ABSTRACT

Care coordination and chronic care management is led by a team of three nurses in the ambulatory care setting at Mayo Clinic Arizona. Maladaptive self-care management and reduced confidence levels in patients with chronic illness, associated with poor self-efficacy, negate some patients’ abilities to adhere to treatment modalities and plans of care (Shen et al., 2019). A direct practice improvement project was initiated by the Office of Equity, involving the interdisciplinary care team, including RN care coordinators and medication therapy management pharmacists. The interdisciplinary team’s goal was to reduce hemoglobin A1c levels of diabetic patients enrolled in the study by 1.5%, from an average of 8.2% to 6.7%. The population consisted of 37 African American, Native American, and Latino/Hispanic patients with a diagnosis of type 2 diabetes and uncontrolled A1c. The intervention included supplying patients enrolled in the study using continuous glucose (CGM) monitors, sensors, and the utilization of CGM app tracking. The interdisciplinary team’s objective was to lower hemoglobin A1c levels among the sample population using the CGM system, medication management, dietary management and the incorporation of activity and exercise over a six-month period. Data was collected via a clinic-based CGM portal. In the ambulatory care setting, RN care coordinators play a causative role in collaborating with diabetic patients to develop self-care management strategies to improve hemoglobin A1c levels. By January 2025, the average hemoglobin A1c level for the sampled diabetic patient population reduced from a baseline of 8.2% to 6.75 %.