COLLABORATIVE TELEHEALTH APPROACH WHERE
TRADITIONAL CARE FAILS: DIABETES CARE NETWORK
By
Kristy Nicole Clark MSN FNP-BC
Doctorate of Nursing Practice, Clarion and Edinboro Universities 2021
A DNP Research Project Submitted to Clarion and Edinboro Universities
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
April 2021

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Dean, College of Education, Health and Human Services
Clarion University

COLLABORATIVE TELEHEALTH APPROACH WHERE
TRADITIONAL CARE FAILS: DIABETES CARE NETWORK
Committee Signature Page

Student’s name
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Abstract:
Collaborative telehealth approach where traditional care fails: Diabetes Care Network
Clinical inertia is the failure to initiate or intensify treatment in a timely manner in people with
type-2 diabetes mellitus (T2DM) in primary care (PC) where collaborative care can be an
approach to overcome inertia. Diabetes care network (DCN) is a telehealth based collaborative
care model to address clinical inertia in the PC environment. In DCN, initial care was delivered
via E-Consult by hub diabetes team for Veterans with A1c of 9% or higher and the longitudinal
collaborative care delivered by PC liaison with weekly team huddle. To study the difference in
the clinical outcomes with DCN vs PC practices, we compared the DCN cohort (97.7% male,
90.8% white, with a mean age 67.2 (8.9), with a PC cohort (100% male, 94.9% white, mean age:
68 year (10.5), with A1C >9%). Methods: Means (SD), frequencies. and percentages were
presented. The DCN cohort had a significant decline in the baseline A1C of 10.2% (1.4), to
8.1% (0.99), 7.6% (0.96), 7.5 % (0.86) at 3, 6, and 12 months while A1c in PC cohort stayed
poor with baseline A1C of 10.1% (0.89), to 10.2% (1.69), 9.7% (1.74) and, 9.5% (1.83) at 3, 6,
and 12 months. Patients who achieved A1c less than 8% in DCN cohort were 38 (43.6%), 56
(64%), and 56 (64%) at 3, 6, and 12 months and were 1(1.7%), 5(8.5%), and 6(10.2%) at 3, 6,
and 12 months in PC cohort. An A1c of less than 7% was achieved in DCN cohort in 10
(11.4%), 21 (24.1%), and 23 (26.4%) patients at 3, 6, and 12 months and only 1(1.7%), 0(0%),
and 0(0%) patients achieved A1c less than 7% at 3, 6, and 12 months in PC cohort. Our study
shows participation in the DCN telehealth program for 1 year was associated with significant
improvement in A1c. This improvement was not seen within the PC with traditional care
practices. Thus, addressing clinical inertia in PC will need a paradigm shift in current practices.
The proposed collaborative approach of DCN can overcome clinical inertia in PC and improve
care for people with T2D by supporting PC access to specialty care expertise, decreasing the
burden of diabetes care for patients and PC providers

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Chapter 1
Introduction
Type 2 diabetes is a prominent and growing medical problem that impacts many patients from all
geographic areas, ethnicities, socioeconomic status, and genetic background. In the United
States, 30.3 million Americans are living with diabetes. Of that 30.3 million, 7.2 million are not
currently diagnosed or seeking medical treatment for diabetes. Some 84.1 million Americans are
living with impaired fasting glucose or prediabetes. (CDC 2019). Among Veterans, the incidence
of type-2 diabetes is 30% higher than the civilian population ~ 10% of the veteran population
presents further unique challenges predominantly because they are part of rural populations with
higher incidences of obesity, and other co-morbid conditions.
Veterans in rural settings have lower socio-economic status thus leading to worse outcomes.
Despite clinical practice guidelines that recommend frequent monitoring of HbA1c (every 3
months) and timely optimizations of antihyperglycemic therapies until glycemic targets are
reached (1,2), therapeutic intervention in uncontrolled type 2 diabetes (T2D) is often
inappropriately delayed. The failure of clinicians to intensify therapy when clinically indicated
has been termed “clinical inertia” (Diabetes Care 2018).
We will look at glycemic control in the sole primary care setting in comparison to that of an
endocrinology collaboration approach. We will look at patients who have uncontrolled diabetes
with A1Cs over 9.0 and who are not terminally as part of criteria.

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Routine Primary Care Management
Primary Care (PC) management of all patients, including those with diabetes mellitus (DM), at
the Veterans Administration Medical Center (VAMC) takes place within Patient Aligned Care
Teams (PACT) that includes the patient, their primary care provider (PCP) who is a physician or
nurse practitioner, and registered nurse (RN), and medical support assistant (MSA), additional
peripheral PACT members are clinical pharmacists who are available for consultation. Dieticians
are also available through a consult. All orders for these diabetic patients are placed by the PCP
and all medicine is ordered and adjusted by the PCP as well. The PACT teams have some
variation in the expertise and knowledge of the PCP in regards to diabetes management and best
practice.
Diabetes care cues are present in the electronic medical records (EHR) as clinical reminders
when a patient’s chart is accessed. These include eye care, foot checks, lab orders that are due
and blood pressure and cholesterol goals. These include:
Diabetic Reminders in the Electronic Medical Records
A1C Due 6 months
LDL Due 6 months
LDL Elevated LDL = or > 100
Diabetic Foot Check 12 months
Retinal Eye Exam 12 months. 24 months
DM Urine 12 months
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Diabetic Reminder results are part of the monthly report given to all PACT teams. This is routine
and this would continue to take place whether or not the patient is enrolled in another type of
diabetic care management program as well.
The PACT PC can consult a home telehealth program that collects vital signs, blood sugars and
patient information and communicates it to the PACT PCP and this program is continued with
the other programs if the patient has it or agrees to take part. It does mean the patient is expected
to download data daily and is contacted if they do not.
Diabetes Care Network
Because of the shortage of Endocrinology specialists a program called Diabetes Care Network
(DCN) was started as the brainchild of the hub Tertiary Care Center VAMC Telehealth Clinical
Director. The program started with recruitment of a local spoke care provider, the DCN provider,
who could prescribe and manage diabetes where there was no endocrinology service present.
Planning, training and some HER templated and order sets were put into place. Several patients a
week were randomly chosen from a list of patients at the spoke VA who had A1Cs of 9.0 or
higher. If they were not terminally ill they were contacted by the spoke provider and if they
agreed to it they had orders placed for any needed services (retinal eye exam, other labs) and a
consult was placed to Pitt VA Endocrinology to start their more intensive management. These
patients came from both the Spoke VA and the Community Based Primary Care clinics (CBOCs)
associated with it. They had a variety of PCPs.
The Endocrinology providers began intensive management and goal setting with these patients
and set an individualized A1C goal based on the American College of Endocrinology guidance.
Endocrinology at the tertiary VAMC continued managed for 1-2 months and during that time

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communicated the plans and medication changes to the DCN Provider as they were made and
they placed orders locally for medication changes and other orders.
Once the patient seemed to be on the right track they were referred back to the DCN Provider
who regularly consulted via phone and EHR with the endocrinology provider. This allowed for
more intensive care for the patients as well as mentoring and increased expertise development in
the local DCN provider. This also offered some decreased workload for the PACT team provider
who was not responsible for the patients DM needs.
Electronic Diabetes Care Management
Primary care providers in VAMC spokes where endocrine services are not available and private
endocrine care is also in shortage with long wait times can consult the specialty clinics for
patients with DM through the EHR. Once consulted the endocrine clinic reviews the patients
chart, contacts the patient to set goals and intensive therapy. Each telephone visit is sent to the
PACT PC to make changes to the medication and order needed labs. Once management goals are
met the patient is discharged back to the PACT PC for maintenance unless the medication or care
regimen is too complex to make that feasible (i.e. they are on concentrated insulins).
Background of the Problem
Currently, in the United States, 30.3 million Americans are living with diabetes. Of that 30.3
million, 7.2 million are not currently diagnosed or seeking medical treatment for diabetes. Also,
84.1 million Americans are living with impaired fasting glucose or prediabetes. (CDC 2019)
The Statement of the Problem

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Diabetes is a growing problem in the United States made worse by the shortage of
endocrinologists. Endocrinologists play a pivotal role in the care of many patients with diabetes.
Chronic diabetes management requires ongoing care to manage these complex patients, who
often have several co morbid conditions directly stemming from their diabetes. “In 2014, the
Endocrine Society conducted a workforce analysis that projected a substantial gap between
endocrinologist supply and demand through the year 2025. This gap of 1484 full-time equivalent
endocrinologists is related to a number of factors, including age and gender shifts, lifestyle
factors, and health reform; a growth rate of 5.5% annually over a 10-year period will be required
to close it.” (Lash 2017)
Upon review of the literature there was found to be a shortage of diabetic support programs
throughout the US. Programs such as the DCN and Endocrinology E-consult help to show that
additional diabetic support and endocrinology care strive to improve outcomes for patients who
are unable to access specialty endocrinology.
Advances in pharmacology, improvement in technology to aid in care including insulin pumps
and continuous glucose monitors provide improvements and while positive, add an increase in
complexity to care for the patient. With the complexity of care required by diabetic patients, and
the decrease in endocrine providers there is support for additional models of care.
With so many patients being affected by type 2 diabetes, providing adequate healthcare is
essential to prevent further health complications. These researchers seek to explore the following
proposed research topic: “What are the differences made to glycemic control, as measured by
hemoglobin A1C when Veterans are enrolled in sole primary care or in a Diabetes Care Network
with endocrinology support?”

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Research Question: PICO Question
“What are the differences made to glycemic control, as measured by hemoglobin A1C when
Veterans are enrolled in sole primary care or in a Diabetes Care Network with endocrinology
support?”
Definition of Terms:
Clinical inertia- The failure of clinicians to intensify therapy when clinically indicated
Glycemic control: current management of diabetes care as evidenced by numerical values shown
in the hemoglobin A1C
Hemoglobin A1C: Lab drawn measure that shows average blood glucose levels over the last
cumulative 90-day interval
Diabetes Care Network: A healthcare team within the VA system that provides additional
diabetic management and care to Veterans with type two diabetes.
Telehealth: the use of electronic information and telecommunications technologies to support
long-distance clinical health care, professional health-related education, public health, and health
administration (Saunders 2003)
Need for the Study
Uncontrolled diabetes can lead to increased mortality, heart disease, and renal failure. (CDC
2019) It is the ideal goal of the patient and provider to implement a plan of care for the patient to
reach optimal glycemic control in hopes of decreasing further health risk factors. Evidence-based
practice shows us that patients are more often likely to reach their diabetes health goals when
they are surrounded and supported by a care team that understands their needs. (ADA 2019)

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Significance of the Problem
Research suggests that 1 out of 3 adults has prediabetes. Of this group 9 out of 10 don’t know
that they are diabetic. About 1.4 million new cases of diabetes are diagnosed annually in the US.
Aside from the devastating effects of ill managed care on overall health, significant costs are also
associated with diabetes. Care for those with known diabetes cost approximately $245 billion
annually in the US. (Healthline 2020)
The stress of chronic disease management can be an ongoing problem that affects quality of life
in the type two diabetic patient. Type two diabetes also has an impact on overall quality of life.
Quality of life is measured as social and physical functioning as well as perceived mental and
physical well-being. (Rubin & Peyrot 1999)
Type 2 diabetes is a disease process that requires continuous support and education for patients
to reach their target glycemic goals. We hope that our program evaluation helps us to identify
the needs and benefits that a specialty diabetes care team approach provides to the patient. The
research team also strives to show that by investing in quality preventative care early on, it is
expected that patients will have improved outcomes.
Assumptions
We plan to focus, recognize and reinforce evidence-based practice support that shows
interventional education is a key element to providing effective support and care for type two
diabetic patients. When enrolled in a supportive program that promotes ongoing education,
monitoring, and the support of an actively involved healthcare team with easy access to

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endocrinology support specialists, patients are better able to achieve glycemic control compared
to those that are not enrolled in such a program.
Limitations
This study is based on a retrospective chart review of glycemic control based upon hemoglobin
A1C levels in Veterans currently active in the Diabetes Care Network and PACT’s within the
Erie and Pittsburgh VA systems. Limitations at this time include the comparison of programs
within one healthcare network. Patient’s perception of their glycemic control is a subjective
experience that will not be obtained at this time. Both of these factors promote possible ongoing
or future research topic needs.
Summary of the Problem
Type two diabetes is an ongoing problem globally, with effects directly notable to our local
community and Veteran population. This research team will assess glycemic control before and
after enrollment in the Diabetes Care Network, Endocrinology Econsult program or sole primary
care management within the VA healthcare system. The DCN and Endocrinology Econsult
programs promote ongoing education, monitoring, and access to specialized endocrinology care
to Veterans who have chosen to actively be enrolled. The goals of both these programs is to
improve glycemic control and access to endocrinology support to the Veteran population that are
enrolled in the Diabetes Care Network or E-consult as opposed to sole primary care.

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Chapter 2
Review of the Literature
During our review of the literature we are looking at programs that may show improved
glycemic control in the diabetic population. To support the need for this program evaluation, we
have reviewed several research studies and literature reviews.
In the review of the literature, the focus was upon evaluating the need for improved glycemic
control as well as measures or programs that were similar to The Diabetes Care Network or
Econsult program. The first focus is an overview of the epidemic problem of type two diabetes
and its effects in the United States. The second focus is upon reviewing evidence-practice
models and algorithms for promoting improvement to glycemic control in type two diabetic
patients.
Type two Diabetes: An Overview
Type two diabetes is an ongoing health crisis that affects many around the world. Currently, in
the United States, 30.3 million Americans are living with diabetes. Of that 30.3 million, 7.2
million are not currently diagnosed or seeking medical treatment for diabetes. Additionally, 84.1
million Americans are living with impaired fasting glucose or prediabetes (CDC 2019.) Overall
diabetes is a disease process that as healthcare professionals, is begging our attention for further
care and attention.
Evidence-Based Practice: Review of the Literature
The first set of articles to review included four articles with a similar methodology of a
randomized control study. The first article “Improvement of Diabetic Patients: Nursing Care by

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the Development of Educational Programs” by Malliarou et al. 2014 reviews how presenting
educational programs to diabetic patients and their families via a visit with a clinical nurse
specialist is beneficial to the improvement of glucose control (Malliarou et al. 2014). Data was
extracted by assessing patients’ overall knowledge of their diabetes disease process, medication
compliance, as well as their glycemic control. The overall conclusion shows that specialized
diabetes clinical nurses help to encourage self-care and medication management when included
in the patient’s plan of care (Malliarou et al. 2014). This study relates to the research topic by
showing that additional educational support is beneficial to the diabetic patient’s plan of care.
This educational intervention is similar to the VA’s DCN and Econsult programs. This research
demonstrated that there is support for educational interventions having a positive impact on the
diabetic patient’s glycemic control.
The second article with a randomized control study “The Impact of Diabetes Education
on Self Care Agency, Self-Care Activities and HbA1c Levels of Patients with Type 2 Diabetes”
by Ergor et al. 2017. The intervention group of this study received self-management education
based on SCDNT completed via outpatient education sessions. The outcome measures show that
self-care and self-management activity education was shown to help improve glycemic control.
This study was conclusive in showing that education on self-management was beneficial to the
patient with type 2 diabetes (Ergor et al. 2017). This study supported the research question by
showing that it is beneficial for diabetic patients to invest in self-management related to their
diabetes care.
The third article of the randomized control studies was entitled “Support for Diabetes
Using Technology: A Pilot Study to Improve Self-Management” by Ellison et al.2014. This
study was focused on an employee health promotion program. An Ipad application for diabetes
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self-care promotion-“Diabetes Buddy” was downloaded for employees to use to engage and
promote self-care behaviors. The Diabetes Management Self-Efficacy Scale was used to evaluate
outcomes related to using technology for the promotion of self-care behaviors.
The study identified a slight increase in positive self-care behaviors using the Ipad App.
It was noted that this was a very small sample study as a pilot study, and a larger study would be
needed to further assess full benefit (Ellison et al. 2014). This study was much different than this
researchers design for study but was beneficial to review in looking at the positive effects of
using technology to promote self-care behavior in the diabetic patient population.
The fourth article of the randomized control studies is by Azami et al. 2018 entitled
“Effect of a Nurse-Led Diabetes Self-Management Education Program on Glycosylated
Hemoglobin among Adults with Type 2 Diabetes.” Criteria for this outpatient study included
type two diabetic patients who had been diagnosed more than a six-month time frame before the
study. The outcomes showed that nurse-led DSME programs improved lifestyle, clinical and
psychosocial outcomes. The data extraction was utilized by conducting questionnaires pre and
post-intervention (Azami et al. 2018). This study supports promotion of intensified clinical
management but did not look at adjustments of medications or endocrine support.
Moving from the randomized control study articles, next a retrospective chart review
article was critiqued. “Evaluating glycemic control for patient-aligned care team clinical
pharmacy specialists at a large Veterans Affairs medical center” by Cadle et al. 2018 focused on
interventional education with Veterans by a clinical pharmacist in the outpatient setting. The
primary objective was to evaluate A1C when a Veteran was followed and evaluated at regular
intervals by a clinical pharmacist. A sample of 79 participants showed improvement of A1C by

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1.5% during the study. With improvement noted to A1C, it was concluded to be beneficial for a
clinical pharmacist to be involved in the patient’s care (Cadle et al 2018). Of all articles critiqued
this one mirrored the most similar to the researcher’s topic question. The key difference between
the DCN and E-consult program and this study was the lack of endocrine involvement and
consistent PACT team follow up.
One quasi-experimental study was reviewed in an article entitled “The Effect of
Educational Interventions on Glycemic Control in Patients with Type 2 Diabetes” by
Zibaeenezhad et al. 2015. This study focused on an educational course of diabetes together with
exercise training and nutritional education that was designed for the study population to increase
patient’s knowledge. The results of the study showed that educational interventions effectively
improved glycemic control in the patient with type two diabetes (Zibaeenezhad et al. 2015). This
study gives support to the research topic at hand by showing improvement in glycemic control
when additional educational interventions are implemented.
In reviewing the articles, one comprehensive literature review was critiqued. “The Impact
of Continuity of Care on A1C Levels in Adult Type 2 Diabetic Patients: A Review of the
Literature” by Franklin 2014. This article looks to see what research there is to support the
hypothesis that patients with type 2 diabetes have better glycemic control with continuity of care
within completed studies (Franklin 2014). Of note, the articles within this literature review were
relevant and useful to the study, but unfortunately we not all recent within these researchers’
five-year guidelines. Of the 41 studies, 10 studies showed a decrease in HbA1C levels with
increased continuity of care. One of the 41 showed no change in HbA1c levels with continuity of
care. The remaining 30 articles addressed other variables than the 2 of interest for this review
study (Franklin 2014). This article while nearing to be more historical data information, was
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helpful to review to see that there was not a clear indication of improvement to glycemic control
when looking solely at the factor of continuity of care.
The next section of review critiques includes two quality improvement process articles.
The first entitled “Partnering with diabetes educators to improve patient outcomes” by Burke et
al. 2014 reviews the use of diabetic educators using the framework of the seven self-care
behaviors known as the AADE7 Self-Care Behaviors. The conclusion of the study showed that
diabetes educators are shown to make an impact to promote patient self-care in regards to their
diabetes, also improving glycemic control (Burke et al. 2014). This quality improvement project
had a similar goal of these researchers, in that the goal is to improve glycemic control in diabetic
patients with an interventional measure.
The second quality improvement article “Supporting diabetes emotional health: The 7As
Model” by Walker 2019, took a different approach than the other articles by reviewing the
importance of supporting mental health in diabetic patients. The effects of the article show that
being aware of mental health and the psychological effects of a diabetes diagnosis is a key
element to adequately managing the diabetic patient (Walker 2019). This article did not pertain
as closely to the researcher’s model as other articles, but it did contain valuable information for
the researcher.
The final article that was critiqued was a mixed-methods style article by Lopez et al 2016
entitled “Understanding preferences for type 2 diabetes mellitus self-management support
through a patient-centered approach: a 2-phase mixed-methods study.” In this study, the
researchers reviewed randomized control studies that utilized the impact of DSME compared to
usual care in the diabetic patient. They then set to conduct a randomized control model to further

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evaluate the DSME impact on diabetic care. The studies noted that DSME programs show an
improvement in diabetic patients’ overall knowledge of the disease process and also showed
improvement in glycemic control (Lopez et al 2016). This study pertained to the research
question by showing that diabetic education programs were beneficial to diabetic patients.
Summary
In summary, we have reviewed a variety of research articles with a range of methods including
randomized control studies, quality improvement interventions, literary and chart reviews,
mixed-method, and quasi-experimental. The vast majority of these yielding results that indicate
further interventions to educate and encourage the type two diabetic patient show a positive
effect on glycemic control. Some contrasting factors include the setting of the studies, as well as
other variables such as length of study time and length of diagnosis, were reviewed. This
researcher hopes to implement a study that will show a positive effect between Veterans enrolled
in the VA’s Diabetes Care Network and improvement in glycemic control.
Review of programs involved:
Diabetes Care Network Model Care:
Background: While over 30% of enrolled Veterans have diabetes and 78% are considered obese.
Veterans struggle with access to specialty care for better control of diabetes. Thus, a dire need
exists for innovative models of care to scale the endocrine expertise to improve diabetes control.
To help with such measures, a telehealth based collaborative care pathway was created- The
Diabetes Care Network (DCN) to scale the endocrine expertise for patients with poorly
controlled type-2 DM and modernize the care delivery. (Bandi et al. 2019)

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Chapter 3 Methodology
Methodology
The design of this project will be that of a program evaluation of the VA’s Diabetes Care
Network. The Diabetes Care Network (DCN) pilot at VAPHS established a collaborative care
process from 2017 to 2018 to study the outcomes of timely intervention in the management of
diabetes for patients in primary care settings. This pilot study team assessed the process to
achieve better diabetes control at two spoke sites: Erie, and Butler VAMC. The results showed
that consults were completed in 2.6 (+/-1.7) days from the day of request. A significant decline
in A1c from baseline of 10.2% to 8.1% at 3 months, 7.6% at 6 months, 7.5% at 12 months was
noted. 100% of patients had optimization or escalation of therapy. This previously acclaimed
data is suggestive that Veterans enrolled in additional treatment, rather than primary care alone,
will have improved glycemic control. This research team will be utilizing a retrospective chart
review design to assess glycemic control previous to involvement in the Diabetes Care Network
in comparison with models based on primary care involvement alone.
The proposed program will compare DCN outcomes with the electronic consultative service and
traditional routine care in primary care settings. We will compare the change in HbA1c from
baseline to 3, 6, 9, and 12-months values as a measure of diabetes control. We will also assess
the qualitative and quantitative differences in therapy optimization in each group to understand
the clinical inertia.

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Research Design
The overall method of data collection will consist of a current review of the medical record to
assess the Veterans’ most recent HbA1C. This will then be compared to the HbA1C that was
obtained before their enrollment in the Diabetes Care Network by using a retrospective chart
review. “The retrospective chart review is a widely applicable research methodology that can be
used by healthcare disciplines as a means to direct subsequent prospective investigations” (Matt
& Matthew 2013). In the case of this proposed research study, data will be conducted and
reviewed as a subsequent research investigation to further investigate the impact of the Diabetes
Care Network. Subsequently, additional research proposals may also stem from this proposed
study as a result of continued retrospective chart reviews
Setting:
The setting of the Diabetes Care Network is based in outpatient care of Veterans
Pittsburgh and Erie VA cohorts medical systems. Comparison was made between the Erie VA
Primary Care and DCN setting. For this program evaluation, data will be obtained only from the
Erie VA database. Ethical considerations for safe patient confidentiality will be utilized by both
Edinboro University and the VA Healthcare system.
Ethical Considerations
The DCN provided specialty care to Veterans via a telehealth environment. The groups were
randomly selected decreasing risks of bias. Those in the selected group for DCN received
additional care measures by the DCN team. Those in the control group did not have decreased

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care but rather were managed by the traditional primary care approach. No patients care was
negatively impacted by the DCN implementation.
Both the university IRB and the health administration IRB boards agreed that this was a QI
project rather than an implemented study with human subjects.
Instrumentation
The design of this QI study was a retrospective chart review. The researchers completed the data
analysis by using a random number generator to select participants. The participants charts were
reviewed in a one year time frame to assess hemoglobin A1C at the initial interval, 3, 6 and 12
month dates.
Chapter 4
Data Collection
The data collection for this proposed study will be focused upon the assessment of glycemic
control in Veterans who are actively enrolled within the Diabetes Care Network. This will be
assessed by using lab drawn Hemoglobin A1C: HbA1C levels. The comparison will be that of
the most recently drawn HbA1C to the HbA1C that was obtained before entering the Diabetes
Care Network program. This data will allow the researchers to look at a numerical value of the
overall glycemic control. Compared to looking at multiple finger stick blood sugar levels,
looking at the lab drawn HbA1C provides comparable data, in a more and measurable method.
Additionally, the research team will also be looking at the length of time that the Veteran has
been enrolled in the program. Current time frame inclusion includes Veterans that were enrolled
in the Diabetes Care Network from the time frame of January 2017-July 2017.

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This data will be collected via chart review and kept in an encrypted excel spreadsheet.
Additionally, to protect patient’s health information the research team will be de-identifying
patients by identifying them with a numerical or alphanumerical value in place of using their
name or other forms of personal health information. This excel sheet will be kept only on secure
VA computer databases, which may only be assessed by the research team. By using excel the
researcher will also be able to show information in a graphical form or charts as applicable.
Before deciding to utilize the retrospective chart review for design, the methods of pre/post-test
and survey data were also reviewed. “For many true experimental designs, pretest-posttest
designs are the preferred method to compare participant groups and measure the degree of
change occurring as a result of treatment of interventions” (Shuttleworth 2009). Additionally,
“Survey method pursues two main purposes: Describing certain aspects or characteristics of the
population and/or testing hypotheses about the nature of relationships within a population”
(Research Methodology 2019). Both methods can be conducted for qualitative or quantitative
research designs. While both of these research methods have great benefits, for this proposed
study they were deemed to be less beneficial and therefore not utilized at this time.
Both the survey design and the pretest/post-test methods can require a written or telephone
review of questions with the patients. This was thought to be a possible disadvantage to this
proposed study as the study population has varied literacy levels, potential language barriers, as
well as some cognitive impairments. While these factors are managed by the Diabetes Care
Network team when conducting educational reviews, the researchers thought it would yield more
accurate results if the data was solely numerically based. Both of these methods due offer the
potential to take this study down a different path for additional research by using a different
method and more qualitative design.
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“Fully developed analysis questions of the DNP usually fall into two categories: descriptive or
evaluative” (Sylvia et al., 2015 pg. 97). This data collection is proposed to be an evaluative
design. These researchers hope to show that this study aims to provide evidence that the Diabetes
Care Network is beneficial to our Veterans by demonstrating that education and continued to
follow up shows improved glycemic control. This is a timely and relevant topic, which will
hopefully support the evidence base findings that there is a benefit to implementing additional
educational interventions in type two diabetic patients.
Data Analysis
In summary, this researcher’s proposed research study includes a current and retrospective chart
review method. This will allow the research team to assess the overall glycemic control of
Veterans enrolled in the Diabetes Care Network by reviewing their HbA1C results. By collecting
and reviewing the data the research team hopes to show evidence-based research that will answer
the research question “What effect is made to glycemic control, as measured by hemoglobin
A1C when Veterans are enrolled in The Diabetes Care Network?” The expected hypotheses
indicate that there will be an improvement to glycemic control of Veterans that are actively
working with the Diabetes Care Network team.
Ethical Considerations:
All research participants completed disclosures prior to submission for publication.
All participants were willingly involved in the DCN and primary care programs. Data was
retrieved upon a retrospective chart review, in such all laboratory data was completed prior for
the routine care of the patients.

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Chapter 5
Results:
The process of referral for the DCN network required the following criteria:
● The data warehouse generated a list of Veterans with A1C over 9 with the potential for
enrollment
● A random number generator was then used to select Veterans with A1C over 9
● The patient was contacted for agreement to start enrollment
● A referral was placed for consultation with PGH Endocrinology
● Consultation occurred with ongoing recommendations
● Veteran was followed up with by a DCN collaborating provider
● Once in better glycemic control, Veteran returned to sole primary care management
To study the difference in the clinical outcomes with DCN vs PC practices, we compared the
DCN cohort (97.7% male, 90.8% white, with a mean age 67.2 (8.9), with a PC cohort (100%
male, 94.9% white, mean age: 68 year (10.5), with A1C >9%). Methods: Means (SD),
frequencies. and percentages were presented. The DCN cohort had a significant decline in the
baseline A1C of 10.2% (1.4), to 8.1% (0.99), 7.6% (0.96), 7.5 % (0.86) at 3, 6, and 12 months
while A1c in PC cohort stayed poor with baseline A1C of 10.1% (0.89), to 10.2% (1.69), 9.7%
(1.74) and, 9.5% (1.83) at 3, 6, and 12 months. Patients who achieved A1c less than 8% in DCN
cohort were 38 (43.6%), 56 (64%), and 56 (64%) at 3, 6, and 12 months and were 1(1.7%),
5(8.5%), and 6(10.2%) at 3, 6, and 12 months in PC cohort. An A1c of less than 7% was
achieved in DCN cohort in 10 (11.4%), 21 (24.1%), and 23 (26.4%) patients at 3, 6, and 12
months and only 1(1.7%), 0(0%), and 0(0%) patients achieved A1c less than 7% at 3, 6, and 12
months in PC cohort. Our study shows participation in the DCN telehealth program for 1 year
was associated with significant improvement in A1c.
Details of the process measures and outcome
Contextual elements that interacted with the intervention(s):
Elements that interact with the direct interventions of the DCN and PC network include: VA
electronic health records, continuity of care, and the PACT TEAM approach. The VA health
records are kept comprehensive and secure through a program called CPRS. CPRS keeps a
database through each Veterans health records from their primary care team and any consults
outside of the VISN network. This comprehensive record approach allows access to those care
providers within the VA network in order to help ensure proper continuity of care.
As discussed in the DCN PC collaborative approach above, the transition of diabetes care back to
the primary care provider allows for comprehensive continuity of care. In management of the
complex diabetic patient, this care is essential and vital to promote quality health outcomes.

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Each Veteran is assigned a VA PACT team for primary care. The PACT team functions with the
MD or CRNP, RN, MSA, social worker, and pharmacy support persons. This comprehensive
approach allows for each Veteran to have access to the same persons to make care decisions
concise.
Clinical inertia is the failure to initiate or intensify treatment in a timely manner in people with
type-2 diabetes mellitus (T2DM) in primary care (PC) where collaborative care can be an
approach to overcome inertia. Diabetes care network (DCN) is a telehealth based collaborative
care model to address clinical inertia in the PC environment. The data of this study observes the
presence of clinical inertia when sole PC care was provided. The addition of the DCN allows for
better care to be provided to patients within their familiar PACT team environment with the
addition of collaborative care.
Unintended consequences such as unexpected benefits, problems, failures, or costs associated
with the intervention(s).
This research noted the need for further comprehensive follow up care for diabetes including:
eye exams, foot exams, and nutritional services. Utilizing the DCN program seemed to overcome
medication lapses in refills by making sure that the patient had medication refills and that the
medication list was up to date with each DCN encounter. The DCN provider would
automatically renew medications with the consultation discussion to assure medications were
active in order. Additionally, patients seemed to become more actively engaged in their A1C
goals while working in the DCN program.
Details about missing data:
Patients who were followed by the DCN network and PC comparison group were the only
Veterans reviewed for this study. A larger sample that included more primary care patients may
have revealed different data. This would be a potential for further research study in the future.
Telehealth has the potential to revolutionize care for Veterans in areas with specialist shortages
and to help overcome the inertial care that can occur for chronic diseases such as T2DM. This
Discussion:
The Diabetes Care Network was able to overcome clinical inertia and leverage scarce endocrine
specialty care to improve the A1Cs of patients with A1C over 9. The VA data warehouse
generated a list of Veterans who had A1Cs of 9 or higher. A random number generator was used
to choose patients to take part in the DCN telehealth collaborative program with a PC provider
partnered with an endocrinology specialist. A comparison group that was demographically
comparable was to the DCN group. The collaborative care included consultations between the
DCN PC provider and endocrine specialty and phone care with the veterans in the DCN group.
There was an improvement in T2DM as demonstrated by lower A1Cs in the DCN patient group
compared to the patients in traditional PC care.

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Summary:
Key findings, including relevance to the rationale and specific aims
The specific aims of this study were to use a collaborative care model to improve diabetes care
for Veterans and overcome the barriers of time and distance for patients. The strengths of this
project included the ability to use the VA electronic medical records and obtain data from the
VA data warehouse. There was no real cost other than the PC provider involved in DCN
collaborative care time. The endocrinology specialist worker during regular hours and telephone
care is already supported by VA. This module is easily generalizable to multiple healthcare
systems.
Particular strengths of the project
The use of telehealth was successful in improving the effects of clinical inertia and expanding
access to endocrinology specialty care for patients who had barriers related to time, distance and
mobility and not available local access to endocrine
Interpretation:
a. Nature of the association between the intervention(s) and the outcomes
The intervention of the DCN provided collaborative telehealth endocrine care not easily accessed
in other ways for these Veterans. Without the intervention the patients would have had to travel
up to a few hours for VA care and if referred locally the rural Veterans would still have had wait
times and significant travel barriers.
b. Comparison of results with findings from other publications
Telehealth is an ongoing approach to provide access to care when access may otherwise be
unavailable. The use of the DCN program shows that a telehealth approach promotes access to
care and in this case promoted better overall health by helping to achieve A1C goal. The use of
telehealth steadily increases as it has become a viable modality to patient care. Patient
satisfaction is a key indicator of how well the telemedicine modality met patient
expectations.(Kruse et al 2017)
c. Impact of the project on people and systems
The DCN did improve A1Cs for their patients with no change to their PACT Team care burden.
There were several templated notes developed to support the project that had no cost. The impact
was minimal and just required some time support for the PC provider working with these
patients.

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d. Reasons for any differences between observed and anticipated outcomes, including the
influence of context
This DCN approach did result in expected outcomes. These researchers did hypothesize that a
comprehensive approach and expert consultation would promote improved glycemic control.
e. Costs and strategic trade-offs, including opportunity costs
The major most for this program was phone encounters for the DCN PC program by providers
that were involved in the Veterans care. Although this DCN review did not directly measure the
consultations ordered, patients in the DCN were routinely sent for diabetic retinal exams,
nutrition consult and nursing appointments for diabetic foot check if they were due. If patients
had uncontrolled lipids or blood pressures or aspirin the DCN did initiate this care. The DCN
could be evaluated for general care of the chronic disease that impacts diabetes outcomes and
this could be a formalized part of the program.
Increased familiarity with diabetes medications may have increased the cost for the DCN
patients by the use of newer agents which the PACT Team provider was not as comfortable
prescribing and led to increased cose. This would be an area that needs more study. However
long term the increased medication costs should be offset by improved diabetes outcomes and a
decrease in the use of resources related to cardiovascular disease, renal care and eye care.
Limitations:
a. Limits to the generalizability of the work
As we’ve noted, type 2 diabetes is on the rise in the US. Additionally there is a shortage of
endocrinology providers. Due to this, there is limited research to compare the specifics of this
data approach to.
Some Veterans also seek care locally or outside of the VA network. Some of these records were
may not be as easily accessed by staff for more comprehensive care.
b. Factors that might have limited internal validity such as confounding, bias, or imprecision in
the design, methods, measurement, or analysis
This study had a relatively small and demographically similar sample size. This retrospective
chart review was completed over a one year period of time. Given this though improvement was
noted in glycemic control while enrolled in DCN, the lasting effects past this year time frame
was not at this time assessed.

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As a benefit, all Veterans enrolled in the DCN program had their medications provided through
the VA system so that patients were able to have filled/refilled easily with the DCN phone
encounters.
c. Efforts made to minimize and adjust for limitations
This sample size did show statistical significance and did not note any large statistical variables.
Conclusions
a. Usefulness of the work
This study is extremely useful as a model that has potential to be implemented in those with
chronic diabetes but other long term disease processes as well.
The telehealth approach promoted access to specialty care or those patients that may otherwise
had not had access due to travel, financial etc.
b. Sustainability
The study is sustainable and offers potential for additional research as well.
The medications used and their potential impact was not reviewed in this study. This assessment
could provide future clinical research that supports the concept of clinical inertia.
c. Potential for spread to other contexts
The use of a comprehensive telehealth approach could be optimize care in other areas of chronic
disease management such as heart failure, rheumatology etc/
d. Implications for practice and for further study in the field
Clinical inertia is a concept that was demonstrated in this study. The addition of comprehensive
care consult from the DCN showed improvement in A1C. This goes to show that telehealth is a
very helpful tool in promoting access to care. The concept of clinical inertia presents a need for
improvement in comprehensive care of the type 2 diabetic patient.
e. Suggested next steps
The DCN program is a telehealth guideline that could be implemented in similar settings in
either primary or specialty care centers. Reviewing resources with primary care programs and
encouraging telehealth evaluation when able as an option for access to specialty care stands to
promote improvement in health outcomes.

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Funding:
This study was completed by the research team. No funding was obtained at this time

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