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A Proposal for a Case Management Program for Chronic Disease at Touro Universitys Student Run Health Clinic By Sarah Rose New Touro University- California.

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Presentation on theme: "A Proposal for a Case Management Program for Chronic Disease at Touro Universitys Student Run Health Clinic By Sarah Rose New Touro University- California."— Presentation transcript:

1 A Proposal for a Case Management Program for Chronic Disease at Touro Universitys Student Run Health Clinic By Sarah Rose New Touro University- California Advisor: Dr. Thairu

2 Capstone Objectives To present a proposal for a Case Management Program that monitors hypertension, diabetes, obesity, and cardiovascular disease at the Touro Universitys Student Run Health Clinic

3 Cardiovascular Disease (CVD) Broad term for all diseases specific to the heart and cardiovascular system – 2,200 Americans die of CVD every day Average of 1 every 39 seconds – Forecasted by 2030= 40.5% of U.S. will have some form of CVD Background and Significance Rogers et al., (2012) Heindenreich et al. (2011)

4 Diabetes – Major risk factor of CVD is diabetes – CVD is a major complication of diabetes and leading cause of premature death of those with diabetes – Diabetes effects 25.8 million people= 8.3% of U.S. population – 81.5 million adults have prediabetes= 37% of U.S. population Background and Significance National Diabetes Education Program, (2007) National Diabetes Information Clearinghouse, (2011)

5 Hypertension – clinically defined as high blood pressure readings two separate occasions – Contributes to 1 in 7 deaths and nearly half of all CVD related deaths – Effects 30% of U.S. adults – Forecasted to increase by 9.9% from 2010 to 2030 – Prehypertension 29.7% U.S. adults >20 Background and Significance 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 Obesity – Increasing rise of obesity leads to increase rise in hypertension, CVD, and diabetes – 149 million U.S. adults are overweight or obese 67.3% of the U.S. population 33.7% are only obese Background and Significance Rogers et al., (2012)

7 Disease Burden on California – 57% of Californians over 65 have high blood pressure – 33% of males and 39% of females will be diagnosed with diabetes in their lifetime – Solano County: 9.5% adults have diagnosed diabetes, largest figure when compared to other Counties in California 22.8% are obese Background and Significance California Healthcare Foundation, (2006) CDC, (2008)

8 Case Management Programs – Defined as collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy options and services to meet individual and family needs – Evolution: 1900s- began as sanitation and immunization practices 1981- case management is integrated into Medicaid Background and Significance Case Management Society of America [CMSA], (2010) Bosshart & Vienna, (2008)

9 Six Components – Client identification and selection, – Assessment and problem/opportunity identification – Development of the case management plan – Implementation and coordination of care activities – Evaluation of the case management plan and follow up – Termination of the case management process Background and Significance CMSA, (2010)

10 Evidence of Case Management Effectiveness – Weingarten et al. (2002) reported: that case management programs were associated with provider adherence to guidelines and patient disease control – Gilmer et al. (2007) found: association with cost effective improvements in quality-adjusted life expectancy and a decrease in incidence of diabetes-related complications that case management programs are cost effective for low income populations Background and Significance

11 California Medi-Cal Type 2 Diabetes Study Group (2004) – found that case management improved glycemic control when added to primary care – reduced disparities in diabetes health status among low income ethnic populations Background and Significance

12 Student Run Clinics – Student initiated endeavors with commitments to underserved communities – First appeared in various cities in the mid 1960s Currently widespread among U.S. medical schools – Provide training to face healthcare crises – Considered impressive, realistic learning methods for preparing young physicians Background and Significance Meah, Smith, & Thomas, (2009) Simpson & Long, (2007) National Research Counsil, (2002)

13 Touro Universitys Student Run Health Clinic (SRHC) Opened in October 2010 Located in Vallejo, California at Norman C. King Community Center Open from 4:30-8:00pm every Thursday Opened under the supervision of Dr. Lopes Mission: 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

14 Touro Universitys SRHC

15 Offers the following services: – Screening exams and health education – Medication review – Blood pressure check – Osteopathic manipulative medicine – Immunizations As of October 2011= 192 patients As of February 2012= 235 patients Touro Universitys SRHC

16 Specific Aims and Objectives of Proposed Case Management Program Increase volunteer positions for MPH students Decrease diabetes, hypertension, high BMI, and cardiovascular disease within Student Run Health Clinic (SRHC) patient population Increase health literacy and adherence to healthy behaviors for the community

17 Proposed Case Management Program TU-SRHC Case Management Program is unique – Use a public health approach by providing services to reduce the burden of disease on the community through outreach and advocacy in addition to reducing individual barriers to health

18 – If successful, the proposed program Will help the SRHC to strengthen their mission to overcome individual and environmental barriers to health Will reduce risks and outcomes that can be maintained under the SRHCs current scope of practice Proposed Case Management Program

19 Preliminary Studies/Progress Report Program implementation began in November 2011 but patients are currently not enrolled Program currently in final stages of development with an anticipated launch date of May 31 st, 2012 I have played an important role in the program since its inception Pilot Program will be launched with 6 case managers Jocelyn Lee DO/MPH Ghazal Ghafari MPH Kyle Severinsen MPH John Suchland MPH Michael Phorth MPH Katie Ho MPH New Public Health Coordinator- Kristoffer Chin MPH

20 SRHC Population

21 Proposed Design of Case Management Program Held simultaneously with SRHC at the Norman C. King Community Center in Vallejo, CA Section of clinic will be allocated for Case Management Case Management Services: – offered from 4:30-5:00pm – followed by Community Education from 5:00pm-6:00pm – Case Management again from 6:00-8:00pm Community Walking Program: – 6:00-7:00pm (seasonal based) – Offered via the Lifestyle Medicine Club

22 Chronic Care Model Conceptual Framework Designed with six interrelated system changes – Increase patient centered, evidence based care Bodenheimer et al., (2002) Coleman et al., (2009)

23 Conceptual Framework Tsai et al., (2005)

24 Conceptual Framework Tsai et al., (2005)

25 Use the 5As Model of Behavioral Change Counseling. This is an evidence-based approach appropriate for a broad range of different behaviors and health conditions Conceptual Framework Fiore et al., (2000) Glasgow et al., (2006) The Quality Indicator Study Group, (1995)

26 Patient Inclusion Criteria Patient attends Touro Universitys Student Run Health Clinic Systolic blood pressure measurement >130 Diastolic 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/dl BMI >25 Pre-diagnosis of hypertension, diabetes mellitus type II, and/or cardiovascular disease This criteria has been approved by Dr. Lopes


28 Data Collection Electronic Disease Registry – Record all vitals taken at SRHC, outside clinics, and own monitoring capabilities Perceived Individual and Environmental Barriers to Health – Assist in future program improvement and developing future community initiatives Satisfaction Surveys – Allow for improvements in quality of care and services offered

29 Case Management Process Acceptance to Case Management Program Begins after triage and medical assessment Only enrolled if they fit criteria Assignment to Case Manager Brief intro to Case Management Program Begin Health Literacy Test and Healthy Lifestyle Questionnaire Health Literacy Test Designed to rate patients knowledge on diabetes, hypertension, obesity, and cardiovascular risk factor and disease. 20 questions exam Self administered The 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 Questionnaire Used to access self perceived views on health, diet, and exercise habits. Interview patient Consist of two different scores Healthy Lifestyle Score Health Risk Score Healthy Lifestyle Score Used to assess the number of healthy choices one makes Health Risk Score Used to assess the amount of sugar and fat one consumes EXAMPLE

31 Treatment Tier Placement – Case managers will place patients into two treatment plan tiers Limited or advanced proficiency Low or high risk – Placement will assist in recognition of the severity of disease or other risk factors. – Allows assessment of the severity of environmental barriers – Will indicate where to begin in terms of health education Case Management Process

32 Assessment with 5As Assess, Advisement, Agree, Assist, and Arrange Includes: recording individual and environmental barriers to better health case manager recommendations to behavior change. creating collaborative goals with the patient develop strategies to achieve these goals giving referrals to outside resources, a diet prescription, and exercise guidelines planning of a follow up visit Case Management Process

33 Follow up appointments All patients will return in 2 weeks for a follow up Follow up appointments after pilot will be set up by treatment plan tiers Appointments will involve triage and patient specific treatment New readings will be recorded in patients registry Reassessment of the Healthy Lifestyle Questionnaire Case Management Process

34 Case management process Follow up appointments Patients will be given more educational tools The 5As will be updated Alterations to treatment plans will be made The case manager will ensure that outside resources are being utilized

35 Case Managers Job Work in bi-weekly, two hour shifts – Must also be flexible according to patients schedule – Follow up with patient between appointments via email address to provide motivation and consultation If not assigned a patient, they will work to update Public Health Library – Primary purpose is to keep staff at SRHC and case managers up to date in chronic disease – Only accessible to registered Touro members

36 Case managers = community health advocate – Program identifies personal environmental barriers to resolve local health problems – Managers use these to create community initiatives, outreach, and increase access to resources Will be working with the Solano County Coalition for Better Health Case Managers Job

37 SRHC and Touro Community Education Case Management Program brown bag series – Topics will include diabetes, hypertension, obesity, CVD, cultural health differences, and health disparities – Open to all students and strongly recommended to those who plan to volunteer at the clinic Protocol created by Jocelyn Lee and Dr. Lopes – Protocol print out given to all staff Aide in better identification of patients with these specific diseases or risk factors Allow staff to correctly utilize the Case Management Program

38 Exit Criteria for Case Management Program No limit on length in program Released upon criteria of graduation Outcomes or goals are as follows: – Patient becomes self sufficient in this or her own recovery or rehabilitation – Patient reduces test results, controls disease, or is undiagnosed with disease

39 Case Manager Limitations No contact with patients via cell phones – Will contact via email address Limitation to scope of practice of SRHC – SRHC only has the ability to monitor the diseases chosen by the Case Management Program Cannot diagnose patients or suggest medication – Will refer to on staff student pharmacist

40 Proposed Pilot for Program During pilot, maximum patient load of 8 and minimum of 6 Will 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 Touro – This may place limitations on patient load – It is possible that the program will only accept those patients who require immediate assistance as directed by student physician

42 Ethical Considerations Patient authorizes treatment Patient will sign form allowing contact via email – Explain risk and benefit of e-mail communication Training for case managers – Specific Case Management Training – New managers will shadow mentor 2 times Flash drive keeps all data and patients information – Locked up at clinic – Case managers will have access to flash drive during clinic hours – SRHC staff will also have access

43 Time Table for Project

44 Budget and Personnel Budget only requires funds for printing materials – Estimated $100 dollars – All other items supplied by Touro University or SRHC Personnel includes: – MPH Coordinator – Case Management Program Director – Volunteers from the MPH Program

45 Future Implications Expand in both size and materials – Develop two volunteer tiers: Case managers who advocate for individuals Case managers who advocate for environmental needs Allow to keep a public health approach as the need for individual monitoring increases with patient load More disease specific training to replace manual Additional cultural sensitivity training Expansion of services: women's health, dental, etc.

46 Conclusion Student run health clinics are increasing in number in the United States and they provide an opportunity to provide healthcare in low income populations Case Management Programs may effectively reduce health disparities The proposed Case Management Program has the potential to improve health outcomes in surrounding areas low income and minority population

47 REFERENCES Bodenheimer, 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), 1775-1779. 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), 95-103. 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 hypertensionUnited States, 1999-2002 and 2005-2008. Morbidity and Mortality Weekly Report, 60(4), 103-108. 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), 75-85. doi: 10.1377/hlthaff.28.1.75 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), 1943-1959. doi: 10.1111/j.1475-6773.2007.00701.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), 245-255. doi: 10.1093/heapro/dal017

48 REFERENCES Heidenreich, 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), 933-944. doi: 10.1161/CIR.0b013e31820a55f5 Keenan, N. L., & Rosendorf, K. A. (2011). Prevalence of hypertension and controlled hypertension - United States, 2005-2008. Morbidity and mortality weekly report. Surveillance Summaries, 60(01 Suppl), 94-97. 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, 446-472. doi: 10.1001/jama.294.4.466 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), 344-356. doi: 10.1002/msj.20128 National Diabetes Education Program. (2007). The link between diabetes and cardiovascular disease. Retrieved from National Diabetes Information Clearinghouse. (2011a, December 6). National diabetes statistics, 2011. 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--2012 update: a report from the American Heart Association. [Comparative Study]. Circulation, 125(1), e2-e220. doi: 10.1161/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), 352-356. doi: 10.1007/s11606-006-0073-4 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), 478-88.

49 Thank you! I would be happy to answer any questions you may have!

50 Triage: get BMI, BP, Random Glucose test, recent weight loss, thirst +FH (DM, CVD, HTN) Prehypertensive >130/85 Hypertensive >140/90 BP 2X Random BS >126 SD/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. Lopess discretion BMI>25 Overweight and no other risk County referral (per Dr. Lopes) and Case Management Program Identify risks for metabolic syndrome 1 Case Management Program only RF 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). If more than 1 Risk Factors, if not please refer to box 1 1. Cigarette smoking 2. Obesity (body mass index 30 kg/m2) 3. Physical inactivity 4.Dyslipidemia 5. Diabetes mellitus 6. Age (older than 55 for men, 65 for women) 7. Family history of premature cardiovascular disease 8. Sleep apnea Identify other risks for CVD Responsibilities: EMERGENCY PROTOCAL Triage H and P Case manager Diabetes risk 1.Age >45 2.High BP 3.At risk weight BMI>25 4.FH of DM 5.High cholesterol 6.Acanthrosis nigrcans 7.Physically inactive 8.High blood sugar CP, SOB, BP>180/120 Notify Dr. Lopes to access urgency Typical patient coming in for screening physical, OMM treatment etc. PROTOCOL FOR RISK ASSESSMENT

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