Erin Burdi
Hope Garcia
Ashley Jacobson
Maureen Koval
Amy Reames
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Provide efficient, individualized, high quality health care
coordination services to residents of Mecosta County.
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Teach current health promotion and preventive education to
residents of Mecosta County on identifying, managing, and
reducing health risk factors common among that population.
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Teach residents of Mecosta County and their families about
models of health care delivery, and community resources.
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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.
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To demonstrate health promoting behaviors every visit.
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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.
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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.
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To provide health screening of potential health risks including physical
assessment, comprehensive health and familial history on the initial visit.
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To provide patients with the appropriate resource referrals to top quality health
services based on identified health risk factors.
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To develop a case management services based on current knowledge and
evidence based practice.
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To develop educational curriculum for the most common health conditions in
the service area.
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To establish a data base of current health plans offered in the service area.
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To build a team of highly qualified health care service providers who will
deliver care to our clients.
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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.
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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.
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).
Case Manager
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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:
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Provide case management and support to clients as needed
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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
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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.
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Refer clients to available therapeutic, social service, educational and medical resources when appropriate.
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Provide crisis intervention as necessary.
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Monitors and verifies services and insurance policies provided to each client on a monthly basis,
determining quality and effectiveness of the services provided.
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:
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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.
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).
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.
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.
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
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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
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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, AugustineSmith, 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.
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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.
Board of
Directors
Program
Director/Office
Manager
Administrative
Assistant
Nurse Case
Manager
Nurse Case
Manager
Nurse Case
Manager
Nurse Case
Manager
Nurse Case
Manager
Nurse Educator
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