NURS FPX6011 ClaytonD Assessment 3 Evidence-Based Population Health Improvement Plan Example

Evidence-Based Population Health Improvement Plan

Diabetes mellitus (DM) is a chronic condition characterized by the body’s inability to use glucose as the primary source of energy for cells. This disease poses significant health care and economic problems, including increased global mortalities, prolonged hospitalization, multiple complications, and increased care costs. According to Mayo Clinic (2020), diabetes leads to various complications, including cardiovascular diseases (CVDs), neuropathy (nerve damage), nephropathy, retinopathy, hearing impairment, depression, and Alzheimer’s disease (AD).

NURS FPX6011 ClaytonD Assessment 3 Evidence-Based Population Health Improvement Plan

The major risk factors for diabetes include age, family or personal history, race or ethnicity, weight, physical inactivity, gestational diabetes, and high blood pressure (Mayo Clinic, 2020) notably, the disease manifests through various signs and symptoms, including blurred vision, unexplained weight loss, extreme hunger, and frequent infections. While diabetes mellitus poses a significant threat to the global healthcare systems, it is preventable by addressing the modifiable factors.

Therefore, this evidence-based population health improvement plan elaborates on the environment and epidemiological data for diabetes, an ethical plan that addresses the disease, the value and relevance of evidence, an evaluation plan, and strategies for communication with community members and colleagues.

Evaluating the Environmental and Epidemiological Data for a Population Health Issues

Diabetes is one of the leading causes of death among adults because of their susceptibility to environmental and epidemiological aspects of the condition. According to Saeedi et al. (2019), over 463 million people had diabetes in 2019, representing 9.3% of the global adult population. Also, the researchers add that the estimated number of people with diabetes will increase to 578 million in 2030 and 700 million in 2045.

In the United States, about 37 million people have diabetes, where 90-95% of them have type 2 diabetes (Centers of Disease Control and Prevention, 2021). The major modifiable and non-modifiable factors that contribute to high diabetes prevalence rates include obesity, alcoholism, tobacco use, unhealthy diets and sedentary lifestyles, aging, family history of diabetes, gestational diabetes, race or ethnicity, and people’s lack of awareness of interventions for diabetes control and management.

Equally, environmental factors exacerbate the situation by increasing people’s vulnerability to diabetes. According to Hill-Briggs et al. (2020), the major environmental aspects that determine people’s susceptibility to type 2 diabetes include air and water quality, housing quality, pollution, presence or absence of physical exercise opportunities, access to food, and exposure to occupational pollutants such as chemicals. These factors are disproportionate to people struggling with unfavorable social determinants of health, including poverty, low-level education attainment, limited access to quality health services, and neighborhood issues such as crime and poor-quality housing.

Notably, the national statistics of the US Department of Health and Human Services (DHSS) indicate that African Americans are the most at-risk population for diabetes in the United States. In 2018, non-Hispanic Blacks were twice as likely as non-Hispanic to die from diabetes (US Department of Health and Human Services Office of Minority Health, 2021).

Although community-level data for diabetes prevalence may be insufficient, people in my community grapple with issues such as obesity, cigarette smoking, pollution, housing quality issues, lack of knowledge of gestational diabetes, and unawareness of effective approaches for preventing and managing type 2 diabetes. Therefore, these concerns necessitate the development of an ethical improvement plan to address behavioral and environmental risk factors for type 2 diabetes.

Developing an Ethical Health Improvement Plan

The collaborative chronic care model (CCM) is a profound framework for enabling effective management and control of chronic conditions such as type 2 diabetes, cancer, and heart disease. Abdulrhim et al. (2021) contend that the CCM model entails forming Interdisciplinary teams and collaborating with patients, families, and communities to deliver quality, optimal care. Further, the researchers associate this framework with the ability to reduce medical errors and improve patients and health outcomes.

The most profound components of care that derive inspiration from the collaborative chronic care model are education and self-management support provided by healthcare professionals (Abdulrhim et al., 2021). Kumah et al. (2021) argue that educating the community about diabetes can result in positive outcomes, including improved knowledge of HbA1c, blood and foot care practices, weight management, self-efficacy, and self-monitoring of blood sugar. Therefore, community health promotion through education programs can address learning and knowledge deficiencies among community members.

When educating people about type 2 diabetes, it is essential to consider the aspects of socio-cultural diversities among community members. According to Goff et al. (2020), tailoring healthcare education programs to be more culturally sensitive is a profound strategy for addressing ethnic inequalities and providing individualized care. It is essential to avoid generalizing the content of community education programs because members have different interactions with the social determinants of health for diabetes. For example, it is vital to educate women about gestational diabetes to address gender-specific inequalities in diabetes self-management.

Justifying the Value and Relevance of the Evidence

The current scientific evidence supports the rationale for using a collaborative chronic care model (CCM) to address community members’ educational needs and knowledge deficiencies regarding diabetes prevention, control, and management. In an exploratory case study, Abdulrhim et al. (2021) revealed that the CCM can promote patient health outcomes, enable healthcare professionals to provide context-specific education programs and improve patient satisfaction.

On the other hand, a randomized controlled trial by Wang et al. (2022) revealed that collaborative nursing intervention (CNI) can significantly boost the self-efficacy of patients with type 2 diabetes, enabling them to control blood glucose and adhere to treatment options. These scholarly studies provide up-to-date, credible, and reliable information that supports the plausibility of applying a collaborative chronic care model in preventing, managing, and controlling diabetes.

Evaluating the Achievement of the Health Improvement Plan’s Outcomes

Undoubtedly, applying appropriate evaluation strategies can reveal the health improvement plan’s outcomes and expose underlying issues that can compromise the achievement of strategic objectives. When assessing the effectiveness of a health improvement plan consisting of education programs, it is essential to apply Kirkpatrick’s evaluation model to assert the programs’ effectiveness in improving people’s knowledge and awareness of self-management interventions.

According to Grant et al. (2020), this evaluation model entails four levels: patient satisfaction, learning, transfer, and results. In essence, it is vital to assess people’s satisfaction with educational sessions, establish the degree of knowledge acquisition based on their participation in educational sessions, evaluate how participants apply learned concepts in their daily practices and lives, and assess the outcomes of applying the acquired knowledge of self-management interventions. The potential outcomes of training and educating community members about diabetes self-management include effective glycemic index control, weight management, and healthy diet choices.

Strategies for Communicating the Members and Colleagues in the Healthcare Profession

Equally, effective communication between stakeholders is an essential aspect of the healthcare improvement plan for diabetes. In this sense, the plan for communicating with patients, families, and other stakeholders should uphold the tenets of culturally responsive care and collaborative interventions. Huang et al. (2021) argue that healthcare professionals should practice empathy and trust, express active listening, and avoid judgmental thoughts when communicating with patients and families.

Also, care providers should avoid implicit and explicit perceptions and stereotypes regarding patients’ or families’ socioeconomic and demographic diversities. When educating patients and families about diabetes self-management interventions, my communication plan will emphasize the importance of providing facts in the simplest language to facilitate understanding. It will be essential to adopt communication channels that facilitate meaningful interactions, consensus goal-setting, and enhanced participation in the health promotion program.


Type 2 diabetes is a chronic condition that results in health and economic ramifications. The interplay between behavioral, environmental, and socio-economic factors increases people’s susceptibility to diabetes. For example, obesity, alcoholism, tobacco use, exposure to pollutants, aging, and physical inactivity are the major risk factors for type 2 diabetes. While communities have varying degrees of vulnerability to the disease, it is essential to embrace population-specific health improvement programs to address inequalities that facilitate the disease.

For instance, implementing a collaborative chronic care model (CCM) enables healthcare professionals to partner with patients, families, and communities in developing culturally responsive education and training initiatives. In turn, the CCM resonates with the determination to embrace effective communication strategies when interacting with patients and families. Eventually, culturally responsive knowledge enhancement programs led to increased knowledge of self-management interventions, improved glycemic control, weight management, and self-monitoring of vital signs.

NURS FPX6011 ClaytonD Assessment 3 Evidence-Based Population Health Improvement Plan References

  • Abdulrhim, S., Sankaralingam, S., Ibrahim, M. I. M., Diab, M. I., Hussain, M. A. M., Al Raey, H., Ismail, M. T., & Awaisu, A. (2021). Collaborative care model for diabetes in primary care settings in Qatar: A qualitative exploration among healthcare professionals and patients who experienced the service. BMC Health Services Research, 21(1).
  • Centers for Disease Control and Prevention. (2021, December 16). Type 2 diabetes.
  • Goff, L. M., Moore, A., Harding, S., & Rivas, C. (2020). Providing culturally sensitive diabetes self-management education and support for black African and Caribbean communities: a qualitative exploration of the challenges experienced by healthcare practitioners in inner London. BMJ Open Diabetes Research and Care, 8(2), e001818.
  • Grant, S. M., J. Glenn, A., M. S. Wolever, T., G. Josse, R., L. O’Connor, D., Thompson, A., D. Noseworthy, R., Seider, M., Sobie, M., Bhatti, G., Cavanagh, J., Jones, E., & B. Darling, P. (2020). Evaluation of glycemic index education in people living with type 2 diabetes: Participant satisfaction, knowledge uptake, and application. Nutrients, 12(8), 1–16.
  • Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2020). Social determinants of health and diabetes: A scientific review. Diabetes Care, 44(1), 258–279.
  • Huang, S. C.-C., Morgan, A., Peck, V., & Khoury, L. (2021). Improving communications with patients and families in geriatric care. the how, when, and what. Journal of Patient Experience, 8, 237437352110340.
  • Mayo Clinic. (2020, October 30). Diabetes – symptoms, and causes.
  • Saeedi, P., Petersohn, I., Salpea, P., Malanda, B., Karuranga, S., Unwin, N., Colagiuri, S., Guariguata, L., Motala, A. A., Ogurtsova, K., Shaw, J. E., Bright, D., & Williams, R. (2019). Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the international diabetes federation diabetes atlas, 9th edition. Diabetes Research and Clinical Practice, 157(157), 1–10.
  • US Department of Health and Human Services Office of Minority Health. (2021, January 3). Diabetes and African Americans.
  • Wang, X., Liang, J., & Yang, W. (2022). A randomized, controlled trial exploring collaborative nursing intervention on self-care ability and blood glucose of patients with type 2 diabetes mellitus. Disease Markers, 2022, 1–7.

NURS FPX6011 ClaytonD Assessment 3 Evidence-Based Population Health Improvement Plan Instructions

Create a 3-5 page paper identifying the health concern that you think is most appropriate to address for the community in your practice environment. Your choice should be based on the evaluation the relevant data that you have gathered for your chosen issue.


The bullet points below correspond to grading criteria in the scoring guide. Be sure that your population health improvement plan addresses all of the bullets below, at minimum. You may also want to read the Evidence-Based Population Health Improvement Plan Scoring Guide and Guiding Questions: Evidence-Based Population Health Improvement Plan [DOCX] to better understand how each criterion will be assessed:

  • Evaluate the environmental and epidemiological data about your community so that you can illustrate and diagnose widespread population health issues.
  • Develop an ethical health improvement plan that addresses the population health issue you have identified in your evaluation. The plan should be based upon the best available evidence and meet the cultural and environmental needs of your community.
  • Justify the value and relevance of the evidence you used as the basis for your population health improvement plan.
  • Propose criteria that can be used to evaluate the achievement of your health improvement plan’s outcomes.
  • Explain how you plan to apply strategies for communicating with community members and colleagues in the health care profession in an ethical, culturally sensitive, and inclusive way about the development and implementation of your health improvement plan.
  • Integrate relevant sources to support assertions, correctly formatting citations and references using APA style.

Also read: NURS FPX6011 ClaytonD Assessment 2 Patient-Centered Care Report