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By Sarah Rose New Touro University- California Advisor: Dr. Thairu

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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 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 University’s Student Run Health Clinic

3 Background and Significance
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 Rogers et al., (2012) Heindenreich et al. (2011)

4 Background and Significance
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 Leaving 7 million undiagnosed National Diabetes Education Program, (2007) National Diabetes Information Clearinghouse, (2011)

5 Background and Significance
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 There 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
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 Rogers et al., (2012)

7 Background and Significance
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 Many of these diseases place a burdens on the populations within California and our own communities California Healthcare Foundation, (2006) CDC, (2008)

8 Background and Significance
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 Case management programs are effective ways to monitor and decrease hypertension, diabetes, obesity, and CVD in a cost effective manner Case Management Society of America [CMSA], (2010) Bosshart & Vienna, (2008)

9 Background and Significance
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 CMSA, (2010)

10 Background and Significance
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 This 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 care reduced disparities in diabetes health status among low income ethnic populations

12 Background and Significance
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 To confront a US healthcare system facing crises Meah, Smith, & Thomas, (2009) Simpson & Long, (2007) National Research Counsil, (2002)

13 Touro University’s 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 .). 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.)

14 Touro University’s SRHC

15 Touro University’s SRHC
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

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 in which I have played a major role since its inception

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 Proposed Case Management Program
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 SRHC’s current scope of practice

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 31st, 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 Help aid patients in recovery along with outside resources Community education class- 5:00-6:00pm Reflect common issues in diabetes, hypertension, CVD, and obesity Help open forum style to promote active education, communication and optimal support Walking Program- 6:00-7:00pm Due to collaboration with Lifestyle Medicine Club Hour walk with member of TU-LMC through different routes in Vallejo Subject to seasonal time change

22 Chronic Care Model Conceptual Framework
Designed with six interrelated system changes Increase patient centered, evidence based care Based off a survey of best practices, expert opinion, more promising interventions in literature, and quality improvement work on diabetes, depression, and cardiovascular disease These changes include health care organization, clinical information systems, delivery system design, decision support, self-management support, and strengthening community resources Bodenheimer 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)

24 Conceptual Framework Tsai et al., (2005)

25 Conceptual Framework Use the 5A’s Model of Behavioral Change Counseling. This is an evidence-based approach appropriate for a broad range of different behaviors and health conditions This 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 disease Fiore 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 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 The 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 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 Used to assess the number of healthy choices one makes Used to assess the amount of sugar and fat one consumes EXAMPLE

31 Case Management Process
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 . 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’s 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

33 Case Management Process
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 patient’s registry Reassessment of the Healthy Lifestyle Questionnaire For 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 appointments Patients will be given more educational tools The 5A’s will be updated Alterations to treatment plans will be made The 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’ schedule Follow up with patient between appointments via 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 Job 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

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 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 Explain risk and benefit of 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. Branch will be based off of past research of structural constraints already collected It 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 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), 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 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), 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 urgency PROTOCOL FOR RISK ASSESSMENT Typical 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 PROTOCAL Triage H and P Case manager 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. Lopes’s discretion BP 2X Prehypertensive >130/85 Hypertensive >140/90 BMI>25 Overweight and no other risk Random BS >126 Identify risks for metabolic syndrome Identify other risks for CVD 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). 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 Diabetes risk Age >45 High BP At risk weight BMI>25 FH of DM High cholesterol Acanthrosis nigrcans Physically inactive High blood sugar 1 Case Management Program only County referral (per Dr. Lopes) and Case Management Program If more than 1 Risk Factors, if not please refer to box 1


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