“Make no little plans; they have no magic to stir men’s blood and probably will themselves not be realized. Make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die” – Daniel Burnham
Executive Summary
According to the Centers for Disease Control and Prevention’s (CDC) (2018) statistics report, in the United States more than 30 million people have diabetes. The report states that in 2014 a total of 7.2 million hospital discharges and 14.2 million emergency visits were reported with diabetes as any listed diagnosis among adults aged 18 years or older, and diabetes was the 7th leading cause of death in 2015 (CDC, 2018). The problem of diabetes in Lowertown is even more significant. According to the community health needs assessment (CHNA) done in order to comply with the Patient Protection and Affordable Care Act (PPACA), diabetes prevalence is 14% among Latinos and African Americans. This is 6% higher than the national average of 8%.
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Creating the Center for Diabetes care will offer comprehensive care of complex cases of diabetes and preventive management for patients with diabetes and pre‐diabetic conditions, aligning it with the core competencies of the Institute of Medicine (2001) and the goals of Healthy People 2020 (2018). The Center will offer evidence-based services in endocrinology, case management and education, and nutrition counseling. A collaborative effort will be developed to improve diabetes patient management with multi‐specialty care such as physical/occupational therapy, prosthetic/orthotics, mental health, vascular surgery, wound care, optometry, and nephrology.
Western Hospital must carefully balance mission and money considerations when deciding the direction that will best serve the people of the Lowertown community. A proactive approach to treating complex diabetes on an outpatient basis will lessen the costs due to hospitalization for these patients and shorten lengths of stay for those individuals who are admitted. Given that the payer mix of the primary service area is not favorable for costly care, strategic action to reduce the cost of diabetes care is required. In addition, the Center for Diabetes Care strategically positions Western Hospital to take better advantage of pay for performance or pay for outcome reimbursement models (Beck, Kelly-Aduli, & Sanderson, 2018).
Based on financial analysis and non‐financial considerations, Western Hospital should proceed with the creation of the Center for Diabetes Care. The consideration of spillover revenue is an issue that is admittedly difficult to quantify and trace back to the Center. Without the consideration of spillover revenue, the Center is not particularly viable based solely on financial considerations. However, conceptually, the Center for Diabetes Care addresses the issue of emerging patients with diabetes who may not seek preventative services or who may go to the emergency room for care. This puts the Center in line with the mission and vision of the organization.
Strategic Plan
This document is intended as a start. It is meant as a living, changing, ever evolving instrument to empower the Center for Diabetes Care to create, imagine, and build the organization in new and innovative ways. This document is meant as a framework to guide growth and progress and shall be revisited annually to ensure there is consistency with the Mission and Vision set forth.
Mission:
Deliver safe, high-quality, cost-effective, patient- and family-centered care, regardless of one’s ability to pay, with the goal of improving the health of the community it serves.
Vision:
Provide patient- and family-centric care in a highly efficient manner with exceptional quality and safety outcomes for the benefit of the residents of the community.
Values: ICARE
The Center for Diabetes Care values apply across the entire Western Hospital’s organization. These core organizational values are the foundation of our culture and support our mission to provide the best care and services to patients, their families, and communities (adapted from: University of Iowa Hospitals & Clinics, 2018).
Innovation. We seek creative ways to solve problems.
Collaboration. We believe teamwork, guided by compassion and commitment is the best way to work.
Accountability. We behave ethically and with integrity in all that we do.
Respect. We honor diversity, recognize the dignity of every person, and strive to earn the trust of all those we serve.
Excellence. We strive to achieve excellence in all that we do.
SWOT Analysis
It quickly became clear that reinforcing and advancing diabetes care in the Lowertown community is our priority. We have an overarching strategic imperative to invest, align, and integrate clinical and educational activities; establish a clear plan of economic interdependency; and prepare our workforce for evolving healthcare. Understanding our capabilities and barriers is crucial to being successful (see Appendix A for the SWOT analysis).
Company Strengths
Western Hospital has recognized the need to enhance diabetes care by offering specialized diabetes outpatient services. At the community level, Western Hospital has shown generous support of the Jefferson County Community Benefit Coalition which formed collaborative efforts with eight affiliated hospitals to identify ten specific community health needs. Diabetes care was chosen as the top priority to address.
Western Hospital has a unique opportunity to change the health of Jefferson County by creating a Center for Diabetes Care and offering comprehensive outpatient diabetes care for the most complex cases. Many of Western Hospital’s previously established service delivery lines such as cardiac, stroke, and wound care, could benefit from spillover effects from the establishment of the Center for Diabetes Care. Collaborative efforts could easily be established and all service lines would be enhanced.
Opportunities
The Center for Diabetes Care has a huge opportunity to make a significant difference in the lives of Jefferson County residents that have 8% diabetes prevalence, specifically in the Lowertown neighborhood where the Latino and African American diabetes prevalence is 14%. Finally, as reported in the CHNA, drivers of diabetes rates include poor nutrition and lack of exercise, and physical environment, such as availability of fresh foods and fast food. This data demonstrates a remarkable need for these services and underscores Western Hospital’s focus on improving the lives of those in Jefferson County.
Product Strategy
People with diabetes want a partnership with their healthcare provider. They want the convenience of having their care in one place and they want superior quality. The services being offered will be developed in two phases. The initial phase is to establish the primary medical and education components of diabetes care and establish collaboration between secondary support services (See appendix B for the project timeline). The long term goal will be to create a larger, all-inclusive multispecialty center.
Short Term Goal
This phase will establish the core primary medical and education components which include an endocrinologist, a nurse practitioner, a receptionist, and four community health workers to monitor and build relationships with patients. Along with these services, a collaborative effort will be developed between supporting services to improve patient management with multi‐specialty care. These key support services include preventative services and complication services. Preventative services can include general practitioners, additional endocrinologists, lab services, pharmacy, and dieticians. Also, patients with complex diabetes will encounter complications and need coordination of these additional services. These complication services can include cardiology, ophthalmology, obstetrics and gynecology, podiatry, and physical therapy.
Long Term Goal
In the next 5-10 years, the goal is to create a centralized multispecialty center with primary and specialty clinics, lab, pharmacy, podiatry, mental health, and other therapies. In addition, pursue a multi‐site expansion by replicating the model throughout a multi-county service area. This multisite expansion would extend access to quality diabetes care in the greater target market, thereby having a widespread impact on the objectives of the organization.
Through these services, this center will meet many of the patient’s needs. Functionally, the Center for Diabetes Care will meet their needs with specialized diabetes care and by offering collaborating services. Receiving services at the center will result in fewer office visits due to reduced complications, fewer co‐pays, less medication, less expensive hospitalizations, and less time away from work. Freedom will be gained through convenience of receiving services in one central location. Emotionally, this will provide a feeling of partnership and a sense of ownership over this disease, creating a feeling of being healthier and also improving their quality of life (See Appendix C for the goals balanced scorecard).
Pricing Strategy
Pricing will be dictated by current reimbursement rates. Clinical visits will be routinely billed and reimbursed. Diabetes care supplies will be set at market standard prices for self-pay or insurance reimbursement. Education will not be reimbursed, but the regulations will be monitored closely for changes (See appendix D for patient-generated revenue by payer).
Western’s current discharge rate for the Hispanic population 65 and older with diabetes is 386 per 1,000. The goal is to reduce this to 310 per 1,000 by the third year of operation. The average cost of an inpatient stay is $2000 a day and the patients with diabetes as the first-listed diagnosis stay for an average of five days. Simple math shows a significant savings to Western’s bottom line just by reducing the number of patients admitted with diabetes (See appendix E for the financial data summary).
Place Strategy
The location of the Center for Diabetes Care will be on site of the Western Hospital’s urgent care in Lowertown with its own proper signage and logo display. This is critical because the space will be convenient for Lowertown residents. Having the center in Lowertown will facilitate home visits for those residents that cannot or will not visit the clinic.
Western Hospital will provide the required start‐up resources through the capital budgeting process and grant funding (See appendix F for grant funding and projected capital costs). Thus, an initial capital cost is projected to total $175,181. The majority of these costs involves remodeling the existing office space to meet the needs of the center but also includes funds needed to upgrade this space to allow connection to Western Hospital’s data mainframe and electronic medical records (EMR).
Marketing Strategy
The strategy is to promote awareness within the target market. The steering committee anticipates that the marketing budget will be in the range of $40,000. There are two groups that the marketing must reach. The first group is healthcare providers in the community who will refer patients to the Center for Diabetes Care. The second is the Hispanic population, 65 years of age or older, in Lowertown diagnosed with Type II diabetes and their primary caregivers.
Marketing tactics to reach providers will include: hosting a lunch for key general practitioners and specialists at a popular local restaurant, where they will serve a healthy Mexican lunch while Dr. Novak explains the program; and deliver the Center for Diabetes Care brochures to the staff of general practitioners and specialists likely to refer patients.
Marketing tactics to reach diabetes patients and their families will include: hosting ribbon cutting by Rosa Sanchez, State Senator, followed by press release and news stories in local papers; arrange a lunch hosted by Rosa Sanchez for church leaders and other key influencers; conduct radio spots on Spanish language radio; target online ads to primary caregivers; and print ads in the local Spanish paper.
Management and Organization
Employees will include a Program Director. This person will be coordinating many of the startup tasks including overseeing the remodel of the facility, working with the marketing staff to assist and supplement the marketing plan implementation, coordinating new staff training, and developing operations optimization for the center. Being an endocrinologist, the Program Director will also consult on complex cases.
Also included in the initial organizational staffing model are: a nurse practitioner to provide clinic support for less complex cases and to supervise the community health educators; four community health educators that will serve as bridges between the healthcare system and people living with and at risk for diabetes; and a receptionist to manage the office (See appendix G for staff salary projections).
The Center for Diabetes care will be located in the urgent care clinic in Lowertown. Facilities will be leased for a 3 year term. The location of the center will be convenient with parking and visible signage with displayed logos. The hours of operation will be Monday through Friday 8:00 until 17:00. During these times the center will offer two main services: diabetes care provided by the endocrinologist, nurse practitioner, and community health workers; and diabetes education classes. Additional education classes will be offered in the patient’s home if necessary.
The space will include a waiting room, a class room, space for the receptionists, four consultation rooms, and an administrative area for the staff. The center will utilize the existing electronic health record at Western Hospital; so medical records storage will not be required. Initially, the center will lease the space to be utilized and staffed by one Endocrinologist and one Nurse Practitioner (See appendix H for projected non-staffing costs).
In addition to direct medical care, the center will provide patient education and nutrition counseling. Critical to this service will be the educational classroom where the group education sessions will be conducted. Group diabetes education has been shown to have equal or slightly greater outcomes in improving knowledge, body-mass index (BMI), health‐related quality of life, attitudes, and HbA1c, as compared to individual diabetes education (Rickheim, Weaver, Flader, & Kendall, 2002). Therefore, the focus on group education will allow for more efficient and cost‐effective methods in the delivery of diabetes education programs.
Other equipment necessary for the center will include exam tables, blood pressure cuffs, thermometers, scales, otoscopes, glucometers, pulse oximeters, stools, computers, desks, office chairs, a copy machine, a fax machine, and telephones. The educational center will include tables, chairs, computer, LCD projector, sound system, and a screen. The waiting room will include furniture and a wide screen HDTV. As a wholly owned and operated division of Western Hospital, many of the aspects of business startup are simplified.
Insurance for the facility, including business liability, worker’s compensation, and medical malpractice limits will be provided Western Hospital.
Western Hospital employee benefits.
Access to group purchasing vendors that provide discounted medical supplies and equipment
Facility maintenance will be provided by Western Hospital maintenance staff.
Technology support will be provided through Western Hospital Information Technology Department.
Recruitment and Training
A big challenge is to get the right individuals in the community health worker roles. Individuals with a combination of language skills, cultural competency, the ability to collaborate with the entire care team, and appropriate clinical knowledge will be needed. The nurse practitioner will have to have the same skill set as the community health workers. They will also have to be flexible and innovative. Human Resources (HR) will be utilized to find the right candidates for the roles. HR will also assist in developing policies and procedures for the center.
It is expected that the community health workers will have some education in healthcare or nursing. They will also need language skills. The success of this program rests on the community health workers’ ability to relate to patients. All of the staff, including the receptionist, will go through an intensive 3-week training program. The training will address cultural competency and diabetes care and prevention. They will also learn basic first aid.
Every year, there will be an annual formal training for the staff.
Social Responsibility
The Center for Diabetes Care is being established to make an impact on the critical problem of diabetes in Lowertown. This is a major healthcare need in the community that is not being adequately addressed. Through the design and availability of services, as well as community involvement, the center will help lead the community to significantly improve diabetes health. In addition, all members of the center’s staff will be expected to be ambassadors of the center’s mission within the community. The center will focus strategies to address the disparities in diabetes care and mortality, such as reaching out to Latinos through community churches and organizations. The community will be engaged through employer and community health initiatives, as well as large community events such as diabetes fundraisers, awareness walks and diabetes camps. Through effective implementation of the business plan, the center will realize success in improving diabetes health in the community. This will be measured by the overall objectives of increased diabetes testing, increased screenings for patients with diabetes, reduced need for emergency care and readmissions, and decreased diabetes mortality rate disparities in Lowertown.
References
Beck, W. E., Kelly-Aduli, C., & Sanderson, B. B. (2018). protecting revenue at risk: Healthcare organization leaders should be familiar with and create strategies for effective performance under Medicare’s new “pay-for-value” quality programs. Healthcare Financial Management, (4), 62. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edsgea&AN=edsgcl.537405342&site=eds-live&scope=site
Centers for Disease Control and Prevention (CDC). (2018). Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20O/PDF%20OpenDoorFinancialAnalysis.pdf
Committee on Quality of Health Care in America, & Institute of Medicine. (2001). Crossing the Quality Chasm : A New Health System for the 21st Century. Washington, D.C.: National Academies Press. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=86916&site=eds-live&scope=site
HealthyPeople.gov. (2018). Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People
Rickheim, P. L., Weaver, T. W., Flader, J. L., & Kendall, D. M. (2002). Assessment of group versus individual diabetes education: a randomized study. Diabetes Care, 25(2), 269– 274. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=11815494&site=eds-live&scope=site
University of Iowa Hospitals & Clinics. (2018). Retrieved from https://uihc.org/about-us
Appendix A
SWOT Analysis for the Center for Diabetes Care
Strengths
Space is available in desired community
Strong leadership/Program Director
New EHR system
Support of HR for staffing
Weaknesses
Space needs significant remodel
Limited marketing budget
15 month timeline
EHR may need customizing to interface with iPads for billing
Opportunities
Lowertown demographics support the program
PPHF grant funds available
Strong community support
Lack of access to healthcare in the county
Lack of Spanish speaking providers
Can be a model for other chronic disease centers
Threats
Finding staff with the right skills and education
Short timeline for remodel construction
Dependent on outside provider referrals
Cannot bill for education
PPHF grant funds only available for three years
Appendix B
Project Timeline
Project
Months
0
1-3
3-6
6-9
9-12
12-15
15-36
Marketing
Referrals
Opening
Post Opening
Operations
Board Approval
Space Converted
Purchase Office Equipment
Policies & Procedures Implemented
Recruitment
Evaluation
Evaluate KPI’s Monthly
Evaluate Program Viability
Appendix C
Goals Balanced Scorecard
Objectives
Measures
Targets
Initiatives
Results
Financial
To operate at breakeven without grant funding
Reduce healthcare costs through preventative care
Operating budget
Key metrics about attitudes toward the healthcare system
Operating at breakeven by year 3 without grant funding
Statistically significant improvement year-over-year
Use best practice for documenting to ensure billing for all services
Empower Hispanic patients through education and advocacy
Customer
Slowing or stopping disease progression
Optimizing and reducing all risk factors associated with micro and macrovascular disease complications
Reduction in average HbA1c levels
8.5 in 2 years
Increase patient compliance and education about diabetes treatments and care
Internal Process
Reduce hospital admission and readmission
Reduce emergency room visits
The “all-cause” hospitalization for patients in the target population or the rate of overall discharge for patients with diabetes as an “any-listed” diagnosis
Third year goal is 310 per 1,000
Increase patient compliance and education about diabetes treatments and care
Network with local providers to provide culturally competent diabetes care to target population
Learning & Growth
Frequency of contacts with patient
Staff engagement
Number of check-ups per patient in a year
Retention rates and employee satisfaction surveys
6 check-ups in a year
Increases in retention and satisfaction annually
Identify patients to enroll in center
Utilize best practices and lesson learned items for education and growth
Appendix D
Projected Patient-Generated Revenue by Payer
Adapted from: Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20O/PDF%20OpenDoorFinancialAnalysis.pdf
Appendix E
Financial Data Summary
Year 1
Income
Patient-generated Revenue
$95,141
Grant Funding
$175,000
Non-staffing Costs
(311,520)
Staffing Costs
(596,094)
Capital Costs
(175,181)
Reduce Diabetes discharges by 25 per 1000 (This calculation only shows a reduction of the first 25 patients)
$250,000
(562,654)
Year 2
Income
Patient-generated Revenue
$120,425
Grant Funding
$150,000
Non-staffing Costs
(285,533)
Staffing Costs
(618,287)
Capital Costs
(3,500)
Reduce Diabetes discharges by 50 per 1000 (This calculation only shows a reduction of the first 50 patients)
$500,000
(136,895)
Year 3
Income
Patient-generated Revenue
$100,214
Grant Funding
$100,000
Non-staffing Costs
(315,659)
Staffing Costs
(641,371)
Capital Costs
(3,500)
Reduce Diabetes discharges by 76 per 1000 (This calculation only shows a reduction of the first 76 patients)
$760,000
(316)
Appendix F
Grant Funds and Projected Capital Costs
Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/O/PDF%20OpenDoorFinancialAnalysis.pdf
Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/O/PDF%20OpenDoorFinancialAnalysis.pdf
Appendix G
Projected Staffing Costs
Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/O/PDF%20OpenDoorFinancialAnalysis.pdf
Appendix H
Projected Non-staffing Costs
Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/O/PDF%20OpenDoorFinancialAnalysis.pdf
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