Date of Award

Spring 5-27-2023

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Razel Bacuetes Milo PdH, DNP, MSN, FNP-C, RN


Background: Virtual Care Team (VCT) began their program approximately 15 months ago to assist their most vulnerable patients with chronic and uncontrolled conditions such as hypertension, diabetes mellitus, and nicotine use disorder. The program follows the patients for a year to help them manage their chronic conditions and comply with chronic management. When the Virtual Care Team followed up a few months after the graduation with some recent graduates, it was found that a small number of patients returned to their pre-Virtual Care Team habits.

EBP Purpose: The purpose of the project is to follow up on those Virtual Care Team graduates who have stopped their chronic care visits or even maintained healthy blood pressure. Conduct telephone calls to patients regarding their chronic care management.

Implementation Plan: Evidenced-based interventions include using the Evidence and Recommendations on the Use of Telemedicine for the Management of Arterial Hypertension from the American Heart Association as guidance, as well as the clinic’s questionnaire for blood pressure monitoring, and then finishing with a question as to why they stopped being compliant with their hypertension management.

Evaluation of Outcomes: One hundred recent Virtual Care Team graduate charts were evaluated. A total of ten graduates met the criteria for outreach. Out of the ten, five patients were surveyed regarding their chronic care management. During the surveys, the patients indicated they either did not continue with their lifestyle modifications or monitor their blood pressure because they didn’t have someone to call and remind them. They thought they were cured and reverted to their old habits. A couple of patients had no insurance or funds to pay for visits or their medications. Care was established with the five patients surveyed, and their blood pressure had remained within normal range or was reduced to normal limits after the phone call survey and reestablishing care.

Included in

Nursing Commons