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Traverse Community Diabetic ServicesFerris State UniversityCheryl Howard, Stephanie Monroe, Michol Popp, Michelle Rowe, Alyson SwinehartAbstractDiabetes is a serious and complicated disease that affects many in Grand Traverse and surrounding counties. After an assessment of the external and internal environment, it was determined that there was a need for a diabetic clinic that provides services both to inpatients and outpatients. Therefore, through careful consideration, the Traverse Community Diabetic Services has been developed with a mission statement of providing exceptional diabetes education, medical management and provide high-quality nursing care for both acute clients in an inpatient setting as well as on an outpatient bases to diabetics within the community. The philosophy of the clinic includes believing clients have rights related to their care they receive and nurses have duties they must uphold. The Traverse Community Diabetic Services organizational goals include providing education, counseling and direct care relating to type 1 or 2 diabetes on an inpatient and outpatient basis. Organizational objectives embrace providing comprehensive care for diabetes by educating the community about awareness, prevention and management of diabetes through the use of seminars and screening. Furthermore, an organizational chart has been constructed and job descriptions were created to include all staff needed at the facility and advertised in diabetes journals, Traverse City Record Eagle, at healthcare organizations, and free electronic resources. Lastly, a fiscal budget was proposed which included staffing, funding/reimbursement, and operating expenses.Traverse Community Diabetic ServicesOrganizing oneself into a group to accomplish a task has been a practice that some may say is as old as time. However, becoming knowledgeable on finding out how an organization achieves its work, how to function productively within the organization and how to manipulate organizational processes is essential to the success of a professional nursing practice (Yoder, 2011). Working within a small group an analysis of both the external and internal environments was made and an agency was created, the Traverse Community Diabetic Services Clinic. This clinic was designed to best serve the healthcare needs of the residents of Grand Traverse and surrounding counties. The clinic’s make-up is complete with a mission statement, philosophy, organizational goals, organizational objectives, organizational chart, job descriptions, job advertisement, and budget proposal.Diabetes Mellitus type 2 is a chronic condition which involves elevated blood sugar levels. According to the 2011 National Diabetes Fact Sheet published by the American Diabetes Association (ADA), there was a reported 25.8 million children and adults in the United States living with diabetes (ADA, 2012). In addition, it was reported that 7 million people were estimated to be undiagnosed and 79 million people are pre-diabetic (ADA, 2012). Diabetes is a serious disease that carries serious complications. Complications include heart disease, stroke, high blood pressure, blindness, kidney disease, neuropathy, and amputations. Risk factors for developing type 2 diabetes include being over the age of 45, having a family history of diabetes, being overweight, not exercising regularly, having low HDL cholesterol, high triglycerides or high blood pressure. Women carry an additional risk if they have had a baby weighing 9 pounds or more at birth or having gestational diabetes during pregnancy. An impaired glucose tolerance or impaired fasting glucose is also a risk factor (ADA, 2012).According to the ADA (2012), in 2007 the total costs of diabetes in the United States was $174 billion, with $116 billion associated for direct medical costs, and $58 billion for indirect cost which include disability, work loss, and premature mortality. Health care costs associated with diabetes have rose 32 percent from 2002 to 2007 (MDCH, 2011). Diabetes is the leading cause of kidney failure, blindness and lower-limb amputation. The Michigan Department of Community Health estimated economic burden of pre-diabetes and diabetes reached $9 billion in 2007. If diabetes continues to grow at this rate, the economic burden of diagnosed diabetes alone will double in size by 2034. Programs that decrease the severity of medical complications associated with diabetes needs to be a priority. Therefore a closer examination of the local environments response to this epidemic is warranted.Assessment of External and Internal EnvironmentExternal EnvironmentMichigan’s growth in diabetes cases parallels with national trends. In Michigan, men have higher diabetes prevalence than females. The older population has a higher prevalence rate peaking among 65-74 year olds. “It is estimated 701,000 Michigan adults have been diagnosed with diabetes, and another 364,400 have undiagnosed diabetes. This means over 1 million adults in Michigan have diabetes” (MDCH, 2011, p. 8). Michigan has consistently been higher than the nation as a whole in prevalence rates of diabetes. Four counties surrounding Grand Traverse County; (Leelanau, Benzie, Manistee and Kalkaska) have a diabetes prevalence rate over 10%, which is higher than the Michigan’s average of 9.2% (MDCH, 2011). Michigan healthcare coverage is a major concern for all adults. Lack of insurance coverage is more of an immediate risk to people with diabetes. Michigan had an estimated 1.15 million uninsured residents in 2008, and the likelihood of being uninsured appears to be higher in the more northern counties (MDCH, 2011).According to the U.S. Department of Health & Human Services (2012) overweight is classified as a body mass index (BMI) of 25-29.9, and obesity is classified as a BMI of 30 or greater. As stated being overweight is a risk factor for diabetes. The Centers for Disease Control and Prevention (CDC) reported that Grand Traverse and surrounding counties had an obesity percent ranging from 28.4-31.1% in 2008 (CDC, 2012). Furthermore, 20.7-25.9% of Grand Traverse County and surrounding residents were reported in 2008 to be classified as physical inactive (CDC, 2012). In addition, the U.S. Census Bureau (2010) reported that 45.3% of the total population for Grand Traverse county was 45 years of age or older in 2010. Lastly a recent CDC report estimates that one third of the population will have diabetes by 2050 (Abc news, 2010). Due to the elevated rates of obesity, an aging population, and physical inactivity in Grand Traverse and surrounding counties along with the estimated increase in diabetes in the years to come Grand Traverse County would benefit from a diabetes clinic.Internal EnvironmentGrand Traverse County is centrally located to many surrounding counties including Wexford, Leelanau, Benzie, Manistee and Kalkaska. Although there is an abundance of primary care physician’s offices around the area, there are not any clinics that provide services to patients on an outpatient and inpatient basis. There is one clinic, Munson Diabetes and Nutrition Center, located at the Munson Community Health Center which offers outpatient services to diabetics. However the goal of our clinic is to provide care, education and counseling to newly diagnosed diabetics suffering from either type 1 or type 2 diagnoses. The clinic will be staffed with three registered nurses, a physician, a midlevel provider, and a registered dietician. The clinic’s staff will provide outpatient services, as well as services for inpatient newly diabetics. We will see patients in the hospital on a referral basis from hospital staff. This will allow for the patient to receive specialized diabetes education before they even leave the hospital. The clinic staff will schedule the patient for further education at our outpatient clinic upon discharge. We will also be taking referrals from local primary care offices for patients in need of diabetes education as an outpatient. Our Mission StatementAt Traverse Community Diabetic Services our purpose is to provide exceptional diabetes education, medical management, and provide high-quality nursing care for both acute clients in an inpatient setting as well as on an outpatient basis to diabetics within the community. We strive to provide a multidisciplinary approach to the care of the diabetic client and are committed to assisting our clients in managing a healthy life with diabetes.Our PhilosophyWe believe that clients:have the right to person centered, non-discriminatory care delivered in an environment of respect and dignity. have the right to high-quality nursing care in any setting which provides continuity of care that may range from an inpatient acute setting to chronic disease management in a community or home setting.have the opportunity to function at the highest level possible through the education, prevention, and treatment of diabetes and diabetes-related illnesses. We believe that nurses:have a duty to advocate for the client and put the client's needs and rights first.have a duty to uphold nursing standards of care in a professional manner.have a duty to provide evidence-based holistic care to address biophysical, psychological, social, and cognitive needs in order to promote the health and well-being of clients and the community as a whole. The clinic’s founders believe that it is important to provide fair and competent care for all clients in a person centered atmosphere. It is a nurses’ professional responsibility to provide evidence-based and comprehensive diabetes education, prevention, and treatment within the construct of a multidisciplinary team. In addition to the mission and philosophy statements, the clinic will have organization goals and objectives to both ensure success and client anizational GoalsProvide education, counseling and direct care relating to type 1 or 2 diabetes on an inpatient and outpatient basis.Be the diabetes education resource for the Traverse area community.Provide compassionate care to all clients that services are provided to.All care given is supported by current, evidenced based practice.Increase awareness of diabetes risk factors, signs, and symptoms to members of the community.Care, education, and services will be provided based on the needs of the individual and the community.Increase in the quality of life of those living with anizational ObjectivesTo educate the community about awareness, prevention, and management of diabetes by providing public education seminars and screening on a monthly basis.To assist clients and families in establishing initial care and education of diabetes both inpatient and outpatient.To provide scheduled ongoing care of diabetes as recommended by health care provider.To provide care in an interdisciplinary way by communicating with primary health providers and consider referrals to specialist assessment when indicated.To improve the quality of life for patients living with diabetes as evidenced by less diabetic complications.To provide comprehensive care for diabetes that aims not only to treat the disease, but to minimize the impact it has on our clients' lives as evidenced by less hospitalizations.To reduce morbidity and mortality rates by 5% in the community over the next 10 years.To have more than 90% of clients with diabetes have two A1C tests done at least three months apart to ensure adequate glucose control for our anizational ChartThe Traverse Community Diabetic Services clinic will offer services in the least complicated manner possible. There will be an RN clinical director who will oversee a shared governance structure. The clinic will be a standalone organization that will partner with local health care providers and facilities to provide diabetes related health care services. In a flat organizational structure, the decision making is generally delegated to the professionals doing the work. Decentralizing allows staff the authority to make decisions with patients that meet their specific needs (Mancini, 2011). Shared governance gives nursing staff autonomy to govern their individual practice and be personally accountable. A phase one shared governance structure has a nurse executive who retains decision making authority, but staff is responsible for practice issues and determining roles, functions and processes (Mancini, 2011).-408472-185166000Job DescriptionsTraverse Community Diabetic Services will be staffed with registered nurses, one of which will be the director of clinical services, a physician, nurse practitioner, registered dietician, and clerical staff.RN Clinical DirectorEducation Requirements.Current registration with the Michigan Board of Nursing as a professional registered nurse or advance practice registered nurse.Graduate of an accredited school of nursing with a Master’s degree in Nursing is preferred.Certification in the American Heart Association (AHA) Basic Life Support (BLS).2 years of management experience required.Certified Diabetes Educator is preferred.Responsibilities.Perform leadership functions of governance and decision-making within the organization.Coordinate all planning, organizing, staffing, and directing of financial funds within the organization.Collaborate with all staff members and run day-to-day operations.Maintain a safe and effective patient environment where diabetes management is viewed as a shared goal within the organization.Provide staff with the latest evidence based practice interventions to implement to improve patient care within the organization.Registered NursesEducation Requirements.Current registration with the Michigan Board of Nursing as a professional registered nurse.Graduate of an accredited school of nursing with a Bachelor’s degree in Nursing is preferred.Certification in the American Heart Association (AHA) Basic Life Support (BLS).2 years of clinical experience required.Responsibilities.Collaboration of care between physician, nurse practitioner, and dietitian.Provide professional care to diabetic clients by utilizing the nursing process to achieve desired outcomes.Report to and collaborate with RN clinical director.Develop and maintain client plan of care.Demonstrate team working skills.Adheres to the ANA’s Scope and Standards of Practice.PhysiciansEducation Requirements. M.D. or D.O. with a minimum of 2 years of medical experience.Responsibilities. Provide direct and indirect care to inpatient and outpatient diabetic clients.Collaborate care with nurse practitioner, dietician, and nursing staff.Report to RN clinical director.Adhere to the American Medical Association standards of care.Mid-level Nurse PractitionerEducation Requirements.Graduated from an accredited Master’s degree of Nursing program.Current MI license as a nurse practitioner and prescription privileges required.2 years of endocrine experience preferred.Responsibilities.Provide direct and indirect care to inpatient and outpatient diabetic clients.Identifies patient needs, skills, and knowledge needed to live with diabetes.Collaborate with the physician, dietician, and nursing staff.Report to RN clinical director.Adhere to the ANA scope and standards of practice.Registered DieticianEducation Requirements.Graduate of an accredited college or university earning a Bachelor’s degree in Dietetics. Obtaining a postgraduate diploma or Master’s degree in Dietetics is pleted at least 1200 hours of practical, supervised experience through an accredited program.Passed the national registration examination to become registered with the Commission on Dietetic Registration.Specialize in diabetes management or Certified Diabetes Educator is preferred.2 years of experience required.Responsibilities.Develop specialized diets for diabetic patients.Teach patients and their families about the importance of nutrition, diet, and food selection and how this affects their diabetes management.Evaluate how patients respond to their diets and make adjustments accordingly.Teach classes about diet, nutrition and food related to diabetes.Collaborate all patient care with the physician, nurse practitioner, and nursing staff.Report to the RN Clinical Director.Adhere to the Registered Dietitian’s Standards of Practice.Clerical SupportEducation Requirements.Minimum of an Associate’s degree with a focus in business administration or finance required.Past medical experience preferred.Past billing experience preferred.Responsibilities.Operation of office front desk.Schedules client appointments.Assists clinical staff with daily operations of the office.Handles the billing and finances for the clinic, as well as, collaborates with the RN clinical director for budget purposes.Demonstrates excellent customer service and maintains a positive attitude.Job Advertisement\sDiabetes JournalThe American Diabetes Association (ADA) publishes the Diabetes Journal on a monthly basis. Traverse Community Diabetic Services plans to run an advertisement for one month. The advertisement would be in full color, and would be a quarter of a page. The price for this is $4370. By running this advertisement in the Diabetes Journal, our hope is to not only attract healthcare professionals who have a passion for diabetes, but also, will make our services known to those in need of diabetic care.Traverse City Record EagleThis local newspaper reaches all of Northern Michigan which provides the clinic an opportunity to reach large volumes of people. Traverse Community Diabetic Services will place an advertisement in the paper on three separate days for the duration of one week. The advertisement will be 3.58” x 8”. The advertisement will first appear in the Sunday edition at the price of $400, again in the Wednesday edition for $200, then again on Friday which will be free of charge.Hospital/Healthcare OrganizationsFlyers and brochures for the clinic will be made to advertise and will be distributed among the healthcare community. Munson Medical Center has multiple areas around the hospital in which flyers may be placed. Nursing homes, doctor’s offices, and the Grand Traverse Health Department will also receive flyers to place on their bulletin boards.Free Electronic ResourcesTraverse Community Diabetic Services will utilize free internet classifieds for further exposure to the community. We will post under jobs on the northern Michigan section on craigslist and on E Bay classifieds. We will also use these two free sites for announcing our services to diabetics in the community. Under the community section we will post an announcement of the new clinic and a highlight of the services offered. The clinic will also create a Facebook page. Facebook is an easy way for the clinic to gain exposure and will allow community members to easy view updates from the clinic.Budget ProposalIn order to properly run Traverse Community Diabetic Services, a budget has to be made. Factors that affect this budget include but are not limited to, operating costs, supplies, equipment, salaries, benefits, and advertising. The fiscal year for the clinic will begin on January 1st and end on December 31st.StaffingThe hours of operation for Traverse Community Diabetic Services will be Monday through Friday from 8:00 am - 4:00 pm. The clinic will be closed for the following holidays: New Year’s Day, Memorial Day, Independence Day, Labor Day, and Christmas. There will be two full time registered nurses Monday through Friday. There will be a full time clerical staff employee present Monday through Friday. The doctor and nurse practitioner will be available throughout the week, as well as the registered dietician. The salaries for these positions are as follows:Registered Nurse Manager- 60,000- 70,000Physician- 145,000-155,000Registered Nurse- 40,000-50,000Nurse Practitioner- 70,000-80,000Registered Dietitian- 40,000-50,000Clerical Staff- 20,000-30,000The clinic will provide benefits to the full time employees. This will include health, vision, and dental plans through Priority Health. There will be PTO time for each 12 hours worked each employee will accrue one hour of PTO time which will be a combination of personal, sick, and vacation days. There will not be any on call pay available.Funding/ReimbursementTo obtain funding for this clinic, medical grants, private donations, and bank loans will be utilized. Through the State of Michigan and the American Association of Diabetes Education, there are an abundance of grants available to apply for. The community in which the clinic is located has an array of members that are known for making large contributions to medical facilities. Any other funds that will be necessary for the initial start-up costs and other expenses will be from bank loans.The care provided to clients will be reimbursed through insurance companies. Traverse Community Diabetic Services will accept Medicare Part A (inpatient) and B (outpatient), Priority Health, and Blue Cross Blue Shield. At this time Medicaid will not be accepted.Operating ExpensesThe yearly costs to operate Traverse Community Diabetic Services will have several expenses. Electric will be through Traverse City Light and Power, gas/heat through DTE Energy will run approximately $13,000 annually. Water through the township is roughly $3360 annually. General waste disposal with Waste Management is around $1200, medical waste through Steri-Cycle $3400. The phone system, with 5 lines through AT&T will run around $16,000 annually. Supplies will be ordered through medical supply wholesalers. We will be purchasing the majority of our supplies in bulk quantities which will cut down on the cost. The gross estimate for the medical supplies for the year is $ 16, 400. The gross estimate for office supplies is around $19,600. Postage costs for the office are estimated out around $2,000 annually. Advertisement costs for the clinic annually will be around $17,000. Insurances for the clinic itself, workman’s compensation, and malpractice will all also be estimated around $20,000 annually.ConclusionTraverse Community Diabetic Services was created due to the identified need in our country and community. With over 25 million adults and children living with diabetes in the United States we see an alarming need for more education clinics nationwide (ADA, 2012). We are committed to help better the lives of people in our community who are affected by diabetes. The identified plan for staffing, advertisement, goals, and budget will guide us through the process of building our clinic. With the support from our state and community we can make this clinic a reality and begin changing lives.ReferencesAbc News (2010). Disturbing diabetes forecast linked to obesity. Retrieved from Diabetes Association (2012). Diabetes statistics. Retrieved from for Disease Control and Prevention (2012). County level estimates of obesity-state maps. Retrieved from for Disease Control and Prevention (2012). County level estimates of leisure-time physical inactivity-state map. Retrieved from , M. E. (2011). Understanding and designing organizational structures. In P. Yoder-Wise, Leading and managing in nursing (5th ed., pp. 137-156). St. Louis, MO: Elsevier Mosby.Michigan Department of Community Health. (2011). The impact of diabetes in Michigan. Retrieved January 25, 2012 from . Census Bureau (2010). Profile of general population and house characteristics: 2010. Retrieved from . Department of Health & Human Services (2012). Calculate your body mass index. Retrieved from . Yoder-Wise, P.S. (2001). Leading and managing in nursing (5th ed.). St. Louis, MO: Elsevier Mosby. ................
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