DPI Project – Proposal Defense

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

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 selecte

d 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.

References

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

American Medication Association. (2020, December 2). 8 reasons patients don’t take their medications. Retrieved from https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications

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Appendix A

10 Strategic Points

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) 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 a 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

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