Nurse-Led Telehealth Quality Improvement Initiative for Chronic Disease Management in Rural North Dakota

In this quality improvement project, I assessed a telehealth-enhanced care coordination model in a rural primary care clinic to improve chronic disease management for adults with limited access to in-person services. The issues addressed included delayed follow-up, inconsistent self-management support, and limited continuity of care, which significantly affect rural populations and health equity. The purpose of this doctoral project was to evaluate whether a structured telehealth follow-up protocol improved key care coordination outcomes, appointment adherence, follow-up timeliness, and documentation completeness for rural adults receiving chronic disease management services. In this project, I employed a pre-/postimplementation evaluation design using de-identified electronic health record (EHR) data from 12 weeks before and 12 weeks after implementation. Descriptive statistics were used to compare appointment adherence, follow-up timeliness, and documentation completeness. Findings showed improvement across all outcomes, with higher appointment adherence, shorter follow-up intervals, and more complete documentation, indicating that structured telehealth integration enhances care coordination efficiency, strengthens rural care delivery, supports nursing workflow, and reduces access-related disparities. The project developed a standardized telehealth follow-up protocol, staff education module, and sustainability plan. It highlights that telehealth enhances nursing care coordination, improves continuity of care, expands access for rural patients, reduces geographic barriers, and promotes inclusive, patient-centered care.