Inpatient Diabetic Self-Management Teaching Program

Business Plan Development Paper

 

Pilgrim Psychiatric Center

Inpatient Diabetic Self-Management Teaching Program

Business Plan Prepared By:

Jacksonville University

 

Executive Summary

The development of an inpatient diabetic self-management teaching program is being proposed to assist long term stay inpatients in learning the skills required to self- manage their diabetic treatment regime in order to live successfully in a less restrictive setting in the community. New York State mental health housing regulations require that a person possess the skills necessary to be able to self medicate with accuracy in order to live in all levels of mental health housing.

The current system that is in place to prepare diabetic patients on insulin for living in the community requires the one RN on the unit to provide 1:1 supervision to the patient while they are mastering all aspects of their diabetic regime. This is a time management issue as the RN is also responsible for administering medications to all the other patients on the unit (average unit census is 25). Data has shown that the mean length of time for the patient to learn the skills necessary using the current self medication system is 16 weeks.

The Diabetic Self-Management Teaching Program proposes to reduce the length of time needed for an inpatient to demonstrate safe and accurate diabetic self-management from 16 weeks to eight weeks thereby reducing an individual’s length of inpatient stay by 56 days. The total cost per patient day is $835 which would reduce the cost of one patient’s hospitalization by $46,760. There are currently 44 inpatients being treated with insulin. Of those 44, 14 are currently in the process of learning self-medication skills.

The Program team would be comprised of three full-time RNs who would exclusively be assigned to the team in order to provide the individual supervision required for daily glucose monitoring and self-medication of insulin. A psychologist and a dietitian would also be assigned to the team as group facilitators but not exclusively as this assignment would be scheduled into their current active treatment group workload.

The CNO would provide executive oversight of the program and the Coordinators would be the Director for Nursing Education and a Psychiatric Clinical Nurse Specialist. The startup cohort would be the original 14 inpatients who are currently involved in self-medication education and they will be individually assessed for their current abilities in diabetes self-management.

It is anticipated that this program will reduce the length of stay, prepare the patient with diabetes for a successful transition into the community and reduce the workload of the unit RN who is having difficulty managing diabetic self-medication skills teaching along with administering medications to all the other patients on the unit. It is also anticipated that diabetic patients will be discharged into the community when psychiatrically stable and not be forced to remain in an inappropriate more restrictive level of care due to the fact that they were not provided the appropriate practical skills training by the facility in order to live a meaningful life in the community.

 

 

 

 

 

 

 

 

 

Table of Contents

Executive Summary……………………………………………………..2 Business Concept……………………………………………………….5

Management Team………………………………………………………8

Market Analysis…………………………………………………………9

Process Analysis……………………………………………………….11

Organization Plan………………………………………………………13

Marketing Plan…………………………………………………………15

Financial Plan………………………………………………………….16

Growth Plan……………………………………………………………17

Appendices and Supporting Documents………………………………18

 

 

 

 

 

 

 

 

 

 

 

Business Concept

Pilgrim Psychiatric Center (PPC) is a psychiatric facility that is governed by the New York State Office of Mental Health. It serves the seriously mentally ill population in Nassau and Suffolk County on Long Island. The bed capacity is 375 with an Average Daily Census of 375. Referrals to PPC are facilitated through acute psychiatric units located in community hospitals across Long Island when patients are not able achieve stabilization of their psychiatric symptoms within one to two weeks of hospitalization. Once accepted for admission, the patient is placed on a wait list and admitted when a bed becomes available.

The Mission of PPC is “To provide a comprehensive array of treatments and services that inspire people with unique mental health needs to experience hope, self determination, and success in their lives.” This coincides with the Office of Mental Health’s recovery philosophy and agenda to transform psychiatric services from inpatient paternalistic care to person-centered collaborative intensive treatment with the goal of quicker psychiatric stabilization and discharge to the community. The average length of stay for the three admission units is nine months and the average length of stay on the 12 psychiatric rehabilitation units is 4.2 years. Ninety percent of patients who are discharged live in some type of mental health housing with ten percent returning to their family home.

Atypical antipsychotics have become the hallmark of treating mental illness in the past decade and have been successful in helping patients with schizophrenia and schizoaffective disorder lead more meaningful lives with excellent symptom management (Parrinello, 2012). A strong link between atypical antipsychotic medication use and metabolic syndrome has been established with a particularly high prevalence of obesity and risk for Type 2 diabetes (Dickerson et al., 2005).

Currently there are 44 patients at PPC who are receiving insulin treatment for type-2 diabetes. In order for them to be considered for discharge to mental health housing patients must be able to demonstrate the ability to self-manage their diabetic regime including fingersticks, use of the glucometer, accurately preparing the correct dose of insulin, and injecting insulin. Currently patients who are assessed by their treatment team as having the ability to learn medication self-management are enrolled in RN facilitated medication education classes once a week for one hour and a diabetic nutrition class for one hour per week. They are also placed on daily ‘self-medication’ which incorporates pharmacy services in that their medications are filled using vials rather than unit dose packages as this will mimic the type of medication dispensing system they will be utilizing in the community. It is the responsibility of the unit RN to supervise the patients who are involved in self medication. There is one RN assigned to each 25 bed unit who must medicate all 25 patients including those patients who have self-medication orders. It is not an efficient method of educating diabetic patients the self-management skills that they need to master in order to be discharged to the community. As a result discharges are delayed resulting in increased lengths of stay and new admissions to the hospital are delayed as there are no empty beds. Community hospitals are housing patients who require long term treatment on their acute psychiatric units where the per-diem rate is higher than the long term hospital per-diem rate. Community mental health housing beds are vacant and patients who are ready to live in the community are remaining in the hospital as they do not have the medication self-management skills required by housing regulations.

This writer proposes the development of an Inpatient Diabetes Self-Management Teaching Program to provide daily intensive education of practical skills as well as other knowledge related to diabetes self-management in order to facilitate the transition of the diabetic patient into the community. The program will relieve the one unit RN from the responsibility of providing the individual education to the patient during real-time medication administration. The program will also carve out the diabetic patients who are currently attending generic medication and nutrition education groups and provide specialized education groups that are more inclusive of their individual needs. This group will also serve as peer support to assist in overcoming the challenges of living with diabetes in the community.

It is anticipated that this collaborative program will decrease length of inpatient stay, improve patient outcomes, and improve the self-efficacy of the patient in successfully managing their diabetes in the community.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Management Team

The management team will be comprised of members of the Nursing Department, Medicine, Pharmacy, Nutritional Services, and Psychology:

· The Director of the Inpatient Diabetic Self-Management Teaching Team will be Chief Nursing Officer (CNO) who will provide oversight to the Program Coordinators.

· The Program Coordinators will be the Director for Nursing Education and a Clinical Nurse Specialist who will provide education and training of the team as well as clinical supervision of RN diabetic educators.

· The Chief of Psychology will develop a schedule related to support groups and provide clinical supervision to the psychologists assigned to the Team.

· The Dietary Supervisor will develop a curriculum related to nutrition groups and provide clinical supervision to the dietitians assigned to the Team.

· The Chief of Medicine and Director of Pharmacy will act as consultants and provide services to the Team when required.

 

 

 

 

 

 

 

 

 

Market Analysis

The Inpatient Diabetic Self-Management Teaching Program will be targeted towards the 44 patients who are currently receiving inpatient psychiatric treatment at PPC and are on insulin therapy for type-2 diabetes. All of these patients are currently attending generic medication and nutrition education groups. Fourteen of the 44 patients are currently on ‘self medication’ which is facilitated by the unit RN who also has to administer medications to all the other patients on the unit.

In order to qualify for community mental health housing you must be able to demonstrate the ability to self medicate. For 24 hour supervised Community Residence level of care you must demonstrate that ability under the visual supervision of a non-licensed staff member who is always in attendance. Regulations prohibit staff from physically assisting with medication administration. For Supported Apartment level of care you must demonstrate the ability to manage your medications with no direct supervision as you are living in housing where there is no staff in attendance.

There is no competition for this particular program. The current program available in the facility is generic and based on the unit RN interacting with the patient on 1:1 level during medication time. During that time the expectation is that the patient is educated, assisted as needed with fingersticks, identifying glucose level and how much insulin is required, injecting insulin, and documenting the site of injection on a Self Medication Administration Record. Other aspects of glycemic control such as diet and exercise are addressed during weekly groups. The process is lengthy; ten of the 14 patients currently involved in diabetic self medication have been in the program for greater than four months. The proposed program will reduce the length of time necessary to learn the skill of glucose monitoring and insulin administration, reduce length of stay, and allow the patient to transition to the community more successfully. The total cost per inpatient day is $835 and the total cost per day for a person living in a 24 hour supervised community residences is $29. Moving people from inpatient to community residences vacates much need inpatient beds, reduces wait times for admissions from community hospitals, and operationalizes the organization’s mission.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Process Analysis

The Inpatient Diabetic Self-Management Teaching Program will incorporate multiple components of diabetic self management. The start-up cohort group will be the 14 patients who are currently practicing self medication as part of their treatment. The primary component will be education of practical skills needed to monitor blood glucose levels as ordered by the physician, determining the proper dose of insulin, and using an insulin pen to self-administer the insulin dose required. Each patient will receive their own Glucometer at a cost to the facility of $125. They will take that Glucometer with them when discharged into the community. The group will also be provided with Insulin pens at a cost of $131.50 for a 300 unit Lispro pen and $202.22 for a 300 unit Lantus pen. Although vials of insulin and disposable insulin syringes are used in the hospital, pens are used to administer insulin in community housing. Patients will be educated in using the pen in order to provide for smooth transition into the community process of insulin administration. This will be facilitated by Team RNs who will supervise self administration on the individual patient’s units. All the units are in two buildings adjacent to each other and currently the 14 patients are located on five separate but geographically close units. RNs will also be facilitating diabetic education groups related to a general understanding of the key components of the disease and its treatment, signs and symptoms of hypo and hyperglycemia, long term effects of poor glycemic control, and wellness maintenance.

Nutrition groups will be offered and incorporated into the patient’s active treatment schedule in place of or in addition to the prescribed 20 hour per week of structured therapeutic group program activities. These groups will be facilitated by Registered Dietitians and held in the Treatment and Learning Center which is located on one floor of the hospital and is the primary site of the organization’s 20 hour/week active treatment program. The focus of these groups will be consistent eating patterns and incorporating healthy food choices into menu planning, food shopping, and meal preparation; all tasks that will be necessary when living in the community.

Currently, there are evening exercise groups and leisure activities facilitated by recreational therapists that this cohort will be encouraged to join and participate in. These groups are located in the Rehabilitation Building on campus which houses an Olympic size swimming pool, full-size gymnasium, and weight room. The focus of these groups will be incorporating physical activity to improve metabolism, reduce stress, and maintain a healthy lifestyle.

Support groups for this cohort will be available and facilitated by a psychologist. These groups will focus on the cohort’s choice of topics, issues and interests as they relate to living with diabetes in the hospital and in the community. These groups may be held on the Treatment and Learning Center or in the Rehabilitation Building. Peer Specialists will be invited to participate in the group, on occasion, to offer real-life experiences related to maintaining wellness in the community.

It should be noted that this inpatient education will be documented in the patient’s aftercare referral to ensure that discharge planning includes the continuation of diabetes education post-discharge.

 

 

 

 

 

Organization Plan

There is a statewide initiative to downsize and reduce the length of stay in state psychiatric centers. PPC is currently participating in a Six Sigma project to improve the efficiency of the discharge process. Delays in discharging patients can result in:

· Longer inpatient stays resulting in increased deficits in functioning and loss of independence

· Increased cost to New York State in staffing and resources

· Increased overtime costs

· Loss of revenue in the outpatient division

· Longer wait times for orders of transfer from community hospitals to be admitted

Delays in discharge also occur when patients are unable to demonstrate the practical skills required to live in community mental health housing, in this case the skills required to manage their diabetic regimes. The Inpatient Diabetic Self-Management Teaching Program will reduce the delay in discharge and endeavor to teach the required skills necessary to make that initial transition from the hospital to the community.

Staff for the program will be recruited from inside the organization. Three FTE RNs who are chosen for the Team will be relieved of their unit assignment and will receive enhanced education and training in diabetes self-management by the Director for Nursing Education and the Clinical Nurse Specialist prior to the initiation of the program. The RNs will share currently available office space in the Department of Nursing Educations. Two FTEs will be covered by RNs who were previously assigned to two inpatient units that recently closed. PPC continuously recruits RNs who will be hired to cover the other unit position vacated by the Team RN. Until this position is filled, floating nurses currently being utilized in the facility will provide coverage as needed.

 

 

Organizational Chart

 

 

 

 

 

 

 

 

 

 

Marketing Plan

The program proposal will be discussed at the Executive Staff meeting to ensure organizational support for the program at the Cabinet level.

The initial cohort for the program will be the 14 patients who are currently participating in insulin self medication with varying degrees of success. The Clinical Nurse Specialist (CNS) will meet with the treatment teams to explain the new program and ascertain any clinical issues that may interfere with their ability to participate in the program. If there are no impediments to the patient participating in the program, the CNS will introduce herself to the patient and explain the program through the use of a color brochure which outlines the various groups and activities available. The patient, the CNS, and the treatment team will incorporate the program into the patient’s current schedule.

Each patient will be given a pre-test prior to the start of the program to assess levels of knowledge related to diabetes as well as a practical analysis of skill level in performing glucose testing and insulin administration. Patients will be provided with a marble composition book to be used for record keeping and journaling.

The treatment team will be provided written feedback as to the patient’s progress in the program. Once the patient demonstrates the ability to perform blood glucose testing and insulin administration accurately, the patient will be referred for discharge. Continuing education beyond the hospital setting will be incorporated into the patient’s discharge plan for continuing education in the community. Referrals to the program will be facilitated by the patient’s treatment team once the patient has been assessed as clinically ready to participate.

 

 

Financial Plan

The goal of the program is to reduce the length of time needed to teach an inpatient to accurately measure their glucose level and self-administer insulin from the current mean time of 16 weeks to eight weeks. The program will be held in the existing buildings of the organization and will not require any additional space. Fixed costs will be the salary of the each of the three RNs who will be assigned exclusively to this program. Individual salary plus benefits will vary depending on the level of seniority of the RN and years of experience within the organization with a range of $65,000 – $80,000/year including benefits but the assumption is they will have a salary of $80,000/year = $240,000 per year or $657.53 per day or $36,821.68 per 8-week program fixed cost. Variable costs will be based on the start-up supplies that each patient in the program will receive and will include the cost of: the glucometer ($125); 300 unit Lispro pen ($131.50); 300 unit Lantus pen (202.22); 500 alcohol pads ($20); 150 lancets ($50); 150 glucose strips ($100); 8 oz. hand sanitizer ($5); journal ($2.50); Folder for educational material ($.60) educational handouts ($25) = $661.82 per patient. The total start up cost for the initial cohort is $9,265.

The total cost to NY State per patient day is $835. The assumption is that this program will reduce the length of stay for each patient by eight weeks or 56 days which amounts to $46,760 per patient. With 14 patients in the initial cohort the total = $654,640 reduction in cost to the facility. The fixed costs are $657.53 per day or a total of $36,821.68 for the eight week program. The start-up cost for the initial cohort is $9,265 for the eight week program.

The facility would realize a reduction is cost of $608,553.32 if each of the 14 patients in the initial cohort had a reduction in length of stay of eight weeks as projected by the initiation of the Inpatient Diabetic Self-Management Program.

Growth Plan

It is anticipated that the initial cohort will master the diabetic self-management skills required in order to be discharge to the community in about eight weeks. Individuals who master the skills earlier will be discharged earlier and other inpatients will be added to the group as a vacancy occurs. The emphasis will be on learning the practical skills of diabetic self-management with the addition of education and support groups as they relate to managing the illness in the community.

Based on current literature, people treated with atypical psychotropic medications are pre-disposed to metabolic syndrome which includes obesity, hypercholesterolemia, and type 2 diabetes. The assumption is that the facility will be treating this syndrome on an increased level as more patients rely on atypical anti-psychotics to help them manage their symptoms and lead meaningful lives in the community.

The current market within the facility is strong and for education of practical skills necessary for psychiatric inpatients to live with type-2 diabetes in the community. It is not expected that housing regulations will change to allow outpatients to receive nursing services while living in mental health housing and more housing options are being funded that are less restrictive than 24-hour supervised community residences. This program will allow patients that are psychiatrically stable the ability to be discharged in a timely manner and not be kept in an inpatient setting because they lack the skills required to manage their medical needs in the community.

 

 

 

Appendices and Supporting Documents

 

Appendix A

Patient

Days

Personal

Service

Non-Personal

Service

Total PS

and NPS

Direct Cost

Per patient

Day

Estimated

Indirect Cost

Indirect

Cost per

Patient Day

Estimated Capital

Cost

Capital

Cost

Per

Patient

Day

Total

Cost per

Patient

Day

35,070 $9,882,240 $82,877 $9,965,117 $284 $13,654,371 $389 $5,686,854 $162 $835

 

 

Appendix B

Insulin Lispro 300 units (3ml) Pen $131.51
Insulin Lantus 300 units (3ml) Pen $202.22
Insulin Lispro 1000 units (10ml) Vial $44.95
Insulin Lantus 1000 units (10ml) Vial $120.97

 

 

 

 

References

Brandt J A Edwards D R Sullivan S C Zehler J K Grinder S Scott K JMaddox K L 2009 evidence-based business planning process.Brandt, J. A., Edwards, D. R., Sullivan, S. C., Zehler, J. K., Grinder, S., Scott, K. J.,…Maddox, K. L. (2009). An evidence-based business planning process. Journal of Nursing Administration, 39(12), 511-513. 20130530202643592735767

Dickerson F B Goldberg R W Brown C H Kreyenbuhl J A Wohlheiter K Fang LDixon L B 2005 Diabetes knowledge among persons with serious mental illness and type 2 diabetes.Dickerson, F. B., Goldberg, R. W., Brown, C. H., Kreyenbuhl, J. A., Wohlheiter, K., Fang, L.,…Dixon, L. B. (2005). Diabetes knowledge among persons with serious mental illness and type 2 diabetes. Psychosomatics, 46(5), 418-424. 20130601142755871657610

Finkler S A Jones C B Kovner C T 2013 Financial management for nurse managers and executivesFinkler, S. A., Jones, C. B., & Kovner, C. T. (2013). Financial management for nurse managers and executives (4th ed.). St. Louis, MO: Elsevier Saunders. 20130530202203926859498

Funnell M M Brown T L Childs B P Haas L B Hosey G M Jensen BWeiss M A 2008 National standards for diabetes self-management education.Funnell, M. M., Brown, T. L., Childs, B. P., Haas, L. B., Hosey, G. M., Jensen, B.,…Weiss, M. A. (2008). National standards for diabetes self-management education. Diabetes Care, 31(1), 97-104. 20130530203312303273320

Haag A B 2013 Writing a successful business plan: An overview.Haag, A. B. (2013). Writing a successful business plan: An overview. Workplace Health and Safety, 61(1), 19-29. 201305302028521457167506

Parrinello M C 2012 Prevention of metabolic syndrome from atypical antipsychotic medications.Parrinello, M. C. (2012). Prevention of metabolic syndrome from atypical antipsychotic medications. Journal of Psychosocial Nursing, 50(12), 37-44. 20130601141234392418265

Shirey M R 2007 entrepreneur and the business plan.Shirey, M. R. (2007). The entrepreneur and the business plan. Clinical Nurse Specialist, 21(3), 142-144. 20130530202028260695696

Ulisse G 2010 Implementation of an inpatient diabetes management team in the university hospital setting.Ulisse, G. (2010). Implementation of an inpatient diabetes management team in the university hospital setting. Diabetes Spectrum, 23(2), 131-133. 20130530203045299846410

Cover page 5
Executive Summary 10
Table of Contents 5
Business concept 15
Management team 10
Market Analysis 15
Process analysis 10
Organizational plan 15
Marketing plan 15
Financial plan 15
Growth plan 10
Appendices and supporting documents 10
Grammar, spelling, sentence structure, syntax, APA guidelines 25

 

 

CNO

 

 

Clinical Nurse Specialist (Team Coordinator)

 

 

Chief of Psychology

 

 

Psychologist

 

 

Dietary Supervisor

 

 

Dietitian

 

 

RN

 

 

Director of Nursing Education

(Team Coordinator)

 

 

RN

 

 

RN

 

 

Chief of Medicine (Consultant)

 

 

Director of Pharmacy (Consultant)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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