FM 010 Walden University Centre for Diabetes Care Report Presentation & Discussion

For your Competency Discussion, consider an instance in which an organization of which you are familiar faced a challenge or opportunity to add or reduce services based on a strategic issue. Next, reflect on how the organization bridged the gap between an idea for how to address the challenge or opportunity and actual implementation. Then, think about the organization’s key strategic and business factors as it relates to planning and implementing the idea. Finally, think about how tools such as strategic plans, SWOT analyses, and business plans help healthcare administrators plan and implement ideas to address the challenges and opportunities they face in improving the health and well-being of individuals and populations.

To begin this Competency and meet your required engagement, post in the Discussion area a brief description of the organization you selected without revealing the name of the organization and explain the strategic issue that compelled the organization to add or reduce services. Next, describe how the organization bridged the gap between the idea and actual implementation. Then, describe the organization’s key strategic and business factors as it relates to planning and implementing the idea. Finally, explain how tools such as strategic plans, SWOT analyses, and business plans help healthcare administrators plan and implement ideas to address the challenges and opportunities they face in improving the health and well-being of individuals and populations.

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Review the details of your assessment including the rubric. You will have the ability to submit the assessment once you submit your required pre-assessments and engage with your Faculty Subject Matter Expert (SME) in a substantive way about the competency.


In this Assessment, you will use information from the documents provided, along with the background reading to demonstrate your ability to develop an integrated strategic plan to address a challenge or opportunity faced by a healthcare organization.

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  • Instructions
  • Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.
  • Rubric
  • Access the following to complete this Assessment:

    Excerpts from the Community Health Needs Assessment for Western Hospital

  • Excerpts from Dr. Novak’s Presentation to the Center for Diabetes Care Steering Committee
  • Interview with Dr. Novak
  • Financial Projections for the Center for Diabetes Care
  • Use the APA course paper template available here.

    Download the

    Writing Checklis

    t to review prior to submitting your Assessment.

    Background reading:

    Centers for Disease Control and Prevention (CDC). (n.d.).

    CDC’s Division of Diabetes Translation: Community health workers/promotores de salud: Critical connections in communities

    . CDC.…

    Centers for Disease Control and Prevention. (2019).

    Hispanic/Latino Americans and Type 2 Diabetes

    . CDC.…

    Silberman, P. (2020).

    The Affordable Care Act: Against the odds, it’s working

    . North Carolina Medical Journal, 81(6), 364 – 369.

    Estrella, M. L., & Allen-Meares, P. (2020).

    Tools to measure health literacy among US African Americans and Hispanics/Latinos with Type 2 Diabetes: A scoping review of the literature.

    Patient Education and Counseling, 103(10), 2155 – 2165.

    To begin, imagine you have just finished your MHA and you have accepted a job offer to work for the strategy group of a healthcare consulting firm. Your first project is developing a strategy for a community health center. Your firm has been hired by Dr. Novak, a well-known endocrinologist working with Western Hospital. He is passionate about prevention and early intervention of diabetes. He has led the effort to establish a community-based program to ensure ongoing treatment for this deadly disease for Hispanic seniors in the Lowertown community. His vision is that patients receive diabetes education and ongoing treatment in the language of their choice and in a culturally appropriate manner. Proper treatment and preventive care will improve patients’ quality of life while reducing hospitalizations from diabetes complications.

  • Dr. Novak and his advisors plan to apply for funding from the Patient Protection and Affordable Care Act’s Community Health Center Fund to establish the Center for Diabetes Care. The fund supports the operation, expansion, and construction of community health centers. Before he can apply for the grant, Dr. Novak needs approval from the board of directors of Western Hospital. The board requires a detailed business case and strategic plan for the initiative.
  • You will create a detailed report that includes a business plan and strategic plan based on the documentation provided and any additional research you conduct. You will also summarize the business case in a slide presentation to Western Hospital’s board of directors. Finally, you will present a report to Dr. Novak outlining the business risks of opening the center and providing strategies for managing those risks.

  • It is November and the plan is to open the center the following April (17 months from today), which coincides with the start of Western Hospital’s fiscal year.
  • This assessment has three-parts. Click each of the items below to complete this assessment.

  • Part I: Detailed Report for Western Hospital’s Board of Directors and CEO
  • Read the case study documents provided. Based on this information create a 15- to 20-page report in which you build a strategic plan and business plan for the Center for Diabetes Care, which extends the reach of Western Hospital and promotes positive health outcomes. This report will be distributed to board members and the CEO prior to the presentation, and a grant proposal will be prepared based on the material in the report. The report should include text, charts, graphics, and financial data. Provide references and sources. The report must include:

  • Executive Overview
  • The summary you will provide for this assessment differs from other Executive Summaries you have prepared during the program as it will not be a summary of your entire report, but will focus on key information needed to make your “case for action.” This Executive Overview establishes several key facts that will be useful to decision makers as they review the Strategic and Business Planning documents.

  • Written in an executive summary format, this section is a “case for action” explaining how the goals of the Center for Diabetes Care align with the goals of the Patient Protection and Affordable Care Act (PPACA), Healthy People 2030, and the Institutes of Medicine (IOM) aims for quality care.
  • Includes a recommendation for the establishment of the Center for Diabetes Care, which takes into consideration the perspectives of internal and external stakeholders—including accrediting bodies.

  • Explains how the Center for Diabetes Care fits within the continuum of care for Western Hospital setting the stage for the next part of the report – The Strategic Plan.
  • Strategic Plan

    Vision, mission, and values statements for the Center for Diabetes Care. Includes introductions for each element of the strategic plan that defines the element and explains its role in the plan.

    SWOT analysis listing the strengths, weaknesses, opportunities, and threats to opening the Center for Diabetes Care. Includes introduction of the SWOT analysis that defines its purpose and provides rationale for key aspects of the analysis.

  • Introduces and describes strategies for launching and operationalizing the Center for Diabetes Care
  • Explains the importance of this strategic planning process and defines long- and short-term goals for the Center for Diabetes Care.

    Business Plan

    Implementation timeline for key activities required to operationalize the Center.

  • Analysis of financial data for the Center for Diabetes Care, including a chart summarizing the financial data.
  • Part II: Business Case Presentation to Western Hospital’s Board of Directors and CEO

    Summarize the business case for the Center for Diabetes Care in a 5- to 10-minute oral presentation to the board of directors using voice-over PowerPoint. The oral presentation should include a 10- to 12-slide presentation in which text, charts, graphics, and financial data are presented. The presentation should also provide references and sources. As you develop the presentation, consider the information that your audience will need to know to make a decision on whether to approve Dr. Novak’s application for the grant. This information would include how the Center for Diabetes Care would:

    Address unmet needs of the community that Western Hospital serves.

  • Improve health outcomes for the community, which will lead to positive social change.
  • Be structured to ensure cultural competency with the patient population.

    Generate enough revenue so that it becomes financially self-sustaining by its third year in operation.

    Measure the success of the project.

  • Part III: Managing Risks for the Center for Diabetes Care
  • You have impressed Dr. Novak with your business and healthcare acumen. He’s asked about risks that you have identified as you have created the business plan, strategic plan, and business case for the Center for Diabetes Care. Write a report for him explaining, in detail, the risks or concerns you have identified and potential strategies for managing those risks.

    Projected Patient-Generated Revenue by Payer
    Fiscal year from April 1 to March 31
    number of
    charge per
    total charges
    Year 1
    $78,125 $ 78,125
    $176,475 $ 176,475
    Private Insurance
    $9,500 $
    Self Pay (sliding fee)
    $3,750 $
    $ 267,850
    *Includes all adjustments and any co-insurance amounts for all visit types
    number of
    charge per
    charge per
    total charges
    Year 2
    $109,375 $ 109,375
    $247,065 $ 247,065
    Private Insurance
    $38,000 $ 38,000
    Self Pay (sliding fee) 200
    $15,000 $ 15,000
    $ 409,440
    *Includes all adjustments and any co-insurance amounts for all visit types
    number of
    total charges
    Year 3
    $127,500 $ 127,500
    $273,607 $ 273,607
    Private Insurance
    $87,210 $ 87,210
    Self Pay (sliding fee) 500
    $38,250 $ 38,250
    $ 526,567
    *Includes all adjustments and any co-insurance amounts for all visit types
    Adapted from: Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience . Retrieved from
    Projected Grant Funding by Source
    Year 1
    Year 2
    Year 3
    PPHF Grant
    Foundation Grants
    $75,000 $ 50,000
    Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience . Retrieved from
    Projected Non-Staffing Costs
    Year 1
    Year 2
    Year 3
    Fringe Benefits
    $ 59,609 $ 60,802 $ 62,018
    5,000 $
    5,000 $ 10,000
    $ 35,000 $ 10,000 $ 15,000
    5,000 $
    2,000 $
    $ 15,000 $ 15,300 $ 15,606
    8,000 $
    8,160 $
    Allocated Rent
    $ 23,418 $ 23,769 $ 24,126
    $ 26,277 $ 35,036 $ 35,036
    4,004 $
    4,204 $
    Overhead Allocation
    9,167 $
    9,442 $
    Uncollectible Income
    $ 21,281 $ 39,865 $ 55,177
    $ 45,000 $ 15,000 $ 15,000
    Indirect Charges
    $ 54,764 $ 56,955 $ 59,233
    Total $ 311,520 $ 285,533 $ 315,659
    Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience . Retrieved from
    Projected Staffing Costs
    Annual Salary
    Contract Specialists
    Nurse Practitioner
    Community Health Workers
    Reception/Office Management
    Year 1
    Year 2
    Year 3
    $ 158,000 $ 165,900 $ 174,195
    $ 75,000 $ 78,750 $ 82,688
    $ 84,094 $ 86,617 $ 89,215
    $ 244,000 $ 251,320 $ 258,860
    $ 35,000 $ 35,700 $ 36,414
    $ 596,094 $ 618,287 $ 641,371
    Adapted from: Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience . Retrieved from
    Projected Capital Costs
    Remodel of Office Space
    Security System
    Practice Management System
    Computers & Cabling
    Year 1
    Year 2
    Year 3
    12,281 $
    1,000 $
    5,000 $
    2,500 $
    175,181 $
    3,500 $
    Adapted from Chelius, L., Hook, J., & Rodriguez, M. (2010). Financial analysis of Open Door Community Health Centers’ telehealth experience . Retrieved from
    Interview with Dr. Novak to Discuss the Center for Diabetes Care
    After you are assigned to the project as lead consultant, you meet with Dr. Novak to discuss the Center for Diabetes Care.
    You: Dr. Novak, it’s great to meet you. I’ve been looking forward to our discussion.
    Dr. Novak: The pleasure is mine. Before we start, here’s some information that you’ll need. I’ve included an excerpt of Western’s
    Community Health Needs Assessment, which will give you background information on our patient population. There are excerpts from
    a presentation I gave to our steering committee. The excerpts cover the program structure, marketing plans, timeline, and Western
    Hospital’s vision and mission. I’ve also included the financial projections for the Center for Diabetes Care. Finally, there are two
    excellent articles for your reference.
    You: Great. Thanks for putting this together. I know we’ve got a lot to discuss. I’d like to start by learning about why you decided to
    start the Center for Diabetes Care.
    Dr. Novak: As you know, I’m an endocrinologist, and I’ve treated many Hispanic patients. This is partly because of my language skills
    and partly based on my clinical interests.
    When patients receive a diagnosis of Type 2 diabetes, they have to navigate a complex and often intimidating healthcare system. They
    may require treatment by multiple specialists. Managing Type 2 diabetes can be confusing and overwhelming for any patient. I’ve
    seen countless patients suffer needless medical complications because they did not receive appropriate treatment or preventative
    care for Type 2 diabetes.
    In many cases, Hispanics with a diagnosis of Type 2 diabetes face even more challenges than other patients. Why? For many of my
    patients, there is a language barrier. But the barriers to my Hispanic patients getting proper care for diabetes go beyond a language
    issue. The issue is a complex combination of culture, accessibility, healthcare literacy, and finances.
    My colleague Dr. Campos wrote an excellent article titled “Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics
    With Type 2 Diabetes” that explores this in detail. I’ve included it in the file I gave you. I have also included an article that outlines the
    state of Diabetes Prevention Policy Post Affordable Care Act that I believe you will find very helpful.
    You: Why are you launching the program now?
    © 2021 Walden University
    Dr. Novak: As you can see, this is an issue I am passionate about. I’ve been tinkering with this concept for some time. New sources of
    grant funding are available since the passage of the Patient Protection and Affordable Care Act in 2010. When I learned about the
    Patient Protection and Affordable Care Act’s Prevention and Public Health Funding (PPHF), I was thrilled at first. Based on my
    understanding of this funding, a PPHF grant would potentially enable Western to create a program to support a vulnerable population.
    However, since enactment this funding has been severely cut and funding for 2020 and beyond has not been approved by Congress.
    The good news is that there is bi-partisan support for continued funding in Congress and language in the President’s Budget for 2020
    retained funding for block grants to states for chronic disease treatment and prevention and additional funding for Diabetes
    Prevention Programs. 1 Because funds have been reduced, our grant proposals will need to strongly make our case, but I am
    confident we can secure PPCF grants to help us fund start-up costs. Additionally, there may be other grants we qualify for to help us
    sustain operations, but we will need to research that when the time comes.
    You: Thanks for this information. I will look into this further. Tell me why you chose a model based on community health workers.
    Dr. Novak: Community health workers are a bridge to healthcare providers and a credible source of education for patients. I’ve given
    you an article from the Centers for Disease Control and Prevention about community health workers. It’s a great overview of why
    community health workers can effectively reach an underserved population of diabetes sufferers.
    Many of my Hispanic patients don’t speak English well. I speak Spanish, but most doctors in this community do not. This
    communication barrier impacts patients’ ability to follow through with treatment. Treatments for diabetes may also be at odds with
    patients’ cultural beliefs. I believe that a group of trained community healthcare workers can support these vulnerable patients and
    even act as their advocates.
    Think about the economics of the Center for Diabetes Care from the perspective of unnecessary healthcare costs that can be
    eliminated. We’ll pay the community health workers roughly $80,000 a year, including the cost of benefits. On average at Western the
    cost per inpatient day is $2,000, and the average length of stay at Western for a patient with diabetes as the first-listed diagnosis is 5
    days. Patients with diabetes hospitalized for other conditions stay an average of 1 day longer than patients without diabetes. If you do
    the math, the economics of the program look pretty good.
    National Association for County and City Health Officials (NACCHO). (2019). FY2020 President’s Budget Proposal, NACCHO Priority
    Public Health Program Funding – Mar 2019. Retrieved from
    © 2021 Walden University
    You: Tell me more about the population that the Center for Diabetes Care will serve.
    Dr. Novak: The patient population we are targeting is the Hispanic population, aged 65 and older, that suffer from type 2 diabetes. For
    our educational endeavors, we expand the target to their families. For our educational outreach, our target is the entire community,
    with an emphasis on the Hispanic population.
    Our geographic target is Lowertown, which is more than 70% Hispanic. Western has an urgent care center there, and the program will
    be housed in the former pharmacy and storage area. The pharmacy at the urgent care center closed a few years ago when a few of
    the big chain pharmacies came to the neighborhood. We’ll renovate the space for the team’s use, and we’ll have four small
    consultation rooms. This will make our space convenient for Lowertown residents. For those who can’t or don’t want to visit the clinic,
    the community health workers can visit them in their homes.
    You: Will insurance reimburse the Center for Diabetes Care for community health workers’ visits to patients’ homes?
    Dr. Novak: Yes, in this state, insurance will reimburse for home visits by the community health workers because they will be my
    employees. The exception is that they won’t reimburse for diabetes education—at least in this state. We’ll have to keep a close eye on
    the regulations, and we’ll have to document everything. That’s one reason we’re providing the community health workers with
    iPads—to ensure proper documentation.
    You: How has the medical community at Western responded to the Center for Diabetes Care?
    Dr. Novak: Support from both the provider and the community is a critical factor for success for this program. My colleagues at
    Western that treat other chronic diseases are interested in this program, as well. The community health worker model can be a viable
    option for treating other populations that would benefit from an alternative to the traditional medical system. It’s exciting to lead the
    team that is driving the protocols, policies, and procedures our community health workers will use at Western.
    You: What’s the reaction from the Hispanic community in Lowertown?
    Dr. Novak: The support from the Hispanic community has been overwhelming. We have several Hispanic community leaders who have
    been strong advocates. Leaders in the Hispanic community recognize that access to healthcare is an issue for many in the Lowertown
    area. Rosa Sanchez, State Senator from this district, is on the steering committee for the Center for Diabetes Care. She’s married to a
    friend of mine from residency. She’s a passionate advocate for healthcare access. We also have Hugo Guzman on the steering
    © 2021 Walden University
    committee. He’s a very successful entrepreneur whose mom and uncle are patients of mine. Rosa and Hugo give us credibility in the
    Hispanic community.
    You: Tell me more about the steering committee.
    Dr. Novak: I’ve created a steering committee that consists of another endocrinologist, a pharmacist, a nurse practitioner, and a
    nutritionist. As I mentioned, we also have community leaders on the steering committee. We’ve been meeting every other week for a
    working breakfast.
    Initially we spent our time refining the vision and mission statement for the program. You’ll see this in the documentation I’ve
    provided. We’ve also developed the organizational structure and roles and responsibilities for the staff.
    You: Let’s discuss the organizational structure of the Center for Diabetes Care.
    Dr. Novak: This is another critical aspect of the Center for Diabetes Care. I’ve worked with human resources at Western Hospital to
    create a program overview, which includes a description of roles and responsibilities. You’ll see this in the information I’ve prepared
    for you. We’ll have a team of four community health workers. I’ll work with a nurse practitioner to oversee the team.
    A big challenge is to get the right individuals in the community health worker roles. I need individuals with a combination of language
    skills, cultural competency, the ability to collaborate with the entire care team, and appropriate clinical knowledge. Human resources
    hasn’t created job descriptions yet but you can get a good sense of the role from the program overview.
    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. We will develop policies and procedures, but the nurse practitioner will support the community health workers in dealing
    with ambiguity in their roles. They will also have to be an excellent presenter, as they will conduct community education seminars and
    represent the Center for Diabetes Care.
    You: What training, if any, will you provide to the community health workers?
    Dr. Novak: We expect our community health workers to have some education in healthcare or nursing. We’ll also look for language
    skills. I believe that the key to this program is finding community health workers that our patients will be able to relate to. We want a
    team that our patients will be happy to see. The success of this program rests on our community health workers’ ability to relate to
    © 2021 Walden University
    All of our 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’ll also learn basic first aid.
    Every year, we’ll have an annual formal training for the staff. This will most likely be a weeklong intensive training at an off-site
    I want to create a learning culture for the staff at the Center for Diabetes Care. We’ll have 2-hour Monday morning meetings. These
    will include an expert speaker every other week. This could be me, a nutritionist, a pharmacist, or a community health worker from a
    different organization.
    The culture will be collaborative. We’ll learn from each other’s successes and failures. Each community health worker will present a
    success from the last week and share a case or an issue that is challenging them. The community health workers will improve their
    patient care skills and knowledge of diabetes with this format.
    You: Let’s go over the financials for the Center for Diabetes Care.
    Dr. Novak: We are so short on time; I’d prefer you review the financials on your own. I’ve worked with a senior financial analyst at
    Western. We’ve pulled together some numbers I feel really good about.
    You: How will you get the word out about the Center for Diabetes Care?
    Dr. Novak: We have to communicate with multiple groups for the Center for Diabetes Care to be successful. First, we need referrals
    from general practitioners and endocrinologists who treat patients in our target population. Second, we need to reach out to patients
    and their extended families.
    We need to explain our program to general practitioners and endocrinologists who treat the Hispanic population with Type 2
    diabetes. They will talk to their patients about this program and encourage them to participate. Of course, we need to educate nurses
    in these practices, as well. We’ll need to create marketing materials for doctors and nurses to give to patients who would benefit from
    our program.
    We’ll do a marketing blitz for our partners within the hospital. Members of the steering committee can lead the charge within their
    professional group. We need to ensure awareness and credibility among those whom the community health workers will interface
    © 2021 Walden University
    We also need to develop a marketing program for the primary caregivers to potential patients for the program. Typically, the primary
    caregivers are adult children. The diabetes patient may or may not live with the adult child, but the child is essentially responsible for
    the parent’s welfare. In my practice, I observe that the children are concerned about their parents’ diabetes, especially as
    complications manifest. Often, they are desperate to help their parents but do not know what to do.
    We want to engage the primary caregivers on two levels. First, we need to encourage their parents to enroll in the Center for Diabetes
    Care. Second, we want them to be as involved as possible in treatment. We’ll conduct ongoing education sessions for them in the
    evenings and on weekends to maximize participation.
    We’ll also use some targeted marketing to reach the Hispanic community. We’ll focus on cost-effective, highly targeted vehicles, such
    as outdoor, online, and radio. You’ll see more detail in the presentation for the steering committee that I gave you.
    You: What role will technology play in the Center for Diabetes Care?
    Dr. Novak: Technology has an important role in allowing us to communicate with patients and with the broader care team. We will
    give the community health workers iPads. They’ll use videos to explain treatment to patients. They will also use the iPads to update
    patients’ records and insurance billing.
    Electronic medical records will allow us to collaborate more easily with the broader care team. Western is finally moving away from
    paper charts. The hospital just started using an electronic medical records system. We need to figure out how we can adapt the
    system to fit our patients’ needs. Since the system is so new at Western, we haven’t determined if customization will be required.
    You: I know the launch date is April of next year. Tell me about the timeline and key milestones.
    Dr. Novak: The timeline is in the presentation to the steering committee.
    You: I know that we need to wrap up soon. I have one more question for you. How will you measure success for the Center for
    Diabetes Care?
    Dr. Novak: I see several ways to quantify success. First, from our patients’ point of view, are we slowing or stopping disease
    progression and optimizing the reduction of all risk factors associated with microvascular and macrovascular disease complications?
    Directionally we’ll measure this by the reduction in average HbA1c levels. Current levels for the target population are 10.5 and our
    © 2021 Walden University
    goal is a reduction to 8.5 in 2 years. This is significant because each 100-basis point reduction means a 15% to 18% reduction in
    mortality, heart attack, and stroke, and a 35% reduction in cardiovascular complications. 2
    We’ll also evaluate the reduction in hospital admission, readmission, and emergency room visits for diabetics in our target population.
    Specifically, we’ll measure the “all-cause” hospitalization for patients in our target population, or the rate of overall discharge for
    patients with diabetes as an “any-listed” diagnosis. In our third year of operation, our goal is to reduce this from 386 per 1,000, 3
    Western’s current rate for the Hispanic population (65 and older) with diabetes, to 310 per 1,000. The target is based on the
    hospitalization rate for the general population in the same age range with diabetes at benchmark hospitals. 4
    The frequency of our contact with patients is also important. Ideally, we’d see patients every 2 months for check-ups. Realistically, we
    anticipate that we will see each patient on average 4.5 times a year. That’s the assumption we used to create projections for patient
    From a financial perspective, success to me means the ability to operate at breakeven without grant funding by Year 3. One key issue
    for me is ensuring that we bill insurance for all services. I want no lost revenue due to insufficient documentation.
    From a community perspective, we should be reducing healthcare costs through preventative care. Beyond that, we want to
    empower Hispanic patients through education and advocacy. We’ll be conducting annual surveys about their attitude toward
    healthcare, and we are looking to see statistically significant year-over-year improvement on key metrics about attitudes toward the
    healthcare system.
    Finally, we’ll assess the engagement of our staff. We’ll measure this through retention rates and annual employee satisfaction surveys.
    We’ll also measure internal success based on the size of our best practices and lessons learned databases. This program is a model for
    Institute for Healthcare Improvement. (2015). Health disparities collaboratives: Improving diabetes care in 3,400 health center sites.
    Retrieved from
    Centers for Disease Control and Prevention (CDC). (2013). Hospital discharge rates for diabetes as any-listed diagnosis [Data set].
    Retrieved from
    Marshfield Clinic. (2015). Reduced all cause hospitalization for diabetes. Retrieved from
    © 2021 Walden University
    others, not just for diabetes care but also for other diseases and other patient populations. We need to ensure that everything we
    learn is documented.
    You: Sounds like great inputs for a balanced scorecard.
    Dr. Novak: I’d be interested in hearing more about that. (Dr. Novak glances at his watch.) I’ve got to run. You should have everything
    you need. I’m looking forward to seeing your report and presentation.
    © 2021 Walden University
    Excerpts From Dr. Novak’s
    Presentation to Center for Diabetes
    Care Steering Committee
    February 2020
    Western Hospital’s Mission and Vision
    • 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.
    • 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
    Adapted from: Memorial Healthcare System. (2015). Memorial Healthcare System mission and values. Retrieved
    Demographic Data
    for the Center for Diabetes Care
    Population of:
    Jefferson County: 1,841, 325
    Middletown: 690, 392
    Lowertown Neighborhood: 10,546
    Population of Lowertown by Ethnicity
    Population of Lowertown by Age
    African American
    0–18 years
    19–25 years
    26–45 years
    46-64 years
    65+ years
    Center for Diabetes Care
    Community Education Programs
    Classes will be available in both English and Spanish!
    Free, 8-Week Diabetes Self-Management Education Series (will be offered at several community locations)

    If you or someone you care about is pre-diabetic or has been diagnosed with diabetes, then this 8-week educational program is for you!
    Each class teaches important health and lifestyle information to help you live better and manage your diabetes. Topics include:
    – Getting to Know Diabetes
    – Staying Well With Diabetes
    – Basic Nutrition and Goal Setting
    – Stress, Depression, and Diabetes
    – Physical Activity
    – Medication Management for Diabetes
    – How to Prevent Diabetic Complications
    Free, 6-Week Diabetes Kitchen Classes

    Learn the tasty secrets to cooking healthier meals, including your family’s favorites. These classes will teach you the skills you need to
    better control or even prevent diabetes. This free, 6-week class is available to anyone who has pre-diabetes or has already been
    diagnosed with diabetes. You are also welcome to attend if you do not have diabetes—but you will cook for someone who does.
    Health Fairs and Community Events

    The program will provide diabetes education and glucose screenings at local health fairs and other community events as time, budget,
    and staffing allow.
    Center for Diabetes Care Program Structure

    Dr. Chris Novak, MD, Program Director:

    Provide organizational leadership.

    Define strategy and goals.

    Consult on complex clinical issues.

    Establish and refine policies and procedures.

    Represent the Center for Diabetes Care to the medical community and the patient community.

    Collaborate with the board of Western Hospital and the Center for Diabetes Care’s steering committee.
    Nurse Practitioner:

    Provide clinical support for less complex cases.

    Supervise community educators.

    Lead the community education program.

    Drive the creation of the best practices database.
    Four Community Health Workers:

    Serve as bridges between the healthcare system and people living with and at risk for diabetes.

    Provide support for diabetes control programs, community-based organizations, and other agencies instrumental in establishing these

    Promote actions that enable community members to access care that meets standard recommendations for diabetes care and
    prevention (e.g., annual eye exams and foot exams, regular A1C testing).

    Develop and communicate culturally and linguistically appropriate messages on diabetes self-care and community action.

    Provide social support to community members as they adapt their lifestyles, through counseling and motivational interviewing.

    Mobilize their communities for social action to address diabetes.

    Schedule appointments.

    Welcome patients.

    Manage the office.

    Bill insurance for services rendered.
    Center for Diabetes Care Marketing
    Strategy and Tactics
    Marketing Strategy:

    The strategy is to promote awareness within the target market.
    Marketing Budget:

    The steering committee anticipates that the marketing budget will be in the range of $40,000. The team will have to be
    creative to accomplish its goals on this budget. Intention is to leverage social media platforms when possible.
    Target Market:

    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:
    For healthcare providers:

    Host a lunch for key general practitioners and specialists at Bobby Fly’s (local celebrity chef) restaurant. He will serve a
    healthy Mexican lunch while Dr. Novak explains the program.

    Deliver the Center for Diabetes Care brochures to the staff of general practitioners and specialists likely to refer patients.
    For diabetes patients and their families:

    Host 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.

    Print ads in local Spanish paper.
    Excerpts From
    Western Hospital
    © 2021 Walden University
    The Patient Protection and Affordable Care Act (PPACA) or as known as the Affordable Care Act (ACA), enacted by Congress on March
    23, 2010, stipulates that non‐profit hospital organizations complete a community health needs assessment (CHNA) every 3 years and make
    it widely available to the public. This assessment includes feedback from the community and experts in public health, clinical care, and
    others. This CHNA serves as the basis for implementation strategies that are filed with the Internal Revenue Service (IRS).
    The IRS requires that the hospital conduct a CHNA and adopt an implementation strategy for each of its facilities by the last day of its first
    taxable year beginning after March 23, 2012. For Western Hospital that tax year is April 1–March 31. The CHNA may be conducted in that
    same year, or in the 2 years immediately preceding the year in which these become effective.
    This CHNA report documents how the 2019 CHNA was conducted, as well as describes the related findings.
    Process & Methods
    The Jefferson County Community Benefit Coalition (“the Coalition”) members, a coalition of eight local non‐profit hospitals and other
    partners, began conducting their third CHNA process in 2018. The Coalition’s goal was to collectively gather community feedback,
    understand existing data about health status, and prioritize local health needs.
    Community input was obtained during the fall of 2018 via key informant interviews with local health experts, focus groups with community
    leaders and representatives, and resident focus groups. Secondary data were obtained from a variety of sources. In November 2018,
    health needs were identified by synthesizing primary qualitative research and secondary data, and then filtering those needs against a set
    of criteria. Needs were then prioritized by the Coalition, using a second set of criteria. See the results of prioritization included on the next
    The Coalition met again in December 2018 to identify resources in the community, including hospitals and clinics, and special health and
    wellness programs.
    Prioritized Needs
    Based on community input and secondary data, the Coalition generated a list of health needs, and then prioritized them via a multiple
    criterion scoring system. These needs are listed below in priority order, from highest to lowest. Note that the cross‐cutting driver, Access to
    Health Care, was not included in the prioritization process but is part of the set of health needs.
    County Health Needs Identified by CHNA Process, in Order of Priority
    1. Diabetes is a health need as marked by high rates of diabetes among adults in the county. For example, county‐wide, diabetes
    prevalence is at 8% (no better than the state average) but for 2019 Community Health Needs Assessment (CHNA), the county’s Latino and
    African American population, diabetes prevalence is 14%. Drivers of diabetes rates include poor nutrition and lack of exercise, and physical
    environment, such as availability of fresh food and fast food.
    2. Obesity is a health need as indicated by high rates of obese youth (24%–31%) and adults (21%) in the county, and high rates of
    overweight youth and adults, as well (14% and 36% respectively). Overall rates miss the Healthy People 2020 targets. Latino and
    Black/African American residents have the highest rates of overweight and obesity. Drivers of obesity are poor nutrition and lack of
    exercise, and physical environment such as availability of fresh food and fast food.
    3. Violence is a health need because the rate of youth homicide (7.4%) is higher than the Healthy People 2020 target. In addition, the
    © 2021 Walden University
    county has seen a large increase in homicides in the years 2016 – 2017. Domestic violence and child abuse rates also miss the benchmark
    for some ethnic subgroups. Drivers of this health need include mental health and social determinants of health such as poverty and
    4. Poor Mental Health is a health need because of self‐reported poor mental health (17%) among county residents, higher than the state
    average. Also, youth of color are disproportionately depressed and suicidal. Community input indicates high concern about stress and
    depression specifically.
    5. Poor Oral/Dental Health is a health need as indicated by the percentage of youth reporting their teeth were in fair or poor condition
    (16%), which is worse than the state average (12%). Also, some ethnic subgroups are less likely to have dental insurance, which is a driver
    of poor oral health.
    6. Cardiovascular Disease, Heart Disease, and Stroke are a health need, as they are among the top 10 causes of death in the county.
    The overall rate of high cholesterol in the county (29%) is higher than the Healthy People 2020 target (17%), as are the rates for all ethnic
    populations. Related to poor cardiovascular health are the health behaviors of smoking, drinking, poor nutrition, and lack of exercise.
    7. Substance Abuse (Alcohol, Tobacco, and Other Drugs) is a health need because youth and adults have higher rates of binge
    drinking (12% and 25% respectively) compared with Healthy People 2020 targets. Youth marijuana use is also high. Drivers of substance
    abuse include poor mental health and lack of treatment/access to care.
    8. Cancer is a health need; incidence rates for breast, cervical, liver, and prostate cancers are higher than benchmarks/state averages.
    Certain ethnic subgroups experience different incidence and mortality rates. For instance, the overall county liver cancer mortality rate is
    6.8%, compared with 5.6% for the state, and even worse for county Latinos (9.0%) and Asian/Pacific Islanders (11.9%). Contributing
    factors to cancer are health behaviors such as smoking and drinking, and lack of screening contributes to mortality rates.
    9. Respiratory Conditions are a health need as indicated by the high asthma hospitalization rate of children ages 0–4 (24.5 per 10,000).
    Asthma prevalence among county adults is no better than the Healthy People 2020 target of 13% and should be monitored.
    10. (Not included in prioritization process) Cross‐Cutting Driver: Access to Health Care Services is a health need in the county because
    socioeconomic conditions (poverty, low levels of education, lack of health insurance) as well as factors, such as the size of the healthcare
    workforce, linguistic, and transportation barriers all affect access to care, which negatively impacts health.
    Next Steps
    After making this CHNA report available to the Public in June 2019, Western Hospital will develop an implementation plan based on this
    Purpose of CHNA Report and Affordable Care Act Requirements
    Enacted on March 23, 2010, federal requirements included in the Affordable Care Act (ACA) stipulate that hospital organizations under
    501(c)(3) status must adhere to new regulations, one of which is conducting a community health needs assessment (CHNA) every 3 years.
    The CHNA Report must document how the assessment was done, including the community served, who was involved in the assessment,
    the process, and methods used to conduct the assessment, and the community’s health needs that were identified and prioritized as a
    result of the assessment.
    As part of the tri annual CHNA assessment, hospitals must:
     Collect and take into account input from public health experts as well as community leaders and representatives of high need
    populations including minority groups, low‐income individuals, medically underserved populations, and those with chronic conditions.
    © 2021 Walden University

    Identify and prioritize community health needs.
    Document a separate CHNA for each individual hospital.
    Make the CHNA report widely available to the public.
    Adopt an Implementation Strategy to address identified health needs.
    Submit the Implementation Strategy with the annual Form 990.
    Pay a $50,000 excise tax for failure to meet CHNA requirements for any taxable year.
    Western Hospital is a 358‐bed acute care, community hospital located in the heart of the largest city in Jefferson County, the county with
    the largest population in the state. We provide care for the youth, adults, and elderly living in the county. Our key services include cardiac,
    stroke, emergency, orthopedic and joint replacement, women and children, and wound care. In an effort to provide services to patients who
    are less fortunate, Western sponsors programs such as the Health Benefits Resource Center and the Family Medicine Residency Program.
    Community Served
    Demographic Profile of Community Served
    Western Hospital serves Jefferson County, which has 1.84 million residents. The county’s six cities contain 95% of the population; more
    than one third (37%) of the county’s residents (53%) live in the city of Middletown.
    Western Hospital is within the top 5% of all U.S. counties in terms of racial and ethnic diversity. According to the 2010 U.S. Census, the
    racial and ethnic composition is 35% White, 32% Asian, 27% Latino, 2% African American, and 3% indicated they were two or more races.
    No one racial or ethnic classification is a majority within the county. Of those who selected Asian, the predominate subgroups are: 27%
    Chinese, 22% Vietnamese, 21% Asian Indian, and 18% Filipino. The vast majority of those who selected Hispanic are Mexican (84%).
    Thirty seven percent of the county’s population is foreign born, compared to 27% of the state’s population. Of those foreign born, 61% were
    born in Asia and 27% were born in Latin America. In the county, 50% of the population speaks a language other than English at home
    Gender and Age
    According to the 2010 U.S. Census, women (49.8%) and men (50.2%) make up equal proportions of the county population. The median
    age of a county resident is 36 years old, which is slightly younger compared to the overall age composition of the U.S.
    Young people (ages zero to 19) make up about 26% of the county’s population, and 38% of households have individuals under 18 living in
    them. The younger population is more diverse than the overall county population: 37% is Hispanic, 31% is Asian, 24% is White, and 5% is
    Residents, aged 65 and over, make up 12% of the county’s population. The fastest growing age group in the county is 85 and over; the
    aging resident trend is expected to continue. In the county, 23% of households have individuals over 65 living in them.
    Although the median annual income in the county is high at approximately $89,064, 9.2% of the population lives below the federal poverty
    level. In 2019, the federal poverty level for a family of two adults and two children was $25,750.
    According to the federal poverty level, only 6% of seniors are considered poor with an individual annual income below $10,201. But,
    according to the State Elder Economic Security Standard Index, nearly half of the county’s older adults (48.4%) are economically insecure.
    The Index measures how much income is needed for a retired adult age 65 and older to adequately meet his or her basic need including
    housing, food, out‐of‐pocket medical expenses, and transportation.
    © 2021 Walden University
    (Sections eliminated)
    Summarized Descriptions of Prioritized County Community Health Needs
    Access to healthcare is a health need in Jefferson County as marked by the proportion of the community who are linguistically isolated. In
    addition, there are areas with low educational attainment, which also impacts health outcomes. The community input indicates that
    underinsurance and lack of insurance coverage is an issue. Lack of transportation is also an access barrier that affects those in poverty.
    Stigma and lack of knowledge both impact the seeking of preventative care or treatment. Also, too few general and specialty practitioners,
    especially in community clinics, results in long wait times for appointments. These issues around lack of access contribute to community
    members using urgent care and emergency rooms for treatment of conditions that have worsened due to lack of treatment or preventative
    Diabetes is a health need in the county as marked by relatively high rates of diabetes. The overall adult rate meets the HP 2020
    benchmark, but Latino and African American residents are disproportionately diabetic and worse off in comparison with the county and
    state averages and benchmark. Of all ethnic groups, African Americans experience the highest percentage of hospitalizations due to
    diabetes. Community input about diabetes was strong and expressed the connection between the disease and related health behaviors,
    such as poor nutrition and lack of physical activity. The health need is likely being impacted by health behaviors, such as low fruit and
    vegetable consumption, soda consumption, the proximity of fast food establishments, and a lack of grocery stores and WIC‐authorized food
    Prioritization of Health Needs
    Before beginning the prioritization process, the Coalition chose a set of criteria to use in prioritizing the list of health needs. The criteria
    1. 2. 3. 4.
    Clear disparities/inequities exist among subpopulations in the community. An opportunity to intervene at the prevention or early intervention
    level. A successful solution has the potential to solve multiple problems. The community prioritizes the issue over other issues.
    Scoring Criteria 1–3: The score levels for the prioritization criteria were:
    3: Strongly meets criteria, or is of great concern
    2: Meets criteria, or is of some concern
    1: Does not meet criteria, or is not of concern
    A survey was then created, listing each of the health needs in alphabetical order and offering the first three prioritization criteria for rating.
    Coalition members rated each of the health needs on each of the first three prioritization criteria during an in‐person meeting in November
    Prioritization scores are based on the results of the primary data gathering process. The score levels for the fourth prioritization criterion
    3: Health need was prioritized by more than half of the key informants and focus groups.
    2: Health need was prioritized but by half or fewer of the key informants and focus groups.
    1: Health need was mentioned by at least one key informant or focus group but not prioritized by any.
    Combining the Scores: For the first three criteria, coalition members’ ratings were combined and averaged to obtain a combined coalition
    score. Then, the mean was calculated based on the four criterion scores for an overall prioritization score for each health need.
    List of Prioritized Needs
    The need scores ranged between 1.4 and 3.0, with 3 being the highest score possible and 1 being the lowest score possible. The needs
    © 2021 Walden University
    are ordered by prioritization score in the table below. The specific scores for each of the four criteria used to generate the overall
    community health needs prioritization scores may be viewed in Attachment 8. Note that while the coalition prioritized access‐related drivers,
    the cross‐cutting driver, access to healthcare services, was not scored during the prioritization process.
    Health Needs by Prioritization Score
    Health Need
    Overall Average Priority Score
    Diabetes 3.0
    Obesity 2.9
    Violence 2.6
    Poor Mental Health 2.6
    Poor Oral/Dental Health 2.5
    Cardiovascular Disease, Heart Disease, Stroke 2.4
    Substance Abuse (Alcohol, Tobacco, and Other Drugs) 2.4
    Cancers 2.2
    Respiratory Conditions 2.0
    STDs/HIV‐AIDS 2.0
    Birth Outcomes 1.6
    Alzheimer’s 1.4
    Adapted from:
    O’Connor Hospital. (2013). Community health needs assessment: O’Connor Hospital. Retrieved from
    © 2021 Walden University

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