CVD Risk Reduction Group Case Management Core Elements: Update July 2005

Case Management Core Elements Draft Case Management Core Elements Reviewed at March, May Planning Meetings Grant Program Input Final decisions/IHS DDTP Case Management Core Elements In Binder, FINAL 7/15/05

Case Management Core Elements Updates Screening for Diabetes Core Elements Baseline Assessment Treatment Goals Weight loss goals – added DPP goals Regular physical activity Improved nutrition Treatment Strategies Tracking of outcomes/goals Self-Management Education

Case Management Core Elements Tracking of Goals/Outcomes Draft documents Team meetings Membership, number of meetings, attendance, topics Participant Information Attendance for Case Management Visits Participant Baseline, Annual Assessment Form Diabetes Care and Outcomes Audit Form - Annual Flowsheets (examples) AADE7 Diabetes Flowsheets (grant program examples) Will have standard flowsheet, must add to existing RPMS/EHR printouts

Case Management Core Elements Planning Year Activities Establish Case Management Team Develop a Case Management Plan (how your program will implement the Case Management Core Elements) Gather input from community on strategies that will help encourage participation Review draft forms – input by August 15, 2005 Determine what data your current flowsheets/patient summaries already gather