Digital Repository Doctoral Projects Spring 2023 Does Mobile Family Practice Treatment of Onychomycosis in the Homebound Elderly Improve Quality of Life? Valarie Jacobs Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Jacobs, V. (2023). Does Mobile Family Practice Treatment of Onychomycosis in the Homebound Elderly Improve Quality of Life?. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. ONYCHOMYCOSIS TREATMENT IN THE HOME 1 Does Mobile Family Practice Treatment of Onychomycosis in the Homebound Elderly Improve Quality of Life? by Valarie Jacobs MSN, APRN, FNP-BC A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah March 13, 2023 ==================================================================== Valarie Jacobs FNP, APRN __________________________________ Student Name, Credentials (Electronic Signature) April 28, 2023 ______________________________ Graduation Date Diane Leggett-Fife, PhD, RN April 28, 2023 ____________________________________ DNP Project Faculty (Electronic Signature) ______________________________ Date ____________________________________ Melissa NeVille Norton (Electronic Signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director ______________________________ Date April 28, 2023 ONYCHOMYCOSIS TREATMENT IN THE HOME 2 Table of Contents Abstract ........................................................................................................................................... 4 Implementation of Toenail Treatment in the Home ......................Error! 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Background and Problem Statement .......................................................................................... 5 Diversity of Population and Project Site .................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership .............................................. 7 Literature Review............................................................................................................................ 8 Search Methods ........................................................................................................................... 8 Synthesis of Literature ................................................................................................................ 9 Foot and Toenail Hygiene and Care ........................................................................................ 10 Toenail Care Challenges in the Elderly.................................................................................... 11 Significance of Onychomycosis................................................................................................. 12 Discussion ..................................................................................................................................... 13 Framework Application to Project ........................................................................................... 16 Project Plan ................................................................................................................................... 16 Project Design .......................................................................................................................... 16 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 17 Cost Analysis and Sustainability of the Project ........................................................................ 19 Project Outcomes ...................................................................................................................... 20 Consent Procedures and Ethical Considerations ..................................................................... 20 Instrument(s) to Measure Intervention Effectiveness ............................................................... 20 Project Implementation ................................................................................................................. 21 Project Intervention .................................................................................................................. 21 Project Timeline ........................................................................................................................ 22 Project Implementation............................................................................................................. 23 Project Evaluation ......................................................................................................................... 24 Data Maintenance/Security ...................................................................................................... 25 Data Collection and Analysis ................................................................................................... 25 Table 1 ...................................................................................................................................... 26 Table 1 ...................................................................................................................................... 26 ONYCHOMYCOSIS TREATMENT IN THE HOME 3 Findings .................................................................................................................................... 26 Strengths ............................................................................................................................... 27 Weaknesses ........................................................................................................................... 27 Discussion ..................................................................................................................................... 28 New and Important Knowledge ............................................................................................ 28 Translation of Evidence into Practice ................................................................................... 30 Implications for Practice and Future Scholarship ................................................................... 30 Sustainability......................................................................................................................... 32 Dissemination ....................................................................................................................... 33 Conclusion .................................................................................................................................... 33 References ..................................................................................................................................... 35 Appendix A ................................................................................................................................... 46 Appendix C ................................................................................................................................... 49 Appendix D ................................................................................................................................... 50 Appendix E ................................................................................................................................... 51 Appendix F.................................................................................................................................... 52 Appendix G ................................................................................................................................... 55 Appendix H ................................................................................................................................... 57 Appendix I .................................................................................................................................... 58 Appendix J .................................................................................................................................... 63 Appendix K ................................................................................................................................... 69 ONYCHOMYCOSIS TREATMENT IN THE HOME 4 Abstract Purpose: The project focused on providing home-based toenail care to geriatric patients with onychomycosis. The project involved implementing a conservative, evidence-based toenail care procedure provided by family practice providers in patients' homes and its effect on the quality of life scores. Methodology: A pre and post-toenail survey was used to assess a patient's reported quality of life. The Rand-36 Quality of Life Survey was given to patients with onychomycosis before the toenail trimming procedure. A follow-up survey was given within three months post-procedure to determine if the quality-of-life scores had improved. Data were analyzed through the Qualtrics survey platform. Results: Twenty-two geriatric patients with onychomycosis participated in this study, and all participants completed the pre and post-toenail procedure surveys. Data revealed improvements in self-reported quality of life scores after receiving toenail services from the mobile family practice providers. In addition, a reduction in toenail onychomycosis was noted but not measured. Implications for Practice: A mobile physician group is ideal for delivering toenail services for homebound geriatric patients with healthcare access disparities. Project findings promote and support mobile primary care provider-administered toenail procedures for patients in their homes. Performing regular toenail and foot care can improve quality of life. Keywords: Homebound, toenail care, primary care intervention ONYCHOMYCOSIS TREATMENT IN THE HOME 5 Does Mobile Family Practice Treatment of Onychomycosis in the Homebound Elderly Improve Quality of Life? Utah's older population, age 65 and over, is expected to increase to 18.7% (1,115,319) by 2060 (Utah Department of Health, 2014). Older adults have many comorbidities and health issues that prevent them from providing optimal self-care (Sharoni et al., 2017). For example, foot conditions account for more hospital admissions in the elderly with diabetes than other associated health conditions (Boulton, 2014). Many older individuals are unable to perform foot care adequately. Foot complications commonly seen in the elderly include neuropathy, ingrown toenails, blisters, plantar warts, foul odor, sores that do not heal, skin changes, calluses, foot ulcers, and poor circulation (Mayo Clinic, 2022). Onychomycosis is a fungal disease of the toenail that affects 50% of all patients with nail disorders. Without proper care, this disorder can decrease a patient's quality of life and increase the cost of their healthcare (Stewart et al., 2021). Early identification of toenail disorders allows for convenient, customized treatment options that are safe for older adults. Practitioners play an essential role in the early diagnosis and treatment of fungal foot infections, such as onychomycosis, in the elderly patient population. Background and Problem Statement Older adults neglect the care of their feet, including their toenails (Widaty et al., 2019). Geriatric patients have difficulty trimming their toenails and performing foot care. Advanced age, physical limitations, comorbidities, homebound status, and the complexity of treatment prevent the elderly from managing issues with their feet (Elewski & Tavakkol, 2005). Unfortunately, nearly half of all patients do not recognize they have a toenail disease (Bunyaratavej et al., 2015). One of the consequences of poor foot care is that onychomycosis is ONYCHOMYCOSIS TREATMENT IN THE HOME 6 frequently untreated in advanced-age patients. For these reasons, onychomycosis can be very challenging to treat. Nail disorders can be an outward sign of disease and other medical conditions like diabetes and peripheral vascular disease. The options for toenail treatment vary based on the patient's health status and functional ability. Current FDA-approved treatment options for fungal nail conditions do not always yield a permanent cure (Gaurav et al., 2021). In addition, there are concerns that pharmaceutical interventions (oral or topical) are not safe and effective in the older patient population (Leung et al., 2020). Many pharmaceutical treatment options for diseased nails are not advised for the elderly due to adverse events, the inability to self-administer, and potential drug-to-drug interactions (Murdan, 2016). Many patients prefer treatment options that avoid systemic medication (Bodman & Krishnamurthy, 2021). Success rates for topical therapies are less effective due to the failure of the elderly to reach their feet for application (Widaty et al., 2019). Early identification, inspection, and grooming of toenail disorders by a healthcare professional allow for convenient, customized treatment options that are safe to administer to older adults. In addition, regular foot exams as a preventative measure can decrease the incidence of limb-threatening wound infections that often result in amputation (Boulton et al., 2008). Mobile primary care providers, who are well-prepared and knowledgeable, can identify early signs of onychomycosis and initiate treatment in patient's homes. Diversity of Population and Project Site This project focuses on reaching homebound geriatric patients across the state of Utah. The elderly experience income, health status, and access to healthcare disparities. As a result of age-related inequalities, older adults forego or delay seeking medical care (Yamada et al., 2015). ONYCHOMYCOSIS TREATMENT IN THE HOME 7 In addition, disease burden, low health literacy, socioeconomic status, national origin, language, and race further alienate older adults from accessing healthcare (US Department of Health and Human Services, 2015). A mobile primary care group is an ideal medical practice "site" that fills this disparity gap by bringing healthcare services to the homes of the elderly. Nearly all these patients have an undiagnosed or untreated toenail condition (B. Peterson, personal communication February 3, 2022). In addition, the United States Census Bureau estimates that by 2030, one in five Americans will be over 65. Because of the rising, disproportionate older adult population, it is important to understand the obstacles that prevent them from seeking medical care (Mass, W., 2018). Significance for Practice Reflective of Role-Specific Leadership The significance of implementing a foot care program within a mobile family practice setting can improve foot health in homebound geriatric patients. DNP leaders demonstrate their importance by combining a primary care provider's clinical skill with current research to fill the gaps in patient care. In addition, identifying vulnerable populations with unmet healthcare needs helps DNP leaders create and implement far-reaching practice changes. Research can be used to prevent and provide early solutions to some of the common problems faced by older adults. Improving access to needed health care helps practitioners identify problems preventatively and customize treatment plans. Timely diagnosis and intervention of toenail conditions help to prevent critical situations from arising. Furthermore, identifying undiagnosed foot conditions as a preventative measure can decrease the medical treatment cost to patients and the health care system. Regular foot exams have been shown to ONYCHOMYCOSIS TREATMENT IN THE HOME 8 help avoid some of the complications associated with diabetes, including infection and amputation (Boulton et al., 2018). Literature Review Older adults' knowledge and practices surrounding the care of their feet are often limited (Sharoni et al., 2017). Common changes affect older people's nails (Abdullah & Abbas, 2011). There are different levels of knowledge and varying attitudes toward the importance of foot care, especially among older adults living with diabetes (Adeyemi et al., 2021). It is crucial to teach self-recognition of foot conditions to improve quality of life (Bunyaratevej et al., 2015). Improving a patient's knowledge and practices will help them to identify problems with their feet. Early recognition of foot problems by a patient enables them to seek medical attention early. Multiple factors are associated with a diagnosis of onychomycosis and its severity when a patient has diabetes (Takehara et al., 2011). Many advanced medical therapies and treatment options are available (Blume &Wu, 2018). Seeking medical attention early can maximize cure outcomes for patients in their preferred environment (Gupta et al., 2019). Search Methods The search was conducted using online search engines EBSCO host, Google Scholar, PubMed, and CINAHL MEDLINE, EMBASE from 2005 to 2021. Limits were set to include the English language. Keywords used for the search included; onychomycosis treatment, nail infections, treatment outcome, toenail, diagnosis, toenail fungus, onychomycosis education, cost of treatment, and nail abrasion. Four hundred thirty full-text articles were assessed, and sixtythree complete-text studies were used for this study. The literature review included studies that ONYCHOMYCOSIS TREATMENT IN THE HOME 9 evaluated types of nail changes, patient knowledge practices and education, treatment options, foot examination, incidence, cost, and effectiveness of treatment related to onychomycosis. Synthesis of Literature A critical appraisal of the literature identified many research articles related to diagnosis, patient education, and treatment of onychomycosis. Commonly seen toenail disorders, diagnostic criteria, laboratory findings, and assessment of the most frequently visited nail changes and conditions among the elderly were examined (Abdulla & Abbas, 2011; Boulton, 2014; Singh et al., 2005). Takehara et al. (2011) conducted a cross-sectional, observational study involving one hundred and thirteen diabetic patients. Over 50% of patients had a diagnosis of onychomycosis. Factors common to the significant association of disease were found with not washing feet daily (p=0.018), having decreased toe brachial index (p=0.040), and higher A1c (p=0.003). The study suggests that early education and intervention may reduce the occurrence of onychomycosisinduced foot ulcers. This information applies to clinical practice and supports improving patient education and foot care procedures for patients to perform in the home. Ghannoum et al. (2000) conducted a large-scale study (1832 subjects), and Li et al. (2018) conducted a retrospective cohort study to determine the frequency and accuracy of clinical diagnosis of onychomycosis across dermatology, podiatry, and other physician groups. Both studies found a higher disease frequency and confirmed the accuracy of clinical diagnosis in more than 65% of the population studied. These studies suggest that clinical diagnosis of onychomycosis is sufficient to provide early treatment and cost savings on confirmatory testing. This applies to clinical practice and supports practitioners making a timely diagnosis in the home to provide education, treatment options, and support to patients. ONYCHOMYCOSIS TREATMENT IN THE HOME 10 Adeyemi et al. (2021) conducted a qualitative study to assess the attitude, knowledge, and diabetic foot care practices of patients with diabetic foot ulcers. Twenty adults in a wound care clinic were evaluated for their knowledge, attitudes, and foot care practices related to foot selfcare. Their ability proved limited. It was concluded that improved health education about diabetic foot ulcers might decrease complication-related mortality rates. This supports the intervention of patient education as a preventative measure to reduce complications of foot conditions. Stewart et al. (2021) systematically reviewed the effect of onychomycosis and treatment on a patient's reported quality of life. The study found that onychomycosis significantly affects the perception of quality of life, warranting timely, effective treatment. This evidence applies to clinical practice and this quality improvement project by providing patients with the knowledge to prevent foot conditions and complications that negatively impact their perception of quality of life. Elewski et al. (2013) conducted an experimental study examining the feasibility, safety, and efficacy of topical efinaconazole 10% in treating onychomycosis in adults. They found that once-daily application of this medication is a viable alternative to oral options for onychomycosis. Although this is an essential finding for older adults, it shows that a mycological cure can be achieved with a topical medication that a patient can safely apply. Foot and Toenail Hygiene and Care Guidelines recommend that foot and toenail care should be performed by an advanced practice provider once per year (Hingorani et al., 2016). An annual examination should include testing for peripheral neuropathy, peripheral vascular disease, and diabetes (Dipreta, 2014). Every healthcare professional involved in the care of elderly patients must take an active role in ONYCHOMYCOSIS TREATMENT IN THE HOME 11 overseeing their foot pathology (Takehara et al., 2011). It is recommended that patients receive education annually about foot care, foot inspection, foot protection, foot hygiene, and what foot conditions they should bring to their primary care provider (Manickum et al., 2021). Foot hygiene education should include comprehensive instruction on the importance of washing feet daily, drying carefully between the toes, and wearing clean shoes and socks (Stolt et al., 2010). Basic foot hygiene improves foot health (Farndon, 2009). The presence of onychomycosis has been overwhelmingly associated with the absence of washing feet daily (Takehara et al., 2011). Other nail disorders that result from inadequate foot hygiene include neglected, chipped, overgrown, thickening, malformed, detaching, discolored, or even ingrown toenails. Nail disorders can be extremely painful and disabling (Menz, 2016). Patients should be dissuaded from walking barefoot and encouraged to wear clean, wellfitting shoes (Farber & Farber 2007). Custom shoes are recommended for patients with significant neuropathy, foot deformities, or prior amputations (Hingorani et al., 2016). Patients should receive basic instructions for identifying abnormal toenails and follow up with their provider regarding any concerns related to their feet (Bunyaratavej, 2015). Patients should be counseled about the dangers of neglecting foot care (Fujii, 2019). Toenail Care Challenges in the Elderly Toenail care challenges in the elderly occur from physical and functional limitations and comorbidities. Addressing these issues can improve patient outcomes and morbidity and mortality rates. Functional limitations impact the successful treatment of onychomycosis and include; limited range of motion, poor eyesight, disease severity, method of administration, length of treatment, consistency of taking medications, clinical lab testing, and poor prognosis for ONYCHOMYCOSIS TREATMENT IN THE HOME 12 mycological cure (Hingorani et al., 2016). Many elderly patients live alone and experience a physically taxing effort to leave their homes to seek medical attention for foot care. Disorders like onychomycosis can lead to foot pain, foot deformities, and foot ulcers, creating a fall risk for patients from the nail catching on clothing or flooring (Lin & Lipner, 2020). Decreased systemic blood flow, difficulty administering treatments, and slow nail growth are additional factors that impact treatment outcomes (Ko et al., 2011). Patients also have challenges finding affordable, accessible podiatric care (Li et al., 2010). Comorbidities significantly affect the outcomes of foot and toenail conditions. Elderly patients diagnosed with onychomycosis with diabetes mellitus and peripheral vascular disease are at increased risk of serious, life-threatening complications. To prevent secondary bacterial infections and subsequent complications, older adults with diabetes should be treated for onychomycosis (Adeyemi, 2021). Secondary complications in this patient population include bacterial cellulitis, foot ulcers, osteomyelitis, gangrene, and toe and limb amputations (Elewski & Smith, 2001). The casualties of peripheral vascular disease, diabetes, and peripheral neuropathy are known to lead to amputation (Dipreta, 2014). These patients have high morbidity and mortality rates and are high resource utilizers of the healthcare system (Manickum et al., 2021). The complications of chronic health conditions affecting foot disease contribute to disability and can be overwhelming and expensive (Taylor, 2018). Significance of Onychomycosis Onychomycosis affects approximately 20% to 25% of the world's population (Thomas et al., 2010). About 26% of all patients with diabetes have onychomycosis (Elewski & Smith, 2001). A large-scale study testing the frequency of onychomycosis found it occurred in 13.8% of adults in North America (Ghannoum et al., 2000). Assessing the risk versus benefit of antifungal ONYCHOMYCOSIS TREATMENT IN THE HOME 13 therapy in the geriatric patient population can be challenging. Many factors are involved. Oral medications to treat toenail fungus require daily treatment from 12 weeks to one year to achieve a mycological cure (Thomas et al., 2010). Most cases of onychomycosis relapse 2.5 years after therapy (Piraccini et al., 2010). Potential drug interactions in older adults could cause drug toxicity or harm the liver (Elewski & Tavakkor, 2005). Oral treatment options have been shown to interact with common medications taken by patients over the age of 65. Medications that have been found to interact with recommended onychomycosis treatment include statins, anti-diabetic, anti-hypertensive, and anticoagulant drugs (Del Rosso, 2004). Balancing patient safety with available therapies and evaluating drug-to-drug interactions due to polypharmacy creates treatment barriers for the elderly (Gupta et al., 2019). Discussion Older adults have decreased manual dexterity, visual acuity, and joint flexibility as they age, making it difficult to cut their toenails (Menz et al., 2018). Toenail maintenance and foot hygiene are essential activities of daily living. Discovering a way to help older adults be successful with this aspect of self-care has been a challenge as a provider, especially when a patient is homebound due to other severe comorbidities. Older individuals with a homebound status cannot comply with recommendations and referrals to podiatry to achieve optimal foot health. A literature review was conducted to discover a way to provide primary foot care and treatment for onychomycosis, one of the most prevalent toenail conditions in the older adult. Limited evidence discusses nonpharmaceutical conservative interventions in the elderly for treating onychomycosis. Lack of funding may prevent research surrounding nonpharmaceutical treatment options for toenail conditions. However, this patient population is increasing in size ONYCHOMYCOSIS TREATMENT IN THE HOME 14 and complexity. More research is needed that utilizes conservative treatment for foot conditions in the elderly. The literature was evaluated for sensible treatment options for onychomycosis that could be feasibly offered to geriatric patients in their homes. After reviewing more than 6o articles, four articles discussed toenail trimming and debridement as a conservative treatment option for the senior patient population (Sumikawa et al., 2007, Farber & Farber, 2007). Unfortunately, the most relevant articles were over ten years old (Elewski & Smith, 2001; Ghannoum et al., 2000 Malay et al., 2008; Singh et al., 2005). Given the prevalence of toenail conditions in older adults, the search criteria were adjusted to determine how investigators use medical foot care interventions to prevent foot complications and falls (Blume & Wu, 2018; Fujii, 2019; Menz et al., 2018). In addition, many investigators note that elderly individuals comprise a large subsection of people with Onychomycosis (Abdullah & Abbas, 2011; Fujii, 2019; Rena et al., 2017; Yamashita, 2019). Gupta, Paquet, and Simpson (2013) have shown the risks and benefits of toenail treatment options and recommend a tailored therapeutic strategy for each patient, including conservative treatment options. In addition, early identification and modification of risk factors for onychomycosis have improved quality of life scores (Bunyaratavej, 2015; Menz et al., 2018; Rana et al., 2017). Implications for Practice It is within the scope of practice for a nurse practitioner (NP), physician assistant (PA), and even a registered nurse (RN) to perform toenail care for older adults. Extra care must be taken with high-risk patient populations to avoid complications associated with the comorbidities of the delicate, more aging adult (Shemer et al., 2018). Complications of Onychomycosis include ONYCHOMYCOSIS TREATMENT IN THE HOME 15 cellulitis, sepsis, or even osteomyelitis, and delaying care for nail deformities can lead to pain and disfigurement (Bodman & Krishnamurthy, 2022) Implications for practice include developing an evidence-based standard of care for toenail trimming based on the latest research. Provider training can also be generated from the literature to provide toenail services during a primary care visit. In addition, provider training can be designed and standardized for family practice settings (see Appendix D). Future scholarship opportunities surrounding research findings could be reproduced and utilized to provide toenail services in all healthcare settings. Future research can also be conducted to evaluate the effectiveness and cure rates of onychomycosis with conservative treatments for high-risk patient populations where other treatment options are contraindicated due to comorbidities. Framework and Project Application The Stetler Model is one of the original models of research utilization used in evidencebased practice in nursing. Developed by Cheryl Stetler in 1994 and revised in 2011, The Stetler Model is a series of critical thinking and decision-making steps used to organize and apply research findings (Stetler, 2001). This model offers a pathway to promote evidence to delineate organizational change. Individual practitioners can also use this model to further critical thinking and practice reflection. The Stetler Model consists of five phases (Stetler, 2001, p. 276): Phase I: Preparation Phase II: Validation Phase III: Comparative Evaluation/Decision Making Phase IV: Translation/Application Phase V: Evaluation ONYCHOMYCOSIS TREATMENT IN THE HOME 16 Framework Application to Project Using the Stetler model of evidence-based practice as an outline, these steps were used to evaluate the evidence for applicability to this quality improvement project. Finally, a compilation of the current procedures for toenail trimming, patient education, recent studies, protocols, policies, and standards of care surrounding toenail trimming and care were gathered to formulate a program to implement in a patient home (see Appendix A through K). Project Plan Older adults face difficulties maintaining foot care to prevent complications (Sharoni et al., 2017; Widaty et al., 2019), leading to disorders that can affect mobility and quality of life for the individual (Menz, 2016). Therefore, bringing a needed foot care service to the homebound patient population is a promising intervention for decreasing foot complications. The following section outlines the plan for implementing routine toenail care in the homebound elderly patient population. In addition, the project design, needs assessment, cost analysis, sustainability, program outcomes, ethical considerations, and project evaluation for toenail care of the homebound elderly client are addressed. Project Design Clinicians were appraised of the process for scheduling patients, toenail trimming equipment, policy and procedure, consent forms, cleansing of equipment, toenail aftercare, and follow-up (see Appendix A-K). Toenail care within the mobile practice will become a routine treatment all family practice providers offer. The project design is to fill a gap for patients needing regular toenail care who need help to perform this task for themselves or gain access to this service due to barriers. This QI project removes obstacles related to transportation, health disparities, and the cost associated with specialty services for patients by providing services in a ONYCHOMYCOSIS TREATMENT IN THE HOME 17 patient's home by a family practice provider. The program started with provider training, where clinicians had an orientation to toenail equipment assembled into a standardized kit (see Appendix A). Utah Mobile Physicians PAs and NPs were trained and observed by a podiatrist, who passed them off on the debridement procedure with a battery-operated toenail drill and clippers. Orientation included cleaning toenail equipment between patients, proper sanitization, storage, and cleaning equipment and other supplies (see Appendix B). Provider instruction was given to obtain a signature on the consent form before performing toenail trimming (see Appendix C). If foot conditions were identified during the procedure, patients were referred to specialists accordingly or scheduled for follow-up appointments to address needs further (Miller et al., 2014; Persaud et al., 2018). If abrasions occurred during the procedure, patients were given a toenail abrasion kit, with instructions to call with any questions or concerns (see Appendix D & E). The project design was beneficial and enhanced the education of staff and clinicians. The implementation process expanded the clinician's scope of practice. Goals were set to improve the quality of care provided to patients. Needs Assessment/Gap Analysis of Project Site and Population The prevalence of self-neglect of toenails in older adults negatively impacts their quality of life. Primary care providers can reasonably develop a toenail trimming program as a health care service for homebound geriatric patients. Routine toenail care provided by Utah Mobile Physicians may improve a patient's quality of life. The Weber State Leadership program IRB approval process addressed this vulnerable population, along with the safety and feasibility of the project. There is a scarcity of resources available to meet the podiatry needs of the homebound elderly patient population. Although patients frequently demand toenail services, many referrals go to other clinics for toenail care when they ONYCHOMYCOSIS TREATMENT IN THE HOME 18 cannot receive it from their primary care provider. Geriatric patients have expressed concern about leaving their homes and becoming exposed to COVID by visiting a clinic with sick people to see a podiatrist. In addition, patients say specialty fees are a barrier to routinely seeing a podiatrist. Patients report co-payments ranging from $20 to $75 per visit to cut their toenails. Utah Mobile Physicians (UMP) reports many calls daily requesting simple toenail care for patients from assisted living facility administrators, patients, and their family members. Long-term care facilities call UMP and report barriers for patients associated with podiatrists who have come into their buildings only to cut toenails. Many patients have additional needs related to their feet that they need the oversight of a primary care physician to address. Due to the inherent risk of injuring patients, many policies in Utah restrict clinical staff from cutting toenails. Potential for injury, infection, and liability cultivates neglectful regard for foot conditions in older adults. However, Nurse Practitioners and Physician Assistants with proper training are authorized to provide this service because they have the medical degree to treat any complication that may arise. Geriatric facility administrators reach out to UMP requesting advice and help to procure high-quality, affordable podiatric services for their residents. Utah Mobile Physicians has started routinely doing toenail care in some buildings. Discussions surrounding "toenail days" have yielded great interest from patients, families, and nursing administrators. Utah Mobile Physicians recognizes this need and is willing to implement this service into their practice as a quality improvement project. Utah Mobile Physicians owners are eager to institute the education, training, and protocol to provide routine podiatric patient visits to meet the demand (see Appendix F & G). In addition, UMP providers offer toenail care as a service to patients when needed. As a result, their practitioners can provide this service to their patients when incorporating comprehensive medical care. Local podiatrists in Davis County and Salt Lake City, Utah, are scheduling two months in advance for appointments. In addition, some podiatrists perform services to care facilities but do not ONYCHOMYCOSIS TREATMENT IN THE HOME 19 go into individual homes. As a result, podiatry needs in the homebound geriatric patient population must be noticed and addressed. The homebound elderly are a high-risk patient population with comorbidities and frailties that lead to hospitalization and amputations. Unfortunately, patients cannot get these services at home (Klein, Hostetter & McCarthy 2017). Utah Mobile Physicians employs full-time NPs and PAs who see patients in their homes, assisted living facilities, memory care units, and independent living facilities. Patients and families regularly request follow-up visits on foot complications and toenail issues. Utah Mobile Physicians encourages their providers to treat "the whole patient, not the hole in the patient" (B. Peterson, personal communication, January 4, 2022). UMP providers currently do toenail trimming during patient visits when requested. UMP providers earn a small monetary bonus from their employer as an incentive to provide comprehensive services like toenail trimming and cerumen decompaction. Many local mobile physician groups do not offer toenail procedures to their patients and instead refer them to podiatry. Cost Analysis and Sustainability of the Project This patient population is vulnerable with limited funds and many on a fixed income. This treatment needed to be cost-effective during a routine primary care visit so the patient would not incur a specialty fee for toenail trimming. Utah Mobile Physicians has the funds to purchase the toenail kits as a provider tool kit for providing comprehensive care. Therefore, a budget was created (see Appendix H). UMP has forecast that this project will have long-term sustainability due to the low equipment cost and maintenance of each toenail kit. Utah Mobile Physicians (UMP) has the staffing to meet the increased demand for these services. UMP has incorporated toenail trimming services into regularly scheduled primary care visits. They intend to continue providing this service to their patient population. ONYCHOMYCOSIS TREATMENT IN THE HOME 20 Project Outcomes Outcomes identified were preventative medicine related. Foot conditions were identified before becoming severe and causing complications- such as ill-fitting shoes, callouses, and injuries that, if left unidentified, could result in hospitalization or amputation. Routine foot maintenance is provided to identify neuropathy, diabetes, ulcerations, initiation of wound care, close follow-up for foot conditions, or referrals to specialists. Consent Procedures and Ethical Considerations Patients are given consent for treatment and information that providers are not podiatrists but can provide routine toenail trimming as part of a primary care visit. In addition, patients will understand the role of the primary care provider in identifying foot issues that could lead to more severe problems. If severe or complex conditions are identified, the patient is notified that they will need to see a specialist, and a referral will be sent. Instrument(s) to Measure Intervention Effectiveness Informed consent was obtained from patients before the initialization of toenail treatment in a home (see Appendix C). In addition, patients voluntarily and anonymously filled out pre and post-intervention health surveys (see Appendix I). Surveys quantify the self-reported quality of life scores before and after routine toenail care. The Quality-of-Life Survey (QOLS) is a tool for evaluating patients perceived quality of life. It is a 36-item tool used to assess personal health and well-being. Feedback from stakeholders, providers, building administrators, medical staff, patients, and families was also encouraged. Formative and summative feedback will be addressed, evaluated, and used as a guide during implementation. For example, patient visits involving toenail care processes will be adjusted based on feedback if indicated. ONYCHOMYCOSIS TREATMENT IN THE HOME 21 Project Implementation This project was implemented in phases. First, staff was informed of the quality improvement project in a staff meeting. Next, toenail kits and equipment cleaning and maintenance training were given to providers (see Appendix A & B). Education surrounding policy, procedure, protocols, and scheduling occurred (see Appendix J). Initial equipment uses training with a podiatrist was scheduled. Next, mobile toenail clinic locations were identified. Clinic locations and times were arranged with facilities and their administrators, who determined the process for scheduling their patients with UMP. The scheduling department and office staff for Utah Mobile Physicians coordinated and organized clinic schedules and determined which providers would be assigned to a location. The podiatrist was scheduled to attend the first toenail clinic with each provider to provide live training and support. The policies and training documents were used as guidance and direction for future patient care. Project Intervention Policies and procedures, mobile toenail equipment, first aid kit, paperwork, and foot exam protocol review were conducted with clinicians during a staff meeting (see Appendices AK). Instructions were given to providers about toenail clinics that would be scheduled. Providers were told that hands-on toenail training instruction, observation, and pass-off of toenail clinical skills would be done with a podiatrist at the clinical site once toenail clinics were scheduled. Providers would offer toenail trimming procedures to all of their clinic patients in their clinical practice and implement scheduled toenail clinic days in care facilities. A podiatrist will train clinicians before performing toenail care as an added service in their clinical practice. ONYCHOMYCOSIS TREATMENT IN THE HOME 22 Project Timeline The project timeline covers initial meetings with stakeholders, research and completion of the literature review, IRB submission and approval, development, training, scheduling, and implementation of the toenail treatment protocol for a mobile family practice clinic (see Appendix K). In addition, the timeline includes evaluation and data dissemination and all other necessary processes and activities needed to provide toenail services to older adults Toenails kits were purchased and assembled into a small, transportable black zippered case (see Appendix F). Clinician training and pass-off were done in a clinical setting on October 3rd and 5th, 2022. A local podiatrist proficiently trained Nurse Practitioners and Physician Assistants in basic toenail trimming and debridement. The podiatrist provided live clinical training and oversite of Utah Mobile Physician providers during a scheduled "toenail clinic," including how to diagnose onychomycosis from visual inspection. UMP NPs and PAs were required to demonstrate appropriate foot exam techniques and referral protocols for foot problems noted during the treatment of toenails. Additionally, providers were instructed on using and properly disinfecting the tools (see Appendix B). The podiatrist approved the competency of each clinician. After podiatry approval, clinicians were authorized to provide service to patients independently. During training, the provider and podiatrist performed a brief physical exam, including vital signs and a foot exam. Toenails were evaluated, and the podiatrist explained and demonstrated the proper technique for toenail trimming specific to the patient's needs. Each provider performed toenail trimming procedures with the podiatrist oversite for an entire day. The podiatrist evaluated each provider individually, requiring a return demonstration. Providers mastered appropriate foot exams and referral protocols for foot problems noted during each ONYCHOMYCOSIS TREATMENT IN THE HOME 23 patient encounter. Once Utah Mobile Physician providers were trained, toenail clinics were scheduled with assisted living facilities. In addition to toenail clinics, providers were authorized to trim toenails for all patients interested in toenail services. Project Implementation The project was implemented three times per week from October 1, 2022, through November 30, 2022. A sign-in sheet was placed at the facility nursing station two weeks before the scheduled toenail clinic. Patients were encouraged to sign up for a time slot on the designated toenail clinic day. Appointments were organized in 15-minute increments from 6:00 am to 6:00 pm. The patient or their responsible party was informed that they would be required to sign a consent form before UMP provided any toenail trimming procedures. In addition, patients were notified that a follow-up appointment would need to be scheduled within three months to evaluate the treatment and to obtain a post-procedure survey. UMP was assigned a clinic space or procedure room in each care facility to conduct patient visits. The "clinic location" was pre-arranged and assigned to UMP by the facility administrator or director of nursing. A schedule of 10 patients from the sign-in sheet was given to each UMP provider the day before the scheduled toenail clinic. Office staff performed insurance verification, and a chart was made for the patient. The provider arrived at the designated location with their mobile equipment and toenail kit on the morning of the scheduled toenail clinic. Patients came to the procedure room at their allocated time during the toenail clinic. Bedbound patients had toenail trimming performed in their patient rooms. Patients were "checked in" in the electronic medical record by the provider for appointment time upon arrival. The patient signed a consent for treatment form before providing toenail services. ONYCHOMYCOSIS TREATMENT IN THE HOME 24 Residents with an existing or new diagnosis of onychomycosis were asked to fill out a pre-treatment quality-of-life questionnaire voluntarily. Patients were asked which format of the survey they would be more comfortable filling out, paper form or using the QR code with a smartphone. Instructions were also provided based on the survey format that was chosen (see appendix I). In addition, residents were asked to fill out a pre-treatment quality of life questionnaire voluntarily. Once the paperwork was completed, insurance was verified, or cash payment was collected for service, the toenail trimming was performed. Project Evaluation The project evaluation covers the initial introduction of the project to Utah Mobile Physicians to the follow-up appointment where the postprocedural QOL survey was completed. The results were better than expected in improving the quality-of-life scale, and in some cases, toenail fungus was cured with the intervention alone. The activities proved appropriate, practical, and consistent with the objectives of the quality improvement project in assessing the quality-oflife scores. In addition, many patients had new healthy toenail growth at the base of the nail that was absent of toenail fungus. Implementation was successful; clinicians adhered to the proposed timeline and schedule. The project was manageable and scaleable to fit the patient's needs and the provider's schedule. The toenail kit was durable and easy to maintain and transport. Providers, patients, and facilities are engaged and eager to continue utilizing toenail services. Patients consistently schedule follow-up appointments. In addition, the summative assessment proved valuable when survey scores revealed improvements in patient quality of life scores from pre to post-intervention. A formative assessment of the project revealed consistent utilization of toenail services by patients who scheduled follow-up visits monthly to keep their toenails healthy. The education ONYCHOMYCOSIS TREATMENT IN THE HOME 25 patients were provided during toenail clinics was well received. Patients became regular utilizers of the toenail clinics month after month and independently signed up for the continuation of toenail trimming services. The patient scheduling and clinician training process has proven sufficient for the current patient demand. Data Maintenance/Security Patients completed paper surveys without protected health information identifiers (see Appendix K). Completed paper surveys were placed in a closed compartment of the provider's clipboard. The researcher transferred information from the paper survey into the Qualtrics platform, and survey forms were shredded. Only the researcher had access to the survey results. Results were secured in a cloud-based databank requiring a two-party authentication process to access. Twenty-two patients filled out the pre and post-procedure surveys. A notation was made in the patient's electronic health record that a survey was completed. A one-month follow-up appointment was made with each patient, and a note was placed in the EMR that a survey needed to be filled out at the next appointment. Data Collection and Analysis A Qualtrics quick response (QR) code for the Quality-of-Life Survey (QOLS) survey was given to patients with mobile devices during their clinic visit. Patients were asked to complete the survey at the initial visit (pre-procedure) and again within three months at the follow-up visit (post-procedure). Patients uncomfortable with using their cell phones to complete the survey were given a paper form. The researcher transferred patients' information from paper surveys into Qualtrics for data analysis. Data were calculated automatically within the Qualtrics survey platform and compiled for twenty-two participants. The mean and standard deviation were calculated within the Qualtrics ONYCHOMYCOSIS TREATMENT IN THE HOME 26 system. Each Rand SF-36 item survey had a calculated mean and standard deviation. A group of scores was added together to comprise a list of eight variables that included physical functioning, role limitations due to physical health, role limitations due to emotional stresses, energy/fatigue, emotional well-being, social functioning, pain levels, and general health. Further analysis and calculations were performed from the scored question groupings data and computed within an excel spreadsheet (see Table 1). Table 1 Pre-Post Measures of Rand 36-Item Health Survey Variable Pre-Assessment M SD 1. Physical 76.36 29.57 functioning 2. Role limitations due 79.55 40.57 to physical health 3. Role limitations due 86.5 41.81 to emotional stresses 4. Energy/Fatigue 57.27 24.85 5. Emotional 68.00 31.50 Well-being 6. Social 82.39 20.59 Functioning 7. Pain Levels 72.05 18.31 8. General Health 67.73 27.58 Post-Assessment M SD Normal M 84.77 29.57 84.2 88.64 31.92 81.0 89.39 31.03 81.3 62.95 23.98 60.9 81.28 21.65 74.7 89.20 21.16 83.3 84.55 69.55 22.84 29.60 75.2 72.0 Table 1 Pre-Post Measures of Rand 36-Item Health Survey Note. n=22. This demonstrates participant responses in the Rand 36-item survey before and after the toenail trimming intervention. Findings Project outcomes were met by analyzing the data from the survey. Findings were consistent with some of the data found in the literature reviews using QOL scores as a final ONYCHOMYCOSIS TREATMENT IN THE HOME 27 measure. Improvements were noted in all eight categories of the Rand SF-36-item Quality of Life Survey scores. Additional findings were not quantified, including the clinical cure of onychomycosis as reported by patients or as evidenced by toenail regrowth and absence of toenail fungus that was seen by providers and reported by many patients. Strengths Participation was voluntary. A vulnerable patient population was reached. Additional strengths included using a mobile physician group to reach a vulnerable patient population. Patients experienced the ease of access to a much-needed service. The outreach was welcomed and needed. Using a validated and reliable resource, such as the QOLS tool, to assess the qualityof-life scores strengthened the study's positive outcomes. The QI project was very successful and well-received. Patients continue to sign up for toenail clinics, and the number of patients who sign up continues to increase by at least ten new patients per clinic. Weaknesses Limitations were met throughout the study involving the clinic space provided to UMP providers. In some assisted living facilities, the assigned clinic locations had limited working space or did not have chairs or a waiting area for patients to sit if the providers got behind on clinic visit times. In addition, some clinic visits exceeded the fifteen-minute time allotment due to the mobility and comorbidities associated with a patient's homebound status. Another weakness was the complexities of using the Qualtrics platform for all the standardized Rand health survey scoring. Much time was spent trying to have the program calculate and score the data from the survey. Ultimately, it was faster to score the surveys by hand and create a spreadsheet in excel to do the calculations. Additionally, the senior patient population was more comfortable filling out the surveys by hand in paper format rather than doing it electronically ONYCHOMYCOSIS TREATMENT IN THE HOME 28 with the QR code. Discussion A mobile family practice group has the capability and skill set to treat homebound geriatric patients with onychomycosis safely and conservatively in the home. Our intervention successfully gives patients access to care they could not obtain due to their homebound status. Furthermore, by removing access disparity in the elderly patient population, as Yamada et al. (2015) discussed, patients were eager to receive the toenail clinic services when offered. New and Important Knowledge Family practice providers are an aggregate team of indispensable medical professionals. Mobilizing a family practice group results in a healthcare delivery system capable of disseminating medical services to vulnerable patient populations. The QI intervention for this patient population was optimal. Disease management was associated with a trend of improved quality-of-life scores. The disease management strategy identified multiple foot conditions where preventative measures were implemented. Fall prevention, wound healing, and, in some cases, onychomycosis cure were unexpected outcomes of the QI intervention. This quality improvement project is relevant in treating homebound older adults. By changing the healthcare delivery model to fit patients' needs, clinicians can bring minimally invasive onychomycosis treatment into their homes (Gupta et al., 2017). Working with associate healthcare entities and stakeholders who share the same patient population and challenges was mutually beneficial in meeting the patient's needs. The project was compatible with the organizational and facility structures. These findings are new and vital because they decrease healthcare costs by adjusting the site of care (Klein et al., 2017). This delivery method improves patient outcomes and demonstrates the value of preventative medical ONYCHOMYCOSIS TREATMENT IN THE HOME 29 practices. Scholarly merit was achieved by actualizing significant advantages over existing approaches providing a potential opportunity for this small mobile practice to outperform some family practice competitors. Compared with the previous review of this topic, Boulton et al. (2018) recognized the value of identifying diabetes foot complications early to prevent complications. Our project identified many foot complications, including onychomycosis, and most patients presented with abnormally long toenails. In addition, self-neglect could be attributed to mobility and access disparities. The coordination of toenail services was managed by clinicians and supported by the facilities where homebound patients lived. A similar study found that delivering foot care interventions in an adult daycare setting was beneficial (Fujii, 2019). Like this study, our QI patient service captured a population who desired to improve their health but lacked the physical capability. Again, a healthcare need was addressed, the solution was implemented, and prevention and chronic care management were achieved. Becker and Childress (2018) implemented over-the-counter treatment options in home care patients with similar positive findings. Our treatments were also conservative. Reflecting on the needs of this group of individuals, creating an "office location" that was compatible with the organization and facility structure, the project also provided the recommended screening, prevention, and management of foot disorders, similar to what was demonstrated by Farber and Farber (2007). The QI group was small (n=22), and technical issues were encountered with the Qualtrics survey platform relating to using the QR codes with the elderly. These issues were addressed and adjusted to fit the user's ability to complete the QOL survey. As a result, the intervention reached ONYCHOMYCOSIS TREATMENT IN THE HOME 30 the desired patient population, generating income for the mobile physician group, filling a need, and taking an activity of daily living (ADL) burden off the clinical staff in the care facilities where the patients reside. Translation of Evidence into Practice The results indicate conservative toenail care can prevent severe complications in a patient's home. In addition, the outcomes show that conventional toenail treatment decreases the occurrence of lower extremity conditions (Bodman & Krishnamurthy, 2020). Becker and Childress (2018) reported decreased falls, ulcerations, wounds, and infections leading to hospitalization and amputation and improved quality of life. Overall, the research suggests using a similar approach as noted in available evidence and literature. In addition, a trained, mobile family practice provider can perform conservative toenail treatment in a patient's home, which provides an opportunity for future research on its efficacy. Care delivery improvements enhanced profitability for the mobile family practice group and expanded their providers' scope of practice. Incrementally higher patient volumes were experienced with each toenail clinic. Using provider education and training as a strategy improved adherence to the QI project. The popularity of this service helped the mobile practice establish a regular cadence for ongoing success. Implications for Practice and Future Scholarship It is within the scope of practice for a nurse practitioner (NP), physician assistant (PA), and even a registered nurse (RN) to perform toenail care for older adults. Extra care must be taken with high-risk patient populations to avoid complications associated with the comorbidities of the delicate, more aging adult (Shemer et al., 2018). Complications of Onychomycosis include ONYCHOMYCOSIS TREATMENT IN THE HOME 31 cellulitis, sepsis, or even osteomyelitis, and delaying care for nail deformities can lead to pain and disfigurement (Bodman & Krishnamurthy, 2022) Implications for practice include developing an evidence-based standard of care for toenail trimming based on the latest research. Provider training can also be generated from the literature to provide toenail services during a primary care visit. In addition, provider training can be designed and standardized for family practice settings (see Appendix D). Future scholarship opportunities surrounding research findings could be reproduced and utilized to provide toenail services in all healthcare settings. Future research can also be conducted to evaluate the effectiveness and cure rates of onychomycosis with conservative treatments for high-risk patient populations where other treatment options are contraindicated due to comorbidities. Family practitioners can broaden their reach and foster health promotion by expanding roles and modifying the point of care. Older adults were engaged in the participatory efforts required to secure an appointment to remedy self-neglect. Ongoing patient compliance is essential in achieving a positive effect on quality-of-life scores. Future scholarship must incorporate findings that facilitate the autonomous fulfillment of self-care deficits and the effect on psychosocial, physical, functional, and emotional aspects. Compliance with this conservative treatment regimen may provide an alternative to other treatment options. In addition, a robust care management plan that promotes patient engagement and outreach is warranted. Care access hurdles and transportation is one of the most salient topics in healthcare. The mobile nature of these services can relieve mobility constraints in many patient populations. Mitigating care access hurdles, including transportation, is among the most common findings in the older adult population. The simple lack of availability of healthcare services leads to harmful ONYCHOMYCOSIS TREATMENT IN THE HOME 32 neglect and missed opportunities for prevention. Therefore, these practices should be promoted and encouraged. Older adults were engaged in participatory efforts to obtain provider visits for toenail service offerings in their living facilities. Patients were keenly aware of their self-neglect and were solicitous in utilizing the mobile practice services. Improving the care process with independent practitioners promoted behavioral changes and improved self-care. There is an unmet need for practitioners to expand their roles and deliberately organize services to fill unmet patient needs. Sustainability This evidence is transferable by creating and developing a standard of care for conservative toenail treatment in a family practice setting (Klein et al., 2017). Healthcare entities can do quality improvement projects with the material and evidence created through this quality improvement project. Standardization of this project into preventative medical practice is feasible, as this is an activity of daily living that applies to all patient populations. Secondary outcomes may be identified and provide an opportunity for future research on the efficacy of toenail debridement on toenail fungal cure rates. The intervention reached the desired patient population, generating income for the mobile physician group, and decreased the activity of daily living (ADL) burden of the clinical staff in the care facility. Understanding all the dimensions of a vulnerable patient population helps practitioners tailor their plan of care and delivery methods to meet the patient's needs. Mobile groups and facility groups know all the dimensions of this vulnerable patient population, and this process brings about ongoing enhancements. ONYCHOMYCOSIS TREATMENT IN THE HOME 33 Dissemination The role of interprofessional team strategy can improve care coordination, affecting patient outcomes. Access disparity and health inequality are at the forefront of failed treatment attempts for toenail conditions (Yamada, 2015). Sharing findings and learnings with interprofessional affiliations and online networks will help create awareness and support for this vulnerable patient population in the community. Primary care physicians can oversee and manage most foot complications using over-the-counter remedies (Becker & Childress, 2018). The dissemination of these findings is manageable and can be used as a guide to clinicians already familiar with QI initiatives. Although there are no restrictions to replicating this project in any setting, the participants' attitudes are potential predictors of the intervention's success. The project was found to be low-cost, scalable, profitable, and can be implemented in different healthcare structures and cultures. Conclusion Older adults have many comorbidities and health issues that prevent them from providing optimal self-care (Sharoni et al., 2017). Home-based primary care offers a promising way to optimize care for many of the nation's sickest and frailest patients, those who are homebound or face functional limitations that prevent them from obtaining routine health maintenance in a physician's office. The evidence indicates the significance of implementing a foot care program within a mobile family practice setting. It can improve foot health in homebound geriatric patients and their quality of life. Early identification of toenail disorders allows for convenient, customized treatment options that are safe to administer to older adults in their homes. For example, practitioners play an essential role in the early diagnosis and treatment of fungal foot infections, such as ONYCHOMYCOSIS TREATMENT IN THE HOME 34 onychomycosis, in the elderly. In addition, there are likely to be many frail older adults who could benefit from home-based primary care (Vespa et al., 2020). Providing toenail services to patients in an environment they can access improves patient outcomes, including their quality of life. ONYCHOMYCOSIS TREATMENT IN THE HOME 35 References Abdullah, L., & Abbas, O. (2011). Common nail changes and disorders in older people. Canada Family Physicians, 57(2), 173-181. Adeyemi, T. M., Olatunji, T. L., Adetunji, A. E., & Rehal, S. (2021). Knowledge, practice, and attitude towards foot ulcers and foot care among adults living with diabetes in Tobago: A qualitative study. International Journal of Environmental Research and Public Health. 18(15), 8021-8029. https://doi.org/10.3390/ijerph18158021 America's Health Rankings (2021). Senior report: High health status- ages 65+ in Utah. United Health Foundation. Retrieved September 22, 2021, from https://www.americashealthrankings.org/explore/senior/measure/health_status_sr/state/U T Becker, B. A., & Childress, M., A. (2018). Common foot problems: Over-the-counter treatments and home care. American Family Physician, 98(5), 298-303. Blume, P., & Wu, S. (2018). Updating the diabetic foot treatment algorithm: Recommendations on treatment using advanced medicine and therapies. Wounds: A Compendium of Clinical Research and Practice, 30(2), 29-35. Bodman, M. A., & Krishnamurthy, K. (2020). Onychomycosis. [Updated 2021 August 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441853/ Boulton, A, J. M., Armstrong, D. G., Kirsner, R. S., Attinger, C. E., Lavery, L. A., Lipsky, B. A., Mills, J. L., & Steinberg, J. S. (2018, October). Diagnosis and management of diabetic foot complications. American Diabetes Association. https://doi.org/10.2337/db20182-1 ONYCHOMYCOSIS TREATMENT IN THE HOME 36 Boulton, A. J. M. (2014). The diabetic foot. Medicine, 43(1), 33-37. https://doi.org/10.1016/j.mpmed.2014.10.006 Boulton, A, J. M., Armstrong, D. G., Albert S. F., et al. (2008). Comprehensive foot examination and risk assessment: A report of the task force of the foot care interest group of the American diabetes association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care, 31(8), 1679-1685. http://doi.org/10.2337/dc089021 Bunyaratavej, S., Pattanaprichakul, P., Leeyaphan, C., Chayangsu, O., Bunyaratave, S., Kalthanan, K. (2015). Onychomycosis: A study of self-recognition by patients and quality of life. Indian Journal of Dermatology, Venereology and Leprology. 81(3), 270274. http://doi.org/10.4103/0378-6323.154796 Del Rosso, J. Q. (2004). Oral Antifungals: What you should know about drug interactions. Podiatry Today, 116, 61–65. DiPreta, J. A. (2014). Outpatient assessment and management of the diabetic foot. Medical Clinics of North America, 98(2), 353-373. https://doi.org/10.1016.j.cna.2013.10.010 Elewski, B., & Tavakkol, A. (2005). Safety and tolerability of oral antifungal agents in the treatment of fungal nail disease: a proven reality. Therapeutics and Clinical Risk Management, 1(4), 299–306. Farber, D. C., & Farber, J. S. (2007). Office-based screening, prevention, and management of diabetic foot disorders. Primary Care: Clinics in Office Practice, 34(4), 873-885. https://doi.org/10.1016/j.pop.2007.07.001 Farndon, L., Barnes, A., Littlewood, K., Harle, J., Beecroft, C., Burnside, J., Wheeler, T., Morris, S., & Walters, S. J. (2009). Clinical audit of core podiatry treatment in the national health ONYCHOMYCOSIS TREATMENT IN THE HOME 37 services (NHS). Journal of Foot and Ankle Research, 2, Article 7 (2009).https://doi.org/10.1186/1757-1146-2-7 Fink, B. R., & Mizel, M. S. (2011). The whole foot book: A complete program for taking care of your feet. Springer Publishing Company. Retrieved from https://books.google.com/books?hl=en&lr=&id=dLUCUAjwwPUC&oi=fnd&pg=PR1&d q=Fink,+B.+R.,+%26+Mizel,+M.+S.+(2011).+The+whole+foot+book:+A+complete+pr ogram+for+taking+care+of+your+feet.+Springer+Publishing+Company.&ots=SrhdSWz VjN&sig=BBoQfFS0x4myTPCysxYIHaIEcfc#v=onepage&q&f=false Fujii, K. (2019). Effect of foot care interventions for older adults using day care services. Nursing Open, 6(4), 1372-1380. https://doi.org/10.1002/nop2.333 Gaurav, V., Bhattacharya, S. N., Sharma, N., Datt, S., Kumar, P., Rai, G., Singh, P. K., Taneja, B., & Das, S. (2021). Terbinafine resistance in dermatophytes: Time to revisit alternate antifungal therapy. Journal de Mycologie Medicale, 31(1), 101087-101092. Ghannoum, M. A., Haijeh, R. A., Scher, R., Konnikov, A. K., Gupta, R., Summerbell, S., Sullivan, R., Daniel, P., Krusinki, P., Fleckman, P., Rich, R., Odom, R., Aly, D., Pariser, M., Zaiac, G., Rebell, J., Lesher, B., Gerlach, G., Ponce-de-Leon, A., Ghannoum, J., … Elewski, B, (2000). A large-scale North American study of fungal isolates from nails: The frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns. Journal of the American Academy of Dermatology. 43(4), 641-648. http://doi.org/10.1067/mjd.2000.107754 Gupta, A. K., Versteeg, S. G., Shear, N. H., Piguet, V., Tosti, A., & Piraccini, B. M. (2019). A practical guide to curing Onychomycosis: How to maximize cure at the patient, organism, ONYCHOMYCOSIS TREATMENT IN THE HOME 38 treatment, and environmental level. American Journal of Clinical Dermatology, 20(1), 123-133. https://doi.org/10.1007/s40257-018-0403-4 Gupta, A. K., & Stec, N. (2019). Emerging drugs for the treatment of onychomycosis. Expert Opinion on Emerging Drugs, 24(4), 213–220. https://doi.org/10.1080/14728214.2019.1685493 Gupta, S., Jangra, R. S., Gupta, S., Mahendra, A., & Kumar, A. (2017). A painless, minimally invasive technique for debulking onychomycotic nails. Journal of the American Academy of Dermatology, 76(1), e17–e19. https://doi.org/10.1016/j.jaad.2016.07.018 Gupta, S., Paquet, M., & Simpson, F., C. (2013). Therapies for the treatment of onychomycosis. Clinics in Dermatology, 30(5), 544-554. https://doi.org?10.1016?jclindermatol.2013.06.011 Hingorani, A., LaMuraglia, G. M., Henke, P., Meissner, M. H., Loretz, L., Zinszer, K. M., Driver, V. R., Frykberg, R., Carman, T. L., Marston, W., Mills, J. L., Sr, & Murad, M. H. (2016). The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery, 63(2), 3S–21S. https://doi.org/10.1016/j.jvs.2015.10.003 Illinois Podiatric Medical Association (n.d.). Resources for patients: Podiatry facts & statistics. Retrieved September 22, 2021, from https://www.ipma.net/page/15 Klein, S., Hostetter, M., McCarthy, D. (2017). An overview of home-based primary care: Learning from the field. The Common Wealth Fund. Retrieved from: http://allcatsrgrey.org.uk/wp/download/commissioning/Klein_overview_home_based_primar y_care_ib_v2.pdf ONYCHOMYCOSIS TREATMENT IN THE HOME 39 Ko, J. Y., Lee, H. E., Jae, H., Oh, D. H., Kim, J. S., & Yu, H. J. (2011). Cure rate, duration required for complete cure and recurrence rate of onychomycosis according to clinical factors in Korean patients. Mycosis, 54(5), e384-e388. https://doi.org/10.1111/j.14390507.2010.01928.x Leung, A. K. C., Lam, J. M., Leong, K. F., Hon, K. L., Barankin, B., Leung A. A., & Wong, A. H. C. (2020). Onychomycosis: An updated review. Recent Patents on Inflammation and Allergy Drug Discovery 14(1), 32-45. https://doi.org/10.2174/1872213X13666191026090713 Li, R., Zhang P., Barker L. E., Chowdhury F. M., & Zhang X. (2010). Cost effectiveness of interventions to prevent and control diabetes mellitus: A systematic review. Diabetes Care, 33(8), 1872–1894. https://doi.org/10.1016/j.jaad.2019.05.069 Lin, K., & Lipner, S. R. (2020). Painless technique for debridement of onychodystrophic nails. Journal of the American Academy of Dermatology, 82(2), e39–e40. https://doi.org/10.1016/j.jaad.2019.05.069 Lipner, S., Josepth, W., Vlahovic, T., Scher, R., Rich, P., Ghannoum, M., Daniel, R., & Elewski, B. (2021). Therapeutic recommendations for the treatment of toenail onychomycosis in the US SKIN The Journal of Cutaneous Medicine, 5(6), s93. https://doi.org/10.25251/skin.5.supp.93 Lopes, A. I., Tavaria, F. K., & Pintado, M. E. (2020). Conventional and natural compounds for the treatment of dermatophytosis. Medical Mycology, 58(6), 707–720. https://doi.org/10.1093/mmy/myz116 Malay, D. S., Yi, S., Borowsky, P., Downey, M. S., Mlodzienski, A. J. (2009). Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for ONYCHOMYCOSIS TREATMENT IN THE HOME 40 the treatment of pedal onychomycosis: A randomized controlled trial. The Journal of Foot & Ankle Surgery 48(3), 294-308. https://doi.org/10.1053/j.jfas.2008.12.012 Manickum, P., Mashamba-Thompson, T., Naidoo, R., Ramklass, S., & Madiba, T. (2021). Knowledge and practice of diabetic foot care- A scoping review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 15(3), 783-793. https://doi.org/10.1016/j.dsx.2021.03.030 Mass, W. (2018). Census bureau forecasts older Americans will outnumber children by 2030. The New American. Retrieved from: Census Bureau Forecasts Older Americans Will Outnumber Children by 2030 - The New American. Matricciani, L., & Jones, S. (2015). Who cares about foot care? Barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes. The Diabetes Educator, 41(1), 106-117. http://dx.doi.org/10.1177/0145721714560441 Mayo Clinic: Diabetes Overview. (2020, September 23). Amputation and diabetes: How to protect your feet. Retrieved from https://www.mayoclinic.org/diseasesconditions/diabetes/in-depth/amputation-and-diabetes/art-20048262Menz, H. B. (2016). Chronic foot pain in older people. Maturitas, 91, 110-114. https://doi.org/10.1016/j.marturitas.2016.06.011 Medicare.org. (2020). Does Medicare cover toenail trimming? Retrieved December 4, 2021, from https://www.medicare.org/articles/does-medicare-cover-nail-trimming/ Menz, H. B., Ayhl M., Spink M. J. (2018). Foot problems as a risk factor for falls in communitydwelling older people: A systematic review and meta-analysis. Maturitas, 118, 7-14. https://doi.org/10.1016/j.maturitas.2018.10.001 ONYCHOMYCOSIS TREATMENT IN THE HOME 41 Miller, J. D., Carter, E., Shih, J., Giovinco, N. A., Boulton, A. J., Mills, J. L., & Armstrong, D. G. (2014). How to do a 3-minute diabetic foot exam. Journal of Family Practice. 63(11), 646–656. Mozena, J. D., & Mitnick, J. P. (2009). Emerging concepts in treating onychomycosis. Podiatry Today, 1-7. Retrieved November 30, 2021, from https://www.hmpgloballearningnetwork.com/site/podiatry/emerging-concepts-in-treatingonychomycosis Murdan, S. (2016). Nail disorders in older people, and aspects of their pharmaceutical treatment. International Journal of Pharmaceutics, 512(2), 405-411. https://doi.org/10.1016/j.ijpharm.2016.05.022 Ogidi, C. O., Ojo, A. E., Ajayi-Moses, O. B., Aladejana, O. M., Thonda, O. A., & Akinyele, B. J. (2021). Synergistic antifungal evaluation of over-the-counter antifungal creams with turmeric essential oil or aloe vera gel against pathogenic fungi. BioMed Central Complementary Medicine and Therapies, 21(1), 47-52. Piraccini B. M., Sisti A., & Tosti, A. (2010). A long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents. Journal of American Academy of Dermatology, 62(3), 411-418. https://doi.org/10.1016/j.jaad.2009.04.062 Persaud, R., Coutts, P. M., Brandon, A., Verma L., Elliot, J. A., & Sibbald, R. G. (2018). Validation of healthy foot screen: A novel assessment tool for common clinical abnormalities. Advances in Skin and Wound Care, 31(4), 154. https://doi.org/10.1097/01.asw.0000530686.16243.d5 ONYCHOMYCOSIS TREATMENT IN THE HOME 42 Rana, M., Bashir, B., Altaf, F., Rani, Z. (2017). Frequency of associated factors of onychomycosis. Journal of Pakistan Association of Dermatologists, 27(3), 226-232. Sharoni, S. K. A., Rahman, H. A., Minhat, H. S., Ghazali, S. S., & Ong, M. H. A. (2017). A selfefficacy education programme on foot self-care behaviour among older patients with diabetes in a public long-term care institution, Malaysia: A quasi-experimental pilot study. British Medical Journal Open,7(6), e014393. https://doi.org/10.1136/bmjopen2016-014393 Shemer, A., Daniel, R., Rigopoulos, D., Farhi, R., & Babaev, M. (2018). Variability in systemic treatment efficacy for onychomycosis: Information that clinical studies do not impart to the office dermatologist. Skin Appendage Disorders, 4(3), 141–144. https://doi.org/10.1159/000481693 Singh G., Haneef, N. S., & Uday, A. (2005). Nail changes and disorders among the elderly. Indian Journal of Dermatology, Venereology and Leprology, 71(6), 386-392. Stetler, C. B. (2001). Updating the Stetler model for research utilization to facilitate evidencebased practice. Nursing Outlook, 49(6), 272-279. https://doi.org/10.1067/mno.2001.120517 Stewart, C. R., Algu, L., Kamran, R., Leveille, C. F., Abid, K., Rae, C., & Lipner, S. R. (2021). Effect of onychomycosis and treatment on patient reported quality-of-life outcomes: A systematic review. Journal of American Academy of Dermatology, 85(5), 1227-1239. https://doi.org/10.1016/j.jaad.2020.05.143 Stolt, M., Suhonen, R., Puukka, P., Viitanen, M., Voutilainen, P., & Leino-Kilpi, H. (2010). Foot health in older people and the nurses' role in foot health care: A review of literature. ONYCHOMYCOSIS TREATMENT IN THE HOME 43 Scandinavian Journal of Caring Sciences, 24(1) 194-201. https://doi.org/10.1111/j.14716712.2009.00700.x Sumikawa, M., Egawa, T., Honda, I., Yamamoto, Y., Sumikawa, Y., & Kubota, M. (2007). Effects of foot care intervention, including nail drilling combined with topical antifungal application in diabetic patients with onychomycosis. The Journal of Dermatology, 34(7), 456-464. https://doi.org/10.1111.1346-8138.2007.00310.x Tabassum, H., Adil, M., Amin, S. S., Mohtashim, M., Bansal, R., & Agrawal, D. (2020). The impact of onychopathies on quality of life: A hospital based, cross sectional study. Indian Dermatology Online. 11(2), 187-194. http://doi.org/10.4103/idoj.IDOJ_272_19 Takehara, K., Oe, M., Tsunemi, Y., Nagase, T., Ohashi, Y., Iizaka, S., Ueki, K., Tsukamoto, K., Kadowaki, T., & Sanada, H. (2011). Factors associated with presence and severity of toenail onychomycosis in patients with diabetes: A cross-sectional study. International Journal of Nursing Studies, 48(9), 1101–1108. https://doi.org/10.1016/j.ijnurstu.2011.02.005 Taylor, M. B. (2018). An innovation in practice for the agency for healthcare research and quality (AHRQ): Initiative for a comprehensive foot examination across health care settings diagnostics and treatment. Juniper Online Journal of Nursing & Healthcare, 9(4). https://doi.org/10.19080/jojnhc.2018.09.555767 Thomas, J., Jacobson, G. A., Narkowicz, C. K., Peterson, g. M., Burnet, H., & Sharpe, C. (2010). Toenail onychomycosis: An important global disease burden. Journal of Clinical Pharmacy Therapeutics, 35(5), 497-519. https://doi.org/10.1111/j.13652710.2009.01107.x. ONYCHOMYCOSIS TREATMENT IN THE HOME 44 US Department of Health and Human Services (HHS). Healthy People 2020. US Department of Health and Human Services; Washington, DC, USA: 2010. HHS action plan to reduce racial and ethnic disparities: A nation free of disparities in health and healthcare. https://www.minorityhealth.hhs.gov/assets/pdf/hhs/HHS_Plan_complete.pdf Utah Department of Health (2014). Utah health status update: Utah's senior population. Retrieved September 22, 2021, from https://ibis.health.utah.gov/ibisphview/pdf/opha/publication/hsu/2014/1404_Senior.pdf van Netten, J. J., Price, P. E., Lavery, L. A., Monteiro-Soares, M., Rasmussen, A., Jubiz, Y., & Bus, S. A. (2016). Prevention of foot ulcers in the at-risk patient with diabetes: A systematic review. Diabetes Metabolism Research and Reviews, 32(Suppl. 1), 84-98. https://doi.org/10.1002/dmrr.2701 Vespa, J., Medina, L., & Armstrong, D. M. (2020). Demographic turning points for the United States: Population projections for 2020 to 2060. Current Population Reports, 25-1144. US Census Bureau, Washington, DC Retrieved March 1, 2022, from: Demographic Turning Points for the United States: Population Projections for 2020 to 2060 (census.gov). https://www.census.gov/content/dam/Census/library/publications/2020/demo/p251144.pdf Widaty, S., Miranda, E., Bramono, K., Menaldi, S. L., Marissa, M., Oktarina, C., Surya, D., & Kusumawardhani, H.T. (2019). Prognostic factors influencing the treatment outcome of onychomycosis candida. Mycoses, 63(1), 71-77. https://doi:10.1111/myc.13018 Yamada, T., Chen, C. C., Murata, C., Hirai, H., Ojima, T., Kondo, K., & Harris, J. R., (2015). Access disparity and health inequality of the elderly: Unmet needs and delayed ONYCHOMYCOSIS TREATMENT IN THE HOME healthcare. International Journal of Environmental Research and Public Health, 12(2), 1745–1772. https://doi.org/10.3390/ijerph120201745 45 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix A 46 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix B 47 ONYCHOMYCOSIS TREATMENT IN THE HOME 48 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix C 49 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix D 50 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix E 51 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix F 52 ONYCHOMYCOSIS TREATMENT IN THE HOME 53 ONYCHOMYCOSIS TREATMENT IN THE HOME 54 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix G 55 ONYCHOMYCOSIS TREATMENT IN THE HOME 56 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix H 57 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix I 58 ONYCHOMYCOSIS TREATMENT IN THE HOME 59 ONYCHOMYCOSIS TREATMENT IN THE HOME 60 ONYCHOMYCOSIS TREATMENT IN THE HOME 61 ONYCHOMYCOSIS TREATMENT IN THE HOME The 36-item survey is free to use for research purposes. 62 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix J 63 ONYCHOMYCOSIS TREATMENT IN THE HOME 64 ONYCHOMYCOSIS TREATMENT IN THE HOME 65 ONYCHOMYCOSIS TREATMENT IN THE HOME 66 ONYCHOMYCOSIS TREATMENT IN THE HOME 67 ONYCHOMYCOSIS TREATMENT IN THE HOME (Appendix J) Permission was granted for use of training materials produced by Dr. Julia Overstreet, DPM, FAPWCA 68 ONYCHOMYCOSIS TREATMENT IN THE HOME Appendix K 69