Project Planning and Preparation - Apr. 13 @ 10_11 pm

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Jun 12, 2024

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1 Project Planning and Preparation Patricia Mezzina Chamberlain University NR-711 Fiscal Analysis and Project Management Dr. Karen Myers April 13, 2024
2 Project Planning and Preparation Introduction The purpose of the proposed DNP project is to provide an overview of the practice problem identified at the Multiple Sclerosis (MS) Center practicum site, along with the greater significance at the population and national level. The evidence-based intervention, a comprehensive wellness program, addresses the three priority focuses identified by the National MS Society including diet, exercise, and emotional well-being (Hart et al., 2011). A synthesis of the evidence will support the proposed practice change and an outline of the implementation plan, milestones, and measurement tools for evaluation will also be presented. Together, the details of the process will demonstrate how the intervention will improve the quality of life for the patients served. Assessment According to the Global Burden of Disease study, in the United States, there was a 23.9% increase in the incidence of MS, a 60.4 % increase in prevalence, a 75 % increase in disability- adjusted life years (DALYs), and as high as an 89.4% increase in mortality from 1990 to 2017 (Feigin et al., 2021). With approximately one million people living with MS in the United States today, the total economic burden has been reported to be 85.4 billion dollars annually ( Global Burden of Disease , 2019). With annual direct excess medical expenses being approximately 65,612 dollars and indirect costs of 22, 875 dollars per patient, the biggest expenses are related to disease-modifying therapy and lost wages/productivity related to comorbidities and disability (Bebo et al., 2022). A focus on secondary and tertiary prevention, through a focus on wellness, may impact the economic burden, DALYs, and mortality (Donkers et al., 2019).
3 The MS center currently serves 942 patients. Results of a chart review and needs assessment at the practicum site reveal a high incidence of obesity, anxiety, depression, and fatigue that negatively impact the overall quality of life (QOL) in the MS population enrolled at the center. This data is in alignment with current research. As much as 80 % of patients living with MS suffer from fatigue, 40-70% experience anxiety-inducing cognitive dysfunction, and 24% are diagnosed with depression which synergistically impacts overall mortality (Kern & Cepeda, 2020). Finally, obesity has been tied to the evolution and progression of MS (Schreiner & Genes, 2021). The practice gap identified was a lack of an organized process to address these comorbidities and modifiable risk factor reduction. Evidence Synthesis The Evidence-based intervention to be implemented is an 8-week wellness program that acknowledges the bio-psycho-neuro-immunological challenges experienced by patients living with MS. In a structured format, it provides education and enrichment activities that address the priorities identified by the National MS Society, modifiable risk factors and support patients to live their most authentic experience of wellness possible at every stage of the disease course and ultimately improve overall quality of life (National MS Society, n.d.-a). Meeting in a group format once per week for the course of the program, the content will also be presented in alignment with the six dimensions of wellness identified by the National MS Society, including physical, cognitive, emotional, social, occupational, and spiritual wellness (National MS Society, n.d.-b). Qualitative data obtained from separate studies involving both healthcare providers and current MS patients reveal a strong sentiment that the MS population is underserved (Donkers et al., 2019, & Faraclas et al., 2022). Across the board, in both the Donkers (2019) and Faraclas
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4 (2022) studies, there was a strong recommendation for a pathway to link patients with a “living well” type of program. The National MS Society Wellness Research Working Group advises the MS Society on evidence-based content for wellness programs to improve quality of life (Motl et al., 2017). Recommendations from this advisory group are supported by results of studies where wellness programs with interventions providing expert education on lifestyle and behavior strategies to address diet, exercise, and emotional health have been shown to improve the quality of life (QOL) of patients with MS (McGuire et al., 2015andWeinstein et al., 2022). Contrasting main points A key contrasting main point is that studies on wellness programs addressing various key comorbidities, from interventions aimed at reducing obesity and increasing physical activity to interventions such as mindfulness training to address emotional dysregulation, to behavioral programs to address symptoms such as pain, depression, and fatigue, all the interventions resulted in positive changes in the intervention groups and improvement in the quality of life domains tested (Cozart et al., 2023, Schirda et sl., 2020, Hart et al., 2011 & Weinstein et al., 2022). A second key contrasting point is that both virtual and in-person formats of wellness- focused programs yielded positive improvements in the overall quality of life measured metrics (Cozart et al., 2023, Hart et al., 2011 & Weinstein et al., 2022). Overarching Synthesis In considering all the evidence presented here, it is clear that key stakeholders have identified a need for a process for addressing interventions to improve the quality of life for patients with MS and, a formal behavioral wellness program, virtual or in-person, that addresses one or more modifiable risk factors for comorbidities can have a positive impact to improve the lives of those suffering with this disease (Cozart et al., 2023, Donkers et al., 2019, Faraclas et al.,
5 2022, Hart et al., 2011, Schirda et al., 2020 & Weinstein et al. 2022). It is also clear that improving physical activity at every level of disability, along with psychoeducational support can help improve the overall quality of life, mitigate fatigue and pro-inflammatory sequelae, and reduce obesity in patients with Multiple Sclerosis (Kalb et al., 2020, McGuire, et al., 2015, Schreiner, T & Genes, T-M, 2021, Young, J., 2015). MS patients often struggle with the self- initiation of these proven strategies, finding conflicting information on social media and other resources, lack of support, and life circumstances including financial issues (Donkers et al., 2019, & Neate et al., 2021). The DNP project will bridge this gap for such underserved pts by bringing this program to all free of charge. It will help eliminate barriers to access to clinical experts and evidence-based information and interventions. Implementation The evidence-based MS wellness program will be structured as a 5-hour weekly program incorporating 2 hours of educational presentations and group discussions provided by materials from the MS Society, 1 hour of unstructured socialization time, and 2 hours of wellness/physical activity-related talks presented by guest speakers. Each weekly program will cover one dimension of wellness by the National MS Society. The dimensions are grouped as physical, intellectual/cognitive, social, spiritual, occupational, and emotional wellness. This intervention was chosen based on the outcomes achieved by the research conducted at Centrastate Hospital in Freehold, New Jersey at the MS center. In the study of 65 patients who participated in the wellness program, investigators found significant improvement in several domains, including functional status (P < .05), fatigue (P < .05), fear-avoidance beliefs regarding physical activities (P < .05), depression (P < .05), somatization (P < .05), and pain (P < .05) (Hart et al., 2011).
6 The instrument to be used to evaluate this outcome indicator is called the Neuro-QOL tool. The instrument includes 13 scales that assess physical, emotional, cognitive, and social domains for use in a variety of neurological illnesses (Miller et al, 2016). Internal consistency was high for all measures (α = 0.81-0.95) and was within the acceptable range (0.76-0.91); concurrent and known group validity was highest on the Global HRQL (Health-Related Quality of Life) questions. These questionnaires will be administered at the start of the program on week one and again upon completion of the program. Participants will be selected based on the inclusion criteria and informed consent will be obtained. Recruitment for participants will begin once the project is approved by the organizational IRB via mailers sent to every patient meeting criterion at the MS center. There will also be signage in the MS Center office and infusion center. Finally, the program will be announced at the MS Center support groups. There are several key milestones during the implementation of the project including; Week 1 – A training meeting will be held with the nursing team. Each will be provided with prepared binders that include all the slide decks, handouts, and discussion guides along with detailed itineraries of the timelines for the activities of each day. Informed consent will be obtained, and pre-implementation data will be collected and aggregated. Weeks 2-9 The wellness program will be implemented and on completion of the program each participant will be presented a certificate of completion. Weeks 9-10 Ongoing remote support will be provided in the form of a Zoom 1-hour meeting to assess the implementation/progress of SMART goals for patients to check-in and/or get live support. Weeks 10-12 Post-implementation data will be collected, aggregated, and analyzed.
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7 Evaluation The measurable outcome is the overall quality of life. The scales from the Neuro-QOL tool that will be used are the short forms for anxiety, depression, emotional and behavioral dyscontrol, fatigue, lower extremity function-mobility, upper extremity function-mobility, positive affect & well-being, sleep disturbance, satisfaction with social roles and activities and cognitive function. The assessment will be delivered to the patients using the Redcap web-based application, which will also provide an overall score and subscore outcome metrics. Conclusion Patients with MS have a significantly higher incidence of comorbid conditions including obesity, anxiety, depression, fatigue, and cognitive dysfunction, which negatively impacts the overall quality of life, morbidity, and mortality. The consensus among key stakeholders is that this population is underserved in the community and there is a strong interest in access to opportunities for interventions that address priority focuses identified by the National MS Society, including increasing physical activity, nutrition, and emotional wellness. Evidence in the literature supports the fact that the evidence-based intervention of a behavioral wellness program can improve the overall quality of life for patients living with MS. The evidence-based MS wellness program will be presented in a structured 5-hour program that will meet once a week for 8 sessions. There will also be support available for 2 weeks post-program for participants as needed. The Neuro-Qol tool will be administered both pre- and post-intervention through a Redcap survey. Because of convenience sampling and the lack of a control group, a paired t-test will be used to measure statistical significance. The project will be evaluated as successful as evidenced by an improvement in overall quality of life measures for the participants in the program.
8 References Bebo, B., Cintina, I., LaRocca, N., Ritter, L., Talente, B., Hartung, D., Ngorsuraches, S., Wallin, M., & Yang, G. (2022). The economic burden of multiple sclerosis in the united states. Neurology , 98 (18). https://doi.org/10.1212/wnl.0000000000200150 Cozart, J. S., Bruce, A. S., Befort, C., Siengsukon, C., Lynch, S. G., Punt, S., Simon, S., Shook, R. P., Huebner, J., Bradish, T., Robichaud, J., & Bruce, J. M. (2023). A pilot study evaluating the prefeasibility of a behavioral weight loss program in people with multiple sclerosis. Preventive Medicine Reports , 36 , 102437. https://doi.org/10.1016/j.pmedr.2023.102437 Donkers, S. J., Oosman, S., Milosavljevic, S., & Musselman, K. E. (2019). Addressing physical activity behavior in multiple sclerosis management. International Journal of MS Care , 22 (4), 178–186. https://doi.org/10.7224/1537-2073.2019-029 Faraclas, E., Merlo, A., Lynn, J., & Lau, J. D. (2022). Perceived facilitators, needs, and barriers to health related quality of life in people with multiple sclerosis: A qualitative investigation. Journal of Patient-Reported Outcomes , 6 (1). https://doi.org/10.1186/s41687-022-00496-1 Feigin, V. L., Vos, T., Alahdab, F., Amit, A. L., Bärnighausen, T., Beghi, E., Beheshti, M., Chavan, P. P., Criqui, M. H., Desai, R., Dhamminda Dharmaratne, S., Dorsey, E., Wilder Eagan, A., Elgendy, I. Y., Filip, I., Giampaoli, S., Giussani, G., Hafezi-Nejad, N., Hole, M. K.,...Murray, C. L. (2021). Burden of neurological disorders across the us from 1990- 2017. JAMA Neurology , 78 (2), 165. https://doi.org/10.1001/jamaneurol.2020.4152 Global burden of disease . (2019). Institute for Health Metrics and Evaluation. https:www.healthdata.org/gbd/2019
9 Hart, D. L., Memoli, R. I., Mason, B., & Werneke, M. W. (2011). Developing a wellness program for people with multiple sclerosis. International Journal of MS Care , 13 (4), 154–162. https://doi.org/10.7224/1537-2073-13.4.154 Kalb, R., Brown, T. R., Coote, S., Costello, K., Dalgas, U., Garmon, E., Giesser, B., Halper, J., Karpatkin, H., Keller, J., Ng, A. V., Pilutti, L. A., Rohrig, A., Van Asch, P., Zackowski, K., & Motl, R. W. (2020). Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. Multiple Sclerosis Journal , 26 (12), 1459–1469. https://doi.org/10.1177/1352458520915629 Kern, D. M., & Cepeda, M. (2020). Treatment patterns and comorbid burden of patients newly diagnosed with multiple sclerosis in the united states. BMC Neurology , 20 (1). https://doi.org/10.1186/s12883-020-01882-2 McGuire, K., Stojanovic-Radic, J., Strober, L., Chiaravalloti, N. D., & DeLuca, J. (2015). Development and effectiveness of a psychoeducational wellness program for people with multiple sclerosis. International Journal of MS Care , 17 (1), 1–8. https://doi.org/10.7224/1537-2073.2013-045 Motl, R. W., Mowry, E. M., Ehde, D. M., LaRocca, N. G., Smith, K. E., Costello, K., Shinto, L., Ng, A. V., Sullivan, A. B., Giesser, B., McCully, K. K., Fernhall, B., Bishop, M., Plow, M., Casaccia, P., & Chiaravalloti, N. D. (2017). Wellness and multiple sclerosis: The national ms society establishes a wellness research working group and research priorities. Multiple Sclerosis Journal , 24 (3), 262–267. https://doi.org/10.1177/1352458516687404 National MS Society. (n.d.-a). Living well with MS . Retrieved November 28, 2023, from https://www.nationalmssociety.org/Living-Well-With-MS
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10 National MS Society. (n.d.-b). Pathways to wellness in MS . Retrieved March 21, 2024, from https://www.nationalmssociety.org/Resources-Support/Library-Education-Programs/ PathwaystoWellness Neate, S. L., Donald, A., Jelinek, G. A., & Nag, N. (2021). Experiences of and attitudes to lifestyle modification for the management of multiple sclerosis: A qualitative analysis of free‐text survey data. Health Expectations , 25 (1), 214–222. https://doi.org/10.1111/hex.13364 Schirda, B., Duraney, E., Lee, H., Manglani, H. R., Andridge, R. R., Plate, A., Nicholas, J. A., & Prakash, R. (2020). Mindfulness training for emotion dysregulation in multiple sclerosis: A pilot randomized controlled trial. Rehabilitation Psychology , 65 (3), 206–218. https://doi.org/10.1037/rep0000324 Schreiner, T.-G., & Genes, T.-M. (2021). Obesity and multiple sclerosis—a multifaceted association. Journal of Clinical Medicine , 10 (12), 2689. https://doi.org/10.3390/jcm10122689 Weinstein, S. M., Reilly, E., Garland, N., Zimmerman, V., & Jacobs, D. (2022). Impact of a virtual wellness program on quality of life measures for patients living with multiple sclerosis during the covid-19 pandemic. International Journal of MS Care , 24 (6), 282– 286. https://doi.org/10.7224/1537-2073.2021-134 Young, J. A. (2017). The Effects of Wellness Center-Based Exercise in People with Multiple Sclerosis: A Program Review ((1896981255)) [Doctoral dissertation, Florida Gulf Coast University]. ProQuest One Academic. https://www-proquest- com.chamberlainuniversity.idm.oclc.org/dissertations-theses/effects-wellness-center- based-exercise-people/docview/1896981255/se-2