Date Available


Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Julianne Ossege

Clinical Mentor

Dr. Beverly Woods

Committee Member

Dr. Angela Grubbs


BACKGROUND: A key aspect of successful Diabetes management is addressing social needs. Patients prefer individualized care that is tailored to their specific needs.

PURPOSE: The purpose of this Doctor of Nursing Practice (DNP) quality improvement project was to screen patients regarding their diabetes distress and social needs requirements to develop and implement individualized social needs interventions.

METHODS: Patients were included in the study if they had a Hemoglobin A1C >9. Patients were screened, provided additional check in points and social needs were addressed in conjunction with the patient’s primary care provider and onsite social worker. Post intervention Hemoglobin A1C levels were collected 3 months after the intervention visit along with a subsequent assessment of diabetes distress. Hemoglobin A1C levels were compared to the control group who received standard care without the individualized intervention.

RESULTS: Nine patients were included in the intervention group and 9 patients were included in the control group. Four (44%) patients in the intervention group and 6 (66%) patients in the control group had repeat A1C collection during the study interval. There was no statistically significant difference between the intervention and control groups. There was a clinical significance as indicated by patient response of “agree” or “strongly agree” that the intervention helped them to better manage their diabetes.

CONCLUSION: While additional check in points and assessment of social needs did not have a statistical significance on A1C level, the clinical significance is encouraging and may improve patient self-efficacy, an important component of self-care. Further research into the impact of individualization of care based on patient social needs is needed.