avoidance in the comprehension of the manner in which previous experiences with their caregivers or their significant others have helped in shaping their identified coping patterns to their various experiences of distress.

Secondly, the clinicians can help the people who have attachment anxiety and avoidance to find the best alternative way to meet their various needs. Most of the individuals who usually seek help want to learn the way in which they can employ different strategies for coping with the various dysfunction in their daily lives along with effectively modifying their various dysfunctional or even inappropriate coping techniques. This is an essential aspect since the caregivers need to form attachment first before delivering the advice and interventions to the diabetic patients on how they can adhere to their medications. It is important to note that for effective outcomes to be realized in these diabetic patients, there is the need to ensure that all the basic needs of the patients are effectively met as well as other types of strategies that are considered effective for changing the individual maladaptive techniques used in conjunction with the theory (In Hunter & In Maunder, 2016). 

Social Cognitive Theory

The other vital theory that can be utilized in the facilitation of the DPI project is the social cognitive theory. Social cognitive theory is a famous theory that is usually utilized in the explanation of the manner in which human behavior is associated with dynamic, reciprocal, and progressive types of interaction that exist between the person and the given surrounding (Bosworth, 2015). The common types of theoretical basis associated with the cognitive theory is considered to be learning since it usually posits that the identified human behavior is effectively learned. Therefore, the Social Cognitive Theory (SCT) is famous because it often proposes that identified behavior aspects are an outcome of the cognitive processes which individuals usually develop via the social acquisition associated with knowledge.

According to Bosworth (2015), the theory usually bases its focus on the identified concept regarding behavioral capability which usually states that prior to any individual acting in a certain situation, the individual needs to have knowledge on what they need to do and the manner in which they need to do it. Bandura’s conceptual model regarding the reciprocal associated determinism is often utilized in addressing all the personal determinants associated with health. He postulated that an identified person or individual is engaged in a cognitive, vicarious, self-reflective, and even a self-regulatory process to attain a given goal. He went further to state that individuals usually effect alterations in themselves via their identified actions in anticipatory and proactive ways through the exercising of control over their given behavior via their well thought types of procedures and even motivations (Bosworth, 2015).

Bandura asserted that without having any kind of aspirations individuals usually course through life unmotivated and uncertain regarding their specific capabilities. Nonetheless, he also stated that people who take part in health promoting behavior have self-belief which enables them to fully take part in control over their thoughts, feelings, and actions. Therefore, the individuals who usually take part in self-control associated with health associated habits is involved in the reduction of key health associated risks leading to healthier and highly productive lives (Bosworth, 2015). In accordance with Bandura, although the prominent SCT usually acknowledge that the associated knowledge regarding the health associated risks along with the given benefits associated with treatment are considered to be necessary in the performance of health associated behaviors, this is in itself not adequate. Comment by Author: Need Citation Comment by Author: Comment by Author: This reads award, please edit

Self-influences are regarded as necessary in the attainment or the various alterations which will lead to the desired health associated outcomes in the identified patients. This concept is usually referred to as self-efficacy. The two types of cognitive processes which are involved in influencing behavior in the identified SCT are usually referred to as the self-efficacy and outcome expectations (Bosworth, 2015)

In accordance with Hadler (2020), the social cognitive theory is considered to be essential during healthcare workers’ counseling regarding various patients that have chronic medical illnesses like HIV and even diabetes. It can be utilized in the offering of help to the given patients in the learning of the vital information associated with HIV and AIDS as well as the related health issues like adherence. Support groups for people who have this could also utilize this social cognitive associated theory along with various behavioral techniques to effectively empower patients to effectively negotiate the various issues that are around medication adherence along with the establishment of effective supportive types of relationship which are efficient in strengthening the ability of the patient to stick to medication plans.

All these are associated with improved adherence as well as effective clinical results. Issues that are around the disclosure associated with the underlying conditions that some patients are subjected to are considered to be skills which could be effectively taught in the identified support groups and which could cause improved medication adherence. The reason why these two theoretical frameworks are used in this situation of diabetic patients who do not adhere to medications is because special intervention is needed to convince diabetic patients to adhere to medications and this will be installed in them as knowledge for behavioral change that will influence a positive change that will cause the patients to adhere to their medications.

Review of the Literature Comment by Author: You are missing any citations in these few paragraphs as indicated before. You need citations to support your assertions or thoughts. Remember that the hall mark of the DNP scholarly journey is translating evidence into practice so all aspects of the project need to have literature support

Medication adherence is considered to be the largest challenge that the healthcare workers as well as their patients are facing in their daily lives. It is often considered to be a critical issue which usually deserves higher level of attention. Inspiration along with the act of supporting of patients to take their identified medications as has been prescribed can be a great issue. The cognitive associated perspective on the identified health associated behavior is usually on the identified assumption that our thoughts along with beliefs usual influence our personal emotions and behavior.

It is important to note that the key focus of people working in the healthcare facility with diabetic patients, consider them as critical patients in the manner in which the identified patients are entailed in the conceptualization of the different health associated threats along with is involved in the appraisal or the elements which are involved in facilitating adherence or even serving as barriers to effective treatment of people.

Although adherence to antiretroviral therapy is considered a predictor of effective clinical associated outcomes among diabetic patients, it is a crucial challenge, and strict adherence is usually considered not to be usual

Medication adherence :  Comment by Author: Please see DPI template for appropriate formatting of your headings and subheadings i.e differentiating between themes and subthemes

This refers to the art of taking medication in the right way as prescribed by healthcare practitioners. This is done in most cases by people in the hospital, and these are health care practitioners. This is through giving prescriptions as they are supposed to. For home-based diabetic patients, they might be missing the opportunity to have a physical person monitoring their recovery process. For those that are home-based, the process is done by those present in that very time. However, their adherence and track of the body changes can play a significant role (Ahmed et al., 2018). Comment by Author: The writing here is not clear, please edit

What can be done to enhance Medication adherence?

To handle the issue of medication adherence among the diabetic patients who have had an issue with the adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as a costly public health associated challenge especially for the healthcare system in the US.

Since the aspect and issue of inappropriate as well as inefficient medication adherence is considered to be a complex change with a variety of contributing causes, there is no universal solution (Rodriguez, 2019). The following theme breaks down into three subcategories which form the basis of the sub-themes associated with this theme. The sub-themes are used to offer comprehensive analysis of all the vital types of interventions which are considered to be effective at enhancing medication Adherence among the diabetic patients but were also considered to be potentially scalable that is they are easy to implement in any given scenario in even large population (Bosworth, 2015). Key traits that make these interventions effective are discussed throughout the DPI. The information offered under each sub-theme is vital in enhancing proven as well as low rescue and even the cost-effective solutions to enhance Medication Adherence.

Strengthening the Relationships with Patients

Patients usually put into consideration their identified HCPs the major along with most dependent source of data regarding their health associated condition along with the treatment, and they are usually considered to be highly likely to effectively follow the treatment types of plan when they are involved in having good relationship with their HCP due to confidence and trust that has been built over time. Relationship building in healthcare is considered to be a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job which necessitates that they all maintain long term relationship with their patients for enhanced medication as well as treatment outcomes (In Heston, 2018).

Trust is usually developed throughout time with the same types of HCP in any kind of mutual relationship between them and the identified specific patients. The patients in these cases usually consider that their identified HCP possesses the highest level of competence along with actually cares about their identified health. Mistrust usury develops when the given patients attain unrealistic as well as inconsiderate and even insensitive advice from their identified HCPs as well as feel some kind of emotional distance from them.

Medication Nutrition Education Therapy 

Appropriate nourishment assumes a vital function in infection counteraction and treatment. Numerous patients comprehend this connection and seek doctors for direction, diet, and diligent work. Nonetheless, real doctor practice is regularly deficient, intending to the nourishment parts of infections, for example, malignancy, adiposity, and diabetes. Doctors do not feel significant, specific, or sufficiently set up to give nourishment guiding, which might be identified with problematic information on fundamental sustenance science realities and comprehension of potential sustenance intercessions. Truly, nourishment training has been underrepresented at numerous clinical schools and residency programs.

This usually makes it hard for the desired coordination as well as level of friendship that is needed for the effective as appropriate manage the issue of diabetes to be attained. When the caregivers are considered to be not friendly as well as not welcoming, it becomes hard to convince the patients on taking their medicine, yet they have a negative perception and attitude towards their care giver (In Mahmoud, 2019). The identified patients who are usually engaged in some meaningful types of partnerships are usually considered to be highly receptive to the various messages that have been delivered by their identified health care associated team.

As an outcome, the given patients usually tend to be in possession of some kind of anti-ballistic perceptions regarding the identified severity of the disease along with the benefits that come with the treatment of the disease and how medical adherence can attend to enhanced efficiency along with results in the healthcare work with the diabetic patients. Therefore, in this case, the factors that are entailed in impacting medication adherence are referred to as the severity of the diabetes illness along with the advantages associated with the treatment.

It is a vital theme which helps in understanding that the different types of patients that have close relationship with their caregivers are associated with high likelihood of following medications prescribed to them (In Sherman & Bednash, 2015). Any patient who is considered to be engaged in an identified partnership or even relationship with the caregiver is usually considered to be highly likely to be entailed in disclosing their various clues which helps the identified HCPs in the employment of numerous personalized models to offering support to medication adherence efforts. Attaining a careful comprehension is considered essential in the comprehension or the needs of patients via appropriate patient- provider types of Communication which are vital in the employment of the practical approaches to enhancing medication adherence as has been suggested throughout this DPI.

How and Why to Adhere to Medications

An estimated American adult of about 35 percent is considered to possess basic as well as the below-basic health associated literacy. This has been recognized globally and is associated with causing their incapability to read as well as write and understand any kind of message that is indicated on the prescribed medicines or the treatment sheets. Health literacy had been considered to be a vital aspect in the receiving of any kind of services. First and for foremost, it helps in helping the identified diabetic patients to not miss out on any fine detail needed for them to put into consideration and has not been written carefully thus can seek clarification on such aspects unlike if one cannot read not clarify on anything. Literacy is the ability to read as well as be able to understand the different aspects that people highlighted them to them (Glanz& Viswanath, 2015). 

For these same reasons, the world practitioners have been involved in the coming up with different strategies that can be used in the reduction of health literacy levels among taunts that have diabetes. It is vital to put this theme into consideration and should be a first priority since it is what makes the basis along with the foundation of having long term sustained profitability rates as they will be able to explain themselves to the identified people that will help them in making sure that they adhere to all their given medication.

It is always vital to adopt the universally implemented as well as published precautions that are made against the identified medication non-adherence as well as the low health associated literacy. This is famous for its nature of purpose. It is always utilized to offer effective encouragement of the various identified HCPs to carry out an assumption that the given patients are not being involved in taking their identified medications as they are prescribed to. Prescriptions need to be taken seriously for them to offer exceptional results and for the continued well-being for the patients who have critical illnesses like Diabetes.

The use of simple language by HCPs as well as medication manufacturers is another vital way, they can be utilized to help in teaching back types of techniques. These methods have been utilized in the enhancement of adherence among many types of non-adherence medication patients. Most of the times people opt to not take their medication as they cannot read all the instructions written on the medicine and are afraid that they will die especially in the cases that they mistake those drugs for poison or some drug that may look like a famous poison causing deash. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine (U.S.), 2018). 

Reading instructions and making a patient understand what is written in a medicine bottle or package should never be taken for granted as it is key for determining the manner in which patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. So that the identified medical practitioner can be aware and sure that what they have explained to the patients has been delivered safely as well as appropriately, there is the need for them to do a verification test. The patients as well as their identified support individuals need to be effectively asked to offer an explanation in their own words what they have understood from everything the practitioner have told them regarding their health along with drug management and intake. This teaching back method is vital in offering additional data on the key topic of interest thus should be used often.

Concerns associated with the issues of side effects can be considered to be challenges to the aspect of medication associated regimen adherence especially when the given advantages associated with taking the identified medication are not properly along with effectively comprehended. To minimize the identified potential associated concerns that are associated with the side effects of drugs since this can be identified as one of the reasons why these patients may opt to not adhere to the medications in fear that they will experience the side effects and be greatly inconvenienced, there is the need for HCPs to offer the relevant data regarding the common types of side effects when they are entailed in the prescription process.

There have been issues of people and patients dying or experiencing very negative and disturbing side effects when it comes to them taking the desired drugs by their doctors. These cases have always been used as forms of examples to explain the reason why people have been reluctant to take the medications for prolonged periods. For most of the critical illnesses, the medication is usually made to be taken for a long time for increased efficiency. This has caused many to withdraw from the medication due to the prolonged side effect issues that is associated with it (Institute of Medicine (U.S.), 2016). 

For instance, when offering a prescription or the metformin, there is the need to inform patients that are suffering from diarrhea during their time of prescription to anticipate that the loose bowel issues will be over in about a week if the drug is continued to enable the adherence of the drug. It is also vital to offer brief expansions due to the issue of time limitations along with engaging other members regarding the health care associated team in the provision of more additional education can be essential. This can be in the form of printed handouts as well as websites and in the use of teaching module which should be readily available for use with the identified patients.

In summary, the level of medication illiteracy among Americans is assumed to be high. This significantly contributes to the difficulties faced by patients when they are required to follow instructions. There is need for practitioners to take time and educate the patients on the right measures to take. Learned patients will have better understanding of the actions to take, and which can positively impact what they are after.

Tools for Building Patient Self Efficacy as well as Support Adherence

Using tools along with instruments that are considered effective along with appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family along with social support are considered to be vital aspects associated with adherence to the issue of Diabetes management (In Rodríguez, 2019). If vital, the engagement of the family members can enhance self-care activities for the patients suffering from Diabetes, including the eating of effective and healthy foods as well as keeping fit and in monitoring the identified blood glucose and even adherent to medication.

An innovative method that entails patients in the identified medication associated reconciliation process through a given web portal to undertake the verification of their various regimens along with the clarification and the verification of any types of inaccuracies after the identified hospital discharge has been received to enhance Medication adherence as well as in the decrement of the potential adverse drug associated events (In Forman & In Shahidullah, 2018). 

In this case, there may be higher roles for the engagement of patients with their identified electronic medical types of records so that they can appropriately verify along with help in the maintenance of accuracy associated with their medication list to undertake the reflection of their actual taking of drugs. Also, the use of screening tests is vital in understanding how well patients are taking their drugs. If there is no consistency in medication taking then motivation aspects should be utilized to enhance Adherence (European Medical & Biological Engineering Conference & Nordic-Baltic Conference on Biomedical Engineering and Medical Physics, 2018). 

In summary, the utilization of tools and instruments simultaneously plays an essential role in upholding medication adherence. Having a supporting and positive minded family also plays an essential role in supporting self-efficacy of the patients. Innovation should be incorporated in searching for medications. This will be advantageous because of the contemporary rapid advancement in technology.

Diabetes Care Concepts

When dealing with patients that have been considered to be reluctant in taking their medication, it is vital that the various care concepts in diabetes patients is understood. It helps in the effective integration of all the Interventions that have been mentioned in theme 1 for enhanced efficiency in the overall improvement of diabetic patients concerning adherence to medications that she been prescribed to them to help them in quick recovery and in the management of the illness for a longer term.

The following theme offers comprehensive knowledge as well as in depth illustrations on the distinct components associated with the clinical control regarding patients have been diagnosed with diabetes. The review offers effective clinical practice associated guidelines which have been considered to be the key to the enhancement of the population associated health, however for the identified optimal outcomes as well as diabetes care ought to be individualized for every identified patient.

Patient-Centeredness

Patient centeredness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped in having effective adherence to the given medication during home care settings. Patients who have been diagnosed with various critical illness and have been asked to go home for home-based care have been associated with lack or poor adherence to the medications they are given when they are discharged from the hospital. It is a global issue that has raised consent for the need to understand how to go about it for enhanced feasibility in treatment of illnesses (Steinberg & Miller, 2015).

Practice recommendations whether they are focused on the identified evidence as well as expert opinion are usually intended to offer the desired guidance on an overall approach to care (In Costa & In Alvarez-Risco, 2018).  The science as well as the art associated with medicine usually come together when the identified clinician is experiencing or has experienced some sort of situation whereby, they have to make treatment associated recommendations for any patient who would be considered to not have effectively met the eligibility associated criteria for the studies on which the given guidelines were based.

Recognition of what an individual needs is vital, and it can be achieved through the use of the studies that offer standards for when as well as the manner in which to adapt the given recommendations. Since the Patients that suffer from Diabetes usually possess highly increased risk for the identified cardiovascular illness, a patient centered approach needs to entail a plan that should be utilized in the reduction of the various cardiovascular risk through offering the address of the identified blood associated pressure along with the identified lipid control and even in smoking associated prevention and even creation and other aspects (Major Topics in Type 1 Diabetes, 2020).

Diabetes Across the Life Span

An increment in the identified proportion associated with patients that suffer from diabetes are usually considered to be mostly the adults (In Balogh & Institute of Medicine (U.S.), 2015). For the less salutary reasons, the identified incidences associated with type 2 diabetes is considered to be highly increasing in the creating in the children as well as the young adults. Patients that possess the type 2 diabetes as well as those that have type 1 diabetes are considered to be having good lives even in their older age which is regarded as a stage of life whereby there is minimal evidence from the identified clinical traits to be used in the guidance of therapy (Bonney, 2016). All these toes of demographic alterations are usually involved in highlighting another key challenge to the high-quality diabetic patients care. In this case, the identified need is usually considered to be the enhancement of the coordination between clinical teams as well as patients in the effective transitioning via the dysfunction phases enticed in life span (In Corcora & In Roberts, 2015). 

Advocacy for People with Diabetes.

Advocacy is a very vital aspect in healthcare since they deal with patients that need their utmost help as well as care for them to go back to their previous health state (In D’Onofrio & In Sancarlo, 2018). Advocacy is an aspect that can be referred to as an active support as well as engagement to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the loves of individuals suffering from patients. Given the various issues in diabetic patients such as the high toll that the issue of obesity as well as physical inactivity and even the various alterations that take place in the society determinants at the identified root regarding these issues can be solved using Advocacy (Stanislaw & Michael, 2017).  Comment by Author: Bola, there are significant formatting as well as content and writing issues with your literature review. Please take the time to review examples of DPI projects in DC network as well as the template before our teleconference to discuss all of these changes. You definitely also need writing/editing assistance as it is really difficult to get your point across if the writing has mechanical errors etc We will need to discuss your literature review during our teleconference Comment by Author:

Summary

Medication associated adherence among most of the critical illness patients such as those suffering from Diabetes as illustrated in the project is considered to be a key challenge for the identified patients that have chronic diseases like Diabetes. Optimal adherence to the identified prescribed medications can be entailed in the decrement of complications along with enhancing clinical outcomes and in saving healthcare associated costs. The following DPI has been comprehensive through the review of diabetic patient care concepts issue of non-adherence along with the time to look deeper for the issue of non-adherence as well as the manner in which to undertake the evaluation of the identified patients appropriately along with effectively in a clinical setting along with has offered practical solutions to helping in the improvement of the medication associated adherence (Major Topics in Type 1 Diabetes, 2020).

Medication adherence is considered to be the largest challenge that the healthcare workers as well as their patients are facing in their daily lives. It is often considered to be a critical issue which usually deserves higher level of attention. Inspiration along with the act of supporting of patients to take their identified medications as has been prescribed can be a great issue, however it is considered to possess the capability to possess the highest effect on their identified long term associated health as the well as on the economic well-being regarding the healthcare system of the nation.

The identified theories point to the possibility of solving the problem of poor medication taking behaviors by the use of attachment and social learning. The theories point out that medication taking is learnt and can be enhanced through the use of cognitive behavior change. The theories also point out that attachment between a health care provider and patient can form the basis of positive interaction between them leading to trust which then enables the health care provider to ingrain adherence into their patients. Comment by Author: This did not really come out doing your discussion of the attachment theory and this is why my feedback was that it does not really align with your project. Remember that you only need two and one has to be a nursing theory. In addition a change theory is needed since this is a change you are making based on evidence.

The empirical review point to the complications caused by lack of medication adherence in diabetes patients. It also highlight possible ways in which health care providers can help patients better adhere to medication through strategies such as advocacy and patient centeredness. Overall, medication adherence is important to the treatment and effective management of diabetes in patients and health care providers can play a vital role in ensuring that diabetes patients learn the importance of adherence. Comment by Author: This summary section still needs work. Remember that the summary needs should:• Synthesize the information from all of the prior sections in the literature review and use it to define the key strategic points for the project.• Summarize the gaps and needs in the background and introduction and describe how it informs the problem statement.• Identify the theories or models describing how they inform the clinical questions.• Use the literature to justify the design, variables, data collection instruments or sources, and population to be evaluated. • Relates the literature back to the DPI-project topic and the practice problem.• Build a case (argument) for the project in terms of the value of the project and how the clinical questions emerged from the review of literature.• Explain how the current theories, models, and topics related to the project will be advanced through your project.• Summarize key points in Chapter 2 and transition into Chapter 3.This section should help the reader clearly see and understand the relevance and importance of the project to be conducted. The Summary section transitions to Chapter 3 by building a case for the project, in terms of project design and rigor, and it formulates the clinical questions based on the gaps and tensions in the

Chapter 3: Methodology

Medication adherence is important to minimize the impact of chronic illnesses and reduce emergency visits to hospitals. Medication adherence refers to how well a patient in home-based care can take their medication correctly in the absence of health practitioners as prescribed by the doctor (Ahmed et al., 2018). It requires the patient to totally adhere and comply with all the medical instructions given. The number of people with diabetes diagnosis in the United States of America is too large and a most of them are living with underlying conditions which increases their risks being under medication. The challenges faced in keeping such large patient numbers on hospitals has necessitated the introduction of home-based care programs (Brown & Bussell, 2018).

Various models and therapies are available for people with diabetes. The medication nutrition therapy determines the types of foods that patients with diabetes will be consuming at various stages of their treatment. It also calls for the education of these patients about nutrition (Brown & Bussell, 2018). The ongoing care management dictates that patients with diabetes need to receive care from multiple integrated teams. These two models help in maintaining home-based care for diabetic patients (Brown & Bussell, 2018). Pharmaceutical-led therapy cannot be ideal for home-based patients because the pharmacist will not always be there to ensure medication adherence. The role of family members in upholding the patient’s health is therefore vital. Various approaches have been designed to improve care in diabetic patients. The patient-centered communication approach focuses on the interest and preferences of the patient and identifies any barriers (Voortman et al., 2017). Chronic care models ensure that any form of care required by the patient is well taken care of.

This quality improvement project will be guided by the following question: To what degree does the implementation of family-led strategies impact medication (what) compared to pharmaceutical-led strategies among diabetic patients in home-based care in Texas over four weeks? Comment by Author: Remember that this section includes both a restatement of project focus and purpose statement for the project from Chapter 1, to reintroduce reader to the need for the project and a description of contents of the chapter. This is not your purpose statement

This chapter will be explaining the methodology of this project. Information such as the project design, selection of the sample, instrumentation, validity, and reliability, data collection procedures, data analysis procedures, ethical considerations, and limitations will be included in this chapter.

This chapter will be explaining the methodology of this project. Information such as the project design, selection of the sample, instrumentation, validity, and reliability, data collection procedures, data analysis procedures, ethical considerations, and limitations will be included in this chapter.

Statement of the Problem

It is not known to which extent are the interventions working so as to ensure that home-based care is having positive implications as it is supposed to as well as to what extent is the implementation of the strategies that are making the patients that are in the home-based care to adhere to the medications despite being out of the hospital set up. Diabetes home-based healthcare can be very effective since the patients are acting independently away from the health facility as and the necessary medical recommendations are adhered to Therefore, they can be of great importance to the patients as they can give ready support compared to doctors. Comment by Author: See prior feedback on the problem statement in chapter 1. Remember there are certain parts of your project that stay consistent regardless of where in the proposal they are. The purpose, problem statement , population, PICOT questions, data collection procedures etc are the same throughout

This is important since it will help in saving lives especially for those that are in this kind of medication.

The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions

The number of patients in the United States with diabetes diagnosis is very high. This, therefore, makes it impossible to accommodate all of them in hospitals (Brown & Bussell, 2018). This means further that most of these patients have to be placed under home-based care programs. In these programs, there are no medical practitioners to ensure that patients adhere to their medication. For diabetic patients in home-based programs, they miss the opportunity of having someone monitoring their recovery process. For instance, there will be nobody to remind them how to take their medication or stick to healthy diets (Norman et al., 2018).

According to Norman et al. (2018), family members are closer to the patient in home-based programs than the healthcare practitioners. For this reason, they can be of great help in offering support to diabetic patients as compared to doctors.

Clinical Questions

Prior studies have demonstrated that medication adherence for patients in home-based care has not been a smooth process. Evidence shows that this is usually because there is nobody to monitor the progress of these patients. There is usually nobody to remind them to take medication the right way or adhere to their dietary instructions (Wolff & Baker, 2019). However, there are chances of improvement in this. The implementation of family-based medical adherence strategies can help to enhance medication adherence among diabetic patients in home-based programs. A family-led health education intervention will be carried out by the health care providers who will educate patients on the disease and how-to manage it, medication they should be taking and also the importance of adherence. This will be done during follow up sessions with patients in home-based healthcare.

There are a number of Strategies and the outcome is strict medication adherence. A quantitative, quasi-experimental design approach has been chosen for this report. This approach will help to assess the effectiveness of family-led strategies in enhancing medication adherence among diabetic patients in home-based care as compared to pharmaceutical-led strategies. The project will be guided by the following clinical questions:

1.Does education on diabetes increase medication adherence in diabetic patients in home healthcare? Comment by Author: Use your PICOT question here

2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?

The following table shows the characteristics of the variables involved.

Table 1

Characteristics of Variables

Project Methodology

A quantitative methodology is appropriate for use in this project because of the feasibility and clinical relevance associated with the practice improvement measurement. This will facilitate the discovery of the effectiveness of family-led strategies as compared to pharmaceutical-led strategies in medication adherence of diabetic patients in home-based care. It will get quantifiable and objective data related to the research question through the statistical analysis. This methodology was preferred rather than the qualitative methodology in this project because there will be a need to collect numeric data to assess the effectiveness of family-led strategies. The numerical data will be collected before and after the study. The results will then be compared and contrasted prior to making the necessary conclusions from the study. Qualitative data cannot be used to conduct this comparison. The quantitative methodology also allows for the numerical representation of the DPI findings so that specific and observable conclusions can be drawn. Descriptive statistics will be used to determine the relationship between the variables and to explain the differences in the two strategies and their impact (Queiros et al., 2017). Comment by Author: This will need editing as this is not research. There is still work to be done in this section re. clarifying exactly what variables you will quantitatively measure and how

The quantitative methodology aims to predict, control, or explain certain theories. To analyze data, this research methodology relies heavily on statistical analysis. According to Fain (2017), this research methodology focuses on objective measurements and analyzes the data collected through statistical, numerical, or mathematical analysis. It also uses computational techniques to manipulate preexisting statistical data. Usually, it is applied to test if or confirm whether certain theories and assumptions are true or false. According to Zaccagnini and Pechacek (2019), the two important foundational aspects of projects that use this research methodology are that they build on results and evidence from past research and that they usually form the basis for future research.

Project Design

This quality improvement project will use the quasi-experimental design as the principal evaluation method (Handley et al., 2018), while the design will assess how family-led strategies compare with pharmaceutical-led strategies in ensuring ensure medication adherence among patients with diabetes in home-based care programs. This approach will be used to determine if family-led strategies make a difference in medication adherence among diabetes patients in home-based care programs. Since this project aims to find out how the two interventions compare, measurement of numerical data will be necessary. An evaluation of the impact of each of the two strategies on medication adherence among diabetic patients in home-based care will also be conducted before and after the application of the strategy.

Family-led strategies among diabetic patients in home-based care have very notable differences with pharmaceutical-led strategies among patients in this care. The design of this project is a two-group pre- and post-intervention quasi-experiment design. The project design chosen for this project is a quantitative quasi-experimental design which will be used to assess the impact of family-led strategies on medication adherence among diabetic patients in home-based care programs. This research design is suitable for this project because the variables cannot be changed by the researcher (Handley et al., 2018).

Information on the gender and age of the patients identified for this project will be collected. A population of 50 diabetic patients has been identified for the project. The project research intends to use entire population as a sample diabetic patient in home-based care and the most valid and reliable instrument to be used in this project is questionnaires. Close- ended questionnaires will be utilized in this case. The project lead, in this case, is a comparison between the impact of family-led strategies and pharmaceutical-led strategies on medication adherence among diabetic patients in home-based care programs. Meanwhile, the pretest and posttest data that will be collected using questionnaires will be analyzed using the Statistical Package for the Social Sciences (SPSS) software.

An impact assessment of the strategies will be conducted before the implementation of the strategies and four weeks after the implementation of the strategies. This design will be applied to determine the relationship between the variables in the study. The project design chosen will facilitate the analysis of the comparison in the impact of family-led strategies and pharmaceutical-led strategies.

Population and Sample Selection

The population from which the sample to be used in this project is diabetic patients in home-based care programs in Texas. This sample is convenient because it includes participants who would be directly impacted by the interventions involved in this research. For this project, patients in home-based care who are interested in increasing their knowledge of medication adherence will be the participants. The population will comprise of diabetic patients aged 35 years and above. The population will comprise of patients who are not in a position of being admitted to hospitals. According to a Texas Medicaid and Texas Diabetes council report (2018), there were 8,700 inpatient hospital claims and 88,988 outpatient hospital claims made by diabetes patients in the year 2018. The figure that will be used as target population in this project is the 88,988 outpatient claims. The sample size will be determined using the Taro Yamane formula: Comment by Author: Do not use this number as your N. Your home health agency only sees a percentage of this number so use the volume of diabetic patients at your home health agency for this calculation

n=N/1+ N(e)2

Where:

n= sample size

N= target population (88,988)

e=error term in this case 10% (0.1)

Thus, sample size is determined to be 99.88 rounded off to 100 patients.

Before data is collected from patients, they will be asked to sign an informed consent form which will explain to them the purpose of the project and also assure them of their confidentiality should they choose to participate in the study. The informed consent form will be administered with care making sure that patients are not coerced or promised benefits for participation. Only patients who agree to participate and sign the informed consent form will be included in the project.

Instrumentation or Sources of Data

Data in this project will be collected through a pre-implementation and a post-implementation survey. Questionnaires and the MMAS-8 tool will be used in this project to gather information about the impact of the family-led strategy on medication adherence among diabetic patients in home-based care programs (Krosnick, 2018). Patients in home-based care programs will be given questionnaires to fill. There will also be questionnaires for family members offering direct support to these patients to fill. The questionnaires in this case will require ‘yes’ or ‘no’ responses. There will also be scaling questions in the questionnaire where participants will be required to assess certain information on a scale of 5 (1=strongly disagree, 2=slightly disagree, 3=neither agree nor disagree, 4=slightly agree, and 5=strongly agree). A questionnaire like this fit perfectly and it is the most effective for this project because it is easy to statistically analyze (Krosnick, 2018). The MMAS-8 questionnaire on the other hand will measure the medication adherence of patients and will be used in both pre and posts assessment.

The questionnaires will include two sections, the first section is where the socio-demographic information of the participants will be captured. This will include information on gender and race, while the other section will capture information about the impact of the respective intervention strategies on the medication adherence of the patients. It will involve getting data from the assessment, which will be compiled in a spreadsheet. The SPSS software will then be used to analyze the data so that conclusions can be drawn from it.

Validity Comment by Author: This section as well as the reliability section still needs some work. You will need to specifically discuss the validity and reliability of the evidence-based tool/instrument you are using. You can find this data in prior research done to validate the tool. Remember you can not make up your own instruments/questionnaires. You need to utilized evidence-based tools/questionnaires/instruments

The validity of the questionnaire will be established through the exploration of its social theoretical construction. The validity of closed-ended and scaling questionnaires has been confirmed through research. According to research, the test for the validity of these types of questionnaires would be a normal distribution curve. The research found the use of closed-ended and scaling questionnaires to be acceptable. According to research, these questionnaires are effective in linking existing knowledge to current findings. Questionnaires will be the only source of data in this research. Research on the validity of these types of questionnaires shows that existing theoretical, as well as empirical constructs, should be well represented in the questionnaires to increase their validity (Francis et al., 2017). For the standard questionnaire that uses Likert scale, Cronbach’s alpha will be used to determine the validity of the questionnaire items. The value of Cronbach’s alpha will be at 0.7 for the questions to be deemed valid. For the MMAS-8 questionnaire, factor analysis will be used to both asses the validity of the items as well as analyze the adherence levels of the patients.

Reliability

The reliability of this project, just like the validity of questionnaires impacts the research findings and consequently the conclusions drawn from the research to a great extent. Reliability is the extent to which a questionnaire produces similar results in different trials. Regarding the reliability of these types of questionnaires, reliability cannot be achieved unless the measurements are based on numerical values. Reliability is closely related to the objectivity of the research. Since this is quantitative research, the objectivity lies in the instrumentation used in the research. Research shows that there are several threats to the reliability of questionnaires in research. These include using unclear and complicated questions, the use of arbitrary and illogical codes, and giving unclear response options (Francis et al., 2017). To ensure that reliability of the standard questionnaire is met, the questionnaire will be given to a few experts in the diabetes management sector to determine if the questions are appropriate and if there are any internal inconsistencies in them. Their opinions will be incorporated into the final questionnaire. Use of the MMAS-8 questionnaire ensures reliability because it is a widely used and tested tool for collecting information on adherence.

Data Collection Procedures Comment by Author: Section still needs work. Remember this is basically a step by step recipe regarding how you will complete your project and collect your data. Use the words pre implementation and post implementation instead of pre test /post test. It is not clear exactly your intervention is and how it will be implemented so makes this section unclear

Informed consent will first be sought from the participants in this research. This will be after informing all the participants in detail what this project is all about. The participants will be provided with a letter explaining the purpose of the project and its benefit to them and the nursing profession. Participants will be notified how their data will be used and will be assured of confidentiality. Personal data regarding the patients and other participants will not be collected and their medication plans will not be affected.

The participants will be asked to complete a pretest and post-test survey which will be anonymous. Participants will be identified using numbers rather than names to protect anonymity. The pre-test will be conducted before the family-led health education strategy is introduced to patients. This will give baseline I formation on adherence. The post-test will be carried out after three months of constant reminders and follow up on the patients to evaluate of the intervention was successful. Post-test and pretest results will be identified in such a way that they correlate for easier and right analysis.

The data will be collected using a questionnaire that is already set by other stakeholders in the health sector so that the right information can be collected so that the research

Data Analysis Procedures

The data will be collected and analyzed using the SPSS software. Through descriptive statistics, the numeric and categorical variables in the questionnaires will be summarized. Comment by Author: How? On paper? Electronically?

Descriptive statistics will be used to describe the patient’s demographic information such as age, weight, gender, level of education and marital status. Central measures of tendency such as mean and standard deviation will be used to describe the population under study and also in the adherence-based questions. Comment by Author: Why do you need this information?

Common Factor analysis will be used to determine common factors amongst patients in regard to adherence and infer from the results which factors are common to all patients and which are least common. Comment by Author: Why do you need 3 different statistical tests for your data analysis? Try to determine what is the best way to analyze your data to answer your clinical question and pick a statistical test that best does that. You do not need more than one unless it is necessary

Logistic regression will also be used to determine the relationships existing between adherence and patients’ sociodemographic characteristics to determine how they interact or influence patient’s medication taking behaviors. Chi-square and Odds ratio will also be used to determine the effectiveness of the intervention in the post assessment phase of the project.

The analysis is important in quality improvement project will begin only after the nature and statuses of the patients and their caregivers are understandable. The SPSS software that will be used in this project will help to determine the relationship between the different variables in the research. It will establish the relationship between family-led strategies of intervention and medication adherence among diabetic patients in home-based care. It will also show how this compares to the impact of pharmaceutical-led strategies of intervention on medication adherence among diabetic patients in home-based care. This software will further be used to predict the possible application of the results drawn from this research. Comment by Author: This section still needs works as well to distinguish the project from research analysis

The data will be analyzed by comparing the results of the pretest and those of the post-test. The characteristic of this research design is to apply an intervention so that it can help to determine the relationship between two variables in the research. The quasi-experimental design that will be used in this project will help to analyze the impact of family-led strategies on medication adherence among diabetic patients in home-based care. It will also help to analyze how this impact compares to that of pharmaceutical-led therapies on medication adherence among diabetic patients.

Potential Bias and Mitigation

There exists a number of possible sources of bias throughout the project. However, the most important issues is formulating solution strategies on how the bias can be addressed. One potential source of bias is recall bias causes. This will emerge from the responses that the respondents will be required to provide. For instance, the diabetic patients will be required to respond to self-report survey based on the medication adherence. In such situations, the researchers normally rely on the information that has been issues out by the respondents, and majorly their memory. Based on the patients’ memory, the information might or might not be accurate, but the investigator will have to rely on it. Two mitigation strategies to recall bias are empathy and acknowledgement. The investigators should empathize with patients, assume their situations and circumstances, and try digging deeper to get an understanding possible causes why the information given out might be true or untrue. Acknowledging that there are possibilities of the problem to exists is important in a number of ways. This will help suppress the bias that might be available in respondents. Comment by Author: Great job as recall bias is pretty evident in self report surveys/tools. However the writing needs work and you need citations for your assertions

Ethical Considerations

An authorization letter has been obtained from the project site (appendix …). The project has also been submitted to the project site IRB exemption ( Appendix…..). The project will need to be submitted to GCU IRB for review. This project will get approval from the university. The participants will be informed on all aspects of the project including how the data will be collected, analyzed, and used. They will also be informed about the importance of this project to them and the nursing field in general. Written informed consent will then be sort from all the participants in this research. This quality improvement project will to the latter the principles and standards of ethical research (Fiesler, 2019). Comment by Author: This section still needs editing for the writing

The participants will answer the questionnaire questions anonymously and they will be assigned numbers will be used to identify participants to further protect anonymity. Also, the questionnaires will be handled with great care to ensure privacy. Data collected for the project will be kept on a password protected computer only accessible to the DPI investigator. The computers that will be used to compile and analyze data in this project will be secured with strong passwords to protect data. Aggregate dData will only be shared among people who are directly affected by the project. Personal information about the participants will not be collected in this research. The participants will be informed of the results of this project via the contact information they would have been provided in the questionnaires. After completion of the project, the questionnaires containing participant information will be disposed of safely (Fiesler, 2019). Comment by Author: Which people? Comment by Author: But previously you said you would collect some information regarding education status etc?

Limitations

The quantitative quasi-experimental approach that was chosen for this project is the best in determining the relationship between variables in this research and showing how the two main interventions compare. However, there are several limitations to this project. One of them is that the time frame set for this project may not be enough to show the impact of an intervention. Four weeks is a relatively short time to determine whether an intervention has had any impact or not. The second limitation is that the sample size set for this research project is also relatively small. This will make it difficult to generalize the results of this project. The fact that only diabetic patients will be participating in this quality improvement project also makes it difficult to establish whether family-led strategies can be effective among other patients with chronic illnesses and those who are in home-based care. The method of data collection chosen for this research could also be a limitation. Participants can give wrong information in their questionnaires which will affect the overall results of the study. Comment by Author: Great start, you need some citation to support your assertions

Summary

Medication adherence among patients with diabetes remains a crucial determiner of their well-being. The purpose of this project is to determine to what extent the implementation of family-led strategies would impact medication adherence when compared to pharmaceutical-led strategies among diabetic patients’ in-home care settings in Texas over four weeks. The problem that aims to be solved in this research is to bridge the gap in knowledge about the impact of family-led strategies on medical adherence among diabetic patients in home-based care programs as compared to pharmaceutical-led strategies. Moreover, the methodology that has been selected for this project is the quantitative methodology (Fain, 2020). A quasi-experimental design will be used in this quality improvement project. The design will facilitate the identification of the relationship between the variables in the research. Questionnaires will be used as the only method of data collection in this research. The validity and reliability of questionnaires for data collection in this research has already been established.

The pretest-posttest approach will be used to collect data in this research. Data will be collected before the application of the intervention and after. An analysis of the two sets of data will be used to determine the impact of the independent variables of this research on the dependent variable. The data gathered will be compiled in excel spreadsheets. The SPSS software will be used to analyze data in this research. This software will ensure that the dependent variables in the research are not manipulated.

To ensure that ethical research is conducted, this project will follow to the latter the principles and standards of ethical research. It will also ensure that written informed consent is sought from the participants prior to beginning the research. The anonymity of the participants and the privacy of data will be upheld at all costs. Among the limitations of this project is the small number of participants used in the research. The short duration of the project and the use of questionnaires as the only method of data collection are also limitations in the study. In chapter four, this project will present the data analysis and results. The chapter will also discuss the findings and results. Chapter five of this project will conclude the project and give directions for future use.

References

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European Medical & Biological Engineering Conference, In Eskola, H., In Väisänen, O., In Viik, J., In Hyttinen, J., & Nordic-Baltic Conference on Biomedical Engineering and Medical Physics. (2018). EMBEC & NBC 2017: Joint Conference of the European Medical and Biological Engineering Conference (EMBEC) and the Nordic-Baltic Conference on Biomedical Engineering and Medical Physics (NBC), Tampere, Finland, June 2017. Retrieved from https://www.worldcat.org/title/embec-nbc-2017-joint-conference-of-the-european-medical-and-biological-engineering-conference-embec-and-the-nordic-baltic-conference-on-biomedical-engineering-and-medical-physics-nbc-tampere-finland-june-2017/oclc/1005134274

HADLER, A. N. D. R. E. W. S. U. T. T. O. N. S. T. E. P. H. E. N. O. S. T. E. R. B. E. R. G. L. A. R. S. (2020). WILEY BLACKWELL HANDBOOK OF TREATMENT ENGAGEMENT: Theory, research, and clinical practice. Place of publication not identified: WILEY-BLACKWELL. Retrieved from https://www.worldcat.org/title/wiley-blackwell-handbook-of-treatment-engagement-theory-research-and-clinical-practice/oclc/1130650913

In Balogh, E., In Miller, B. T., In Ball, J., & Institute of Medicine (U.S.). (2015). Improving diagnosis in health care. Retrieved from https://www.worldcat.org/title/improving-diagnosis-in-health-care/oclc/1001623571

In Forman, S. G., & In Shahidullah, J. (2018). Handbook of pediatric behavioral healthcare: An interdisciplinary collaborative approach. Retrieved from https://www.worldcat.org/title/handbook-of-pediatric-behavioral-healthcare-an-interdisciplinary-collaborative-approach/oclc/1062418920

In Corcoran, K., & In Roberts, A. R. (2015). Social workers’ desk reference. Retrieved from https://www.worldcat.org/title/social-workers-desk-reference/oclc/1030982838

In Costa, F. G., In Mil, J. W. F., & In Alvarez-Risco, A. (2018). The pharmacist guide to implementing pharmaceutical care. Retrieved from https://www.worldcat.org/title/pharmacist-guide-to-implementing-pharmaceutical-care/oclc/1053888074

In D’Onofrio, G., In Greco, A., & In Sancarlo, D. (2018). Gerontology. Retrieved from https://www.worldcat.org/title/gerontology/oclc/1084323462

In Heston, T. (2018). Ehealth: Making health care smarter. Retrieved from https://www.worldcat.org/title/ehealth-making-health-care-smarter/oclc/1099336057

In Hunter, J., & In Maunder, R. (2016). Improving patient treatment with attachment theory: A guide for primary care practitioners and specialists. Retrieved from https://www.worldcat.org/title/improving-patient-treatment-with-attachment-theory-a-guide-for-primary-care-practitioners-and-specialists/oclc/1005792343

In Mahmoud, S. H. (2019). Patient assessment in clinical pharmacy: A comprehensive guide. Retrieved from https://www.worldcat.org/title/patient-assessment-in-clinical-pharmacy-a-comprehensive-guide/oclc/1091029018

In Rodríguez, S. J. (2019). The diabetes textbook: Clinical principles, patient management and public health issues. Retrieved from https://www.worldcat.org/title/diabetes-textbook-clinical-principles-patient-management-and-public-health-issues/oclc/1106168761

In Sherman, S., In Hansen-Turton, T., In King, E. S., & Bednash, G. (2015). Nurse-led health clinics: Operations, policy, and opportunities. Retrieved from https://www.worldcat.org/title/nurse-led-health-clinics-operations-policy-and-opportunities/oclc/1034939410

Institute of Medicine (U.S.). (2016). A framework for educating health professionals to address the social determinants of health. Washington, DC: The National Academies Press. Retrieved fromhttps://www.worldcat.org/title/framework-for-educating-health-professionals-to-address-the-social-determinants-of-health/oclc/1021273933

Glanz, K., Rimer, B. K., & Viswanath, K. (2015). Health behavior: Theory, research, and practice. Retrieved from https://www.worldcat.org/title/health-behavior-theory-research-and-practice/oclc/1085343214

Liu, M., & Butler, L. M. (2017). Patient communication for pharmacy: A case-study approach on theory and practice. Retrieved from https://www.worldcat.org/title/patient-communication-for-pharmacy-a-case-study-approach-on-theory-and-practice/oclc/1017661990

Major Topics in Type 1 Diabetes. (2020). Place of publication not identified: InTech. Retrieved from https://www.worldcat.org/title/major-topics-in-type-1-diabetes/oclc/1096930284

Mollaoglu, M. (2018). Caregiving and home care. Rijeka: InTech. Retrieved from https://www.worldcat.org/title/caregiving-and-home-care/oclc/1039625354

National Academies of Sciences, Engineering, and Medicine (U.S.). (2018). Health-care utilization as a proxy in disability determination. Retrieved from https://www.worldcat.org/title/health-care-utilization-as-a-proxy-in-disability-determination/oclc/1030971027

Stanislaw, P. S., & Michael, S. F. (2017). Vignettes in Patient Safety – Volume 1. Retrieved from https://www.worldcat.org/title/vignettes-in-patient-safety-volume-1/oclc/1193045081

Steinberg, M. P., & Miller, W. R. (2015). Motivational interviewing in diabetes care. Retrieved from https://www.worldcat.org/title/motivational-interviewing-in-diabetes-care/oclc/1167659294

Choi, D., Choi, H., & Shon, D. (2019). Future changes to smart home based on AAL healthcare service. Journal of Asian Architecture and Building Engineering, 18(3), 190-199.

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.

Medina, M., Babiuch, C., Card, M., Gavrilescu, R., Zafirau, W., Boose, E., … & Boissy, A. (2020). Home monitoring for COVID-19. Cleveland Clinic journal of medicine.

Parker, M. L., Yip, P. M., DeCherrie, L. V., Escobar, C., Füzéry, A. K., Price, C. P., & St John, A. (2018). There’s No place like home: exploring home-based, acute-level healthcare. Clinical chemistry, 64(8), 1136-1142.

Ahmed, I., Ahmad, N. S., Ali, S., Ali, S., George, A., Danish, H. S., … & Cox, B. (2018). Medication adherence apps: review and content analysis. JMIR mHealth and uHealth, 6(3), e62. Retrieved from https://mhealth.jmir.org/2018/3/e62/

Brown, M., & Bussell, J. (2018). Medication Adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), 304-314. Retrieved from https://doi.org/10.4065/mcp.2010.0575

Fain, J. A. (2020). Reading, understanding, and applying nursing research. FA Davis. Retrieved from https://books.google.com/books?hl=en&lr=&id=-Y__DwAAQBAJ&oi=fnd&pg=PT8&dq=Fain,+J.+A.+(2017).+Reading,+understanding,+and+applying+nursing+research.+FA+Davis.&ots=JHcH0p64cR&sig=3Rd1qARsV5AERkZ7TcrYTC9aFWA

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Voortman, T., Kiefte-de Jong, J., Ikram, M., Stricker, B., van Rooij, F., & Lahousse, L. et al. (2017). Adherence to the 2015 Dutch dietary guidelines and risk of non-communicable diseases and mortality in the Rotterdam Study. European Journal of Epidemiology, 32(11), 993-1005. Retrieved from https://doi.org/10.1007/s10654-017-0295-2

Wolff-Baker, D., & Ordona, R. B. (2019). The expanding role of nurse practitioners in home-based primary care: Opportunities and challenges. Journal of gerontological nursing, 45(6), 9-14. Retrieved from https://www.healio.com/nursing/journals/jgn/2019-6-45-6/%7Ba5e68fe2-1e03-4962-af70-9dfea6d85e1e%7D/the-expanding-role-of-nurse-practitioners-in-home-based-primary-care-opportunities-and-challenges?fat=MJ9ZQQM69Y

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Appendix A

10 Strategic Points Table

DPI Project – Proposal Defense PowerPoint and Call Presentation SAMPLE

ADDITIONAL INSTRUCTIONS FOR THE CLASS – DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – DNP 960 : DPI Project – Proposal Defense PowerPoint and Call 

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

• Guarantee

  

  
  

• Zero Plagiarism
• On-time delivery
• A-Grade Papers
• Free Revision
• 24/7 Support
• 100% Confidentiality
• Professional Writers

• Services Offered

• Custom paper writing
• Question and answers
• Essay paper writing
• Editing and proofreading
• Plagiarism removal services
• Multiple answer questions

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. DNP 960 : DPI Project – Proposal Defense PowerPoint and Call

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