Document Type

DNP Project

Publication Date


Degree Name

Doctor of Nursing Practice

Faculty Advisor

Sylvie Rosenbloom, DNP, APRN, FNP-BC, CDCES

Practice Mentor

Annie Kaisen, MSN, APRN, CDCES

Second Practice Mentor

Judy Petersen-Pickett, MSN, RN


Background: Diabetes is the seventh leading cause of death in America with approximately 1.5 million people diagnosed yearly (ADA, 2020). The current problem in the practice setting is the lack of follow-up of patients with hemoglobin A1c’s (HbA1c’s) 9% or greater. The current workflow utilizes care coordinators to perform patient outreach to patients with diabetes and a HbA1c of 9% or greater. This workflow is not structured and consists of randomly selecting a patient with a HbA1c 9% or greater and placing one phone call to them to provide education.

Purpose: The purpose of the project was to develop and implement a structured clinic RN-led telephone follow-up process for patients with T2DM and a HbA1c of 9% or greater.

Methods: Interventions used throughout the telephonic follow-up align with the ADCES7 Self-Care Behaviors (ADCES7), a framework used to optimize care and education for patients with diabetes. This framework includes a focus on health coping, nutrition, exercise, medication adherence, blood glucose monitoring, reducing risk factors, and problem solving (Kolb, 2021). Patient activation, defined as level of patient activation (or engagement) related to self-management, was assessed during each call. Adherence to diet, blood glucose testing, medications, and exercise was also included in these assessments. Dashboard reports within the electronic record were run at the end of the implementation process to gather the results.

Results: Ten out of 11 patients enrolled in this QI project had a decrease in their HbA1c values with four of these bringing their HbA1c < 9%, one patient had an increase. The average HbA1c prior to intervention was 10.8%. Post-intervention the average HbA1c dropped to 8.8% indicating a 2% decrease. Several educational interventions were utilized with each patient during the telephonic follow-up. Disease education (67%), nutrition education (89%), and physical activity education (41%) were utilized most frequently. Patient activation levels increased post-intervention, meaning patients became more engaged in their care over time.

Discussion: The implementation of the RN-led telephone follow-up process for patients with uncontrolled T2DM demonstrated an improvement in HgA1c and an increase in patient engagement. Organizations would benefit by implementing this process across primary care offices.


A DNP project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice.

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Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.



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