Care Coordinators’ Use Of An EHR Tool To Enhance Their Ability To Engage Patients In Developing A Self-management Goal Utilizing The Revised SMG-contract

Abstract

The purpose of this evidence-based practice project was to train the Kalihi-Palama Health Center’s (KPHC) care coordinators (CCs) to use an electronic health record (EHR) tool that would enhance their ability to engage patients with type 2 diabetes mellitus (T2DM) in developing a self-management goal utilizing a revised self-management goal (SMG)-contract. The patients with diabetes who had a Hgb A1c greater than 8% participated in this project. The CCs met with the patient with T2DM and developed a patient-driven plan utilizing the revised self-management goal (SMG) contract. The CCs highlighted the hemoglobin (Hgb) A1c graph in red as a stop, yellow as a slowdown, and green as a go, then engaged patients by assessing the patients’ understanding of their diabetes. The patients were encouraged to choose attainable and measurable activities for their contract. Patients completed and signed the SMG contract to commit to meeting the target goal. The CCs reminded patients that small changes could create an impact on their health. The highlighted Hgb A1c graph and signed SMG contract were given to patients to place where they would be visible at their house as a reminder for them to keep their agreement. The outcome of patients' Hgb A1c showing improvement compared to the baseline was met after meeting with their care coordinators. Care coordinators enhanced ability to engage patients in self-management goals and boosts their confidence in dealing patients with chronic conditions.