Date of Conferral

2015

Degree

Doctor of Nursing Practice (DNP)

School

Health Services

Advisor

Cassandra Taylor

Abstract

The management and treatment of chronic diseases, such as end-stage renal disease, is often unproductive because of patients' poor adherence to treatment. The chronic care model toolkit is an Agency for Healthcare Research and Quality supported framework, associated with improved outcomes in patients living with chronic disease. The purpose of this project was to develop and plan an educational program using the chronic care model toolkit for the interdisciplinary clinical staff of a renal hemodialysis center. The goal of this project was to adapt team building between patients and their clinicians through the use of the chronic care model in order to improve patients' adherence to treatment. The educational program materials were developed, including a plan for future implementation over 6 weeks in 2-hour twice-weekly sessions. Program planning accounted for the mixed roles and responsibilities of the interdisciplinary clinical team members, who will share their knowledge among the team and act as patient advisors. The pretest and posttest materials were developed from the toolkit Team Health Audit Questionnaire, which can be used to evaluate staff learning after the program is delivered. Existing clinical metrics are tracked through a Quality Assessment Performance Improvement measure, which will be used to evaluate potential long term influences of the program on patient adherence and outcomes. The project may contribute to social change in practice by enhancing teamwork that has the potential to improve clinical outcomes. Future research should include longitudinal studies on team building using the chronic care model toolkit to determine if its adaption enhances team effort and contributes to a collaborative workforce that improves clinical outcomes.

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