SDPI Healthy Heart Project SDPI Competitive Grant Program Technical Assistance Meeting October 23-24, 2006 Tucson, AZ Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project OVERVIEW – What we will cover in this session Case Management Core Elements – Baseline Activities  Case Management Core Elements as related to Baseline Activities  What does “Baseline” Mean?  Baseline Activities – What do we really do?  Overview of materials/Information available to assist you in completing baseline activities Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project Case Management Core Elements Case Management Core Elements Case Management Team  Team Membership Lead Case Manager Lead Case Manager Licensed Primary Care Provider Licensed Primary Care Provider Pharmacist Pharmacist CVD Project Coordinator CVD Project Coordinator Other recommended Team members (depending on plan, budget) Other recommended Team members (depending on plan, budget)  Team Meetings Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project Core Elements: Case Management – Protocol/Required Activities II Case Management Intensive Activities  Components of Case Management for CVD Risk Reduction: Individual Case ManagementIndividual Case Management Disease ManagementDisease Management Self-Management EducationSelf-Management Education  Individual Case Management AssessmentAssessment Care planCare plan Implementation/coordination of careImplementation/coordination of care Care plan/referralsCare plan/referrals Follow-upFollow-up

SDPI Healthy Heart Project  Disease Management Baseline Physical ExamBaseline Physical Exam Physical exam Physical exam Weight/height/BMI Weight/height/BMI Baseline labs/tests (A1C/Fasting Blood Glucose, BP, Lipids, Renal function tests) Baseline labs/tests (A1C/Fasting Blood Glucose, BP, Lipids, Renal function tests) ECG at Baseline ECG at Baseline Consider cardiac clearance Consider cardiac clearance Other assessments Other assessments Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project Baseline Activities  Rationale Baseline: Term used to identify a set of measures taken at the beginning of a study or project, just before the participant starts to receive any of the intervention (treatment or education) of the project. Baseline: Term used to identify a set of measures taken at the beginning of a study or project, just before the participant starts to receive any of the intervention (treatment or education) of the project. Requirements as described in Case Management Core Elements Requirements as described in Case Management Core Elements Physical exam, ECG, lab tests, BP, height, weight, BMI, Waist/Hip Circumference, other assessments as necessaryPhysical exam, ECG, lab tests, BP, height, weight, BMI, Waist/Hip Circumference, other assessments as necessary Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project Baseline Activities What do we really need to DO?  At first clinical meeting with individual (following consent process): Review project goals, make sure Informed Consent Form has been signed Review project goals, make sure Informed Consent Form has been signed Review HIPPA Authorization Form, answer any questions about it, ask participant to sign the form (if this was not done at the same time as consent form) Review HIPPA Authorization Form, answer any questions about it, ask participant to sign the form (if this was not done at the same time as consent form) Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project  At first clinical meeting with individual (continued): Obtain baseline information from the individual about level of activity, diabetes/CVD knowledge, attitude about their diabetes, perception about level of health, etc. – the Participant Baseline Questionnaire Obtain baseline information from the individual about level of activity, diabetes/CVD knowledge, attitude about their diabetes, perception about level of health, etc. – the Participant Baseline Questionnaire Where did these questions come from???Where did these questions come from??? Topic Citations Topic Citations Topic Citations Topic Citations Test for/measure and record current (baseline) laboratory, clinical and physical values used to assess level of health (physical exam & lab tests) not already scheduled and completed following consent form meeting - the Baseline Assessment of Core Elements Test for/measure and record current (baseline) laboratory, clinical and physical values used to assess level of health (physical exam & lab tests) not already scheduled and completed following consent form meeting - the Baseline Assessment of Core Elements How much time do we have in which to get this information collected?How much time do we have in which to get this information collected? Timeline for physical exams and lab results Timeline for physical exams and lab results Timeline for physical exams and lab results Timeline for physical exams and lab results Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project  At first clinical meeting with individual (last but not least): Obtain information from family member for Family Baseline Questionnaire or schedule time to administer this questionnaire as appropriate Obtain information from family member for Family Baseline Questionnaire or schedule time to administer this questionnaire as appropriate Family Baseline Questionnaire Talking PointsFamily Baseline Questionnaire Talking PointsFamily Baseline Questionnaire Talking PointsFamily Baseline Questionnaire Talking Points Schedule intensive activities (case management, diabetes education, other) Schedule intensive activities (case management, diabetes education, other) Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project Baseline Activities  Things to think about when scheduling baseline activities Timelines Timelines Workload Workload Provider availability Provider availability Scheduling and completing laboratory tests and ECGs Scheduling and completing laboratory tests and ECGs Scheduling of first Case Management Visit Scheduling of first Case Management Visit Scheduling of HGHH classes Scheduling of HGHH classes Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project  Information to assist with activities recorded on the Baseline Assessment of Core Elements (BACE or B1) Form Each of the documents listed below can be found on the Coordinating Center Website under Resources/Clinical Guidelines: or in “Appendix N. Clinical Guidelines” of the SDPI Operations Manual Each of the documents listed below can be found on the Coordinating Center Website under Resources/Clinical Guidelines: or in “Appendix N. Clinical Guidelines” of the SDPI Operations Manualhttp:// Guidelines for Screening Physical ExamGuidelines for Screening Physical Exam Exercise Stress Test Recommendations for Patients with DMExercise Stress Test Recommendations for Patients with DM Chronic Diseases and ConditionsChronic Diseases and Conditions Timelines for Physical Exams and Lab ResultsTimelines for Physical Exams and Lab ResultsTimelines for Physical Exams and Lab ResultsTimelines for Physical Exams and Lab Results *Resources/Project Related Resources/Glossary of terms*Resources/Project Related Resources/Glossary of terms Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project  Information to assist with understanding and answering questions regarding the Participant Baseline Questionnaire (PBQ or B2) Each of the documents listed below can be found on the Coordinating Center Website under Data Collection/Forms/Participant Baseline Questionnaire: Each of the documents listed below can be found on the Coordinating Center Website under Data Collection/Forms/Participant Baseline Questionnaire: or under Forms, Step 2, of the SDPI Operations Manual Topic CitationsTopic Citations Participant Baseline Questionnaire Talking PointsParticipant Baseline Questionnaire Talking Points Answers to Knowledge QuestionsAnswers to Knowledge Questions Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project  Information to assist with understanding and answering questions regarding the Family Baseline Questionnaire (FBQ) The document listed below can be found on the Coordinating Center Website under Data Collection/Forms/Participant Baseline Questionnaire: The document listed below can be found on the Coordinating Center Website under Data Collection/Forms/Participant Baseline Questionnaire: or under Forms, Step 2, of the SDPI Operations Manual Family Baseline Questionnaire Talking PointsFamily Baseline Questionnaire Talking Points Core Elements: Case Management – Protocol/Required Activities I

SDPI Healthy Heart Project RECAP Case Management Core Elements – Baseline Activities  Case Management Core Elements  Importance of Baseline data  Specific Baseline Activities  Resources for baseline materials/Information Core Elements: Case Management – Protocol/Required Activities I