Nurs660 Group3b Cva Slip Final Proposal

Running head: CVA PREVENTATIVE PERSPECTIVE
Keep Away CVA

A DRHA Holistic Preventative Perspective
Leighanne Morton, Tracy Terrones & Vanessa Mason
Systems Leadership Immersion Project
University of Arizona
April 3, 2016
Executive Summary
A stroke aftercare program is the spark that would ignite the transformation of health
modernization at Desert Regional Healthcare Alliance and the clinical enterprise comprised
thereof (Clayton, 2013). It is what propels DRHA toward fulfilling its mission of becoming a
recognized top-tier academic medical center that provides phenomenal health care that is both
personalized and compassionate (Reichert, 2014). In order to achieve this mission and reshape
CVA PREVENTATIVE PERSPECTIVE
the future of health care, DRHA has created a comprehensive, two-year post-stroke care clinic
proposal that underpins all that it hopes to accomplish for the years to come (Griffith University,
2011). Over the next two years, DRHA will pursue a strategic pathway focused on external
development to ensure program success (Clayton, 2013). The pathway requires investment in
and development of a broad network of clients targeted to offer DRHAs world-class care
directly to the community (Reichert, 2014).
Group 3B has a unique solution to the ever growing diagnostic challenge of
Cerebrovascular Accident (CVA). We are recommending the creation of a holistic framework
clinic affiliated with the American Stroke Association for CVA survivors in our community titled
Keep Away CVA (KACVA-pronounced ca-see-va). This concept was created by three
Masters prepared, Sigma Theta Tau International Honor Society nurses with a collective of over
95 years of healthcare experience. These amazing professionals realize a need for a sustainable,
all encompassing, holistic, community wide post CVA education program to be offered at Desert
Regional Healthcare Alliance to raise awareness, educate and engage the community on the
prevention of stroke. This important clinic would not only assist, educate and empower
individuals who have already sustained a CVA, but inspire their friends, family and loved ones to
unite together within their families and community to bring awareness to the causes and the
avoidable measures that can be taken to prevent a stroke.
Stroke is the leading cause of long-term adult disability in the United States. It affects
almost 795,000 people every year. Approximately 10% of stroke survivors recover almost
completely, 25% recover with minor impairments, and 40% experience moderate to severe
impairments requiring special care. According to the American Stroke Association (2016), up to
80% of CVAs are preventable and it is estimated that the cost of health care services,
pharmaceuticals for CVA patients, and absence from work is 34 billion dollars annually
(Mayoclinic.org, n.d.). Early detection, recognition of symptoms, and treatment can improve
functions and sometimes-remarkable recoveries for someone who has suffered impairments due
to CVA, non-hemorrhagic, while decreasing healthcare costs from prevention of a CVA
recurrence. We are proposing a CVA stroke aftercare clinic for our patients 65 years of age and
older and their support person to bring about community engagement and awareness of the
causes and lasting effects of a stroke, and to implement prevention framework strategies from a
holistic perspective. The goal of the Keeping Away CVA at DRHA is to improve education so
that the stroke survivor and family can achieve an increased awareness of CVA symptoms and
prevention of the recurrence with holistic support. Aftercare and prevention must be
accomplished in a way that preserves dignity and motivates the survivor to take charge of their
condition. Our unique holistic influenced clinic will help empower the client to live the healthiest
lifestyle possible and reduce their individual risk factors through education with a collaboration
of interprofessional healthcare providers.
The KACVA stroke aftercare clinic, will be clinically managed by a licensed registered
nurse who will be responsible for ensuring the proper operation and regulatory compliance of the
practice. The supporting staff will consist of an additional registered nurse and a consulting
physical therapist, speech therapist and an occupational therapist, to assist in creating a viable
and profitable business model. Throughout the first year, the clinic team will work closely with
advisers from Desert Regional Healthcare Alliance in an attempt to acquire a sound clinical
financial and operational footing, using this medical clinic proposal as a guiding management
tool (Reichert, 2014). The second year will bring a focus on teaching, awareness, and diagnostic
management of cerebrovascular accidents while emphasizing preventative measures and the

overall health and wellness of the patients (Clayton, 2013). The clinic will utilize presentation
equipment and trained, professional staff in order to optimize the care of each patient (Reichert,
2014). While it is evident DRHA understands that there are many factors that can affect stroke
health, including exercise, diet, comorbidities and heredity, the KACVA stroke aftercare clinic
will try to provide the most comprehensive medical awareness possible in order to optimize the
care and well-being of each patient it serves (Clayton, 2013). The clinic staff will also
thoroughly inform patients of both the risks and benefits of stroke aftercare compliance in an
effort to increase the patient knowledge base and thwart reoccurrence (Griffith University, 2011).
Patients would typically be prescribed by the discharge physician from DRHA, a series of
prescribed sessions 1-2 per week for 4-6 weeks post discharge. Written consent will be sought
and obtained from the patient as a basis for participation in the program. Patients shall also be
referred, when deemed appropriate, to specialists and/or to hospitals for more in-depth tests, and
further treatment and therapy (Gaertner-Johnston, 2013).
Therapeutic management sessions will be included within the context of the twice weekly
sessions for patients that will include medication supervision, side effects, body empowerment,
acute and preventative treatment and ASA (2016) sponsored Healthy Living Resource Guides for
seniors. Distribution of material on antiplatelet medications and their significance will be
provided to help accomplish CVA prevention, as well as a review of personalized risk factors and
methods to help reduce chances of a second cerebral event (Traynelis, 2012). The phrase FAST,
Facial drooping, Arm weakness, Speech difficulty, and Time to call 911, creating a new
awareness by the Strokeassociation.org. will be taught at the clinic to the clients and families as
they are valuable indicators of a CVA and necessary for community awareness for early
treatment and prevention for this target population (American Stroke Association, n.d.). Holistic
therapeutics will be presented and offered for our clients and families wellbeing, to achieve
wholeness of their mind, body, and spirit through meditation, aromatherapy, and other options. In
addition to prescribed sessions for patients, patients may attend holistic therapy sessions such as
cooking and diet change/substitution classes, the art of movement and breath and stress
management through singing. All classes will be offered by the clinic staff or community
volunteers as deemed suitable by the clinical director.
The marketing plan for this proposal involves a combination of printed presentation
media, flyer advertising, website development, networking, and promotional events, all aimed at
residents living within a 35-mile radius of the clinic (Reichert, 2014). We project a gradual
increase in patient load over the first several years, as we find our voice in the community
(Griffith University, 2011). The past experiences of the staff in conjunction with the progressive
and diversified approach to each patient, will allow the KACVA clinic to rapidly grow a large
and devoted patient base (Clayton, 2013). With an anticipated sponsorship of the American
Stroke Association, community fairs that are sponsored by DRHA would be able to present
KACVA booths that offered clinic and community information on the prevention of stroke.
Benefits to the projected population will be measured within the DRHA HCAHPS Compliance
Tracker already in existence within DRHA compliance management department.
The Keeping Away CVA clinic stroke aftercare program proposal requests $250,000.00 to
support the total unit implementation and equipment cost at DRHA. There is no balance to be
paid directly by DRHA out of funds in hand (Sutherland, 2015). Project implementation is
anticipated to begin in January 2017 and completed by January 2019. These funds would
apportion the launch and promotion of the stroke aftercare program clinic, equipment, supplies,
and staffing expenses to be instigated by January of 2017. The client payment and
reimbursement shall exist by a fee-for-service Medicare prospective payment system using the
HMO model (Sutherland, 2015). We propose a financial plan that outlines our 2-year projected
care management plan and we will be utilizing 2000 square feet within the existing hospital with
minimal improvements necessary. At first, the aftercare clinic will be dependent upon the
support received from the DRHA grant (Reichert, 2014). The proposal will also include the
salary and expenses for the first 2 years of operation (Clayton, 2013). As patient volume
increases, we will begin supporting our expenses from revenue generated by patient insurances.
At the end of the second year, the subsidies will cease, and the staff compensation will become
one of the clinic's expenses (Reichert, 2014). We expect to incur a mild operating loss within the
first year, but have planned for a strong revenue increase by the end of the subsidy period
(Gaertner-Johnston, 2013). We will begin making a profit into the start of the third year (Griffith
University, 2011). DRHA will benefit from the projected quarterly decrease in CVA
readmissions after a patient completes a prescribed KACVA clinic rotation (ASA, 2016).
Improvement processes shall be ongoing. Our projected outcomes are the development
and sustainability of this care management clinic plan utilizing quarterly audits and patient
satisfaction surveys to gage continuous quality improvement and participation (Ward, 2013).
Sustainability of the clinic would be enhanced through grants and the sponsorship process by
way of the American Stroke Association. A short term projected outcome for the KACVA
program would be a 60-75 % decrease in readmission for CVA to DRHA as monitored by
Professional Research Consultants, Inc. through the DRHA Emergency Department on a
quarterly basis, within a twelve month assessment cycle. Long Term program measurements
would be monitored through the DRHA HCAPS and Key Drivers for the PRC program on a
fiscal quarterly foundation over a twenty-four month probationary period. Patient and family
centered outcomes, anticipated care outcomes and measures of satisfaction with the care
management program will include, the patient, their family members, DRHA care providers and
fellow support personnel. It is anticipated that the outcomes and measures of success will seek to
achieve the DRHAs vision of being the guiding force for community health and well-being.
The Quality and Safety Plan for the clinic was developed and offered as a component of
the proposal in order to show the importance the clinic places on the safe delivery of aftercare. It
also works to ensure the safe utilization of the daily operations of the stroke aftercare clinic and
to aid in managing workplace health initiatives (Morello et al., 2013). The Quality and Safety
plan will outline the quality management initiatives to drive critical practice changes and the
regulatory safety compliance requirements mandated by the Centers for Medicare and Medicaid
Services (Brock et al., 2013).
With the KACVA stroke aftercare program as the spark, DRHA will become a recognized
academic partner to both patients and community physicians, and ensure access to stroke
expertise and service awareness. With the necessary investments and the fulfillment and
execution of this proposed plan, DRHA will emerge as a leader among academic medical centers
and a dominant health care provider to those living in the community and beyond (Reichert,
2014). Reducing preventable disparities through education to the CVA survivors in our KACVA
clinic will benefit DRHA and its investors by decreasing costly readmissions. Cost containment
is evident by recent changes in governing laws that organizational readmission rates and patient
satisfaction scores are now driving healthcare reimbursement (Satinsky, 2014). It would be in
DRHAs best interest to invest in this clinic to prevent patients from experiencing a second CVA
through the education and training of the surrounding population. Support of our community as
lead by DRHA, is imperative for the sustainability of its peoples health, ideologies, values and
beliefs. With the realization of the Keep Away CVA stroke aftercare program through DRHA, not
only will the community be witness to the hospitals basic desire to service its community
through education, awareness and disease prevention, but individuals, as a collective, will be
eyewitness to DRHAs aspiration to stimulate holistic wellness for the generations of today and
those in the future.
Program Introduction
Nursing care is instrumental to patients while in the acute phase of a cerebral vascular
accident (CVA) disease process. CVA is one of the foremost causes of high illness and death
rates in the United States often resulting in permanent, serious complications, incapacity or
demise. According to the American Heart Association (2015), CVAs are the second leading
cause of death worldwide and the third leading cause of demise in the United States.
Approximately one-half million people per year in the U.S. are expected to experience a CVA.
Of these numbers, 10% will die instantly followed by 20-40% yielding directly subsequent to the
acute phase of the CVA itself. Of those who endure, 10% will become totally disabled and 40%
will retain some form of infirmity. Only 10% of individuals will return to normalcy following a
CVA. The average age of the infinite majority of CVAs occur in people over the age of 65.
Cautious initial treatment becomes aggressive management after formal diagnosis following
traumatic signs and symptoms that present in patients in emergency rooms across the nation
every forty seconds. Different forms of the CVA diagnosis become apparent such as transient
ischemic attack (TIA), progressive stroke, reversible ischemic neurologic deficit (RIND) and
completed, hemorrhagic stroke. Although diagnosis and treatment have progressed within the
past decade, CVA can be an avertable condition.
We come to you on behalf of adults stricken with cerebrovascular accidents, proposing a
care management plan that will undoubtedly assist in the overall reduction of incidence and
severity of CVA. The focus of this proposal is twofold; awareness and prevention. To bring
about community engagement and awareness of the cause and lasting effects of stroke, and to
implement prevention framework strategies from a holistic perspective. With the increase in
health care coverage, medications and treatments, our proposed care management plan is to
prevent CVA through a holistic perspective. Keeping Away CVA is a program to be offered at
DRHA for the community-specifically the mature population, that encompasses a holistic
approach through diet, medications, exercises and lifestyle, to help prevent CVA. Our CVA care
management plan is simple and consists of identifying our team, establishing client eligibility,
defining our model of healthcare delivery and a presenting a plan for that care delivery. This
proposal also addresses our fiscal budget, use of health technologies, quality and safety, policy
and procedures and a detailed implementation plan. Our anticipated outcomes and measures of
success will seek to achieve the DRHAs vision of being the guiding force for community health
and well-being.
Development Team
Leighanne Morton MA, RN: A registered nurse for 27 years bringing knowledge and
experience by having developed an initial educational base on a neurologic unit in Northern
Arizona. Having completed her first Masters degree in Human Resource Development,
Leighanne will graduate this spring with a second graduate degree- a Masters of Science in
Clinical Systems Leadership. Leighanne is a people person and has worked with the adult
population for much of her career at the acute level in addition to long term rehabilitation,
Orthopedic/Neuro/Trauma and skilled care. Leighanne will bring not only an excellent
neurological skill set to the project, but a positive and nurturing motivational personality to the
patients and their families.
Tracy Terrones RN: Registered nurse for the past 30 years in critical care. Tracy has cared for
the adult population and CVA survivors during her 13 years in the intensive care unit. Currently,
Tracy is the resource coordinator of a high patient volume and progressive Cardiac Cath lab. At
present the Cath lab is looking into a Stroke Team for thrombectomy for CVA patients. Tracy is
graduating with a Masters of Nursing in Healthcare Leadership from the University of Arizona
in the spring 2016. Tracy is applying for a Doctorate of Nursing program for the fall of 2016.
Tracy will bring excellent communication skills to this project for the patients, colleagues, and
all involved.
Vanessa Mason, RN: A registered nurse for the past 25 years specializing in skilled nursing and
disease systems management. Vanessa offers a vast array of knowledge having applied many
research principles to the detection and prevention of cerebrovascular accidents in older adults.
She is currently working in a nursing leadership role as a Director of Nursing at a skilled care
facility. Vanessa is scheduled to graduate with a Masters of Nursing Science degree in Clinical
Systems Leadership and has been accepted into a Doctorate of Nursing program for the fall of
2016. Vanessa will bring a strong technical skill set and an expertise in stroke awareness and
comprehensive care management to the team.
Mission, Vision, Core Values and Strategic Plan
Mission Statement: Dedicated professionals to improve and provide quality and safety in an
efficient healthcare system by promoting the health and well-being of our community and
organization.
Vision Statement: Improve the culture of patient safety with an emphasis on teamwork leading
to a collaborative, effective, and safe environment that promotes the health and well-being of our
patients and communities.
Core Values: Our DRHA holistic values for CVA preventative perspective include respect,
teamwork, integrity, innovation, compassion, wellness, and excellence for all we serve.
Strategic Plan: Efforts to meet the goals of Healthy People 2020 by increasing public awareness
to decrease CVA risk factors, increase identification of stroke symptoms, early detection, early
treatment, and prevent recurrences.
Target Population
A growing body of evidence indicates that patients do better with a well-organized,
multidisciplinary approach to post-acute rehabilitation after a stroke (AHA/ASA, 2016). The
focus population for the KACVA clinic is aimed at clients without a diagnosis of hemorrhagic
CVA, aged 65 and older. This mature population is at a high risk for disease impairment due to
comorbidities, sedentary lifestyles and life-long poor eating habits. Many risk factors affect
individuals likelihoods of having a CVA. This is the diagnostic population that the KACVA
clinic will target in addition to educating the local community, care-givers and families of the
risk factors that are uncontrollable: age, gender, ethnicity, family history, previous CVA, transient
ischemic attack (TIA), patent foramen ovale (PFO), and fibromuscular dysplasia (FMD)
(American Heart Association, 2016). The primary pathophysiology of a CVA is an underlying
cardiac or blood vessel disorder (Kanekar, Zacharia, & Roller, 2012). The secondary
manifestations in the brain are the consequence of one or more of these primary disorders or risk
factors (Kanekar et al., 2012). According to the National Stroke Association, 87% of CVAs are
ischemic, meaning blood flow to the brain is obscured. During an ischemic stroke process, a
piece of infarction tissue or emboli that forms generally elsewhere, becomes dislodged and
travels to the cerebral cortex, occludes the vessel, and obstructs the blood flow to and within the
brain (Henderson et al, 2013). The stenosis in the brain then leads to a loss of aerobic energy and
causes the brain to employ its anaerobic energy which yields less of the high energy phosphate
adenosine triphosphate or ATP and initiates a release of lactic acid, which is unfavorable to brain
cells and tissue (Niewada & Michel, 2016). This type of medical disorder can be regulated with
healthcare management consisting of life-style changes, education, medication management,
anticoagulant therapy, ongoing, scheduled hemodynamic monitoring, periodic neurologic
assessments, and management of increased intracranial pressure through blood pressure
monitoring and observation (Sangha et al., 2014). Educating patients to control comorbidities,
such as hypertension, which is the number one cause of stroke, is an absolute necessity in the
prevention of a repeated CVA episode. Boden-Albala, & Quarles (2013) suggest that a
community accessible, hospital based, post stroke health and wellness treatment program will
decrease the incidence of a reoccurring stroke, possibly preventing an initial stroke and increase
a patients quality of life.
Client Eligibility for Care Management Plan
The eligibility criteria of the target population for admission to this care management
project are inclusive to the adult ischemic CVA patients 65 years of age and older. The patient
status post ischemic CVA must have a certain level of independent function. This assessment will
be completed prior to admission. The Barthel index will be the screening tool utilized for the
proposed CVA clients entrance to the program (Appendix A-The Barthel Index), (De Wit et al.,
2014). The initial Barthel index score must be greater than 60. The main aim of the assessment is
to establish degree of independence from any assistance that is needed verbal or physical for
readiness to learn (De Wit et al., 2014). We will be assessing each participants level of readiness
by utilizing the Trans theoretical model of change (Barrow, 2013). The TTM will allow the
assessor to determine how to tailor the educational intervention that is provided to the CVA
survivor (Barrow, 2013). To be eligible for this program the participant needs to be in the
prepared phase of readiness to change (Barrow, 2013).
Each participant will need to provide own transportation to and from each session.
Transportation will be assessed prior to approval of program. All survivors will need an
established support team of family, friends, or private help. It is essential that a support team be
established to maximize results of retained information. Being literate is not a requirement
however would be preferred. Written and picture educational material will be provided to each
participant. Spanish speaking participants are welcomed to the program. All literature will be in
Spanish and English. Having internet or a smartphone is not a requirement but is found to be
helpful. A list will be formulated of applications that participants and family members can use on
smartphones for medications, vital sign monitoring, healthy eating and activity. Daily text
messages will be sent to all participants providing inspirational phrases, diet and exercise tips,
and reminders of next clinic session. (Appendix A-The Barthel Index).
Plan for Delivery of Care
In numerous facilities worldwide, the Transitional Care Model (TCM) has been used with
pronounced success. Although existing research suggests that there has not been a patient care
delivery model that has surpassed another care delivery model for adults who suffer ischemic
stroke (CVA) or transient ischemic attack (TIA), post discharge from the hospital (Valdez, 2015),
the model chosen for this proposal is the Transitional Care Model. TCM was designed by Dr.
Mary Naylor and a multidisciplinary team of colleagues at the University of Pennsylvania.
Schraeder & Shelton (2013) describe TCM as engaging a multidisciplinary team to provide
evidence-based protocols overseen by an advanced trained, intermediate care nurse. TCM
addresses the negative effects associated with common breakdowns in care when older adults
with complex needs and various comorbidities, transition from the acute care setting to their
home or other care setting. TCM prepares patients and family caregivers to more effectively
manage changes in health associated with multiple chronic illness elicited by CVA. Stroke
rehabilitation involves care issues concerning the physical, psychosocial and spiritual aspects.
Common concerns for post-stroke patients are uncertainty about survival and handling physical
symptoms in daily living. For direction in predicting and planning discharges, we turned to the
National Institutes of Health Stroke Scale (NIHSS)a quantitative measure of stroke-related
neurologic deficit.
Hospitals are challenged with reexamining transitional care practices, to reduce 30-day
readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital
to home. According to a recent study by Wong & Kam Yuet (2015), successful hospital-initiated
transitional care programs include a bridging strategy with both pre-discharge and postdischarge interventions with pre-planned conversion providers involved at multiple points during
the recovery and at the home rehabilitation phase. TCM involves a holistic assessment prior to
hospital discharge in addition to a care planning session followed by structured events that occur
each week for four weeks post-discharge. When the patient is discharged home, family
meetings, home visits and telephone calls are scheduled by the hospital TCM team and a
structured plan is forged for optimal patient home recuperation. Prior to a patients discharge
from DRHA, a KACVA consultation is ordered by the discharging hospital physician. When the
consultation is ordered through the DRHA electronic system, an email request for assessment is
generated to the KACVA Medical Director and Clinical Director for follow through. At that time
the KAVCA Medical or Clinical Director assesses the patient while they are still admitted within
DRHA and acceptance or denial of program admittance is deemed prior to patient discharge. If
the patient is admitted, a formal clinic offer is made to the patient and an appointment time for
clinic start is given to the patient. At that time, transportation is secured for the patient to the
clinic through the assistance of the Case Manager assigned to the patient prior to discharge. If a
patient is not in admitted into DRHA and requires the need of the KACVA clinic, a paper referral
from the patients primary care provider is obtained and the patient is notified of their scheduled
clinic assessment and appointment over the phone.
Facility & Equipment
The care delivery environment for KACVA clinic will be comprised of a small unit
within existing DRHA unused clinical space. A unit developed into a clinic with a main
admission desk, quiet area with no phones allowed, four classrooms, medical director office,
clinical director office and a clinical employee office with four work space areas for employees
of the clinic will be created from existing previous patient care areas. Emphasis on an optimal
healing environments appropriate for the target population will include soothing wall colors,
furniture for patients that include recliners and chairs with arms and storage trays along with
piped in, intercom music appropriate for the clinic atmosphere and client age population of 65
years and older. Lighting with be applied that are not glaring bulbs, but soft white to reduce
brightness for patients and encourage relaxation and calm. Patients of the clinic are asked to
wear loose fitting, cotton breathing clothing that does not bind. Flat shoes or socks are
preferable for exercising, meditation, music or other therapies.
Staff
The interprofessional team chosen for the KACVA clinic will be from a diverse group of
candidates with varied clinical backgrounds in addition to diverse holistic therapy experience and
will display the appropriate qualifications in order to achieve excellent patient outcomes with
qualities that are in alignment with the clinics mission and goals. There are a total of 6
professionals assigned to the KACVA clinic with qualifications as follows:
Medical Director
The Medical Director is a DRHA vetted, licensed medical physician and shall be board
certified by the American Board of Neurology. The director will hold the senior level
administrative position with accountability for all clinical services within the KACVA clinic
situated within the DRHA facility. Responsibility includes the authority to supervise all aspects
of health care delivery including planning, resource allocation, growth and development,
regulatory compliance, quality, efficiency and the recruitment and supervision of all staff. This is
initially a part time position with a flexible balance of clinical and administrative duties targeting
an approximate time ratio of 70% administrative and 30% clinical with projection of growth to a
full time position within two years of clinic start up. Clinical duties include inpatient referrals
and outpatient services as a physician consultant secondary to the individual patients primary
care provider. The Medical Director is accountable to the DRHA Executive Director with
collateral accountability to the DRHA Board of Directors.
Clinical Director
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The Clinical Director will be a licensed Registered Nurse with 5+ years acute care and
administrative experience. The Clinical Director supervises and coordinates all service, training,
operational and personnel functions of the KACVA clinic including direct management of the
clinic RN, physical therapist, occupational therapist and speech therapist. The clinical director
will report to Medical Director for all service and operational matters and works closely with the
Medical Director, hospital providers and clinic staff matters relating to patient care. Functions
include hiring, evaluation, work flow, discipline, standards and overall performance of all
clinical personnel. Additional duties include overseeing compliance with OSHA regulations
including testing, quality control and Quality Assurance and maintaining the DRHA and KACVA
Quality and Patient Safety Plan as a member of the DRHA quality and safety team monitoring
HCAPHS and patient satisfaction surveys, scores and all necessary plans of corrections. Assists
in the development, implementation and maintenance of clinic and patient care procedures and
respective clinic protocols. Provides direct service to patients in the conduct of various clinical
procedures within the approved scope of nursing licensure. Assists in determining required levels
of medical supply inventories, conveying needs to the Purchasing Department and overseeing
other supplies and equipment needs and maintenance requirements. Under the general direction
of the Medical Director, develops and maintains appropriate policies and procedures for clinic
operations and helps ensure compliance with all federal, state and local regulatory organizations.
Registered Nurse
The clinic Registered Nurse (RN) is to provide basic nursing care to participants at the
KACVA clinic sited during scheduled clinic hours. The clinic RN provides nursing care to
program participants at the KACVA clinic on an as needed basis as determined an individualized
needs assessment and treatment. Ensures patient needs are being met during clinic hours. Works
with the interdisciplinary team to ensure appropriate continuity of care. Gathers information for a
complete initial patient assessment and enters that assessment into the DRHA/clinic section
electronic health chart that includes a complete physical and psychological history and
assessment by the patients primary care physician, list of current medications, dosages, and
allergies, and obtains vital signs on each patient at every class. Performs some nursing case
management, which may include scheduling medical appointments, clarifying the follow-up plan
of care with appropriate medical provider, assisting patients with obtaining needed medication,
and occasional scheduling transport of patients to and from clinic. Provides patient education that
is tailored to the individual learning style, education and\or reading level and is sensitive to the
culture of the individual patient. Clinic RN is to be a graduate of an accredited school of nursing
with a Bachelors degree preferred. Minimum three years of nursing experience, recent acute
care, neurological patient care and or community health nursing experience preferred. Clinic RN
is required to complete 30 hours of yearly continued education regarding holistic therapies and
stroke training.
Physical Therapist
The clinic Physical Therapist (PT) must possess a minimum of a Master of Physical
Therapy (MPT), a Doctor of Physical Therapy (DPT) degree is preferred (AHS, 2016). Evidence
of a passing score on the National Physical Therapist Examination (NPTE) exam and be in
possession of a license through the state of Arizona with a minimum of 2 years acute
rehabilitation experience (AHS, 2016). As a part of the KACVA team, the therapist will treat
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patients by teaching them different exercises intended to strengthen or stretch muscles as well as
alleviate pain during the course of a patients clinic experience regarding a post-stroke diagnosis.
The PT will consult with the patient on their symptoms and develop and support a KACVA
rehabilitation plan. Provide services that help restore function, improve mobility, relieve pain,
and prevent or limit permanent physical disabilities of patients suffering from stroke. They assist
all team members to restore, maintain, and promote overall fitness and health of clients.
Regular duties of the clinic Physical Therapist include:
Consulting with patients to learn about their physical condition and symptoms
Developing a treatment plan within clinic guidelines with preventative measures
Teaching patients how to properly use exercise techniques
Providing stimulation or massage, relaxation techniques and breathing exercises
Use equipment and devices to assist patients
Uphold patients records, keeping track of goals and progress
Counsel patient and family about in-home treatment options and exercises
Occupational Therapist
The clinic Occupational Therapist (OT) must possess a master's degree (AHS, 2016) and
hold a certification from the National Board of Certification for Occupational Therapists
(NBCOT). A minimum of 3 years of neurological experience in a rehabilitation facility is
preferred. As a part of the KACVA team, the OT will be consulting with patients, developing
treatment plans and using a number of exercises and equipment to treat patients during clinic
classes. The clinic OT will be supportive, compassionate and patient centered with experience in
aromatherapy, essential oil therapy and music therapy desired. Occupational therapists use
treatments to develop, recover, or maintain the daily living and work skills of their patients. The
therapist helps clients not only to improve their basic motor functions and reasoning abilities, but
also to compensate for permanent loss of function. The goal is to help clients have independent,
productive, and satisfying lives.
Speech Therapist
The clinic Speech therapist (ST) must possess a minimum of a bachelors degree from an
accredited university by the Council on Academic Accreditation in Audiology and SpeechLanguage Pathology; completed 400 training hours; 25 of which are observation and 375 hours
in direct clinical contact (AHS, 2016). The ST will be eligible to take the Certificate of Clinical
Competence (CCC) from the American Speech and Hearing Association (ASHA) or be in
possession of the CCC within one year of hire. The ST must have excellent interpersonal skills
organizational skills, communication skills, initiative, flexibility, adaptability, patience and team
working skills. Treat speech, language, cognitive-communication and swallowing disorders in
individuals of clinic admission requirements utilizing an individualized plan with both long-term
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goals and short-term goals established for each individuals needs (AHS, 2016). Regular duties
of the clinic Speech Therapist include:
patient assessments at clinic admission
arrangement and providing appropriate treatment within clinic/class description
giving advice and support to patients, family members and community members
maintaining records and case notes within the electronic health charting system
liaising with doctors, physiotherapists, teachers and family members and care takers
performing holistic based therapy sessions with individuals, groups and/or families
Sponsorship
With approved funding for the KACVA clinic from DRHA, the Clinical Director will
submit a corporate application for sponsorship by the American Heart Association, which is a
corporation strategically aligned with DRHAs mission to improve the health of families, make
communities healthier, provide emotional support to patients and ensure quality of care for all.
Sponsorship would provide cost free, online healthcare resources, additional clinic grant
opportunities, current, electronic health awareness programs and cost effective continuous
employee education while simultaneously meeting business objectives for both employees and
customers. Alongside with the AHA, we have the prospective to save 863 lives per day by the
year 2020 (AHA, 2016).
Plan for Financing
This total care management initiative project cost is $250,000.00 over a two year period.
This proposal requests $250,000.00 to support the total unit implementation and equipment cost.
Project implementation is anticipated to begin in January 2017 and completed by January 2019.
Part of the fee structure for this unit located within the hospital, shall be utilized for salaries and
various equipment costs to run the aftercare clinic. The annual salary and benefits for the staff
totals 70,674 and is further outlined in the appendix below. The equipment and supply annual
costs total 4,600 as most of the items are already in place on the unit from previous department
use; such as computers, AV equipment, bar code scanners for patient identification and
communication with the broad hospital database, televisions and DVD/CD players/recorders and
auto-generated music via the public address system for patient relaxation. In addition, it is
imperative to note that reimbursement to the clinic shall exist by a fee-for-service Medicare
prospective payment system using the HMO model (Sutherland, 2015). The HMO receives a flat
dollar amount and is responsible for providing whatever services are needed by the patient
(Kalman, Hammill, Schulman, & Shah, 2015). The revenue cycle is generated with the
registering of patients, as well as the completion of the additional paperwork for
Medicare/Medicaid Secondary Payer (Sutherland, 2015). This questionnaire should be
completed or updated at the time of registration. Co-pays can be collected at the time of
13
registration, before the patient moves forward in the process (Sutherland, 2015). This helps to
improve the patient flow. The Desert Regional Healthcare Alliance (DRHA) is committed to
healthcare excellence and community driven care. Therefore, we propose a financial plan that
outlines our 2-year projected care management plan. We will completely utilize the unit within
the existing hospital for group presentation and holistic therapy, screening, training, private
consultation rooms and will ensure that the unit is equipped to handle the accessibility
requirements under the Americans with Disabilities Act; as some of the clients served may have
a physical disability resulting from their stroke (Sutherland, 2015). These improvements will
result in a large and well organized unit, well suited to the services available to the stroke patient
population (Kalman, Hammill, Schulman, & Shah, 2015).
The payment amount is based on diagnoses and standardized functional assessments, but
the payment concept is the same as in an HMO (Sutherland, 2015). For private insurance and
self-pay patients, this is a service that is not available at this time through the clinic (Kalman,
Hammill, Schulman, & Shah, 2015). Once an agreement to offer services is reached, then the
patient shall receive only the services outlined in the initial contract and remit payment via the
insurance option listed above (Kalman, Hammill, Schulman, & Shah, 2015). This total care
management initiative project cost is $250,000.00. This proposal requests $250,000.00 to support
the total unit implementation and equipment cost. There is no balance to be paid directly by
DRHA out of funds in hand (Sutherland, 2015). Project implementation is anticipated to begin in
January 2017 and completed by January 2019. (Appendix B-The Budget).
Use of Integrated Health Technologies
The challenge facing DRHA healthcare professionals is to determine which new ideas
regarding quality stroke programs and models are trends that will last and which ones will fade
into the background when a new trend emerges (Shaw & Elliott, 2012). As part of our vision
statement, promotion of a patients safety, health and well-being is available at the touch of a
smartphone application. Sponsored through the American Stroke Association, is a free
application that can easily be downloaded onto a patients or caregivers phone that details
instructions on the signs and symptoms of a stroke entitled Spot a Stroke FAST (Appendix CSpot a Stroke FAST). Social media is a tool by which DRHA is able to reach out to the
community and educate about the KACVA program in addition to all other programs within the
hospital setting. By utilizing the social medium of Twitter, DRHA and the KACVA team set up a
media interaction page that allows patients and those in the community to ask questions, share
information and follow clinic interactions in real time. Twitter is an online, internet constructed
social networking service that facilitates consumers to propel and read short messages entitled
"tweets" (Twitter, 2016). Patients and community members who are registered users of this free
service, are able to follow a particular person or group, send and receive information through a
designated page by a hashtag or word title or phrase. As part of the clinic staffs responsibilities,
each member of the team is assigned alternating weeks to attend to social media updates and
response messaging. (Appendix D-Twitter Page).
Set Up Medical I.D. on Your Smartphone
To make your essential health information available in case of emergencies, patients
admitted to the KACVA clinic will be assisted in setting up their Medical ID on their
14
smartphones (Apple, 2016). To add emergency contacts and health information like your birth
date, height, and blood type, medications and history can be accessed at the swipe of a finger,
even if the patients phone screen is locked. To use the Health app, you need an iPhone or iPod
touch with iOS 8 or later (Apple, 2016). Health information can be tracked from multiple
sources, like compatible applications and fitness accessories. For example, if a patients wrist
watch monitors heart rate and a third-party application tracks a patients lab results, data can be
accessed from the Health application and generates important health information that is easy to
obtain in case of emergencies. (Appendix E-Medical ID).
The electronic patient record has become an important aspect in the information
workflow, and using evidence technology will result in educating patient outcome quality and
efficiency. Patient documentation is a vital proficiency in communicating the patient's condition
and organizing their care according to the patient's needs. Nursing practice is primarily guided by
patient's' needs and depending on those needs and their environments, different theories can be
applied for individualized care. The application of individual nursing practice is based on a
sequence of medical, philosophical, psychological and other nursing theories. Given the relative
ease of access of electronic records for those within the healthcare community, educating the
community in regards to personal privacy of information within healthcare records is a top
priority within the technological modernization process (Thede, 2010). DRHAs patient portal
offers an easy, secure way to manage healthcare online. The portal enables individuals to view
health information from all doctor visits and hospitalizations, retrieve lab results and update
personal key information such as email addresses, telephone numbers and insurance information.
Access for patients to the DRHAs secured portal website can be granted if an individual has
been a registered patient at any DRHA facility. Patients will be asked, prior to discharge and
again at the start of their admission to the KACVA clinic, if they would like to receive an email
invitation to join the portal. If a patient does not have access to a computer, DRHA has made
available, in the hospitals library, free use of three computers that are available to the public
Monday-Saturday from 0800-1700. These computers have easy to use, step by step instructions
on how to access the DRHA portal in addition to a DRHA employee librarian who is positioned
at the help desk within the library for patient support.
Quality and Safety Plan
All equipment at the CVA Survivors Clinic will be checked prior to utilizing in direct
patient care (Carayon et al., 2014). To assure the readiness of all equipment and products for the
care of CVA patients, a hands on verification of supply inventory, availability, and readiness of
emergent devices, will be performed upon opening and closing (Carayon et al., 2014). The 0630
scheduled CVA Clinical staff person will be responsible for verifying all equipment and
necessary supplies are available and in working order. Where a discrepancy is noted, that staff
person (or designee) will contact the appropriate service provider for corrective action (Carayon
et al., 2014). At the end of the shift, the same person will again perform the same duties and
additionally alert other staff members of any discrepancies that have been addressed with
15
alternative department(s) and or service provider(s). All emergent equipment and supplies will be
replenished prior to the commencement of any patient therapy. Throughout daily operations,
scheduled staff will replenish supply inventory and make requests to appropriate service
providers when required.
The DRHA Quality and Patient Safety Plan recognizes that all aspects of the organization
have an impact on high quality care and safety: leadership, governance, staff/physicians, the
patients and their families (Brock et al., 2013). Workplace health initiatives such as staff culture,
organizational development, staff competencies, training, education and organizational health
impact on our core business of patient care (Morello et al., 2013). Our quality and safety plan
includes, executive walking rounds performed to offer insight into the care process and the
potential of harm to the patient (Brock et al., 2013). This is demonstrated when hospital senior
executives walk a particular unit/area on a monthly basis. We also feature an online safety event
reporting system which tracks safety data and also allows any employee to report a near miss,
process problem, or a patient event (Morello et al., 2013). Our quality and safety plan also
encompasses a hand hygiene, falls reduction, infection control/flu vaccine, and environmental
safety program. These quality and safety indicators drive compliance and best practice standards
within the workplace (Brock et al., 2013). Good hand hygiene directly affects hospital infection
control and reduces the incidence of disease transmission (Wolfe et al., 2014). Falls are
considered a major public health problem around the world (Ward, 2015). Reducing the number
of falls within the clinic will serve to reduce the number of adverse events and keep patients safe
while minimizing the likelihood of serious injury (Ward, 2015). Instituting a flu vaccination
program will provide for the safety of not only the patients, but the providers who institute care
by decreasing the transmission and increasing the resistance to the virus (Frank, Dresner, Shani,
& Vinker, 2013). The environmental safety quality indicators of safe building structure and fire
safety are implemented to ensure a safe environment for the patient and staff. Through
environmental rounds and equipment and fire safety periodic audits, the unit is sure to be kept
free from preventable complications (Van Horenbeek, & Pintelon, 2014). (Appendix F-Fall &
Injury Data).
The DRHA Safety Committee are personnel responsible for tracking and reporting trends
in quality and safety. The committee is made up of various department designees within the
hospital, are responsible for quarterly reports to the DRHA governing board complete with fiscal
data and quality management initiatives to drive critical practice changes and regulatory safety
compliance requirements (Brock et al., 2013). The KACVA Clinical Manager is appointed as a
part of DRHAs Quality and Safety management team representing the KACVA clinic. The
Quality and Safety management team gathers data throughout the each department within DRHA
and are responsible for the quarterly presentation to the hospital board, of indicators and trending
data incorporated into DRHAs strategic mission statement. In January 2011, CMS published the
anticipated rule for value-based purchasing (VBP)-reimbursement based on the quality, not just
the quantity of care provided (PRC, 2011). The patient experience area which comprises 30% of
a hospitals total performance score used to determine incentive payments for any given fiscal
year, uses 17 measures from the Hospital Consumer Assessment of Healthcare Providers and
Services (HCAHPS0 survey (PRC, 2011). The HCAHPS survey measures regularity of several
actions or practices from a patients perspectives, all thought to enhance clinical outcomes (PRC,
2011). The HCAHPS survey examines questions dedicated toward standardization (PRC, 2011).
If a hospital works to improve these processes, quality of care will also improve. When
assessing the quality of healthcare by staff, complying with HCAHPS measurements and earning
16
patient loyalty are areas to be monitored by clinical management. KACVA needs to focus on
improving and or maintaining high HCAHPS scores in order to maximize reimbursement from
CMS (CMS, 2016). KACVA will focus on compliance and excellence. Acquiescence with the
expected behaviors 100% of the time, is the goal. An emphasis on quality will motivate staff not
simply to do the behaviors, but to give quality to patient interactions (PRC, 2011). CMS
projected the HCAHPS data to produce meaningful contrasts across the nation concerning the
patient experience. With public reporting thereby increasing culpability of staff, motivation to
improve quality of care is apparent. Goals can be interpreted as aiming to standardize methods of
providing excellent patient care all across the DRHA facilities (PCR, 2011). (Appendix F & F1Measuring HCAHPS Compliance).
Shared governance is correlation and collaboration with clinical practice changes,
implementing evidence-based practice into the DRHA stroke model. It involves teamwork,
problem-solving, and accountability, with the goals of improved staff satisfaction, productivity,
and patient outcomes. Real shared governance increases collaboration, creates useful links
between constituencies, and builds needed partnerships. When shared governance is regarded as
more than a traditional set of limitations and rules of engagement, it can create a system where
the integral leaders move beyond the fusion of customary governance (Bahls, 2014). Shared
governance is teamwork, whether in scheduling staff, educating new staff, or applying evidencebased practice. It encompasses teamwork, problem-solving, and liability, with the objectives of
improved staff satisfaction, throughput, and excellent patient conclusions. The KACVA clinic,
along with DRHA, is working together to make comprehensive, virtuous choices that affect
nursing practice and patient care in a positive manner-such as the prevention and reoccurrence of
stroke. It is working with other disciplines such as physical therapy, occupational therapy and
speech therapy, for the good of the patient. It is collaborating to advance nursing practice
(Bonsall, 2011). Working together to make resolutions that affect nursing practice and patient
care along with other disciplines produces excellent patient outcomes (CMS, 2016). To realize
the goals of KACVA, the clinic has adopted a model of integral leadershipcollaborative but
decisive leadership that can energize the vital partnership between the DRHA board, executives
and clinical management. Integral leadership links all involved in a well-functioning partnership
purposefully devoted to a well-defined, broadly affirmed institutional vision (Bahls, 2014). As
shared governance is regarded as more than a set of limitations and rules of engagement, it can
create a system where the integral leaders move beyond the fragmentation of traditional
governance (Bahls, 2014). KACVA will move to shared responsibility for identifying and
pursuing an aligned set of sustainable strategic directions. The KACVA structure is shared
governance; the method is expert nursing practice; the outcomes are affirmative productivity data
(Bonsall, 2011). Safety collaboration increases nursing organizations. Based on quality and
safety data, critical practice changes are a necessity with stroke prevention and aftercare in order
to prevent further incidents as demonstrated by data collected within DRHAs admission
department pertaining to falls and injuries sustained due to CVA and the admissions of patents
with a diagnosis of CVA, all groupings. (Appendix G-DRHA CVA Fall & Injury Data).
Quality and safety processes are reported to the Centers for Medicare and Medicaid
Services (CMI). With the execution of the Keep Away CVA clinic, patient care, education, family
support and training will increase leading to positive and healthy outcomes thus having a direct
impact on decreasing reported CMI DRHA indicators (CMS, 2016). Directly in proportion with
the CMI indicators, quality measures will begin to show a sharp decline as patients are
17
immediately referred to the clinic prior to acute hospital discharge. All data measured is
integrated into the quality and safety plan. As data is collected and reported by means of
HCAPHS, review of said data will occur at the DRHA quarterly quality and safety meetings. If
the committee finds variances to departmental outcomes, that being less than an excellent
outcome, as reflected by scores on analysis, a plan of correction integrated with unit specific key
drivers will be required from that specific units clinical manager. Ongoing monitoring from
committee members will ensure compliance from all DRHA managerial staff.
Policies and Procedures

The Desert Regional Health Alliance CVA survivors clinic respects patients rights. The
CVA survivors clinic recognizes that each client is an individual with unique health care needs.
Each client is entitled to dignified, considerate, confidential, and respectful care. Client services
at the clinic are provided through an organized and systematic process designed and
implemented to ensure safety, timeliness, effectiveness, quality, respect, and trust. It is the
organization's commitment to respecting clients rights and responsibilities for appropriate care,
numerous policies and procedures on current care guidelines have been developed and
implemented to support this process. Included are operational, administrative, and clinical care
policies and procedures. (Appendix H-Policy and Procedures; H1-Clinic Referral).
Operational Policies and Procedures
Hours of Operation Guidelines

Scheduling & Staffing Guidelines
CVA Clinic Equipment Check
Acceptance of: DRHA Policy
and Procedures
Admission, Continuing Therapy,
and Discharge from CVA Clinic
criteria *
* See Appendix H & H1
Administrative Policies and Procedures
Plan for Provision of Care

Budgeting
Nursing Director Qualifications
Clinical Director Qualifications
Medical Director Qualifications*
* See Appendix H
Clinical Care Policies and Procedures
Client Assessment
Nursing Diagnosis
Holistic Therapeutics
Procedural Documentation
Code Blue in the CVA Clinic*
* See Appendix H
18
Implementation Plan
Stroke is a significant growing health problem in the world today (Henderson et al.,
2013). It is the third leading cause of death, and the number one cause of disability in the United
States (Onwuchekwa, Tobin-West, & Babatunde, 2014). With the Baby Boomers approaching
Medicare agethe period at which prevalence of stroke increaseshospitals should anticipate
growth in stroke volume for the years to come (Henderson et al., 2013). For this, we believe the
time is now to implement a leading edge stroke awareness and management program. Our
implementation plan includes stages of positive progression to assist in executing and marketing
the plan. The Rogers diffusion of innovations key elements such as adopters, communication
channels, time, and the social system combine to drive the success of the innovative idea or
proposal (Ward, 2013). While the aspect of a CVA survivor clinic is novel, and appears to be an
innovation-system fit for DRHA, the concept must become a part of the organizations culture in
order to diffuse quickly and be fully implemented. The five marketing stages to full adoption of
this innovative idea are; awareness/knowledge, interest/persuasion, evaluation/decision,
trial/implementation, and full adoption/confirmation (Ward, 2013). In an attempt to influence the
spread of this new concept for stroke survivors, it is our plan to consistently provide and manage
this program which allows best practices to be used and ensures that energy and time are spent
on this high quality, well-thought-out program.
Initial Launch of the Care Management Plan
Development of the initial aftercare clinic will include two registered nurses and licensed
therapist consultants. The clinic will allow for approximately 25,000 patients visits per year, or
8,000-10,000 patients annually (Ward, 2013). The patient mix to start will be approximately
90% DRHA acute care referrals and 10% private practice referrals. The clinic will offer
extended hours including 8am-5pm Monday through Friday and 8am-12pm on Saturday (Brock
et al., 2013). It is anticipated that two additional support staff will need to be hired later in the
program for additional holistic classes for patients and community members. The
implementation goals are to decrease CVA risk factors, increase identification of stroke
symptoms, early detection, early treatment, and prevent reoccurrences.
Full Implementation of Services Provided
The full implementation/assessment begins when a patient is referred to the clinic and arrives
at their designated appointment. With every interaction, staff must be accessible, courteous,
knowledgeable, and helpful (Henderson et al., 2013). After registering and signing in, the
patients' needs and concerns will be addressed and they will be asked politely to have a seat in
the quiet room-waiting area (Brock et al., 2013). In this area, they will experience comfortable
seating, good lighting and soft music. No T.V. or telephone conversations are permitted in this
area as general comforts are appreciated by any patient (Ward, 2013). The walls will have
beautiful art and perhaps there may even be a fish tank (Henderson et al., 2013). The clinic
rooms will be professional, clean and organized and the walls will be decorated with holistic
based posters and therapy information that will help explain the most communal stroke
prevention measures (Kalman, Hammill, Schulman, & Shah, 2015). The flow of the aftercare
19
clinic will be effortless and will leave the patient with a sense of accomplishment, peace and
gratitude.
Plan for Growth and Sustainability of the Proposal
The first year is all about implementation planning and piloting (Ward, 2013). During the
first 6 months, the program should be developing and finalizing its implementation plan
(Kalman, Hammill, Schulman, & Shah, 2015). During months 712, the program should be in
pilot testing mode, with DRHA approval, with tweaking the implementation plan as necessary
(Brock et al., 2013). We shall sustain the program with quarterly evaluations that reveal
performance improvement metrics and continue to generate revenue for support of the program
structure. We shall grow it by constant networking, advertising and quality improvements.
Marketing Plan
Upon opening up a new aftercare clinic, it is important to create momentum before the actual
opening day (Henderson et al., 2013). In conjunction with our thorough marketing plan, this
momentum will be created 2 months prior to the opening date (Ward, 2013). We will first ensure
our name is recognized in conjunction with promoting the location and the services we can offer
(Henderson et al., 2013). We shall then establish a strong presence within the community and at
hospitals and physicians offices. Then we track our results and utilize best practices.
In keeping with Rogerss diffusion of innovation steps, we intend to bring about
awareness/knowledge of the clinic utilizing a marketing flyer and/or personal contact with the
stroke survivor via seminars, home/hospital visits, their physicians office, emails and personal
telephone calls (Ward, 2013). In order to generate interest/persuasion in our aftercare clinic
initiative we shall ensure the clinic values align with the survivors values and keep the
participation experience user-friendly, timely and easy to navigate through (Ward, 2013).
Always placing emphasis on the positive aspects of the clinic. To aid the patient in evaluating
and deciding to move forward with our offered services, we plan to gauge the interest level via
feedback and interest survey forms and ask for a decision (Ward, 2013). When the patient
decides to proceed in the program, we will offer a trial/implementation of the innovative clinic
on our first fifty CVA survivor participants in order to obtain constructive feedback on the
process system utilizing a completion survey or telecommunication tool (Ward, 2013). Finally,
our planned innovation shall be brought to full adoption/confirmation by full implementation of
the aftercare clinic and by also confirming and networking with the various other organizations
and individuals that support our innovative idea of a CVA survivors clinic (Ward, 2013).
It is important to note that the initial launch of the marketing plan has already begun with full
implementation of services solidified by the end of the second quarter. We shall grow and
sustain this care management clinic plan by utilizing quarterly audits and patient satisfaction
surveys to gauge continuous quality improvement and participation (Ward, 2013). Improvement
processes shall be ongoing. (Appendix I- Marketing Flyer).
Anticipated Outcomes and Measures of Success
Measurement of Patient Satisfaction
20
A significant element of any program is the assessment and evaluation of its efficiency
from the initial stages of execution. Patient and family centered outcomes, anticipated care
outcomes and measures of satisfaction with the care management program will include the
patient, their family members, DRHA care providers and fellow support personnel. The KACVA
patient and family programs evaluation context is a loyalty survey designed to summarize and
organize the essential elements of the KACVA program. Statistical analysis of the patient loyalty
survey will identify key drivers of excellence. This exploration highpoints the survey questions
that are the most important in differentiating an excellent experience from a very-good
experience as measured through the overall quality of care (PRC, 2011).
Appendix J-Measuring Patient Loyalty
Nationally, the most common key driver is Overall, how would you rate the teamwork
between doctors, nurses and staff preceded by the second most common key driver: Overall,
how would you rate your safety? (PRC, 2011). Neither of these questions is located within the
HCAPHS structured survey, but for patients, these inquiries are vital for an outstanding and
positive clinical experience (PRC, 2011). Loyalty questions ask patients how they ardently feel
about their medical care. Patients and families do not want only duties to be completed within a
clinical setting; they want to experience that their team is synchronizing with one another to
provide remarkable care for them. Loyalty questions are focused less towards the quantity of the
preferred behaviors and more toward the quality of the interfaces (PRC, 2011). How patients
and their families are connected with their providers and with a hospital and their programs can
predict future purchasing behaviors and how they will talk about DRHA within the community
(PRC, 2011). When patients rate their overall quality of care as excellent, they are four times
more likely to be loyal to the hospital and therefore recommend the facility and its programs
within their community setting (PRC, 2011). (Appendix K-Inpatient Perception of Overall
Quality of Care).
A critical step in planning and the measuring of data is the identification of key questions
that will be answered by the assessment. The intentional use of the evaluation directs the nature
of the questions chosen. The four indicators of our quality and safety plan: hand hygiene, falls
reduction, infection control/flu vaccine, and our environmental safety program will incorporate
many perspectives from all clinicians involved that will aid in the acceptance of the overall
evaluation. All end result evaluation questions need to be understood by clinicians, family
members and most importantly, by the patients. (Appendix L- Future Projected GrowthSustainability Post Initial Year of Program).
Sample Evaluation Questions
What part of the clinic is functioning well? What system or process should to be altered?
How do we know that weve been effective and or successful? What have we achieved?
Have we made a difference? Is there evidence to suggest that things are working and if so,
is there new research available? How should we do things differently the next time a new
program is created?
Measurement of Employee Satisfaction
During the development stage, the scope of an evaluation can easily expand as ideas are
generated and new input is obtained from participants. By staying focused on how appraisal
21
results will be used by the program and its participants, evaluators will be better able to
distinguish between information that is a necessity and that of which is a subtlety (Haney, 2010).
Care providers will participate in monthly group staff meeting discussions with the KACVA
clinical manager in addition to participating with the DRHA employee engagement survey,
available by email invitation from the Human Resource Department via employee email with a
link to the survey. Employees of DRHA are able to complete surveys from any computer at
work or at home that has email access. Results from the DRHA employee engagement survey are
anonymously relayed to each department director for a plan of correction if indicated. Being
aware of the intended use of the evaluation findings will help to safeguard that crucial
information is obtained without superfluous, expensive distractions and overly heavy evaluation
systems.
Supposition
Lives change forever when a person experiences a stroke. Once a formal diagnosis is
completed, an individuals independence can evaporate. In addition to an individual losing selfesteem, financial disintegration may result causing personal hopelessness and helplessness. At
Desert Regional Healthcare Alliance hope is not lost. Optimal patient health is what propels
DRHA toward fulfilling its mission of becoming a recognized top-tier academic medical center
that provides extraordinary health care that is both customized and compassionate while
maintaining and supporting our mission statement of ensuring that dedicated professionals are
employed to improve and provide quality and safety in an efficient healthcare system by
promoting the health and well-being of our community and organization.
Keep Away CVA (KACVA) is a post stroke clinic plan that will undoubtedly assist in the
overall reduction of frequency and severity of a CVA and possibly the complete prevention of a
reoccurring CVA. With the allocation of funding from DRHA, the KACVA clinic would be
created for patients and their families or care givers, with a focus of awareness and prevention
and to bring about community engagement and a collective consciousness of the cause and
lasting effects of stroke, and to implement prevention framework strategies from a holistic
perspective. As a unified interdisciplinary team with DRHAs mission and goals in mind, we are
asking for funding for the KACVA clinic in order to further enhance our vision statement of
improving the culture of patient safety with an emphasis on teamwork leading to a collaborative,
effective, and safe environment that promotes the health and well-being of our patients and
communities. Our care management experts completely feel united with our holistic values for
the CVA preventative perspective that includes respect, teamwork, integrity, innovation,
compassion, wellness, and excellence for all we serve. Our strategic plan is simple-to meet the
goals of Healthy People 2020 by increasing public awareness to decrease CVA risk factors,
increase identification of stroke symptoms, early detection, early treatment, and prevent
recurrences.
Secondary prevention is fundamental to preventing stroke reoccurrence as well as
coronary vascular events, coronary artery disease and mediated death (AHA, 2016). Early
assessment and intervention are critical to prevent the advancement of a stroke event. As stroke
effects almost one million people per year, education within the community is an integral
component for community stroke statistical improvement. Standardized evaluations and valid
22
assessment tools are crucial to the development of a comprehensive plan for after care and
community involvement. KACVA comprises evidence based interventions founded on
functional goals. Every patient should have access to an experienced multidisciplinary
rehabilitation team to ensure optimal outcomes. Allocating approval of the KACVA clinic would
ensure that optimal patient outcomes are achieved. The patient and the family members and or
caregivers are essential members of the rehabilitation team-patient and family education
improves informed decision making, social adjustment and maintenance of rehabilitation gains
(ASA, 2016). The multidisciplinary team should utilize community resources for community
reintegration. Ongoing medical management of risk factors and comorbidities is essential to
ensure survival.
The Keep Away CVA after stroke care program is a paramount clinic that would enable
not only a recovering stroke patient, but their family, friends and the community to become a
catalyst in which they could revise, control and manage a life threatening diagnosis. This
KACVA team will help our patients, their families, and the community maximize their increase
level of prevention through early recognition and lifestyle modifications. Our holistic care clinic
will help prevent unnecessary cost for the patient and healthcare system through tailored
individualized education to identify risk factors and the changes necessary one must make to
obtain and maintain optimal healing (Colorafi, Solomons, & Lamb, 2014). It is in your best
interest to approve this proposal and be present to witness the KACVA after care program assist
our healthcare facility in reaching the goal of achieving a healthier community. We implore
DRHA to fund this new and life changing clinic and Keep Away CVA.
23
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26
27
Appendices
Appendix A
The Barthel Index
28
29
30
Appendix B
Budget
Revenue = $34,660.00
Expenses = $71,268.00
Total Net Loss = (-36,608.00)

Year One Start Up
31
Appendix B
Budget Continued
Revenue = $79,255.00
Expenses = $82,463.00
Total Net Loss = (-3,208.00)
Year Two
32
Appendix C
Spot a Stroke FAST
American Stroke Association (ASA). (2016). Stroke warning signs. Retrieved from
http://www.strokeassociation.org/STROKEORG/
33
Appendix D
Twitter
Twitter. (2016). Keep away CVA. Group 3B. Retrieved from #keepawaycva
34
Appendix E
Medical ID
Apple Inc. (2016). Use the health app. Retrieved from

https://support.apple.com/en-us/HT203037
35
Appendix F
Measuring HCAHPS Compliance

36
Appendix F1
HCAHPS
Centers for Medicare and Medicaid Services (CMS). (2016) Research, statistics, data and
systems. Retrieved from https://www.cms.gov
Appendix G
37
DRHA CVA Fall & Injury Data
DRHA Admission to Acute Care Setting - Injury Due to Falls Per 100,000 --CVA
50 41.5
40.5 38.8
40.4 39.5
40.1
36.5 38.9 34
36.4 39.1 35.2
40
30
Injuries 20
10
0
10 11 12
Quarters 1/13-12/15
DRHA CVA
50
40
30
Stroke Like Symptoms
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12
Quarters 1/13-12/15
Appendix H
Policy and Procedures
38
Admission, Continuing Therapy, and Discharge/Transition Criteria for Persons Served in

the CVA Survivor Clinic Desert Regional Health Alliance (DRHA)
POLICY PURPOSE:
To document and define the Admission, Continuing Therapy and Discharge/Transition Criteria
for the CVA Survivor at DRHAs clinic.
Responsible Personnel: Clinical Operations Manager, Manager of Clinic Quality &
Compliance, and CVA Survivor Team.
Admission Criteria: The criteria for admission to the CVA Survivor Program at DRHA, an
outpatient service, are as follows:
The client must have a referral/order for admission to the program.
The client must be status post CVA, non-hemorrhagic, with deficits that require interventions to
address physical impairments, activity limitations, and referred by their healthcare provider, with
the goal of safe return to activities of daily living.
The client has not reached his or her potential for independence in mobility, speech, and holistic
therapeutics.
The client must be medically stable and of a medical acuity that allows full participation in a
rehabilitation program.
Services must be reasonable and necessary. Services must require the experience and expertise of
a skilled registered nurse, and therapist/provider.
The clients condition must indicate a potential for improvement in functional and work
capacities in a reasonable period of time.
39
Appendix H1
Policy and Procedures Clinic Referral
Nurses Journal, 95(1), 85-103. http://dx.doi.org/10.1016/j.aorn.2011.05.021
40
Continuing Stay Criteria:

Each of the following conditions must be met in order to justify continuation of services:
The client is able to tolerate and participate actively in therapy.
The client must make significant, objective, progress or demonstrate the potential to make
change in function that moves the client towards the goal of safety and independence.
Continuous progress has been demonstrated and documented in the clinical notes.
The clients condition and treatment plan continues to require the experience and expertise of a
skilled RN and/or therapist.
Services continue to be reasonable and necessary.
The client must demonstrate good feasibility characteristics in the areas of productivity, safety,
and interpersonal behaviors.
Discharge/Transition Criteria:
Release/discharge from the CVA survivor program will occur when:
The client has achieved the goals that he or she established with the rehabilitation CVA treatment
team.
Multidisciplinary therapy is no longer needed. Discharge from single discipline therapy will be
considered when the services of skilled therapists are no longer necessary.
Additional change in functional &/or activity of daily living capacities cannot be anticipated.
The clients progress has slowed or temporarily stopped and he or she is no longer benefiting
from the services of the program.
The presence of medical, psychological, or social problems hinder the clients ability to
participate.
POLICIES AND PROCEDURES:
Organizational Leadership/ Medical Director Qualifications
CVA Survivor Clinic at Desert Regional Health Alliance (DRHA)
POLICY PURPOSE:
To insure the delivery of quality therapy and consultative services to the CVA survivor clinics
patients and staff at DRHA. The Medical Director of the CVA clinic shall be a board certified
physician by the American Board of Neurology. The Medical Director also serves as the CVA
Clinic Committee Chairperson whose primary responsibility is to provide effective leadership for
the CVA Clinic and interdepartmental through the Cerebrovascular service line with DRHA.
Responsibilities:
1.
Responsible for developing programs to obtain CVA services not available in the clinic
when required.
2.
Technical Staff
Makes recommendations for hiring of new staff and provides input into the evaluation of
clinical competency of staff and overall performance.
Evaluates and recommends changes in staffing levels to support clinical services.
3.
4.
5.
41
Assists the CVA Clinics director in arranging for continuing education to staff.
Performance Improvement
Responsible for the overall development, implementation, and on-going evaluation of
quality of care and services provided by the healthcare staff of the clinic.
Serves as Chairperson of the CVA clinic committee.
Assists in the development and review of patient protocols.
Assists in the evaluation of performance measures in order to assess the appropriateness
of services.
Consultation
Provides consultative and interpretive services and acts as a liaison to other departments
and committees.
Administrative Duties
Collaborates with the CVA Clinic Director in:
Long and short range planning supporting the mission and vision of the hospital.
Recommending addition/replacement of equipment or other resources.
Strategically planning for the revision and/or addition of services in efforts to meet
patient and healthcare providers needs.
Assuring financial viability and appropriate utilization of resources.
POLICIES AND PROCEDURES:
Code Blue in the CVA Clinic
CVA Survivor Clinic at Desert Regional Health Alliance (DRHA)
POLICY PURPOSE:
To provide information in case of an emergent need for Code Blue staff from DRHA. In the
event of a non-reversible, life threatening clinical scenario, any CVA Survivor clinic staff may
initiate a code Blue.
1.
To initiate a Code Blue, attending or auxiliary staff at the CVA survivor clinic, may either
push the code blue button within the clinic or dial 0.
When dialing 0 the staff member will indicate to the hospital operator the location of
the event for the overhead page.
2.
DRHA assigned code team staff will respond as indicated in the DRHA code blue policy.
3.
Patients with do not resuscitate (DNR) orders will be resuscitated while undergoing
treatments in the CVA survivor clinic unless otherwise directed by the attending
Physician.
Appendix I
Marketing Flyer
42
43
Appendix J
Measuring Patient Loyalty
44
Appendix K
Inpatient Perception of Overall Quality of Care
45
Appendix L
Future Projected Growth-Sustainability Post Initial Year of Program
Line Item
Line 1Administrative
and legal expenses
Year 1 - ALLOWABLE COSTS
Year 2 ALLOWABLE
COSTS
$3,600 is allocated to pay DRHAs project

manager (for work associated with the
implementation project and for an environmental
analysis and costs associated with evaluation of
the environmental effects of proposed activities
and producing an Environmental Statement to
the local authorities.)
$3,600 Same
related cost to
complete the
project for year
2
Line 2Land,
structures, right-ofway, appraisals, etc.
The current facility is owned by DRHA. No

additional land is required for this project.
Same as Year 1
Line 3Relocation
expenses and
payments
Although temporary relocation may be required

for this project, no costs are anticipated for this
classification.
Same as Year 1
Line 4Architectural
and engineering fees
Line 5Technology
$30,500 is the cost for the architectural and

engineering fees, which will cover the following:
structural, civil engineering, mechanical and
electrical design; bid construction documents
(plans and specifications); and assistance during
the construction bidding (answer questions
presented by the contractors).
No additional
costs
$5,000 is anticipated for the installation of the

technology software program and computers
needed for this project.
$2,000
Additional
related cost to
complete the
project for year
2
Line 6Start-up
Project fees
$12,000 is the cost to cover the following start-up

services: Rent, utilities, phones, equipment lease
payments, office supplies, dues/Subscriptions,
business insurance, professional fees, taxes, and
employee compensation.
$4,300
Additional
related cost to
complete the
project for year
2
Line 7Clinic
Space/Offices
$8,000 is the anticipated cost for site work, which

includes:
Entry Lobby: waiting, reception/registration,
$8,000 Same
related cost to
complete the
Line 8Demolition
and removal
Line 9Construction
46
payee window.
General Patient Care: physician office/consultant,
exam room, nurse work area, patient toilets,
clean/supply room, medications storage, soiled
utility room.
Medical Records: medical records file.
Staff Support Spaces: Staff toilet (male), staff
toilet (female), staff break rooms, housekeeping,
and patient suite.
project for year

2
$6,000 is the total cost associated with removal

of a particles and debris after new unit
construction is complete. The cost also includes
removal of the replaced ceilings, lights, flooring
and finish materials.
$3,000
Additional
related cost to
complete debris
removal for year
2
$80,000 is the total construction cost to renovate

the existing 2,000 square feet, including
installation of new partitions, new ceilings and
lights, new flooring and painting throughout the
facility unit. The roof of part of the DRHA will be
replaced. The construction budget is derived from
the following cost breakdown: structural
($16,000), architectural ($24,000), mechanical
($22,400), and electrical ($17,600).
$50,000
Additional
related cost to
complete the
project for year
2
The structural cost of $16,000 is comprised of the

following: footing excavation, compacted base
course, concrete wall footing, and concrete slab
on grade, exterior, and roof structure.
The architectural cost of $24,000 is comprised of
the following: wood and plastic, thermal and
moisture, flashing, and sheet metal, doors and
windows, and finishes.
The mechanical cost of $22,400 covers the
following: air conditioning and ventilation system,
water, sewer, and piping systems, cold water, hot
water, water storage tank, and piping insulation;
and fire protection system.
The electrical cost of $17,600 includes the
following: power system, lighting system,
communication system, and computer data
networking system, telephone outlet, TV outlet;
security alarm, and fire sprinkler system.

Line 10Capital
Equipment
47
$34,000
$14,000 will be used to procure 3 exam tables for
the exam rooms, and 2 beds with wheels and
height adjustment for the patient care rooms.
No additional
costs
$20,000 will be used to purchase office

equipment:
3 desks, 6 computers with Intel Pentium
Processors would be purchased for each of the
new exam rooms, and 12 chairs would be
procured; 25 chairs for the waiting room and 4
chairs for the offices.
Line 11SUBTOTAL
Line 12
TOTAL
PROJECT
COSTS
Line 13
DRHA
Grant
(Note:
round to
the nearest
whole
dollar
amount)
179,100.00
70,900
$250,000.00
(Total from Years 1 and 2)
$250,000.00
Retrieved from
http://www.harriscountytx.gov/CmpDocuments/99/Budgets/Hospital%20District
%20Budget%202011.pdf

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Running head: CVA PREVENTATIVE PERSPECTIVE

Keep Away CVA

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

management of cerebrovascular accidents while emphasizing preventative measures and the

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

Developing a treatment plan within clinic guidelines with preventative measures

Teaching patients how to properly use exercise techniques

Providing stimulation or massage, relaxation techniques and breathing exercises

Use equipment and devices to assist patients

Uphold patients records, keeping track of goals and progress

CVA PREVENTATIVE PERSPECTIVE

patient assessments at clinic admission

arrangement and providing appropriate treatment within clinic/class description

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

Policies and Procedures

Hours of Operation Guidelines

Administrative Policies and Procedures

Plan for Provision of Care

Clinical Care Policies and Procedures

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

Journal of Stroke and Cerebrovascular Diseases, 23(3), 505-510. Retrieved from

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

Total Net Loss = (-36,608.00)

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

Apple Inc. (2016). Use the health app. Retrieved from

CVA PREVENTATIVE PERSPECTIVE

Measuring HCAHPS Compliance

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

DRHA CVA Fall & Injury Data

Stroke Like Symptoms

CVA PREVENTATIVE PERSPECTIVE

Admission, Continuing Therapy, and Discharge/Transition Criteria for Persons Served in

CVA PREVENTATIVE PERSPECTIVE

CVA PREVENTATIVE PERSPECTIVE

Continuing Stay Criteria: