Executive Summary: Implementing a Comprehensive Tele-Diabetes Management Program in Nakuru County

Project Proposal: This proposal outlines the implementation of a Comprehensive Tele-Diabetes Management Program (CTDMP) within our healthcare organization, targeting adults diagnosed with Type 2 Diabetes Mellitus (T2DM) in Nakuru County, with a particular focus on improving health outcomes for those in rural and underserved areas. This program will leverage digital technology to provide remote patient monitoring, virtual consultations, and enhanced diabetes self-management education and support (DSMES).

I. Stakeholders Impacted by This Project:

• Patients: Adults (20-79 years) with T2DM, particularly those in rural or underserved areas of Nakuru County with limited access to consistent specialist care.
• Healthcare Providers (Nurses, Clinical Officers, Doctors): Nurses at primary care clinics, specialists (Endocrinologists, Dietitians) at larger referral centers, and community health workers (CHWs).
• Healthcare Organization Leadership/Administration: Responsible for resource allocation, strategic planning, and quality improvement initiatives.
• County Health Management Team (CHMT): Oversees health service delivery across Nakuru County.
• Payers/Insurers: Such as the National Hospital Insurance Fund (NHIF), potentially bearing the cost burden of diabetes complications.
• Families/Caregivers of Patients: Who often support patients in their daily management.

II. Outcome/Efficiency to Be Improved and How This Improvement Would Occur:

This project is primarily aimed at improving glycemic control (measured by HbA1c reduction) and reducing the incidence of diabetes-related complications (e.g., foot ulcers, hospitalizations for DKA/HHS) among adults with T2DM. This will lead to enhanced quality of life for patients and significant cost efficiencies for the healthcare system by reducing expensive emergency department visits and inpatient admissions.

How Improvement Would Occur:

1. Enhanced Accessibility to Care: By providing virtual consultations and remote monitoring, geographical barriers to specialist care and regular follow-up will be significantly reduced, especially for patients in rural Nakuru. This ensures more consistent engagement in their care plans.
2. Proactive Management and Early Intervention: Continuous glucose monitoring (CGM) and remote vital sign monitoring will allow healthcare providers to detect concerning trends (e.g., persistent hyperglycemia, impending hypoglycemia, elevated blood pressure) in real-time. This enables timely adjustments to medication, dietary advice, or lifestyle recommendations, preventing escalation to acute complications.
3. Personalized Diabetes Self-Management Education and Support (DSMES): Digital platforms can deliver tailored educational content and support based on individual patient data and learning styles. Virtual group sessions or individual coaching can reinforce healthy behaviors and empower patients to take a more active role in their self-management, leading to better adherence to treatment plans.
4. Improved Provider Efficiency: Nurses and clinical officers can monitor a larger cohort of patients remotely, triaging those who need immediate in-person attention versus those who can be managed virtually. This optimizes clinic flow and allows for more efficient allocation of specialist time.

III. Technologies Required for Implementation:

1. Continuous Glucose Monitoring (CGM) Devices: Wearable sensors (e.g., Freestyle Libre) that provide real-time glucose readings.
2. Remote Patient Monitoring (RPM) Devices: Bluetooth-enabled blood pressure cuffs, glucometers (if not using CGM), and smart scales that sync data to a central platform.
3. Secure Telehealth Platform: A robust, HIPAA/Kenya Data Protection Act compliant platform for video consultations, secure messaging, and sharing educational resources (e.g., adapted versions of existing platforms like MyDawa or new, purpose-built platforms).
4. Electronic Health Record (EHR) Integration: Seamless integration of data from RPM/CGM devices and the telehealth platform into the existing EHR system (e.g., Afya.KE or facility-specific EMR) for comprehensive patient records.
5. Data Analytics and Visualization Dashboard: A system to aggregate, analyze, and display patient data trends for nurses and clinicians, allowing for quick identification of patients needing intervention.
6. Patient-Facing Mobile Application: A user-friendly app for patients to view their data, access educational materials, communicate with their care team, and receive reminders.

IV. Project Team (by Roles):

• Project Sponsor: Hospital CEO/County Director of Health (Provides strategic direction, secures resources).
• Project Manager: Clinical Operations Manager (Oversees daily project activities, timelines, budget).
• Medical Director (Endocrinology/Internal Medicine): Provides clinical expertise, protocol development, physician buy-in.
• Nurse Manager/Team Lead: Coordinates nursing staff, oversees training, ensures clinical workflow integration.
• Informatics Nurse Specialist (Key Role):
  • How Incorporated: The Informatics Nurse Specialist will be central to the project’s success by serving as the bridge between clinical practice and technology. Their expertise will be crucial in: