A Lifetime Condition – Type 1 Diabetes Mellitus Assignment | Online Assignment

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Jane Smith

Pathopharmacological Foundations for Advanced Nursing Practice

Western Governors University

 

 

*** This paper and topic are for example purposes only. Diabetes is not an approved topic for the Task 1 submission. The authors cited in this paper are fictitious and for example purposes only. ***

 

 

A Lifetime Condition – Type 1 Diabetes Mellitus

Investigated Disease Process

         Each year in the United States there are 100,000 people who die from complications of type 2 diabetes mellitus (Centers of Disease Control & Prevention, 2018).  This disease can be prevented, and risks minimized through lifestyle modification. This paper will discuss various aspects of this disease process including pathophysiology, review of the standard of practice, patient outcomes and development of a best practices plan to mitigate negative outcomes of this disease within an organization.

Pathophysiology

Diabetes is a disease that affects multiple body systems through altering cellular metabolism. At a cellular level each cell requires glucose for metabolism purposes. Insulin produced by the pancreas functions to allow transport of glucose from the extracellular area to intracellular area (Hoffner, 2018). Those with diabetes have pancreatic insufficiency which eventually eliminates complete production of insulin. The result is that glucose present in the intravascular area is not able to move into the cells. The cells will then be starved for glucose and no longer function appropriately.

With numerous cells lacking glucose the endocrine system stimulates additional glucose from body reserves that is stored in the liver as glycogen. When glycogen is broken down into glucose, this increases the circulating glucose levels even more, compounding the severity of this disease. When intravascular fluid (e.g. serum) is overly saturated with glucose molecules, the body chemistry changes causing shifts of electrolytes, water molecules, leading to electrolyte abnormality and pH imbalance (Hoffner, 2018).  The body systems that are mostly affected by these abnormalities and glucose are the cardiovascular system, nervous system, kidneys and eyes (Hoffner, 2018).

When serum glucose levels are consistently above normal levels, the blood vessels distribute blood to the eyes, kidneys, distal tissues (e.g. fingers and toes), become inflamed and respond by constriction decreasing blood flow perfusion (Hoffner, 2018). With decreased perfusion, oxygen is not delivered, and those organs and cells slowly deteriorate. Over time, uncontrolled diabetics can be blind, have renal failure, and lose body limbs.

Diabetes is a treatable condition however when uncontrolled negatively affects many areas of the body. These negative effects lead to poor health outcomes and decreased life expectancy. While type I diabetes is not preventable, understanding of the disease process is well known and when treated appropriately patients can live a very normal life.

Standard of Practice

The standard of practice for the disease, diabetes mellitus was published in 2015, by the American Diabetes Association. This publication provides specific recommendations pertaining to screening intervals, prevention of comorbidities such as renal failure, skin integrity impairment, and visual deficits to name a few. The Standard of Practice also provides clear parameters for the assessment, diagnosis, nonpharmacologic strategies of management and medication recommendations. The objectives for the standard of practice are to minimize complications commonly associated with unmanaged diabetes and extend the life expectancy for this vulnerable population (American Diabetes Association, 2015).

Health promotion strategies are consistent throughout the standard of practice for diabetes. Not only are there medical guideline recommendations for this disease process, but also various patient education materials. These extra resources allow providers across the country to have consistent practices in diagnosing and managing this common disease. The next two sections will explore the standard of practice recommendations for pharmacologic treatments and the clinical guidelines.

Pharmacologic Treatments

The best health outcomes occur when patients are compliant with medication recommendations and lifestyle modifications. Diabetes is best treated through providing insulin through parenteral routes. Insulin is deteriorated in the acidic environment of the stomach; therefore, oral insulin is not available as a form of treatment.

Insulin – Short Acting

              Short acting insulin is the most common type of insulin given for diabetic ketoacidosis and glucose correction following a meal (American Diabetes Society, 2018). Short acting insulin can be administered through injection using an insulin needle and syringe, or through an insulin pump. Short acting insulin has an onset of action ranging from 5 to 30 minutes, with a duration of one to two hours (American Diabetes Society, 2018). The most common adverse effect associated with short acting insulin is hypoglycemia (American Diabetes Society, 2018). This can be prevented by correctly calculating carbohydrate to insulin ratios and the patient needs to consume the meal soon after the insulin has been administered.

Insulin – Intermediate Acting

Intermediate acting insulin allows the patient to minimize how many injections they give in a day by mixing the intermediate insulin with the short acting insulin injection. The short acting insulin will affect glucose consumed for the meal occurring at that time, where intermediate insulin will cover glucose consumed two to four hours later (American Diabetes Society, 2018). Just like short acting insulin the adverse effect of this insulin type is also hypoglycemia. This can be avoided by encouraging the patient to have a snack in between breakfast and lunch such as an apple or graham crackers.

Insulin-Long Acting

Like the intermediate acting insulin, long-acting insulin works by affecting glucose consumed later in the day and to regulate glucose overnight while the patient sleeps. The onset of action is 1 to 2 hours, with a duration of 6 to 8 hours (American Diabetes Society, 2018). To avoid hypoglycemia the patient should consume a small snack prior to bedtime. Appropriate snacks include fruit such as an apple or orange, or crackers.

Local Outcomes

University Hospital is the leading organization in the Greene County, Missouri area who manages patients with diabetes.  This organization cares for patients who are newly diagnosed through their lifetime. University Hospital aligns with the American Diabetes Association guidelines recommendations for use of the medications as previously outlined, in addition to technological advances such as continuous glucose monitoring devices and insulin pumps.  The latest initiatives at University Hospital have been the implementation of technology in insulin dosing. Insulin pumps provide a more consistent way to administer appropriate doses continuously as opposed to interval injections given by the patient. This technological intervention has greatly improved management of diabetes for patients care at University Hospital.  In the past year, the average hemoglobin A1C measurement of patients managed at University Hospital was 8%, which is 6% lower than averages two years ago (University Hospital, 2018). This impressive data suggests that adapting to innovative medication practices are an effective means to improve medication compliance and patient outcomes as evident by the improvement of hemoglobin A1C of diabetes patients at University Hospital.

Clinical Guidelines

Assessment

Patients with diabetes who are not yet diagnosed will often report excessive thirst, hunger and urination (American Diabetes Society, 2018). Despite excessive drinking and eating the patient will continue to lose weight, have decreased energy and eventually may have neurological changes such as altered mental status, and worst-case scenario, a coma (American Diabetes Society, 2018). On physical assessment the patient may be jittery, diaphoretic, and pallor. If laboratory studies are obtained the patient may have changes in their potassium, metabolic acidosis, and elevated blood glucose level (American Diabetes Society, 2018).

Diagnosis

Unfortunately, when diabetes is diagnosed the patient is often quite ill and experiencing diabetic ketoacidosis. There isn’t a specific test for diabetes but a diagnosis of inclusion including elevated blood glucose, elevated hemoglobin A1c and associated laboratory test abnormalities consistent with the disease process such as potassium and bicarbonate abnormality (American Diabetes Society, 2018).

Patient Education

      Once a patient is diagnosed with diabetes, they will sustain a complete change in lifestyle such as altering their nutrition, checking blood glucose frequently and dosing of insulin for the rest of their life. Priority patient education that is recommended are accurate calculation of carbohydrates, proteins and fats consumed in their diet (American Diabetes Society, 2018). This calculation is essential because insulin dosing is based on grams of carbohydrates. Other priority education should take place is making the patient aware of the available resources that they have questions or trouble managing their blood glucose, as well as unique situations such as glucose changes when ill or when the disease has been diagnosed in a child (citation, year). Each patient will have a unique experience and education should be provided accordingly.

Standard of Practice Disease Management

As previously identified, University Hospital is the leading expert in the Denver area where patients with diabetes or managed. University Hospital aligns with the American Diabetes Society standard of practice regarding the diagnosis, and management using nonpharmacologic and pharmacologic strategies when required. To diagnose diabetes, University Hospital uses laboratory studies including a fasting glucose and hemoglobin A1c to diagnose diabetes, consistent with recommendations by the American Diabetes Society (2018).  Non-pharmacologic strategies provided by University Hospital providers include referral to a nutritionist who specializes in caring for patients who have diabetes, and referral to exercise therapies in cases where patients are obese. Nutrition and exercise are both recommended strategies suggested by the American Diabetes Society.

Patient outcomes that have resulted from these practices have been positive. In 2017, 72% of patients referred to University Hospital have improved control of their diabetes through the previously mentioned practices (University Hospital, 2017).  Of those who demonstrated control of their diabetes, hemoglobin A1c’s were consistently less than 9%, body mass index was maintained less than 28 kg/m², and 52% of this population consistently met with the nutritionist as recommended (University Hospital, 2017).  This data represents that following recommendations set forth by the American Diabetes Society are effective and yield promising outcomes for those who have diabetes.

Managed Disease Characteristics and Resources

           The first characteristic of the patient with well managed diabetes is adherence to the diabetic diet. To maintain consistent blood glucose levels, patients must count carbohydrates and proteins with each meal and dose insulin needs accordingly (American Society of Diabetes, 2017).  Patients who consistently keep track of their nutrition are more likely to have a healthy body mass index, less likely to have hypertension and decrease the risk of comorbidities associated with diabetes (American Society of Diabetes, 2017). To achieve this goal a resource that a patient will use is a nutritionist who specializes in the management of diabetes (American Society of Diabetes, 2017). This individual can help them with food choices and answer any questions they have if blood glucose levels are inconsistent.

The second characteristic of a patient with well managed diabetes is medication compliance. Management of blood because levels requires daily tracking and medication administration. Patients who consistently follow blood glucose levels will be more likely to note inconsistencies and make appropriate changes with medication dosing (American Society of Diabetes, 2017). Proper use of medication leads to more consistent blood glucose levels, which in turn leads to better health outcomes. A resource the patient can access to improve medication compliance can be a resource nurse specific to the management of diabetes. Or the healthcare provider who manages their diabetes can be a great resource for the patient to ask questions and clarify aspects of medications (American Society of Diabetes, 2017).

The last characteristic of the well managed diabetic patient includes consistent medical evaluation according to the recommended intervals. When patients are 1st diagnosed, the recommendation is that they are evaluated every three months to determine that they are managing the disease process correctly (American Society of Diabetes, 2017). A hemoglobin A1c is a common test performed at these visits, which provides information regarding the patient’s management of their diabetes over the past three months (American Society of Diabetes, 2017). This interval assessment allows you nutrition and medication adjustments to better meet the requirements for that specific patient. The resource most appropriate for this characteristic is having a medical home that specializes in the management of diabetes.

The American Society of Diabetes (2017), reports that those who managed their diabetes can live 10 to 20 years longer than counterparts who do not manage the disease successfully. In managing the disease, the characteristics outlined previously are those that contribute to this difference in life expectancy outcomes. The emphasis suggested to improve the outlined characteristics begins with patient education (American Society of Diabetes, 2017). Therefore, upon initial diagnosis healthcare professionals need to prioritize a successful educational experience throughout the patient’s life.

International and National Disparities

Diabetes is a worldwide issue. It is not a disease process specific to the United States alone. In Australia, the mortality rate of diabetes is 18%, compared to 26% in the United States (World Health Organization, 2016). In Afghanistan, the reliability of tracking statistics related to diabetes is inconsistent however the World Health Organization (2016) estimates a mortality rate of 39% in those who are known to have diabetes at the time of death. What are these countries doing differently in terms of managing this common disease process?

In Australia, the healthcare structure is very different from United States. Health insurance is not just something achieved through employment, it is something that every citizen has by right. This leads to improved health maintenance exams and interval health care visit needs (citation, year). As a result, more patients are screened for diabetes and the diagnosis is promptly found. With earlier diagnosis, treatment can be initiated, and health outcomes are subsequently improved. The prevalence of diabetes is 32% in Australia compared to 28% in the United States (Cantery, 2019). This difference in prevalence is likely caused by increased screening for the disease process. Meaning, in the United States there are likely many who are not yet diagnosed because they have not sought medical care or been appropriately screened according to guidelines practiced in Australia. Once diagnosed, healthcare providers follow similar guidelines in managing the disease process through the use of nutritional modification (e.g. carbohydrate and protein modifications), and pharmacologic management including injectable insulin (Cantery, 2019). Another factor leading to better control of diabetes and Australia is related to the costs associated with medical equipment. These costs are covered 100% by the Australian government health insurance plan (Cantery, 2019). This prevents patients from limiting supplies or medication secondary to income.

As previously mentioned, statistics around diabetes in Afghanistan are not reliable, therefore it is difficult to understand the true disparity. In areas where medical facilities exist, patients will seek care with illness or health concerns. It is common that patients who are not yet diagnosed with diabetes often seek medical care when their disease is severe and more life-threatening (Simms, 2017). This is likely the reason for a higher mortality rate. In areas of the country where primary care type facilities exist, screening practices are performed and management including injectable insulin is prescribed (Simms, 2017).  The population that these serves are likely those who have health insurance or a means to pay for healthcare. However, most of the population are not getting routinely screened for this disease process and there are many who are not diagnosed appropriately and therefore health outcomes are grim (Simms, 2017). Once diabetes is diagnosed, insulin is the medication of choice used for these patients. Depending on the provider, they will prescribe various practices around checking glucose levels and assigning insulin unit dosing (Ross, 2015). Without specific guidelines regarding management, there is great variability across Afghanistan which leads to numerous different patient health outcomes.

Using these two countries as a representation of international practices compared to national practices of the United States, it is evident that routine screening for diabetes is a predictor of mortality. In countries where screening is routine, the diagnosis of diabetes is punctual and management strategies can be initiated. In countries where routine screening for the disease does not occur, treatment is delayed leading to worse health outcomes and death. It is also evident that consistent adherence to management guidelines are also a predictor of mortality and comorbidities associated with diabetes. In Afghanistan for example, each provider has their own way of managing the disease process that may or may not lead to desirable health outcomes for their patients. If there were a guideline we could follow, patient health outcomes would be easier to track and adjustments to the guidelines be made. In countries like the United States and Australia, specific guidelines are published by reliable evidence-based resources which allows patients to receive care immersed in best practices.

Managed Disease Factors

The first factor that allows the patient to manage the disease process of diabetes is economic stability. Patients with diabetes will require many healthcare visits, medications and durable medical equipment to manage their disease process (Ross, 2015). Depending on insurance status these items will have copayments or deductibles associated with them. A patient who is economically stable is more likely to have the means to pay for them and therefore better manage the disease process.

The next factor that influences a patient to have better managed diabetes is health insurance. Patients who have health insurance will be able to seek medical care promptly when acute or chronic health concerns arise (Ross, 2015). When healthcare is easily accessible health outcomes will be evaluated and treated preventing negative health effects and better overall health outcomes.

Last, transportation is an essential component to accessing necessary aspects of disease management. A patient with transportation is going to be able to travel to healthcare appointments, the pharmacy to get prescription medications and other locations required as part of managing this disease process. When a patient is initially diagnosed, healthcare appointments will be more frequently ensuring that they are managing their blood glucose correctly, therefore a means of transportation is essential for this to occur (Ross, 2015).

Unmanaged Disease Factors

The first factor leading to unmanaged diabetes is economic stability. As previously mentioned, management of this disease process requires frequent medical visits, medications and medical equipment. These resources can become quite costly therefore patients who have lack of financial reserve will be less likely to purchase medications and medical equipment they require and are less likely to follow healthcare visit recommendations. When diabetes is unmanaged, health maintenance needs and health outcomes can worsen leading to even more financial burden (Kunich, 2017).

Patients who do not have health insurance will be required to pay out of pocket costs for all healthcare visits, medications and durable medical equipment (citation, year). Patients who have to pay out of pocket for these things are going to be less likely to obtain all necessary modalities to care for their diabetes. There is a high Association of individuals who do not have health insurance as pertains to negative health outcomes and shorter life expectancy, which is compounded in patients with chronic diseases such as diabetes (Hoffner, 2018).

Patients who lack transportation are less likely to travel to healthcare appointments, pharmacies to get medications and other needs required of the disease process (Hoffner, 2018). Those with diabetes can have sudden changes in health status, therefore being able to travel promptly to care facilities is essential. Those who do not have transportation will have to find another means which the patient might not be successful, or care interventions may be delayed.

Unmanaged Disease Characteristics

The first characteristic found in patients with unmanaged diabetes is inconsistent blood glucose measurement and insulin dosing titration. Patients who do not trend their blood glucose measurements will not be able to adjust their insulin dosing accordingly leading to more fluctuate blood glucose levels (Ross, 2015). When blood sugar levels are very high and very low, negative health outcomes such as renal failure, blindness, decreased perfusion and potentially altered mental status can occur (Ross, 2015).  These negative health outcomes will ultimately affect life expectancy and the patient’s quality of life.

The second characteristic of a patient with unmanaged diabetes is altered nutritional intake (citation, year). Patients with diabetes must closely monitor each meal and measurement of carbohydrates, proteins and fats. When patients do not attend to these meal components, they are less likely to dose their insulin correctly and likely to consume foods that are not conducive to a stable glucose level.

Last, the patient who does not attend recommended healthcare visits will be more likely to miss priority educational opportunities. In addition, when patients are 1^st diagnosed with diabetes they are required to manage their glucose by providing several injections throughout the day and checking blood glucose frequently. There are other modalities of treatment such as an insulin pump, however care providers require that patients know how to manage blood glucose using a blood glucose measurement and several injections throughout the day. The rationale for this is that if an insulin pump were to malfunction, the patient would be able to still manage blood glucose through old methods. Therefore, if patients are not consistently attending healthcare visits, they are not going to be given this opportunity for modalities such as an insulin pump. Insulin pumps create a more consistent blood glucose level and overall management is much easier for the patient. The patient not given this opportunity is more likely to have fluctuating blood glucose levels.

Patients, Families and Community

Burden to Patient

         In the Denver area, patients with diabetes have limited options available for healthcare providers. Specialty providers who focus on diabetes management are limited in the area which has decreased available appointments for patients with diabetes. As a result, there is a 27% prevalence rate of progressive diabetes causing negative health outcomes related to comorbidities such as renal failure or blindness (Anderson & Lebowski, 2019).

Burden to Family

         Families who have a family member with diabetes will often experience lifestyle changes as well. It is estimated that 42% of the diabetes population in Denver are children. When children have this disease process, they will be reliant on family members for management. This creates an increased risk for a phenomenon called “caregiver burden” (Johnson, 2018, para. 4). In the pediatric population, those who require daily health management interventions are in an increased risk for child abuse (citation, year). This can range from neglect to physical abuse.

Burden to Community

         As previously mentioned, 42% of the diabetic population are children 18 years of age are younger, therefore there will be other environments where parents will not be available to check glucose levels and dose insulin. This results in care providers such as daycare institutions, schools and other friends and family members being held accountable and managing the patient’s blood glucose levels. This can be a challenging responsibility for someone who has not gone through the same level of education as the patient and their family (Johnson, 2018).

Costs

Patient Costs

Diabetes is a lifelong disease process that requires daily management. It is estimated that each year diabetic patients pay $8,000 – $15,000 for the various requirements of managing this disease process (Diaz, Morse & Ramsey, 2018). Some of these costs can be reduced through the use of discount program offerings and health insurance, however many times copayments and deductibles will be expensive as well.

Family Cost

Costs that incur to the family and managing diabetes of one family member can decrease available funds for other necessary living expenses. This can be things such as housing, food, transportation, and clothing. Shifting expenses away from necessary medical needs will result in poor management of diabetes. When diabetes is unmanaged, it is estimated to double the baseline costs in patients who manage their disease well (Anderson & Lebowski, 2019).

Community Costs

Most chronic diseases will interfere with daily activities such as school or work attendance. Absenteeism within the workplace is a significant problem when employees have chronic health conditions. While the disease is not preventable, management of it is a choice. Anderson, Smith and Jones (2017), calculated that employees with unmanaged diabetes will cost organizations on average, $4,300 each year. What makes up this quantity is lost productivity, payment of others to perform job function of the employee, and benefits such as paid time off for short-term and long-term disability (Johnson, 2018).

Best Practices

Within the medical surgical unit at my hospital many patients admitted for complications of diabetes such as skin integrity impairment, diabetic ketoacidosis, hypertension or kidney abnormalities. When these patients are admitted to the hospital the acute health issue is managed, however the underlying issue being diabetes is rarely addressed. The American Association of Endocrinologists (2017) recommends diabetic assessment with every healthcare visit in patients who have type I or type II diabetes. This represents a clear contradiction occurring within my organization that I will address using recommendations from the Standard of Practice. The goal would be to improve assessment of diabetic management of patients admitted to the medical surgical unit within my organization.

Plan Implementation

         The first intervention will be to develop an electronic health record screening modality that identifies patients who have diabetes. Currently there is no screening process, therefore these patients are not provided with additional information or management to help them better control her disease process. To develop this screening report, a request will be sent to the IT department with specific patient metrics that are consistent with those that have diabetes. The report will capture patients who have diabetes on their problem list, a body mass index above 26 kg/m², or laboratory measurement indicating elevated blood glucose or hemoglobin A1c. The American Association of Endocrinologists (2017) identifies these metrics as being a reliable predictor of unmanaged diabetes.

         Once the patient population is screened, a referral will be made to initiate an endocrine nurse visit. The endocrine nurse will develop a chronic disease action plan with the patient that provides guidance with nutrition, physical activity and medication management. Chronic disease action plans provide patients with a triaging system allowing them to be better informed about managing not only complications but everyday requirements of the disease process (Anderson & Lebowski, 2019).

Last, patients identified through the screening process will be required to use a smartphone application to track blood glucose trends and insulin dosing. Smartphone applications increase accountability and improve the management of patients who have chronic disease processes like diabetes (Johnson, 2018).

Plan Evaluation

         Electronic health records provide numerous benefits including the ability to obtain retrospective data and prospective information pertaining to the patient population. The evaluation method that will be used to determine effectiveness of the intervention of screening will be retrospective data trending consistent with practices suggested by the American Association of Endocrinologists (2017). Using consistent metrics as suggested allows for data trending and prevalence analysis. Retrospective data analysis will occur once monthly, and data trends will be collected and compared from month-to-month.

To evaluate the intervention of providing a chronic disease action plan, the teach back method will be used upon completion of the action plan. The endocrinology nurse will ask the patient to explain the chronic disease action plan steps and actions in their own words. This method demonstrates that the patient successfully perceived management suggestions for their disease process (Wilmer, Presley & Smith, 2016).

Last, to evaluate blood glucose and insulin dosing trends, the patient will meet with the endocrinology nurse one month following implementation of the smartphone application. The smartphone application allows evaluation of patient accountability, correct dosing of medications based on measured glucose levels (Jones, 2017). If the patient had consistent blood glucose levels, and insulin dosing was appropriate for those levels this intervention would be found successful.

 

 

 

 

 

 

References

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Journal Name, #(#): pg # – #.

RUBRIC

ARTICULATION OF RESPONSE (CLARITY, ORGANIZATION, MECHANICS):

UNSATISFACTORY / NOT PRESENT The candidate provides unsatisfactory articulation of response.

DOES NOT MEET STANDARD The candidate provides weak articulation of response.

MINIMALLY COMPETENT The candidate provides limited articulation of response.

COMPETENT The candidate provides adequate articulation of response.

HIGHLY COMPETENT The candidate provides substantial articulation of response.

1. INVESTIGATED DISEASE PROCESS:

UNSATISFACTORY / NOT PRESENT The candidate does not investigate 1 of the given disease processes.

DOES NOT MEET STANDARD Not applicable.

MINIMALLY COMPETENT Not applicable.

COMPETENT Not applicable.

HIGHLY COMPETENT The candidate investigates 1 of the given disease processes.

A1. PATHOPHYSIOLOGY:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a plausible analysis of the pathophysiology of the disease process selected in part A.

DOES NOT MEET STANDARD The candidate provides a plausible analysis, with no detail, of the pathophysiology of the disease process selected in part A.

MINIMALLY COMPETENT The candidate provides a plausible analysis, with limited detail, of the pathophysiology of the disease process selected in part A.

COMPETENT The candidate provides a plausible analysis, with adequate detail, of the pathophysiology of the disease process selected in part A.

HIGHLY COMPETENT The candidate provides a plausible analysis, with substantial detail, of the pathophysiology of the disease process selected in part A.

A2. STANDARD OF PRACTICE:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of the standard of practice for the selected disease process.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of the standard of practice for the selected disease process.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of the standard of practice for the selected disease process.

COMPETENT The candidate provides a logical discussion, with adequate detail, of the standard of practice for the selected disease process.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of the standard of practice for the selected disease process.

A2A. PHARMACOLOGICAL TREATMENTS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of the evidence-based pharmacological treatments in the candidate’s state and how they affect management of the selected disease in the candidate’s community.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of the evidence-based pharmacological treatments in the candidate’s state and how they affect management of the selected disease in the candidate’s community.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of the evidence-based pharmacological treatments in the candidate’s state and how they affect management of the selected disease in the candidate’s community.

COMPETENT The candidate provides a logical discussion, with adequate detail, of the evidence-based pharmacological treatments in the candidate’s state and how they affect management of the selected disease in the candidate’s community.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of the evidence-based pharmacological treatments in the candidate’s state and how they affect management of the selected disease in the candidate’s community.

A2B. CLINICAL GUIDELINES:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of clinical guidelines for assessment, diagnosis, and patient education for the selected disease process.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of clinical guidelines for assessment, diagnosis, and patient education for the selected disease process.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of clinical guidelines for assessment, diagnosis, and patient education for the selected disease process.

COMPETENT The candidate provides a logical discussion, with adequate detail, of clinical guidelines for assessment, diagnosis, and patient education for the selected disease process.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of clinical guidelines for assessment, diagnosis, and patient education for the selected disease process.

A2C. STANDARD PRACTICE OF DISEASE MANAGEMENT:

UNSATISFACTORY / NOT PRESENT The candidate does not provide an appropriate comparison of standard practice for managing the disease within the candidate’s community with state or national practices.

DOES NOT MEET STANDARD The candidate provides an appropriate comparison, with no detail, of standard practice for managing the disease within the candidate’s community with state or national practices.

MINIMALLY COMPETENT The candidate provides an appropriate comparison, with limited detail, of standard practice for managing the disease within in the candidate’s community with state or national practices.

COMPETENT The candidate provides an appropriate comparison, with adequate detail, of standard practice for managing the disease within the candidate’s community with state or national practices.

HIGHLY COMPETENT The candidate provides an appropriate comparison, with substantial detail, of standard practice for managing the disease within the candidate’s community with state or national practices.

A3. MANAGED DISEASE PROCESS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of characteristics of and resources for a patient who manages the selected disease well, including access to care, treatment options, life expectancy, and outcomes.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of characteristics of and resources for a patient who manages the selected disease well, including access to care, treatment options, life expectancy, and outcomes.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of characteristics of and resources for a patient who manages the selected disease well, including access to care, treatment options, life expectancy, and outcomes.

COMPETENT The candidate provides a logical discussion, with adequate detail, of characteristics of and resources for a patient who manages the selected disease well, including access to care, treatment options, life expectancy, and outcomes.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of characteristics of and resources for a patient who manages the selected disease well, including access to care, treatment options, life expectancy, and outcomes.

A3A. DISPARITIES:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a plausible analysis of disparities between management of the selected disease on a national and international level.

DOES NOT MEET STANDARD The candidate provides a plausible analysis, with no support, of disparities between management of the selected disease on a national and international level.

MINIMALLY COMPETENT The candidate provides a plausible analysis, with limited support, of disparities between management of the selected disease on a national and international level.

COMPETENT The candidate provides a plausible analysis, with adequate support, of disparities between management of the selected disease on a national and international level.

HIGHLY COMPETENT The candidate provides a plausible analysis, with substantial support, of disparities between management of the selected disease on a national and international level.

A4. MANAGED DISEASE FACTORS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion, of any factors that contribute to a patient being able to manage the selected disease.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with sufficient detail, of 1 or 2 factors that contribute to a patient being able to manage the selected disease.

MINIMALLY COMPETENT Not applicable.

COMPETENT Not applicable.

HIGHLY COMPETENT The candidate provides a logical discussion, with sufficient detail, of 3 or 4 factors that contribute to a patient being able to manage the selected disease.

A4A. UNMANAGED DISEASE FACTORS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical explanation of how a lack of the factors discussed in part A4 leads to an unmanaged disease process.

DOES NOT MEET STANDARD The candidate provides a logical explanation, with no detail, of how a lack of the factors discussed in part A4 leads to an unmanaged disease process.

MINIMALLY COMPETENT The candidate provides a logical explanation, with limited detail, of how a lack of the factors discussed in part A4 leads to an unmanaged disease process.

COMPETENT The candidate provides a logical explanation, with adequate detail, of how a lack of the factors discussed in part A4 leads to an unmanaged disease process.

HIGHLY COMPETENT The candidate provides a logical explanation, with substantial detail, of how a lack of the factors discussed in part A4 leads to an unmanaged disease process.

A4AI. UNMANAGED DISEASE CHARACTERISTICS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide an appropriate description of the characteristics of a patient with the selected disease that is unmanaged.

DOES NOT MEET STANDARD Not applicable.

MINIMALLY COMPETENT The candidate provides an appropriate description, with insufficient detail, of the characteristics of a patient with the selected disease that is unmanaged.

COMPETENT Not applicable.

HIGHLY COMPETENT The candidate provides an appropriate description, with sufficient detail, of the characteristics of a patient with the selected disease that is unmanaged.

1. PATIENTS, FAMILIES, & POPULATIONS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a plausible analysis of how the selected disease process affects patients, families, and populations in the candidate’s community.

DOES NOT MEET STANDARD The candidate provides a plausible analysis, with no detail, of how the selected disease process affects patients, families, and populations in the candidate’s community.

MINIMALLY COMPETENT The candidate provides a plausible analysis, with limited detail, of how the selected disease process affects patients, families, and populations in the candidate’s community.

COMPETENT The candidate provides a plausible analysis, with adequate detail, of how the selected disease process affects patients, families, and populations in the candidate’s community.

HIGHLY COMPETENT The candidate provides a plausible analysis, with substantial detail, of how the selected disease process affects patients, families, and populations in the candidate’s community.

B1. COSTS:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of the financial costs associated with the selected disease process for patients, families, and populations from diagnosis to treatment.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of the financial costs associated with the selected disease process for patients, families, and populations from diagnosis to treatment.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of the financial costs associated with the selected disease process for patients, families, and populations from diagnosis to treatment.

COMPETENT The candidate provides a logical discussion, with adequate detail, of the financial costs associated with the selected disease process for patients, families, and populations from diagnosis to treatment.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of the financial costs associated with the selected disease process for patients, families, and populations from diagnosis to treatment.

1. BEST PRACTICES PROMOTION:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of how the candidate will promote best practices for managing the selected disease in the candidate’s current healthcare organization.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of how the candidate will promote best practices for managing the selected disease in the candidate’s current healthcare organization.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of how the candidate will promote best practices for managing the selected disease in the candidate’s current healthcare organization.

COMPETENT The candidate provides a logical discussion, with adequate detail, of how the candidate will promote best practices for managing the selected disease in the candidate’s current healthcare organization.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of how the candidate will promote best practices for managing the selected disease in the candidate’s current healthcare organization.

C1. IMPLEMENTATION PLAN:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a discussion of 3 strategies the candidate could use to implement best practices for managing the selected disease in the candidate’s current healthcare organization.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of 3 strategies the candidate could use to implement best practices for managing the selected disease in the candidate’s current healthcare organization.

MINIMALLY COMPETENT The candidate provides logical discussion, with limited detail, of 3 strategies the candidate could use to implement best practices for managing the selected disease in the candidate’s current healthcare organization.

COMPETENT The candidate provides a logical discussion, with adequate detail, of 3 strategies the candidate could use to implement best practices for managing the selected disease in the candidate’s current healthcare organization.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of 3 strategies the candidate could use to implement best practices for managing the selected disease in the candidate’s current healthcare organization.

C2. EVALUATION METHOD:

UNSATISFACTORY / NOT PRESENT The candidate does not provide a logical discussion of an appropriate method to evaluate the implementation of each of the strategies from part C1.

DOES NOT MEET STANDARD The candidate provides a logical discussion, with no detail, of an appropriate method to evaluate the implementation of each of the strategies from part C1.

MINIMALLY COMPETENT The candidate provides a logical discussion, with limited detail, of an appropriate method to evaluate the implementation of each of the strategies from part C1.

COMPETENT The candidate provides a logical discussion, with adequate detail, of an appropriate method to evaluate the implementation of each of the strategies from part C1.

HIGHLY COMPETENT The candidate provides a logical discussion, with substantial detail, of an appropriate method to evaluate the implementation of each of the strategies from part C1.

1. SOURCES:

UNSATISFACTORY / NOT PRESENT When the candidate uses sources, the candidate does not provide in-text citations and references.

DOES NOT MEET STANDARD When the candidate uses sources, the candidate provides only some in-text citations and references.

MINIMALLY COMPETENT When the candidate uses sources, the candidate provides appropriate in-text citations and references with major deviations from APA style.

COMPETENT When the candidate uses sources, the candidate provides appropriate in-text citations and references with minor deviations from APA style.

HIGHLY COMPETENT When the candidate uses sources, the candidate provides appropriate in-text citations and references with no readily detectable deviations from APA style, OR the candidate does not use sources.