A Health Systems Approach to Nurse-Led Implementation of Diabetes Prevention and Management in Vulnerable Populations

Abstract

Diabetes mellitus is seventh leading cause of death in the United States, and has a substantial economic burden, contributing $237 billion in direct medical costs. The incidence rate of type 2 diabetes (T2DM) is expected to continue to increase, disproportionally impacting vulnerable groups. The increasing prevalence and disproportionate burden emphasize the need for health systems to effectively integrate and implement large- and small-scale, culturally tailored nurse-led diabetes prevention programs (DPP) and diabetes self-management education programs (DSME). This two-stage analysis used a health system approach to provide a synopsis of evidence-based nurse-led DPP and DSME implementation across various health system settings. Using the results from an integrative review, a health system focused framework was developed and applied to two case studies highlighting specific aspects of how successful large- and small-scale nurse-led interventions are integrated into health systems across varying vulnerable populations specifically Veterans, Asian Americans and Haitians. Case study results use examples to show large-scale implementation of DSME across the federal Veterans Health Administration (VHA) improves diabetes self-management and access for Veterans and smaller-scale DPP and DSME programs within community health centers targeting vulnerable populations impact health literacy and diabetes self-management. These examples demonstrate key steps towards improving access and outcomes for diabetes management and the critical role of nurse-led diabetes interventions as a priority across the health system and the importance of financial and organizational support for DPP and DSME programs to overcome access barriers to improve diabetes interventions and management.

Introduction

Diabetes mellitus is seventh leading cause of death in the United States (U.S.) and the leading cause of kidney failure, vision loss, and lower limb amputation ^1,2. The economic burden of diabetes on the U.S. healthcare system is high, contributing direct medical costs of $237 billion with two thirds of these costs paid for by Medicare and Medicaid³. Complicating this is the U.S. healthcare system, which encompasses numerous health insurance and healthcare facilities and providers. Despite this, the U.S. has high rates of under and uninsured individuals, and high healthcare expenditures⁴, which has been shown to increase the risk of catastrophic health expenditures, particularly for individuals with diabetes⁵. While individuals can receive care from for-profit and non-profit hospital systems, community health facilities, federally funded health care systems (i.e. Veterans Health Administration), or private outpatient primary care offices, there are still numerous barriers to healthcare for individuals^6,7.

Over the next 30 years, the incidence of type 2 diabetes (T2DM) is expected to increase with higher rates of disease occurring in vulnerable, disadvantaged populations including older adults, minority race and ethnic groups, those with lower educational attainment, and those with a high incidence of comorbidities including obesity^8,9. The increased prevalence and disproportionate burden of T2DM in minority and disadvantaged populations emphasizes the need for effective implementation of large- and small-scale, culturally tailored, effective diabetes prevention and management interventions that involve appropriate technology⁸.Evidence-based diabetes prevention programs (DPP), diabetes self-management education programs (DSME), and diabetes technology programs provide a model for the design and implementation of these interventions. DPP and DSME are evidence-based programs that have been shown to effectively prevent and manage diabetes, improve quality of life, and decrease the incidence of diabetes complications¹⁰. DPP is a life-style modification program focused on physical activity and healthy eating to prevent or delay the onset of T2DM, for individuals at-risk for diabetes¹¹. DSME provides individuals the knowledge and skills to support optimal diabetes self-management once an individual is diagnosed with diabetes. DSME interventions provide education on informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team and it has been shown to improve clinical outcomes, health status, and quality of life^12–15. DSME activities include implementing and sustaining behaviors associated with improved diabetes or pre-diabetes management including behavioral, educational, psychosocial, and clinical support¹⁶. Further, DSME interventions can be delivered without exacerbating inequities for those with low health literacy¹⁷ and have been shown to be effective when delivered in individual, group, or virtual settings^18,19. In addition, clinical studies and systematic literature reviews demonstrate the success of both DPP and DSME interventions on diabetes clinical outcomes including lower hemoglobin A1c (HbA1c), lowering BMI, and improving medication adherence^12,20–26.

Despite the demonstrated effectiveness of DPP and DSME programs, there have been several barriers in implementing both programs. There is evidence showing difficulties in implementing DPP and DSME programs especially with culturally sensitive population and at scale, therefore reducing access to key diabetes preventive activities in the most vulnerable populations^27–29. While health technology and digital interventions have been increasingly incorporated into DSME programs to improve diabetes clinical outcomes, decrease healthcare utilization and combat raising healthcare costs^19,21,22, uptake and sustainability of the digital components has been slow ³⁰. Finally, utilizing the nursing workforce has been a key strategy to increase the availability of clinicians to implement these key programs with the initial literature showing that nurse-led DPP and DSME interventions improve diabetes outcomes across many populations and diverse settings and may be one of the more effective strategies to address the complex nature and unique burden of treating patients with diabetes across a variety of health-care settings³¹. Although other health professions, including pharmacists, nutritionists, and community health workers, offer successful DPP and DSME programs, these programs often emphasize the unique expertise of each profession including medication compliance, nutrition, or patient advocacy^32–34. In the U.S., registered nurses (RNs) and in particular advanced practice registered nurses (APRNs) specially trained as certified diabetes care and education specialists (CDCES), are in a unique position to facilitate comprehensive T2DM care due to their focused education on chronic disease management, health behavior change, and therapeutic patient-provider relationship ³⁵ Despite evidence supporting nurse-led diabetes prevention and self- management education programs in the U.S., there has not been a formal review of the literature summarizing the successful strategies of large- and small-scale nurse-led DPP and DSME programs.

While many health system levers have been used to improve implementation of DPP and DSME, another less studied system solution is leveraging the nursing workforce at both leadership and delivery levels ^36–39. While there has been some anecdotal evidence of nurse-led interventions to improve delivery of DPP and DSME ^38,39, a deeper review of the literature is necessary to understand the mechanisms for how delivery of DPP and DSME by nurses can improve access and outcomes. The purpose of this article, using a two-staged design, is to provide an evidence-based synopsis, utilizing an integrative review, of successful nurse-led DPP and DSME implementation across various health care settings on both leadership and delivery levels. The first part of the results qualitatively summarizes the current literature related to nurse-led diabetes prevention and self-management education interventions based on the results of the integrative review. Using the results from the integrative review, two case studies are presented focusing on specific aspects of successful nurse-led interventions at both the leadership and delivery level: culturally tailored interventions with Asians and Haitians populations living the U.S. and large-scale implementation with Veterans.

Methods

This study employed a two-staged study design incorporating an integrative review of the literature to understand the health system components related to nurse-led and advanced practice nurse-led diabetes interventions in Stage 1. In Stage 2, two case studies were developed to highlight the varying levels of health system integration and work force innovations incorporated into successful DPP and DMSE programs.

Integrative Review Methodology:

The methodological quality of the studies was assessed using the appropriate CASP (Critical Appraisal Skills Programs, 2014) criteria for research studies. A robust search strategy was conducted using the following databases: Cochrane (including Embase), Pubmed (including Medline) and CINAHL databases using search terms including “Diabetes Prevention Program”, “Diabetes Self-Management and Education” “nurse”, “nursing”, “nurse-led” and “advanced practice”. Study inclusion criteria included intervention studies published in peer reviewed journals between January 1998 to July 2024 conducted in the U.S., being a DPP or DSME/S intervention and having nurse-leadership of the study itself. Nurse leadership was defined by the study team as inclusion of an RN or APRN as a co-author on the manuscript or explicit mention of nurse leadership in the study design. DPP and DSME interventions were categorized as RN led, APRN led or RN and APRN led, based on nurse leadership criteria, through a review of manuscript authors credentials. The results presented distinguish between RN and APRN led interventions as the original authors of the research made this distinction, however we present these results with the understanding and recognition that both RNs and APRNs are trained nurses with a unique approach, and therefore the entirety of this literature can help understand the mechanism by which nurse-led and delivered interventions improve access and outcomes. Studies that utilized nurse implementation were reviewed to determine if nurse leadership inclusion criteria were met, however, if studies only utilized nurse implementation, the study was excluded (N=22). Additionally, studies were excluded (N=25) if empirical data were not collected on pertinent diabetes clinical outcomes including body mass index (BMI), glycated hemoglobin A1c (HBA1c), and blood pressure were not obtained. Studies conducted in the hospital setting were excluded due to the unique setting and acutely ill patient population (N=2). Studies that met the inclusion criteria were then reviewed to catalog the study design and key health system themes, including efficiency (scale of the intervention measured by the number of participants), access (use of cultural tailoring and technology use), equity (implementation with a vulnerable or at-risk population), and health system integration. Health system integration was used to assess where the intervention was delivered, such as in a primary care office, federally qualified health center (FQHC) or outside the health system such as in a workplace or community area such as a YMCA. The integrative review database search resulted in 730 studies, 213 were excluded based on title and abstract review and 384 were excluded based on full text review including 40 duplicates, 36 systematic reviews or meta-analysis, 25 articles that did not contain key clinical outcomes, 22 articles that only utilized nurse implementation, 2 studies conducted in in-patient hospital settings. A total of 47 studies met all inclusion criteria and the summarized results of the review are shown in Table 1 below. A complete table of all included articles is included in Supplemental Table 1.

Table 1.

Integrative Review Results by Health System Thematic Results (Efficiency, Access, Equity, and Integration)

Heath System Components	Access		Efficiency	Equity	Integration
	Cultural tailoring	Technology	Scale (< 500 participants)	Vulnerable Population	% in health system
DPP (N = 15)
RN Leadership (11, 73%)	64% (N=7)	27% (N=3)	100% (N=11)	73% (N=8)	27% (N=3)
APRN Leadership (4, 27%)	50% (N=2)	75% (N=3)	100% (N=4)	50% (N=2)	25% (N=1)
Average Percent	57%	51%	100%	62%	26%
DSME (N = 32)
RN Leadership (7, 22%)	43% (N=3)	29% (N=2)	86% (N=6)	71% (N=5)	14% (N=1)
APRN Leadership (18, 56%)	39% (N=7)	17% (N=3)	94% (N=17)	56% (N=10)	33% (N=6)
RN and APRN Leadership (7, 22%)	29% (N=2)	14% (N=1)	100% (N=7)	100% (N=7)	43% (N=3)
Average Percent	37%	20%	93%	76%	30%

Table 1 shows the results of the integrative review results categorized in terms of access, efficiency, equity and integration.

Abbreviations: RN: registered nurse, APRN: advanced practice registered nurse

Using the health system themes identified through the integrative review (access, efficiency, equity and integration), two case studies were developed to provide examples of nurse-led DPP and DSME programs that addressed each of these health system themes. For each of the case studies, information and data were provided on the incidence of diabetes in the population of focus (Haitians and Asian American for Case Study 1 and Veterans for Case Study 2). Each case study then summarized some the key barriers to diabetes prevention faced by each population and provided evidence of how each of the health system themes are addressed in the successful implementation of DPP and DSME programs for Haitians, Asian Americans and Veterans.

Case studies were created by clinical experts and nurse leaders directly involved in these specific interventions. Case studies were developed to highlight the varied approaches to DPP and DSMES implementation and captured the range of nurse-led programs. Case study 1 collected data using national surveillance data as well as prior publications from the pilot studies of the culturally tailored community interventions for Asian Americans (entitled SHIP-DM- Self-Help Intervention Program for Diabetes Management) and Haitian Immigrants (entitled Nou Kapab Viv an Sante Avèk Dyabèt [NKV-ASAD]) Self-Management Program). Case study 2 contains data obtained from a national cohort of Veterans receiving care through Veteran Health Administration and clinician interviews (VHA) ^{40 41–43}.

Results

Integrative Review: Nurse-led interventions

Table 1 shows the results of the integrative review summarizing information on access, efficiency, equity and integration of nurse-led interventions. The results included 47 articles where DPP or DSME program were nurse led, with 15 (35%) nurse-led DPP and 32 (65%) nurse-led DSME interventions. 11 (73%) of the DPP interventions were led by RN leadership and 4 (27%) were led by APRN leadership, whereas 7 (22%) DSME interventions had RN leadership, 18 (56%) had APRN leadership and 7 (22%) had a combination of RN and APRN leadership. With regard to scale, almost all the studies involved less than 500 participants, with only two studies (one RN-led and one APRN-led) being implemented in large-scale settings.

In the health system theme of access, cultural tailoring was present in 57% of DPP and 37% of DSME programs ^44–49. Of those that included cultural tailoring, interventions are focused on the following populations: Mexican Americans, Chinese Americans, African Americans, and Armenians. Studies utilized methods such including language tailoring, faith-based tailoring, and workplace integration.

Technology, including telehealth delivery, video recordings, text messaging and smart watches ^50,51, were incorporated in 51% of DPP programs and 20% of DSME programs ^52–57. The highest group with technology incorporated were the APRN-led DPP programs, but this may be confounded by the small number of studies in this category.

Vulnerable populations have often been a focus of DPP and DMSES programs; this review revealed 73% of RN-led and 50% of APRN-led DPP programs were focused on vulnerable populations, including African Americans, Filipinos, Mexican immigrants, Chinese Americans, and low income or underserved populations ^50,58–60. Vulnerable populations were also a focus in DSME programs, with 71% of the RN led interventions, 56% of the APRN interventions and all of the RN and APRN led interventions focusing on similar vulnerable populations ^{46–49,54,61–63,63}.

Finally the results demonstrate that 27% of RN led and 25% of APRN led studies were integrated in the health system, mainly in primary care clinics ^52,64–66, with the remainder of studies occurring in community centers, YMCAs, in work sites, or in faith/worship settings ^{50,58,59,67–69}. Similar to the DPP interventions, 14% of the RN led interventions, 33% of the APRN interventions and 43% of the RN and APRN led interventions were implemented within the health system ^{55,62,70–73}, with the remainder occurring in centers such as those listed above.

Case Study 1: Nurse-Led DPP and DSME in Haitian Immigrant and Asian American Populations

Community-Based Programs Background:

Prior research has demonstrated that integrating diabetes care into communities is critical for racial and ethnic populations as decisions related to diabetes self-management, such as the importance of dietary habits and physical activity are influenced by community infrastructure and support ⁷⁴. This is also critical for vulnerable and minority groups who may struggle to navigate the healthcare system due to issues such as language barriers and mistrust of medical providers ^74,75. Specifically, T2DM disproportionally impacts Asian Americans and Haitian immigrants with prevalence estimates in South Asians (23.3%) and Southeast Asians (22.4%), surpassing rates observed in Hispanic (22.1%) and non-Hispanic Black populations (20.4%)⁷⁶. Similarly, Haitian immigrants born outside the U.S. face disproportionately high rates of diabetes-related complications and mortality, impacting 13.2% of the population, often masked by their broader categorization as non-Hispanic Blacks⁷⁷.

Access Barriers

Asian Americans and Haitian immigrant populations encounter distinct cultural and social barriers that hinder access to effective diabetes prevention and self-management. Asian Americans often struggle with language difficulties and low health literacy, complicating their ability to navigate the healthcare system leading to poorer health outcomes, limited access to care, and significant communication barriers ^75,78. Similarly, Haitian immigrants encounter various social and environmental barriers, including psychosocial factors such as acculturative stress, linguistic challenges, food insecurity, and health system barriers. These issues affect their ability to effectively manage and prevent complications related to T2DM. Additionally, traditional cultural practices among Haitian immigrants often prioritize natural remedies, and there is a general skepticism toward medical treatment^77,79.Like Asian Americans, Haitian immigrants often reside in communities where English is not the predominant language, and limited Haitian Creole proficiency among healthcare providers can further deter individuals from seeking care. Socio-economic hardships, cultural dietary preferences, the absence of supportive networks, and limited community engagement impede crucial lifestyle changes. These factors, coupled with diabetes-related stigma and misinterpretations of medical instructions, hinder open discussions and proper management of T2DM. Delivering effective care to these populations require thoughtful cultural tailoring and linguistic considerations.

Addressing Access Barriers through Nurse-Led Intervention and Cultural Tailoring

Self-Help Intervention Program for Diabetes Management (SHIP-DM) was designed by nurses specifically for first-generation Korean American immigrants, integrating cultural and linguistic adaptations with a focus on self-efficacy and education delivered by Korean American nurses and community health workers (CHWs). SHIP-DM included three subcomponents: (i) information aimed at enhancing patients’ knowledge of T2DM and its treatment, while reducing risk factors, (ii) advancing Korean Americans’ self-efficacy capacities through improved problem-solving skills, cognitive reframing, and belief in self, and (iii) a health literacy component to address the critical need to enhance essential skills (e.g., reading food labels, understanding medical terminology, and follow written healthcare provider instructions/ resources) ⁷⁵.

The newly developed multi-level Nou Kapab Viv an Sante Avèk Dyabèt (NKV-ASAD) is a Haitian-Focused Diabetes Self-Management Education (DSME) program designed by nurses and nurse scientists to improve T2DM self-management and reduce T2DM-related complications among Haitian adults. NKV-ASAD is an interactive DSME intervention delivered by nurses focused on nine key areas of T2DM self-management, integrating unique cultural practices, dietary habits, and health behaviors of this population. The nurse-led intervention emphasizes modifiable targets of T2DM care and self-management behaviors such as culturally and linguistically specific content on dietary guidance, psychological support, and connections to food and housing resources. These modifiable targets have the potential to improve glycemic control among Haitian immigrants, underscoring the importance of cultural relevance in diabetes care (Magny-Normilus et al., 2020; Magny-Normilus et al., 2023). Participants have been recruited within community health centers, and the intervention is delivered by nurses in-person and virtually to increase access and support program retention. Research suggests that delivering the intervention within the community health center is critical for eliminating barriers, facilitating hard-to-reach populations reducing travel time, and establishing trust in communities (Kaiser, Thomas, and Bowers 2017).

Small Scale Impact

SHIP-DM is a small scale (N= 215) longitudinal randomized trial that included community-dwelling Korean American who (a) are diagnosed with prediabetes or diabetes but without kidney failure, (b) are able to read and understand Korean, (c) use a smartphone, and (d) can visit the study site and provide evaluation data three times (at baseline and at 3 and 6 months). SHIP-PM demonstrated statistically significant A1c reductions in the intervention group over time (at 3, 6, 9, and 12 months), as well as statistically significant improvements in T2DM related self-efficacy, knowledge, quality of life, and attitudes toward T2DM in the intervention group (N=120) when compared with the control group.

Participant feedback highlights that the use of translated material and lay language that enhanced their literacy skills were critical for patients as they have experienced a lack of accessible information previously⁸⁰. The programs offer social interaction, shared experiences and the opportunity to grow their community, reducing feelings of social isolation⁸⁰. Another valuable component has been the use of recruitment in community spaces to meet individuals where they are at, including community centers, churches and removing reliance on traditional primary care settings⁸⁰.

NKV-ASAD is currently in its pilot randomized control trial phase (N = 40). Participant are recruited over a six-month timeline (baseline, follow-up at 3, and 6 months) and are eligible if they: 1) self-identify as Haitian immigrants aged 18–64-years, 2) have had T2DM for at least one year, 3) have lived in the US for more than a year; 4) are English speaking, and 5) are willing and able to participate in the study and use wearable devices. Although still in the pilot phase, initial results indicate that the virtual recruitment and technology use have increased participant enrollment, suggesting the potential for future success with this approach.

Recipients of the program face several challenges related to both care delivery and diabetes technology use. Many participants experience barriers such as financial constraints and a lack of culturally tailored resources, which hinder their ability to navigate self-management effectively. Additionally, high costs of continuous glucose monitoring (CGM) devices, insurance limitations, and digital literacy gaps, further complicate the adoption of diabetes technology. NKV-ASAD is pivotal in bridging these challenges by providing culturally competent education, hands-on training with diabetes technology to enhance self-efficacy.

By integrating ASAD into community-based settings and health systems, nurses can enhance the practical applicability of DSME programs. Study investigators will evaluate the cost and efficacy of implementing this program within a larger health care system and a diverse patient population. Through these future analyses, the program will evaluate and understand the critical role of nurse-led interventions in strengthening care coordination and promoting health equity within vulnerable and underserved communities.

Health System Integration: Technology Use and Increasing Scale

Moving forward, the next steps for these nurse-led programs involve scaling and adapting them for broader implementation. For the SHIP-DM program, evaluating the cost-effectiveness of the intervention across different phases and integrating services with healthcare systems to scale the program to reach more Asian Americans will be crucial. Attending to some notable challenges will also be important. Specifically, one should be mindful of the workforce pipeline as it is difficult to find bi-lingual nurses to deliver the program. A solution to that problem is to work with nurse/CHW teams, which the SHIP-DM demonstrated as effective. Second, although SHIP DM focused primarily on patients with diabetes, it is useful to note that Medicare/Medicaid reimbursement for the CDC Diabetes Prevention Program in Asian populations is challenging. This is because Asians tend to get diabetes and pre-diabetes at lower weights. However, to receive full reimbursement rates, Medicare requires that participants lose at least 5% of their baseline weight. This is often not feasible for Asians who have pre-diabetes at normal baseline weights. As a result, the lower reimbursement rates often do not off-set the large financial commitment and human resource requirements to deliver the tailored and linguistically appropriate intervention.

Similarly, after its pilot phase, the NKV-ASAD program for Haitian immigrants will focus on refining the intervention and conducting larger-scale trials to evaluate efficacy and implementation strategies for national integration. Additionally, increasing efforts to incorporate culturally sensitive technology, such as telehealth visits and wearables, may enhance the sustainability of these programs and facilitate large-scale implementation. Feasibility and implementation studies of these mechanisms, alongside advocacy for policy changes that support well-reasoned reimbursement of culturally tailored diabetes education programs in underserved and immigrant communities, will be essential for ensuring long-term sustainability.

Addressing the growing diabetes burden among Asian Americans and Haitian immigrants requires interventions that are not only culturally tailored but also scalable and sustainable. The success of the SHIP-DM and ASAD programs offers valuable insights into designing and implementing such nurse-led interventions effectively.

Case Study 2: Large-Scale Implementation of Diabetes Self-Management Education Program Supported by Nurse Leadership: Veterans Health Administration

Background on VHA

The VHA is the largest integrated health care system in the United States providing care for Veteran populations ⁸¹. The VHA provides care at over 1,300 health care facilities including 172 medical centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year ⁸¹. The incidence of diabetes in the VHA is approximately 25%; significantly higher than the national average of 11% ⁸². Despite receiving access to the benefits of an integrated health care system, Veterans with diabetes experience comorbidities (i.e. obesity and chronic kidney disease) and complications (cardiovascular events and microvascular complications) at higher rates than non-Veterans with diabetes ^83,84. Further complicating care delivery, Veterans that utilize VHA care represent a vulnerable population with low SES, high rates of disability, and a high percentage of individuals living in rural, poor areas ⁸⁵. In order to improve access and address inequalities with these populations, the VHA encourages nurse-led DSME programs and provides an infrastructure to support nurse training and program implementation.

Nurse Leadership Supports DSME Workforce

Nurse leadership within VHA supports accredited DSME programs as outlined in a 1992 VHA directive to promote the establishment of DSME education programs ^41,43.The VA Metabolic Syndrome & Diabetes Field Advisory Committee (FAC), led by the Office of Nursing Services (ONS), was established in the early 2000s to support nursing practice specific to diabetes care. Nursing leads many diabetes initiatives within VHA providing a strong and capable work force as demand for diabetes and obesity specialists increases while physician interest in endocrinology training has diminished ^86,87. The FAC produces evidence-based resources, develops policies in coordination with other VHA program offices, and provides support to obtain national recognition and certification for DSME programs throughout VHA. VHA DSME programs are certified through accredited diabetes care and education specialists (ADCES) or American Diabetes Association (ADA) and can be delivered by individually or in groups, through in person or virtual visits. Each nationally certified DSME program is led by a certified diabetes care and education specialist (CDCES); who is most often and primarily a nurse, however sometimes can include additional providers, such as nutritionists, pharmacists, and physicians.

Access

The VHA recognizes the importance of providing equitable access to high-quality DSME programs that address the unique needs of the diverse Veteran population ⁸⁸. The Office of Health Equity (OHE) champions VHA efforts to eliminate health disparities for all Veterans and supports the delivery of DSME programs by increasing health literacy for older Veterans and providing virtual interventions for rural Veterans. Indeed, recent research suggests that despite higher incidence of T2DM, Veterans who identify as Black and non-Hispanic White are less likely to be prescribed newer diabetes medications and diabetes technology ^89,90. Further, some DSME programs had difficulty enrolling eligible Veterans into DSME programs due to scheduling conflicts. Strategies to address health inequities in the delivery of high-quality DSME and diabetes management programs include use of virtual visits to increase access to specialty care, developing exercise interventions targeted at disabled Veterans, and developing interventions that address food insecurities ⁹¹. Using virtual care and recorded education sessions led to increased access to services. DSME programs within VHA will continue to work with OHE to address disparities and deliver high-quality interventions to all in need.

Scale

Currently, the VHA has 156 accredited DSME programs (Table 2) with 52 of these sites coordinate through a single ADA program. To facilitate uptake of DSME at VA sites, work commenced in 2020 years ago with Cerner (now known as Oracle Health) to create an electronic health form for DSME. The electronic medical record (EMR) template documents comprehensive assessment and education in diabetes. The form collects data which can then be summarized for any certified diabetes education entity without the need for cumbersome data collection. Pilot field testing of the form is currently in process.

Table 2.

Summary of Case Study of DPP and DSME Programs in Vulnerable Populations

Population	Diabetes Incidence	Nurse-Led Diabetes Programs Definition and Description	Access Barriers Addresses	Cultural Tailoring	Technology Incorporated	Health System Integration
VHA	25%(2023)	VHA Nurse Leadership DSME	Increases health literacy and virtual delivery for rural veterans	DSME for rural and/or disabled veterans; increasing health literacy and reducing food insecurity	Online website for DSME curriculum and evidence-based practice guidelines	Certified DSME Programs N=156
Haitian immigrant	13.2% (2023)	Multilevel and culturally tailored pilot randomized controlled trial “Nou Kapab Viv an Sante Avèk Dyabèt [NKV-ASAD]”	Cultural differences, language barriers, financial hardship, difficulties acquiring fresh/healthy food	Increase understandin g of social roles and contexts, psychosocial factors, linguistic, health habits; Nurse-led, implemented in Community Health Center	Wearable devices	Community based delivery
Asian American	23.3% (South Asians) (2019) 22.4% (Southeast Asians) (2019)	SHIP-DM---small scale longitudinal randomized study designed for first-generation Korean American immigrants, integrating cultural and linguistic adaptations delivered by Korean American nurses	Language barriers, cultural attitudes, lack of health literacy and health insurance, and immigrant status	Language and cultural adaptation, case managers and community workers, family members or friends	Wearable devices	Community based delivery

Table 2 shows the summary of the case study results, highlighting the incidence, program definition, access barriers, cultural tailoring efforts, use of technology and health system integration.

Abbreviations: DSME diabetes self-management education, VHA: Veteran Health Administration, SHIP-DM: self-help intervention program for diabetes management

Veteran feedback highlights the importance of using of Veteran focused educational material and Veteran group support when delivering diabetes self-management interventions (PMID 35877092). The group settings offers social support and community focused on the unique needs of Veterans.

Technology

To support providers delivering DSME interventions, the FAC delivers content through a website, providing updated, evidence-based DSME curriculum outlines, nursing competencies, and evidence-based practice guidelines on DSME and diabetes management ^92,93. Further, national provider training programs and nurse competencies have been developed virtually through the VHA online training program. Most recently, CGM initiation and data interpretation provider trainings have been developed with a total of ~1200 providers (pharmacists, nutritionists, and nurses) completed training. VHA has also partnered with industry leaders (Dexcom and Abbott) to develop Veteran focused patient and provider technology resources that support diabetes technology use. These resources include patient education pamphlets, provider education sessions, and a Veteran specific telephone support line that offers additional technical support and education. National support for provider education and DSME program implementation is essential for initiating and sustaining certified DSME programs throughout VHA.

Integration

The successful, large-scale implementation of certified DSME interventions across a federal health care system is one step towards improving diabetes management for a vulnerable, high-risk population. Delivering DSME intervention within VHA primary care clinics and community-based outpatient clinic (CBOC) with ONS support highlights nurse-led diabetes education interventions as a priority across the health-care system. The ADCES clinical guidelines highlights the importance of organizational support for DSME programs as a strategy to overcome barriers to program utilization ¹³. Committed support from organization leaders leads to consistent access to and participation in DSME programs.

Discussion

While nurse-led DPP and DSME programs have demonstrated improved diabetes clinical outcomes, the results of the integrative review and case studies provide some evidence that utilizing both nurse leadership and nurse delivery can have an important impact in addressing key access barriers, providing culturally tailored programing, and incorporating some types of technology to address the burden of T2DM in vulnerable populations. The manner in which these programs are integrated into the United States health system varies with some large-scale examples, like with the VHA, and a number of smaller scale examples integrated into the community.

Importance of Nurse Leader’s role in health system integration and workforce sustainability

Results from this integrative review highlight how nurse leadership appears to be an integral component of successful DPP and DSME program development and implementation. Nurses have always been at the center of diabetes education and care. Historically, nurses and nursing education has focused on patient-centered care with an emphasis on the therapeutic relationship with patients. This focus and training have made nurses skilled in providing diabetes education and care, with a foundation in trust, communication, and compassion.

DSME can be delivered by providers of many backgrounds and, generally, clinicians across the spectrum can provide compassionate care, but nurses have long been recognized as a particular foundational asset in fostering the patient-provider trust relationship that makes educational interventions impactful in diabetes care. This interpersonal relationship develops when care is not simply focused on the biomedical model, prioritizing diagnoses and treatments, but also integrates the transforming power of nursing relationships. While the research above does not examine the outcomes between nurse-led and other health care provider led interventions as that is beyond the scope of this review, there are some studies showing that APRN led outpatient diabetes management generate similar health outcomes at equal cost when compared to care provided by physicians and physician assistants^94–98. Importantly, opportunities to obtain advanced degrees in nursing (i.e. doctorate of nursing practice (DNP) and advanced practice nurses (APRN)) are abundant in the United States and offer specialized clinical training that support autonomous, independent nursing practice. APRN and DNP trained nursing can independently diagnosis, treat, and manage patients with chronic disease, including patients with type 2 diabetes, cardiovascular disease, and obesity. Diabetes self-management education and clinical care, led by advanced practice nurses, increases patient access to effective and comprehensive diabetes care that is unique and different from pharmacy or nutrition led care. Therefore, the results of this review and the two case studies help to clarify that nurses specifically appear to bring a skill set and approach to both leadership and delivery of interventions that improves access and outcomes in adults living with diabetes.

Research demonstrating feasibility and successful implementation of these mechanisms, alongside advocacy for policy changes that support the inclusion of culturally tailored diabetes education programs in underserved and immigrant communities, are essential for ensuring long-term sustainability. Successful programs have buy-in and support from nurse leadership resulting in a nurse workforce that is invested in the program success. It is not surprising that nurse leadership appears to have substantial potential to drive positive health outcomes as this has been demonstrated in other nurse-led initiatives focused on chronic disease management ^99,100.

Importance of Cultural Relevance

The results of the integrative review and the two case studies also demonstrate that culturally tailored interventions can effectively bridge the gap between standard diabetes care and the unique needs of minority populations. Other studies have shown similar results to the SHIP-DM and AVAD case studies presented above. For example, in South Asian Americans, other DPP interventions tailored to lifestyle choices around diet (importance of South Asian foods), physical activity preferences, influences of cultural family roles, and impacts of immigration to the U.S., determined at the end of the intervention, over half of participants’ glucose levels returned to normal ¹⁰¹.

Despite these positive results, it is important to note that addressing the cultural barriers is difficult, and requires interventions that are not only culturally tailored but also scalable and sustainable. The success of the SHIP-DM and ASAD programs offers valuable insights into designing and implementing such interventions effectively. Each vulnerable, high-risk and minority groups will have varying needs, which complicates implementation and sustainability of prevention programs, despite the large burden of T2DM. Future research should quantify the additional financial investments that are needed to implement culturally tailored programming, including linguistic and other needs; as these investments are rarely reflected in billed reimbursements.

Why Technology is Difficult to Implement

While studies consistently demonstrate that DPP and DSME program delivered using technology platforms (virtual clinics, smart-phone apps) provide the same clinical benefits, few health care systems have successfully delivered technology based DPP and DSME programs ^102–104. Our integrative review demonstrated that DPP and DSME programs are delivered using technology in 14–75% of the studies. Virtual delivery of diabetes prevention and education programs increases access to care and decreases overall health care costs ¹⁰⁵, but sustainability can be difficult due to interstate licensure challenges, limited access to technologic devices, low provider comfort, and differences in cultural acceptance ³⁰. Studies that successfully use technology to deliver DPP and DSME programs provide the technology directly to the patient, engage nurse leaders to secure work-force buy-in, and focus on culturally tailoring the intervention to the population in need ^50,52. These themes should be considered when designing and implementing large-scale DPP and DSME interventions.

Why Large-Scale Works in the VHA

This integrative review identified two studies that successfully implemented DPP and DSME programs in large populations (>500 patients as shown in Table 1). The VHA case study highlights four key themes from these studies: a patient population with a high disease prevalence, nurse leadership buy-in to support the nurse work-force implementing the programs, an infrastructure that supports virtual care, and easy integration of the programs into current models of care. The case study highlights the importance of nurse leadership and support of DPP and DSME programs. National nurse-leader support for DPP and DSME programs provides funding and a workforce infrastructure that supports program development and provides provider training. Further, as the largest provider of virtual care in the United States, VHA understands how to implement virtual care ¹⁰⁶. This undoubtedly helps the success of virtual DPP and DSME programs within VHA. Overall, the successful implementation of DPP and DSME within the national health care system can serve as a model for other large-scale systems working to incorporate DPP and DSME into their clinical management plans.

Health System Thinking for DPP and DSME

Taking a health system perspective to think about DPP and DSME is important, as these are two key prevention interventions that can have a large impact on the growing disease burden of diabetes. However, the traditional manner in which we have organized our health systems needs to be re-thought, as many of the programs are implemented at a smaller scale and in the community setting. In the United States, the financing and payment for community prevention programs is not as well developed as the financing and payment for billable services offered through hospitals and facilities. Better understanding of community financing will improve sustainability of programs like SHIP-DM and AVAD. The VHA is an excellent example of a large-scale implementation of DSME which is most likely facilitated by the national level financing of the VHA. Medicare should look to the VHA as an example of how a large, federally financed health care system can improve access to preventive care with a thoughtful focus on nurse-led programming.

Conclusion

This integrative review of nurse-led diabetes prevention and self-management education interventions highlights the critical role that nurse leaders play in implementing successful DPP and DSME interventions, especially for vulnerable populations. The case studies demonstrate the key themes for successful programs for populations with high disease incidence including nurse leadership that supports the workforce and infrastructure for program implementation, culturally tailored programs, and a health care system equipped to deliver high-quality virtual care. These themes can be used by health care leadership to guide the development and implementation of future nurse-led DPP and DSME programs.