Care Connections

1. Care Connections Erin Burdi Hope Garcia Ashley Jacobson Maureen Koval Amy Reames

2. Introduction • The Board of Directors of Care Connections developed this strategic plan with the good of the community in mind. It provides Care Connections with a strategy for supports, services, and organizational development. The Board of Directors, in conjunction with the Care Connections staff, will review its progress quarterly and update the plan annually as needed.This plan was developed to reflect on the mission, vision, and values of this organization. An environmental scan including an internal organization assessment was conducted as part of the planning process. Care Connections has and will continue to assess both the challenges and opportunities it is likely to face over the upcoming years and set the context for the choices reflected in this strategic plan. Care Connections will be a resource available for those with or without insurance with disease education and prevention as the top priority. Care Connections' focus is to prevent hospitalization and maximize health through health promotion.

3. Assessment of Internal and External Environment • Care Connections is a not-for-profit agency that provides education regarding health promotion, illness prevention, disease management, and care coordination. Care Connections assists individuals to take control of their own health. • A large number of Americans are uninsured or underinsured. In fact, 49% of Americans have insurance through their employer, 5% have purchased private individual insurance coverage, 28% are covered through Medicaid and Medicare, and 17% are without insurance (Kaiser-Family Foundation, 2010).

4. Assessment of Internal and External Environment • Those people who have insurance do not always know the most cost effective way to use their benefits. Those without insurance are often forced to use the emergency room as a substitute for a primary care physician. This practice may result in poor outcomes for the patient and places a heavy burden on the health care delivery system. “Nationally and locally, about 20 percent of Medicare patients are readmitted within 30 days, and the annual cost is $20 billion, according to the Centers for Medicare & Medicaid Services (Singer, 2011)”. In the next couple of years Medicaid and Medicare may no longer pay for these readmissions. There needs to be outside resources to help prevent readmission.

5. Assessment of Internal and External Environment • There are few agencies that focus on health promotion and illness prevention as a means to decrease health insurance costs to the individual. Insurance companies contract with providers for the most services for the least amount of money. • Care Connections works with individuals to help them use their insurance policy wisely, choose the best insurance policy for their needs, or access services at a reasonable rate.

6. Assessment of Internal and External Environment • Projected Staff Number and Qualifications • Full time program director • Answers to the board of directors. Master’s degree in health related field and five years of management experience. • Five full time nurse case managers • No less than a Bachelor’s degree and five years clinical experience. • Nurse educator • Master’s degree in education and five years of clinical experience. • Administrative assistant • Associates Degree in business or related filed and five years of experience.

7. Assessment of Internal and External Environment • Lay out of the facility plant • lobby/reception area – the administrative assistant would be placed in this area. • The case managers and nurse educator would share an office space with cubicles for privacy. • Separate office space would be needed for the program director and conference room area. • Restroom facilities, store room for office supplies, and break room space would also be needed. • A minimum of 1500 square feet of office space would be needed to accommodate our employees and clients. • Technical requirements would be the following: eight computers with internet access, two printers, eight phones, and computer server. A contract with a computer support and service company will be needed to maintain our software and server.

8. Assessment of Internal and External Environment • Reimbursement • Clients will be asked to pay a percentage of the money they saved by using the service. • Government grants could be a source of funding. The Public Health and Human Services (PHHS) block grant gives grantees the flexibilities to use funds to prevent and control chronic diseases. • Contracts allowing Care Connections to be a liaison between local employers and insurance carriers will be obtained. • Volunteers from all areas of the health care industry, insurance industry, and private sector will be sought. • Partnerships between health care providers, educators, businessmen, clergy, and private citizens will be forged to foster cooperation among members of the community.

9. Mission Statement • Care Connection’s purpose is to assist residents of Mecosta County to take control of their health through education regarding health promotion, illness prevention, disease management, care coordination, and utilization of available resources.

10. Philosophy • Patients • We believe: • Every individual has the right to high-quality medical care that is delivered with respect to individual values and beliefs. • Individuals desire to be healthy and free from illness and disease. • All individuals should have the same opportunities to live a healthy life, free from illness or disease. • Every individual is capable of making positive decisions about their health and lifestyle choices when given adequate education, resources, and support.

11. Philosophy • Nursing • We believe: • Healthcare providers should provide their patients with individualized care that respects the wishes of the patient. • Healthcare providers should act as advocates for their patients. • Healthcare providers should provide care and education that is best on current knowledge and evidence-based practice.

12. Organizational Goals • Provide efficient, individualized, high quality health care coordination services to residents of Mecosta County. • Teach current health promotion and preventive education to residents of Mecosta County on identifying, managing, and reducing health risk factors common among that population. • Teach residents of Mecosta County and their families about models of health care delivery, and community resources. • Incorporate a multidisciplinary approach to case management through the use of nurses, social workers, chiropractors, dieticians, physical therapist, occupational therapist, speech therapists, psychologists, and clergy.

13. Organizational Objectives • To demonstrate health promoting behaviors every visit. • To provide education on management of common diseases such as heart disease, stroke, cancer, chronic respiratory diseases, diabetes, and accidental injury on the first visit. • To identify health risk factors and management of common diseases such as heart disease, stroke, cancer, chronic respiratory diseases, diabetes, and accidental injury every visit. • To provide health screening of potential health risks including physical assessment, comprehensive health and familial history on the initial visit. • To provide patients with the appropriate resource referrals to top quality health services based on identified health risk factors.

14. Organizational Objectives • To develop a case management services based on current knowledge and evidence based practice. • To develop educational curriculum for the most common health conditions in the service area. • To establish a data base of current health plans offered in the service area. • To build a team of highly qualified health care service providers who will deliver care to our clients. • To develop relationships with local business owners who are affiliated with the health and wellness industry (ie: gyms, health food stores, ect.) to establish referral sources.

15. Organizational Chart • Care Connections will begin with a very simple, bureaucratic, centralized organizational structure because of the small number of staff and the need to make quick decisions in the beginning stages of building their business (Appendix A). The program director will need to autonomy to make business decisions independently. The clinical staff will have the autonomy to perform their daily tasks independently as well.

16. Job Descriptions Program Director/Office Manager • The following roles and procedures are executed by the program director/office manager: • Create, communicate, and implement the organizations vision, mission, and overall direction. • Formulate and implement the strategic plan that guides the direction of the business. • Form, staff, guide, lead, and manage the organization sufficient to accomplish the program director's responsibilities and the strategic plan of the business. • Maintain awareness of both the external and internal competitive landscape, opportunities for expansion, customers, markets, new industry developments and standards, and so forth. • Oversee the complete operation of the organization in accordance with the direction established in the strategic plans. • Organize and Implement: organizing the production of the work, and the workforce, training, and resources necessary, in a way that accomplishes the desired and required outcomes to meet the goals. • Direct: providing the employees and their resources with enough guidance, direction, leadership, and support necessary to ensure that they are able to accomplish their goals. • Monitor: following up to ensure that the plan to achieve the goals is being carried out in such a way that its accomplishment is assured. • Evaluate: reviewing and assessing the success of the goal, the plan, and the allocation of the employees and their resources. • Represent the organization in civic and professional association responsibilities and activities in the local community, the state, and at the national level (Human Resources, 2011).

17. Job Descriptions Case Manager • The Case Manager is knowledgeable and able to collaborate on quality clinical outcomes and healthcare reimbursement while being cost-effective. The following roles and procedures are executed by the case manager: • Provide case management and support to clients as needed • Provide comprehensive client assessments on functional, environmental, psychosocial, financial, employment, housing, educational, and health information as appropriate to develop a case plan. • Educate clients on assessed needs and preventative care • Develop support systems to meet client needs by identifying and coordinating a variety of available services necessary to maintain independent living, and, when possible, self sufficiency and family stabilization.Provide supportive counseling and advocacy for clients. • Refer clients to available therapeutic, social service, educational and medical resources when appropriate. • Provide crisis intervention as necessary. • Monitors and verifies services and insurance policies provided to each client on a monthly basis, determining quality and effectiveness of the services provided.

18. Job Descriptions Nurse Educator The Nurse educator will plan, organize, and direct the health education program for Care Connections. They work with other health professionals, civic groups, and community officials to determine health needs, develop desirable health goals, and evaluate the availability of health services. They focus on promoting good health and preventing disease, but they must also deal with social, behavioral, legal, and economic issues.The following roles and procedures are executed by the health educator: • Collaborate with health specialists and civic groups to determine community health needs and the availability of services, and to develop goals for meeting needs.Design and conduct evaluations and diagnostic studies to assess the quality and performance of health education programs.Develop and present health education and promotion programs such as training workshops, conferences, and school or community presentations.Develop operational plans and policies necessary to achieve health education objectives and services.Develop, conduct, or coordinate health needs assessments and other public health surveys.Prepare and distribute health education materials, including reports, bulletins, and visual aids such as films, videotapes, photographs, and posters.Provide guidance to agencies and organizations in the assessment of health education needs, and in the development and delivery of health education programs.

19. Job Desciptions Nurse Educator (continued) Provide program information to the public by preparing and presenting press releases, conducting media campaigns, and/or maintaining program-related web sites.Develop and maintain cooperative working relationships with agencies and organizations interested in public health care.Develop and maintain health education libraries to provide resources for staff and community agencies.Develop, prepare, and coordinate grant applications and grant-related activities to obtain funding for health education programs and related work.Document activities, recording information such as the numbers of applications completed, presentations conducted, and persons assisted.Maintain databases, mailing lists, telephone networks, and other information to facilitate the functioning of health education programs.Supervise professional and technical staff in implementing health programs, objectives, and goals (Career planner, 2011).

20. Job Descriptions Administrative Assistant • At Care Connections our Administrative Assistant will help provide administrative support to our department. It is important to have a knowledgeable background in general clerical work, receptionist duties, and be able to project a professional image through in person and on the phone (http://www.hrvillage.com/hrjobdesc/AdministrativeAssistant.htm). • Answer telephones and transfer calls. • Meet and greet clients and visitors. • Create and modify documents. • Perform general clerical duties: photocopying, faxing, mailing and filing. • Maintain hard and electronic filing system. • Sign and distribute packages. • Research, prices, and purchase office supplies. • Coordinate and maintain records for staff office space, phones, parking, company finances, and office keys. • Setup and coordinate meetings and conferences. • Maintain and distribute staffs weekly schedules.

21. Job Descriptions Administrative Assistant (continued) • Relieve management of administrative detail. • Coordinate work flow. • Update and chase delegated tasks to ensure deadlines are met. • Keep projects on schedule. • Maintain procedural manual to ensure quality performance and skills. • Arrange essential mail in priority. • Check deadlines on incoming requests and put preliminary work in play. • Process replies. • Transfer calls and route them where necessary. • Prepare agenda in advance. • Arrange meeting facilities. • Act as recording secretary and prepare meeting minutes. • Assure discrete handling of all business and maintain confidentiality. • Basic reading, writing, and arithmetic skills required. • Working knowledge of Microsoft Office and telephone protocols. • Professional verbal and written communication skills. • Ability to type 50 words per minute.

22. Job Advertisment • Care Connections • Now hiring! New Mecosta county-based care coordination service organization looking for Case management rn’s! Five full-time positions available Competitive pay and benefits Experience preferred Interested applicants call 1-231-5we-care Fax resume to 1-231-555-5555

23. Budget Proposal • Labor costs for eight full time employees with fringe benefits $459,000.00. • Rent and utilities $21,600.00 • Office furniture $8,200.00 • Computers and Telephone service $5,000.00 • Office supplies $10,100.00 • Advertising $1,500.00 Total annual operating budget needed = $505,400.00

24. Budget Proposal • Case Management services have shown to save insurance companies between 19.5-70.8% of total costs per person, when caring for older adults with chronic and terminal illnesses (Head, LaJoie, Augustine-Smith, Cantrell, Hofmann, Keeney, & Pfeifer,2010). Head et al. (2010) demonstrated a monthly savings between $716 and $5691(p. 213). • Hawkins, Diehl-Svrjcek, & Dunbar (2006) found a 46.9% total costs savings per month when caring for young children with chronic illnesses. • Based on these numbers, employers using Care Connections as their case management service could expect to see a 45% decrease in their health care costs. • The estimated cost savings to clients would be an average of $2,000 per person per month or $24,000 annually. • Care Connections charges a fee of 25% of the savings incurred. This would result in estimated annual revenue of $600,000 when serving 100 clients.

25. Conclusion • The mission of the Care Connections organization is to assist individuals and families to take control and manage their health needs. It is our vision to accomplish this mission through education regarding health promotion, illness prevention, disease management, care coordination, and utilization of available resources. As founding members of Care Connections, we have identified a need for this service in the communities of Mecosta County. Goals and individual objectives have been identified to ensure our missions’ success. In addition to founding board of directors, nurse case managers, and administrative clerical personnel will be utilized to meet staffing needs of the organization. It is the intent of Care Connections to provide these services as a non-profit organization. A fiscal budget plan, as well as a means of meeting these requirements, has been identified in detail. Finally, it is the belief of Care Connections to assist residents of Mecosta County in identifying and efficiently coordinate their health care needs with respect to individual beliefs and values.

26. Appendix A

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