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Transformative Healthcare – DNP’s Role in Improving Chronic Disease Management

Lashuuda Lewis

University of Mississippi

NUR 805 H001

Lisa Morgan

November 11, 2023

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Transformative Healthcare – DNP’s Role in Improving Chronic Disease Management

Introduction

The Doctor of Nursing Practice (DNP) professionals play an integral role in modern

healthcare. They are healthcare leaders and agents of change who are uniquely positioned to

address and confront serious clinical practice problems to improve outcomes for diverse systems

and populations. This research explores an advanced practice problem in healthcare. It articulates

the DNP’s intricate role in planning and coordinating interventions that foster a transformative

impact within a healthcare ecosystem while tackling immediate healthcare challenges.

Overview

Clinical Practice Problem and Advanced Practice Nursing Role

Various challenges mar contemporary healthcare. One of the critical advanced practical

issues is the suboptimal management of chronic diseases within primary care settings (Conley,

2023). The issue involves intricate challenges simultaneously addressing multiple chronic

conditions, necessitating a patient-centric and comprehensive approach. At the forefront of

dealing with this problem decisively is the instrumental role of the Adult-Gerontology Primary

Care Nurse Practitioner (AGPCNP) within a community-based primary care health clinic.

Target Population and Setting

The gist of the above challenge is evident in the experiences of adults and older adults

grappling with various complexities of managing chronic conditions like heart failure,

hypertension, and diabetes. Notably, this affected population is a diverse group with distinctive

challenges and needs. In addition to the above, the setting is a community-based primary care

clinic strategically situated in an urban location, addressing the needs of a demographically

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varied population. This setting acknowledges the unique dynamics in urban healthcare delivery,

where cultural diversity, socio-economic factors, and access to healthcare intertwine and interact

to shape the healthcare provision experience.

Current Knowledge of the Problem

Research demonstrates the multifaceted nature of managing multiple chronic conditions

in primary care. Studies articulate the effect on individuals’ quality of life, the challenges that

healthcare professionals grapple with, and the strain on healthcare systems (Savitz & Bayliss,

2021). These insights are the premises for developing proposed interventions, ensuring they are

based on the current understanding of the problem and that they are innovative.

Potential Solution

The proposed solution is an integrated healthcare model. At the center of the model is the

AGPCNP, its central figure, who designs and orchestrates a collaborative approach that

encompasses seamless coordination with an organized interprofessional team, robust patient

education initiatives, and advanced practice nursing (APN) interventions (Duffy, 2020). The

potential solution does not only aim to manage these chronic diseases but to redefine the patient

experience in the urban setting in tandem with their needs, preferences, and lives.

Ethical Concerns

Ethical concerns are intertwined with healthcare interventions and warrant careful

attention from healthcare professionals. In this case, the ethical considerations include

safeguarding patient confidentiality (sensitive health information), respecting patient autonomy

in decision-making, and equitable access to healthcare (Kenny, 2018). Hence, ethical concerns,
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especially in the context of this research, are integral in designing and implementing healthcare

interventions instead of being ancillary.

Desired Outcomes and Measurement

Healthcare interventions aim to achieve positive transformation and not just change. The

desired outcomes in this research transcend mere statistical improvement and include enhanced

patient satisfaction, reduced cases of hospitalizations, and tangible improvement in disease

management. Measuring these outcomes will be via qualitative (changes in patient satisfaction

and experience) and quantitative assessments (changes in health indicators). The aim is to

positively impact the patients' lives with the target population.

Potential and Identified Barriers

Relevance to Population and Practice Problem

Addressing suboptimal chronic disease management in this setting attracts potential

barriers that might hamper progress. One of the major barriers is limited access to healthcare

resources. The targeted population – adults and older adults with chronic diseases – have limited

access to resources, a situation which is aggravated by socio-economic disparities that ultimately

affect their health outcomes (Conley, 2023). In the urban setting, various factors constrain

healthcare, including cultural nuances, financial constraints, and transportation. In addition to

these, demographic diversity is a complex barrier. For instance, linguistic and cultural

differences constrain effective care delivery and communication. Thus, it is imperative to tailor

linguistically appropriate and culturally sensitive. Lastly, institutional resistance is a formidable

barrier that can impede the seamless integration of innovative healthcare models. These

challenges demand advocacy and strategic leadership to overcome.

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Role of the DNP in Addressing Barriers

The DNP is crucial in addressing these barriers as a change agent and leader. To address

limited access to resources in healthcare, they conduct a comprehensive needs assessment in

collaboration with the urban community to establish the unique challenges bedeviling them. The

approach fosters community engagement and intervention design, ensuring a co-creation of the

proposed solution as opposed to their imposition (“Personal perspectives on role

integration,”2018). Regarding socio-economic disparities, the DNP employs a holistic and

targeted approach. They champion policy changes by engaging with relevant policymakers to

break down economic barriers to access while fostering financial inclusion initiatives.

Moreover, they create a support network in the community via collaboration with

community organizations and social workers to address the disparities (Conley, 2023). Lastly,

the DNP leverages strategic leadership and clinical expertise to address institutional resistance.

They demonstrate value propositions for innovative healthcare models, garner support from key

stakeholders, and navigate complex organizational structures, bridging the institutional policy

and evidence-based gap.

Identified Priority Advanced Practice Roles

Addressing the suboptimal chronic disease management challenge requires a diversified

and interprofessional team of members with unique perspectives and skills. In addition to the

AGPCNP who spearheads clinical management, other essential players include a social worker

to navigate psychosocial health determinants and create a holistic and patient-centered care

environment, a pharmacist specialized in polypharmacy intricacies, and a clinical nurse specialist

(CNS) with a specialty in chronic disease management – the CNS also provides specialized
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education and support to the nursing staff. This team will help to address all the needs of the

target population.

Plan and Responsibilities

The collaborative plan entails joint patient care planning, interdisciplinary education

sessions, and regular team meetings, with the AGPCNP leading these initiatives. The AGPCNP

accentuates open communication, a conducive environment for all team members, and breaking

down the silos (Duffy, 2023). Besides clinical responsibilities, the AGPCNP facilitates

interdisciplinary collaboration by facilitating regular meetings to discuss complex cases and fine-

tune interventions based on the team’s expertise. These meetings are the cornerstone of a

strategic forum for refining the healthcare plan, troubleshooting, and knowledge exchange,

ensuring that all team members are well-informed of the latest developments in evolving

healthcare delivery, emerging best practices, and chronic disease management, fostering a

culture of adaptability and continuous learning.

Utilization of Non-Interprofessional Team Members

The above collaboration plan transcends the core interprofessional team discussed above.

It also encompasses community health workers for patient education and outreach. They help

bridge the gap between the community and healthcare providers, making them vital in the

healthcare plan. The AGPCNP also utilizes external consultants such as health informatics

specialists for community organization and data analytics for advocacy. Health informatics

specialists provide insights from data analytics that drive continuous improvement and inform

decision-making. Community organizations are instrumental in creating a supportive

environment, addressing socioeconomic disparities, and advocating for policy changes. Hence,
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the DNP is a strategic orchestrator of an interdisciplinary and strategic team, helping create a

strategic environment where the efforts and expertise of all team members are strategically

utilized, valued, and recognized.

Summary

The DNP’s role in a complex healthcare environment is instrumental in

dealing with the clinical challenge of suboptimal chronic disease management in an urban

primary care setting. Their strategic deployment of potential and identified barriers, collaboration

with an interprofessional and non-interprofessional team, and strategic deployment of advanced

practice roles lead to improved quality outcomes and transformation for the target population.

Thus, this holistic and collaborative approach aligns with DNP evolving roles as catalysts,

leaders, and advocates for positive change in modern healthcare systems.

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References

Conley, N. (2023). Social determinants of health, chronic disease management, and the role of

the primary care provider—include cardiovascular disease, cancer, diabetes, and major

causes of morbidity and mortality affected by social determinants of health. Primary

Care: Clinics in Office Practice, 50(4), 671-

678. https://doi.org/10.1016/j.pop.2023.04.011

Duffy, E. G. (2020). Adult-gerontology primary care nurse practitioner. Clinical Simulations for

the Advanced Practice Nurse. https://doi.org/10.1891/9780826140364.0006

Evolution to revolution: Positioning advanced practice to influence contemporary healthcare

arenas. (2018). DNP Education, Practice, and

Policy. https://doi.org/10.1891/9780826140197.0001

Kenny, D. J. (2018). Ethical issues in advanced practice nursing. Advanced Practice Nursing

Roles. https://doi.org/10.1891/9780826161536.0012

Personal perspectives on role integration. (2018). DNP Education, Practice, and

Policy. https://doi.org/10.1891/9780826140197.0008

Savitz, L. A., & Bayliss, E. A. (2021). Emerging models of care for individuals with multiple

chronic conditions. Health Services Research, 56(S1), 980-

989. https://doi.org/10.1111/1475-6773.13774