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NURS FPX 6011 Assessment 3 Evidence-Based Population Health Improvement Plan

Evidence-Based Population Health Improvement Plan

NURS FPX 6011 Assessment 3 Evidence-Based Population Health Improvement Plan

The care for patients is not limited to the emergency unit or the bedside. Patients come from communities and populations, a proportion of which could be having similar conditions that pose a public health concern. In such cases, it is important for the nurse to identify and advocate for strategies for improving the health outcomes of specific patient categories and vulnerable groups at the community or population level. This population health improvement plan aims at detailing a plan for improving the health of women who develop gestational diabetes mellitus during pregnancy and are at risk of developing type 2 diabetes mellitus after childbirth. 

Environmental and Epidemiological Data

The selected community for the intervention includes Asian Americans in Long Island, NY. Recent reports indicate that approximately 11,000 Asian Americans live in the neighborhood, making up 34% of the Long Island population (Hong, 2021). One of the conditions that affect women of Asian origins is gestational diabetes mellitus (GDM). The condition is more prevalent among women from Asian, Mexican, Hispanic, non-Hispanic black, and other racial groups as compared to non-Hispanic white women (Zhou et al., 2018). The New York Department of Health (n.d.). reported that the prevalence of GDM is highest among non-Hispanic Asian women (at 7.9%) as compared to other racial groups. The issue of interest, therefore, is to improve the health of Asian American women in Long Island who suffer from GDM.

According to Casagrande et al. (2018), the most notable risk factors for GDM included race and ethnicity, having more than four live births, an advanced age at first birth, a family history of diabetes mellitus, and obesity. Consequently, having a non-Hispanic Asian background is a risk factor. Furthermore, patients who subsequently develop diabetes tended to have an older age, more years since their GDM diagnosis, lower educational attainment levels, a family history of diabetes, or obesity (Casagrande et al., 2018). It is also notable that those with a higher level of income have lower rates of subsequent diabetes diagnoses. 

Therefore, the biggest concerns for the community are the low educational attainment, prevalence of overweight and obesity, and family history of diabetes among women from minority racial backgrounds who are also of low socioeconomic backgrounds. According to Johns et al. (2018), obesity is the most significant environmental risk factor that poses a challenge to the health of pregnant women. In the implementation of the community plan, one area of uncertainty is whether existing interventions have successfully reduced the prevalence and burden of disease within the target population, and the reasons behind any lack of success.

Ethical Health Improvement Plan

The proposed health improvement plan is the implementation of a community health maternal care initiative that targets women from minority racial groups and low socioeconomic backgrounds. The initiative should be implemented at the community level through a partnership among pre-natal and post-natal care facilities, hospitals, nutritional service providers, community health centers, and non-government organizations (NGOs). The NGOs will be of help in identifying the categories of women who are at elevated risk within the community and in promoting awareness of the intervention. Casagrande et al. (2018) highlighted the action plans that the National Diabetes Education Program recommended for improving the health of women at risk of GDM and their offspring. From the action plans, the first plan for intervention is the improvement of prenatal and postpartum testing for women at risk of GDM (Casagrande et al., 2018). In the proposed health improvement plan, the tests will be carried out at the hospital which forms part of the partnership.

The second action plan is the referral of the women to early treatment and referral efforts for the at-risk population (Casagrande et al., 2018). Among the collaborating partners, there should be obstetrician-gynecologists and primary care providers with the skills to provide early treatment services for the patient population. Zhou et al. (2018) highlighted the strategies that the service providers can adopt in the early treatment and subsequent management of GDM among pregnant women and in post-natal care. The management intervention should incorporate dietary advice, blood glucose monitoring, insulin therapy if needed, hemoglobin checks, blood pressure monitoring, medication reconciliation, and breastfeeding (Zhou et al., 2018). The recommendation is to administer these services in a multidisciplinary setting, which informed the recommendation of the partners to include as part of the intervention. The early intervention should be followed up by education and support for lifestyle interventions including dietary modifications, physical activity, and weight regulation (Zhou et al., 2018). These can be performed at community health centers and nutritional service providers’ facilities.

The third and fourth action plans, as Casagrande et al. (2018) highlighted, included the counseling of mothers on subsequent diabetes tests after pregnancy and before their next pregnancies, and counseling mothers on the need for early diagnosis and treatment for diabetes for their children, who will be at risk. As Dasgupta et al. (2018) explained, the prevention of diabetes after pregnancy is an important strategy for women who have had GDM. However, the authors noted potential barriers to the effectiveness of GDM interventions, including low penetration of the interventions, low rates of participation in the programs among women, poor recruitment of participants to proposed programs, and poor education among some targeted populations (Dasgupta et al., 2018). Misunderstandings can occur as a result of language barriers and poor education.

Value and Relevance of Evidence

The evidence from various authors has been valuable in curating the population health improvement plan for women with GDM in the community. Casagrande et al. (2018), based on an analysis of the prevalence of gestational diabetes in the US, highlighted the public health importance of interventions for GDM including diabetes education, diabetes testing, and the application of the National Diabetes Education Program’s action plans. It is these action plans that informed the design of the elements of the health improvement plan. Johns et al. (2018), on the other hand, studied emerging evidence to uncover the mechanisms, treatment, and complications of GDM. From their findings, the authors outlined the treatment strategies and lifestyle interventions for GDM that have been incorporated into the health improvement plan, informing the goal of implementing evidence-based practice for GDM management. Dasgupta et al. (2018) then provided insights into the health promotion challenges associated with the interventions for GDM, with the evidence helping to highlight the possible barriers that the proposed improvement plans will face.

Criteria for Evaluating Outcomes

The desired outcomes for the health improvement plan include the enrollment of more women in the GDM community initiative, reductions in infant deaths due to GDM, reduction in post-partum diabetes mellitus among the patients, and weight reduction. The proposed criteria for evaluating the outcomes of the improvement plan are contained in the Consolidated Framework for Implementation Research (CFIR). CFIR is a framework that provides a guide for effectively implementing evidence-based practices through five domains, each with specific criteria for evaluating the outcomes of an intervention. 

The domains of CFIR include, 1) the characteristics of the intervention used, 2) the outer settings or environmental influences on the implementation process, 3) the inner setting or characteristics of the implementing organization, 4) individual characteristics that affect the implementation, and 5) the process of implementation (Safaeinili et al., 2020). The outcomes will be evaluated using the criteria under the domains of the individual patient characteristics (no. 4) and the process of implementation (no. 5). The specific criteria will include patient self-efficacy in complying with treatments, patient knowledge of diabetes and management plan, and the evaluation of the success of the improvement plan through the metrics for the proposed outcomes.

Strategies for Communication

A task force will be implemented to steer the communication among healthcare providers working for the partnering organizations, with various stakeholders needed for the success of the improvement plan, and with individual patients. The task force will ensure that the collaborating partners have a healthcare management tool to enhance the exchange of the necessary patient information to avoid the disclosure of their Protected Health Information (PHI), the leakage of patient information to unwanted parties, and the loss of pertinent information required for referrals and continuity of care. Only the providers with appropriate credentials will be able to exchange information through the system. 

Communication with the community will occur through the use of community leaders for minority populations living in the neighborhood, social workers who interact with disadvantaged women, and officers at the community centers who interact consistently with the needy populations in the community. These contact persons will be used to enlist patients for the improvement plan, communicate the plan to them, promote the plan in the community at large, and form part of the team involved in patient education. The use of these contact persons will also facilitate the communication of health information without language barriers to those who are not proficient in English or limitations to those with low levels of education. Their interactions with the community members have equipped them with an understanding of the communication needs and preferences, along with the skills to participate in the communication process.


Casagrande, S. S., Linder, B., & Cowie, C. C. (2018). Prevalence of gestational diabetes and subsequent Type 2 diabetes among U.S. women. Diabetes Research and Clinical Practice, 141, 200-208. https://doi.org/10.1016/j.diabres.2018.05.010

Dasgupta, K., Mandal, H. T., Nielsen, K. K., & O’Reilly, S. (2018). Achieving penetration and participation in diabetes after pregnancy prevention interventions following gestational diabetes: A health promotion challenge. Diabetes Research and Clinical Practice, 145, 200-213. https://doi.org/10.1016/j.diabres.2018.04.016

Johns, E. C., Denison, F. C., Norman, J. E., & Reynolds, R. M. (2018). Gestational diabetes mellitus: Mechanisms, treatment, and complications. Trends in Endocrinology & Metabolism, 29(11), 743-754. https://doi.org/10.1016/j.tem.2018.09.004

Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., & Winget, M. (2020). CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learning Health Systems, 4(1), e10201. https://doi.org/10.1002/lrh2.10201

Zhou, T., Sun, D., Li, Y., Heianza, Y., Nisa, H., Hu, G., Pei, X., Shang, X., & Qi, L. (2018). Prevalence and trends in gestational diabetes mellitus among women in the United States, 2006–2016. Diabetes, 67(Suppl 1), 121-OR. https://doi.org/10.2337/db18-121-OR

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