Presentation on theme: "By Sarah Rose New Touro University- California Advisor: Dr. Thairu"— Presentation transcript:
1 By Sarah Rose New Touro University- California Advisor: Dr. Thairu A Proposal for a Case Management Program for Chronic Disease at Touro University’s Student Run Health ClinicBy Sarah Rose NewTouro University- CaliforniaAdvisor: Dr. Thairu
2 Capstone ObjectivesTo present a proposal for a Case Management Program that monitors hypertension, diabetes, obesity, and cardiovascular disease at the Touro University’s Student Run Health Clinic
3 Background and Significance Cardiovascular Disease (CVD)Broad term for all diseases specific to the heart and cardiovascular system2,200 Americans die of CVD every dayAverage of 1 every 39 secondsForecasted by 2030= 40.5% of U.S. will have some form of CVDRogers et al., (2012)Heindenreich et al. (2011)
4 Background and Significance DiabetesMajor risk factor of CVD is diabetesCVD is a major complication of diabetes and leading cause of premature death of those with diabetesDiabetes effects 25.8 million people= 8.3% of U.S. population81.5 million adults have prediabetes= 37% of U.S. populationLeaving 7 million undiagnosedNational Diabetes Education Program, (2007)National Diabetes Information Clearinghouse, (2011)
5 Background and Significance Hypertensionclinically defined as high blood pressure readings two separate occasionsContributes to 1 in 7 deaths and nearly half of all CVD related deathsEffects 30% of U.S. adultsForecasted to increase by 9.9% from 2010 to 2030Prehypertension29.7% U.S. adults >20There are two major risk factors for diabetes and CVD which are predominant throughout the United States. These are hypertension and obesity.Center for Disease Control and Prevention [CDC], 2011)Keenan & Rosendorf, (2011)Heindenreich et al., (2011)Rogers et al., (2012)Lloyd-Jones, Evans, & Levy, (2005)
6 Background and Significance ObesityIncreasing rise of obesity leads to increase rise in hypertension, CVD, and diabetes149 million U.S. adults are overweight or obese67.3% of the U.S. population33.7% are only obeseRogers et al., (2012)
7 Background and Significance Disease Burden on California57% of Californians over 65 have high blood pressure33% of males and 39% of females will be diagnosed with diabetes in their lifetimeSolano County:9.5% adults have diagnosed diabetes, largest figure when compared to other Counties in California22.8% are obeseMany of these diseases place a burdens on the populations within California and our own communitiesCalifornia Healthcare Foundation, (2006)CDC, (2008)
8 Background and Significance Case Management ProgramsDefined as collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy options and services to meet individual and family needsEvolution:1900s- began as sanitation and immunization practices1981- case management is integrated into MedicaidCase management programs are effective ways to monitor and decrease hypertension, diabetes, obesity, and CVD in a cost effective mannerCase Management Society of America [CMSA], (2010)Bosshart & Vienna, (2008)
9 Background and Significance Six ComponentsClient identification and selection,Assessment and problem/opportunity identificationDevelopment of the case management planImplementation and coordination of care activitiesEvaluation of the case management plan and follow upTermination of the case management processCMSA, (2010)
10 Background and Significance Evidence of Case Management EffectivenessWeingarten et al. (2002) reported:that case management programs were associated with provider adherence to guidelines and patient disease controlGilmer et al. (2007) found:association with cost effective improvements in quality-adjusted life expectancy and a decrease in incidence of diabetes-related complicationsthat case management programs are cost effective for low income populationsThis study found that many interventions, including provider education, provider feedback, provider reminders, patient education, patient reminders, and patient financial incentives, were all associated with improvement in provider adherence to guidelines and patient disease control
11 Background and Significance California Medi-Cal Type 2 Diabetes Study Group (2004)found that case management improved glycemic control when added to primary carereduced disparities in diabetes health status among low income ethnic populations
12 Background and Significance Student Run ClinicsStudent initiated endeavors with commitments to underserved communitiesFirst appeared in various cities in the mid 1960sCurrently widespread among U.S. medical schoolsProvide training to face healthcare crisesConsidered impressive, realistic learning methods for preparing young physiciansTo confront a US healthcare system facing crisesMeah, Smith, & Thomas, (2009)Simpson & Long, (2007)National Research Counsil, (2002)
13 Touro University’s Student Run Health Clinic (SRHC) Opened in October 2010Located in Vallejo, California at Norman C. King Community CenterOpen from 4:30-8:00pm every ThursdayOpened under the supervision of Dr. LopesMission: to create an interprofessional clinic that focuses on improving access to health care in the surrounding areas while improving clinical and education skill of students at Touro University.). Development of the SRHC was structured to overcome barriers that had been exposed by conversations with local healthcare stakeholders (TUC-SRHC, n.d.). The most significant barriers identified were a lack of after-hours care, insufficient medical insurance, inadequate transportation, cultural stigmas, a significant language barrier in a variety of languages, and poor health literacy (TUC-SRHC, n.d.)
15 Touro University’s SRHC Offers the following services:Screening exams and health educationMedication reviewBlood pressure checkOsteopathic manipulative medicineImmunizationsAs of October 2011= 192 patientsAs of February 2012= 235 patients
16 Specific Aims and Objectives of Proposed Case Management Program Increase volunteer positions for MPH studentsDecrease diabetes, hypertension, high BMI, and cardiovascular disease within Student Run Health Clinic (SRHC) patient populationIncrease health literacy and adherence to healthy behaviors for the communityin which I have played a major role since its inception
17 Proposed Case Management Program TU-SRHC Case Management Program is uniqueUse a public health approach by providing services to reduce the burden of disease on the communitythrough outreach and advocacy in addition to reducing individual barriers to health
18 Proposed Case Management Program If successful, the proposed programWill help the SRHC to strengthen their mission to overcome individual and environmental barriers to healthWill reduce risks and outcomes that can be maintained under the SRHC’s current scope of practice
19 Preliminary Studies/Progress Report Program implementation began in November 2011 but patients are currently not enrolledProgram currently in final stages of development with an anticipated launch date of May 31st, 2012I have played an important role in the program since its inceptionPilot Program will be launched with 6 case managersJocelyn Lee DO/MPHGhazal Ghafari MPHKyle Severinsen MPHJohn Suchland MPHMichael Phorth MPHKatie Ho MPHNew Public Health Coordinator- Kristoffer Chin MPH
21 Proposed Design of Case Management Program Held simultaneously with SRHC at the Norman C. King Community Center in Vallejo, CASection of clinic will be allocated for Case ManagementCase Management Services:offered from 4:30-5:00pmfollowed by Community Education from 5:00pm-6:00pmCase Management again from 6:00-8:00pmCommunity Walking Program:6:00-7:00pm (seasonal based)Offered via the Lifestyle Medicine ClubHelp aid patients in recovery along with outside resourcesCommunity education class- 5:00-6:00pmReflect common issues in diabetes, hypertension, CVD, and obesityHelp open forum style to promote active education, communication and optimal supportWalking Program- 6:00-7:00pmDue to collaboration with Lifestyle Medicine ClubHour walk with member of TU-LMC through different routes in VallejoSubject to seasonal time change
22 Chronic Care Model Conceptual Framework Designed with six interrelated system changesIncrease patientcentered, evidencebased careBased off a survey of best practices, expert opinion, more promising interventions in literature, and quality improvement work on diabetes, depression, and cardiovascular diseaseThese changes include health care organization, clinical information systems, delivery system design, decision support, self-management support, and strengthening community resourcesBodenheimer et al., (2002)Coleman et al., (2009)
23 Conceptual Framework Tsai et al., (2005) Since the different sections of the CCM have been broadly defined in literature, Tsai, Morton, Mangione, and Keeler (2005) have categorized interventions according to the CCM elements. This table reflects how each component of the model will be used within this program. Many of these components will be further discussed throughout this proposal. The basic components of the Chronic Care Model are…Tsai et al., (2005)
25 Conceptual FrameworkUse the 5A’s Model of Behavioral Change Counseling.This is an evidence-based approach appropriate for a broad range of different behaviors and health conditionsThis model offers flexibility for severity of disease and will be used in the assessment phase to increase the patients confidence through self-management of their own diseaseFiore et al., (2000)Glasgow et al., (2006)The Quality Indicator Study Group, (1995)
26 Patient Inclusion Criteria Patient attends Touro University’s Student Run Health ClinicSystolic blood pressure measurement >130Diastolic blood pressure measurement >85 on two separate occasions (hypertension)Fasting plasma glucose >126 mg/dl or 100 md/dl – 125mg/dl (pre-diabetes)Casual plasma glucose concentration >200 mg/dlBMI >25Pre-diagnosis of hypertension, diabetes mellitus type II, and/or cardiovascular diseaseThis criteria has been approved by Dr. LopesThe Case Management Program will exclude anyone who does not fit at least one criterion
27 Blood glucose has been excluded from this data since there was a lack in documentation on when the patient last ate. This documentation is very important when reading finger stick glucose test as it fluctuates broadly based on the patients last meal along with other factors.
28 Data Collection Electronic Disease Registry Record all vitals taken at SRHC, outside clinics, and own monitoring capabilitiesPerceived Individual and Environmental Barriers to HealthAssist in future program improvement and developing future community initiativesSatisfaction SurveysAllow for improvements in quality of care and services offered
29 Case Management Process Acceptance to Case Management ProgramBegins after triage and medical assessmentOnly enrolled if they fit criteriaAssignment to Case ManagerBrief intro to Case Management ProgramBegin Health Literacy Test and Healthy Lifestyle QuestionnaireHealth Literacy TestDesigned to rate patients knowledge on diabetes, hypertension, obesity, and cardiovascular risk factor and disease.20 questions examSelf administeredThe higher the score, the more competent the patient is on the disease or risk factors related to the disease.
30 Case Management Process Healthy Lifestyle QuestionnaireUsed to access self perceived views on health, diet, and exercise habits.Interview patientConsist of two different scoresHealthy Lifestyle ScoreHealth Risk ScoreUsed to assess the number of healthy choices one makesUsed to assess the amount of sugar and fat one consumesEXAMPLE
31 Case Management Process Treatment Tier PlacementCase managers will place patients into two treatment plan tiersLimited or advanced proficiencyLow or high riskPlacement will assist in recognition of the severity of disease or other risk factors.Allows assessment of the severity of environmental barriersWill indicate where to begin in terms of health education. For example, if the patient is placed in both tiers for limited proficiency and high risk, treatment plans will be longer and more detailed in approach. These patients exhibit the need to use more clinical resources outside of the SRHC and will also require adjustments for structural restrictions that prevent them from reaching optimal health.. On the other hand, if a patient falls into the tiers for advanced proficiency and low risk, they may have a shorter time span within the program and may be able to make easy but effective changes with follow up only at the SRHC.
32 Case Management Process Assessment with 5A’sAssess, Advisement, Agree, Assist, and ArrangeIncludes:recording individual and environmental barriers to better healthcase manager recommendations to behavior change.creating collaborative goals with the patientdevelop strategies to achieve these goalsgiving referrals to outside resources, a diet prescription, and exercise guidelinesplanning of a follow up visit
33 Case Management Process Follow up appointmentsAll patients will return in 2 weeks for a follow upFollow up appointments after pilot will be set up by treatment plan tiersAppointments will involve triage and patient specific treatmentNew readings will be recorded in patient’s registryReassessment of the Healthy Lifestyle QuestionnaireFor example, if the patient had difficulties finding transportation to an outside clinic and therefore could not go, the case manager would work to try to resolve this situation. If their current disease is uncontrolled, this monitoring of the utilization of outside resources is imperative as the SRHC is unable to provide certain services due to limitations of their practice. . If patients do receive outside treatment, any new test results or information will be added to the disease registry for that patient. Information of this type can be ed to the case manager via the programs address or brought in on their next appointment. This will aide in properly monitoring the patient.
34 Case management process Follow up appointmentsPatients will be given more educational toolsThe 5A’s will be updatedAlterations to treatment plans will be madeThe case manager will ensure that outside resources are being utilized
35 Case Manager’s Job Work in bi-weekly, two hour shifts Must also be flexible according to patients’ scheduleFollow up with patient between appointments via address to provide motivation and consultationIf not assigned a patient, they will work to update Public Health LibraryPrimary purpose is to keep staff at SRHC and case managers up to date in chronic diseaseOnly accessible to registered Touro members
36 Case Managers Job Case managers = community health advocate Program identifies personal environmental barriers to resolve local health problemsManagers use these to create community initiatives, outreach, and increase access to resourcesWill be working with the Solano County Coalition for Better Health
37 SRHC and Touro Community Education Case Management Program brown bag seriesTopics will include diabetes, hypertension, obesity, CVD, cultural health differences, and health disparitiesOpen to all students and strongly recommended to those who plan to volunteer at the clinicProtocol created by Jocelyn Lee and Dr. LopesProtocol print out given to all staffAide in better identification of patients with these specific diseases or risk factorsAllow staff to correctly utilize the Case Management Program
38 Exit Criteria for Case Management Program No limit on length in programReleased upon criteria of graduationOutcomes or goals are as follows:Patient becomes self sufficient in this or her own recovery or rehabilitationPatient reduces test results, controls disease, or is undiagnosed with disease
39 Case Manager Limitations No contact with patients via cell phonesWill contact via addressLimitation to scope of practice of SRHCSRHC only has the ability to monitor the diseases chosen by the Case Management ProgramCannot diagnose patients or suggest medicationWill refer to on staff student pharmacist
40 Proposed Pilot for Program During pilot, maximum patient load of 8 and minimum of 6Will allow case managers to assess the proper patient load ratio for full launch
41 Potential Challenges for Implementing the Case Management Program Limited human resources as the program will depend on volunteer students from TouroThis may place limitations on patient loadIt is possible that the program will only accept those patients who require immediate assistance as directed by student physician
42 Ethical Considerations Patient authorizes treatmentPatient will sign form allowing contact viaExplain risk and benefit of communicationTraining for case managersSpecific Case Management TrainingNew managers will shadow mentor 2 timesFlash drive keeps all data and patients informationLocked up at clinicCase managers will have access to flash drive during clinic hoursSRHC staff will also have access
44 Budget and Personnel Budget only requires funds for printing materials Estimated $100 dollarsAll other items supplied by Touro University or SRHCPersonnel includes:MPH CoordinatorCase Management Program DirectorVolunteers from the MPH Program
45 Future Implications Expand in both size and materials Develop two volunteer tiers:Case managers who advocate for individualsCase managers who advocate for environmental needsAllow to keep a public health approach as the need for individual monitoring increases with patient loadMore disease specific training to replace manualAdditional cultural sensitivity trainingExpansion of services: women's health, dental, etc.Branch will be based off of past research of structural constraints already collectedIt will allow for the effective management of individuals lifestyle changes while reducing disparities and preventing new cases. If these preventative services are not embedded into the program, patient case load will continue to increase as well as the burden of these chronic diseases on the SRHC and the community.Another future addition is allowing students in Touro University’s nutrition class to preform a detailed dietary assessment on patients within the Case Management Program. In return, case managers and nutrition class students will receive training from a registered Dietitian as part of the Touro University’s budget by encompassing this activity into a class. Other disease specific trainings from experts for case managers in place of or in addition to the case management manual would help students feel more confident and better management patient’s cases. The addition of a formal cultural sensitivity training would be beneficial as a majority of the patient population is from a Hispanic or African American background. Eventually, the program should expand services to women’s health, smoking cessation, dental health, and other chronic disease. This aspect will rely heavily on the expansion of the scope of the SRHC.
46 ConclusionStudent run health clinics are increasing in number in the United States and they provide an opportunity to provide healthcare in low income populationsCase Management Programs may effectively reduce health disparitiesThe proposed Case Management Program has the potential to improve health outcomes in surrounding areas low income and minority population
47 REFERENCESBodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. [Research Support, Non-U.S. Gov't]. The Journal of the American Medical Association, 288(14), Bosshart, J., & Vienna, M. (2008). Recommendations for case management collaborations and coordination in federally funded HIV/AIDS programs. U.S. Department of Health and Human Services. Retrieved from California HealthCare Foundation. (2006). Chronic disease in California: facts and figures. Retrieved from California Medi-Cal Type 2 Diabetes Study Group. Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study. (2004). Diabetes care, 27(1), Case Management Society of America. (2010). Standards of practice for case management. Retrieved from Center for Disease Control and Prevention. (2008). Diabetes data and trends. [Data file]. Retrieved from Center for Disease Control and Prevention. (2011). Vital signs: prevalence, treatment, and control of hypertension—United States, and Morbidity and Mortality Weekly Report, 60(4), Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the Chronic Care Model in the new millennium. Health Affairs, 28(1), doi: /hlthaff Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., et al. (2000). Treating tobacco use and dependence: clinical practice guideline. U.S. Department of Health and Human Services. Retrieved from Gilmer, T. P., Roze, S., Valentine, W. J., Emy-Albrecht, K., Ray, J. A., Cobden, D., Nicklasson, L., Philis-Tsimikas, A., & Palmer, A. J. (2007). Cost-effectiveness of diabetes case management for low-income populations. [Research Support, Non-U.S. Gov't]. Health Services Research, 42(5), doi: /j x Glasgow, R. E., Emont, S., & Miller, D. C. (2006). Assessing delivery of the five 'As' for patient-centered counseling. [Research Support, Non-U.S. Gov't]. Health Promotion International, 21(3), doi: /heapro/dal017
48 REFERENCESHeidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., Woo, Y. J. (2011). Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. [Consensus Development Conference]. Circulation, 123(8), doi: /CIR.0b013e31820a55f5 Keenan, N. L., & Rosendorf, K. A. (2011). Prevalence of hypertension and controlled hypertension - United States, Morbidity and mortality weekly report. Surveillance Summaries, 60(01 Suppl), Lloyd-Jones, D.M., Evans, J.C., & Levy, D. (2005). Hypertension in adults across the age spectrum: current outcomes and control in the community. Journal of the American Medical Association, 294, doi: /jama Meah, Y. S., Smith, E. L., & Thomas, D. C. (2009). Student-run health clinic: novel arena to educate medical students on systems-based practice. [Review]. The Mount Sinai Journal of Medicine, New York, 76(4), doi: /msj National Diabetes Education Program. (2007). The link between diabetes and cardiovascular disease. Retrieved from National Diabetes Information Clearinghouse. (2011a, December 6). National diabetes statistics, Retrieved from National Research Counsil. (2002). Fostering rapid advances in health care: learning from system demonstrations. [Executive Summary]. Washington DC: The National Academies Press. Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E. J., Berry, J. D., Borden, W. B., Turner, M. B. (2012). Heart disease and stroke statistics update: a report from the American Heart Association. [Comparative Study]. Circulation, 125(1), e2-e220. doi: /CIR.0b013e31823ac046 Simpson, S. A., & Long, J. A. (2007). Medical student-run health clinics: important contributors to patient care and medical education. Journal of General Internal Medicine, 22(3), doi: /s The Quality Indicator Study Group (1995) An approach to the evaluation of quality indicators of the outcome of care in hospitalized patients, with a focus on nosocomial infection indicators. Infection Control and Hospital Epidemiology, 16, 308–316. Tsai, A.C., Morton, S.C., Mangione, C.M., & Keller, E.B. (2005). A meta-analysis of interventions to improve care for chronic for chronic illnesses. American Journal of Managed Care, 11(8),
49 Thank you! I would be happy to answer any questions you may have!
50 Case Management Program only CP, SOB, BP>180/120 Notify Dr. Lopes to access urgencyPROTOCOL FOR RISK ASSESSMENTTypical patient coming in for screening physical, OMM treatment etc.Triage: get BMI, BP, Random Glucose test, recent weight loss, thirst +FH (DM, CVD, HTN)Responsibilities:EMERGENCY PROTOCALTriageH and PCase managerSD/PA: Evaluate, discuss with Dr. Lopes after H and P and Refer to case manager if BS> 126 0r BMI>25 0r BP >130/85, and/or by Dr. Lopes’s discretionBP 2XPrehypertensive>130/85Hypertensive>140/90BMI>25Overweight and no other riskRandom BS >126Identify risks for metabolic syndromeIdentify other risks for CVDRF 1: abdominal obesity (waist circumference >40 inches in men or >35 inches in women) *RF 2: glucose intolerance (fasting glucose >100 mg/dL), *RF 3: BP >130/85 mmHg, *RF 4: high triglycerides (>150mg/dL)RF 5: low HDL (<40 mg/dL in men or <50 mg/dL in women).1. Cigarette smoking2. Obesity (body mass index ≥30 kg/m2)3. Physical inactivity4 .Dyslipidemia5. Diabetes mellitus6. Age (older than 55 for men, 65 for women)7. Family history of premature cardiovascular disease8. Sleep apneaDiabetes riskAge >45High BPAt risk weight BMI>25FH of DMHigh cholesterolAcanthrosis nigrcansPhysically inactiveHigh blood sugar1Case Management Program onlyCounty referral (per Dr. Lopes) and Case Management ProgramIf more than 1 Risk Factors, if not please refer to box 1