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SDPI Healthy Heart Project SDPI Competitive Grant Program Technical Assistance Meeting October 23-24, 2006 Tucson, AZ Core Elements: Case Management and.

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Presentation on theme: "SDPI Healthy Heart Project SDPI Competitive Grant Program Technical Assistance Meeting October 23-24, 2006 Tucson, AZ Core Elements: Case Management and."— Presentation transcript:

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

2 SDPI Healthy Heart Project OVERVIEW – What we will cover in this session Case Management Core Elements – Intensive Activities  Case Management Core Elements as related to ongoing activities  Case Management Visits  Healthy Heart Curriculum What do we really need to DO? Retention Core Elements – Intensive Activities  Retention Plan and Activities Things to think about when planning/scheduling Intensive Activities Overview of materials/information available to assist you with Intensive Activities Core Elements: Case Management and Retention Activities

3 SDPI Healthy Heart Project Core Elements: Case Management – Protocol/Required Activities II Case Management Core Elements - Intensive Activities Case Management Core Elements - 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

4 SDPI Healthy Heart Project  Disease Management Reduction of CVD Risk in Patients with Diabetes Reduction of CVD Risk in Patients with Diabetes Standards/GuidelinesStandards/Guidelines Baseline Physical ExamBaseline Physical Exam Treatment GoalsTreatment Goals Treatment StrategiesTreatment Strategies Tracking Risk factors/goalsTracking Risk factors/goals Core Elements: Case Management – Protocol/Required Activities II

5 SDPI Healthy Heart Project  Self-Management Education Standards/Guidelines– Reference Materials/Options Standards/Guidelines– Reference Materials/Options Honoring the Gift of Heart Health CurriculumHonoring the Gift of Heart Health Curriculum Balancing Your Life and Diabetes CurriculumBalancing Your Life and Diabetes Curriculum Nationals Standards for Diabetes Self-management EducationNationals Standards for Diabetes Self-management Education Components of Education Components of Education Individual or GroupIndividual or Group Lifestyle: Nutrition, Activity, Stress Reduction, Motivation, Mental Health, etc.Lifestyle: Nutrition, Activity, Stress Reduction, Motivation, Mental Health, etc. Involvement of familyInvolvement of family Awareness of risk of CVD for AIANsAwareness of risk of CVD for AIANs Core Elements: Case Management – Protocol/Required Activities II

6 SDPI Healthy Heart Project  Motivational Activities Project sponsored activities Project sponsored activities Involve family and youth Involve family and youth Combine with Community Based Activities Combine with Community Based Activities Document Participation Document Participation  Monitoring/Follow-up of CVD Risk Factors Testing for Clinical Care Testing for Clinical Care Evaluation of Project/Reporting to CC Evaluation of Project/Reporting to CC Core Elements: Case Management – Protocol/Required Activities II

7 SDPI Healthy Heart Project Intensive Activities  What do we really need to DO? Monthly Case Management Visits – Monthly Case Management Visits – HIGHER LEVEL OF CARE HIGHER LEVEL OF CARE Clinical componentClinical component Lifestyle componentLifestyle component Case Management Team Meetings – Provider Involvement Case Management Team Meetings – Provider Involvement Teach Honoring the Gift of Heart Health curriculum Teach Honoring the Gift of Heart Health curriculum Retention Activities – See Retention Core Elements Retention Activities – See Retention Core ElementsRetention Core ElementsRetention Core Elements Core Elements: Case Management and Retention Activities

8 SDPI Healthy Heart Project  Things to think about when scheduling intensive activities Timeliness Timeliness Scheduling/convenience for participant (visits and classes) Scheduling/convenience for participant (visits and classes) Case Manager schedule Case Manager schedule Scheduling team meetings – provider availability? Scheduling team meetings – provider availability? Team meeting Class site/instructor availability Team meeting Class site/instructor availability Time to complete paperwork Time to complete paperwork Core Elements: Case Management and Retention Activities

9 SDPI Healthy Heart Project  More things to think about when scheduling intensive activities Keeping people interested/involved – RETENTION Keeping people interested/involved – RETENTION Brainstorm the same way you did for recruitment activitiesBrainstorm the same way you did for recruitment activities Identify and remove (or reduce) barriers to participationIdentify and remove (or reduce) barriers to participation Be diligent with your tracking so no one “falls between the cracks”Be diligent with your tracking so no one “falls between the cracks” Remember – Remember – This is INTENSIVE CASE MANAGEMENT – it means a higher level of care than regular case management, so you need to be diligent and creative Core Elements: Case Management and Retention Activities

10 SDPI Healthy Heart Project  Tracking Intensive Activities The following forms are used to track the activities of your project and the progress of your participants throughout the duration of the grant The following forms are used to track the activities of your project and the progress of your participants throughout the duration of the grant Case Management Team Meetings Form (I1)Case Management Team Meetings Form (I1)Case Management Team Meetings Form (I1)Case Management Team Meetings Form (I1) Participant Attendance Form (I2)Participant Attendance Form (I2)Participant Attendance Form (I2)Participant Attendance Form (I2) Individual Retention Form (I3)Individual Retention Form (I3)Individual Retention Form (I3)Individual Retention Form (I3) These forms should be updated monthly/regularly and submitted to the Coordinating Center annually in December. These forms should be updated monthly/regularly and submitted to the Coordinating Center annually in December. Core Elements: Case Management and Retention Activities

11 SDPI Healthy Heart Project  Information to assist with intensive activities Each of the documents listed below can be found on the Coordinating Center Website under Resources/Clinical Guidelines: http://www.uchsc.edu/ai/sdpi/sdpi_login.htm, 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: http://www.uchsc.edu/ai/sdpi/sdpi_login.htm, or in “Appendix N. Clinical Guidelines” of the SDPI Operations Manualhttp://www.uchsc.edu/ai/sdpi/sdpi_login.htm IHS Standards of Care for patients with Type 2 DiabetesIHS Standards of Care for patients with Type 2 Diabetes *Care Plan Sample (only on website)*Care Plan Sample (only on website) The following additional resources can be found on the Coordinating Center Website under Resources/Clinical Guidelines: http://www.uchsc.edu/ai/sdpi/sdpi_login.htm The following additional resources can be found on the Coordinating Center Website under Resources/Clinical Guidelines: http://www.uchsc.edu/ai/sdpi/sdpi_login.htmhttp://www.uchsc.edu/ai/sdpi/sdpi_login.htm Guidelines for diagnosis and treatment of hypertensionGuidelines for diagnosis and treatment of hypertension Guidelines for pharmaceutical and lifestyle treatment of hypertensionGuidelines for pharmaceutical and lifestyle treatment of hypertension Guidelines for diagnosis and treatment of dyslipidemiaGuidelines for diagnosis and treatment of dyslipidemia Guidelines for pharmaceutical treatment of dyslipidemiaGuidelines for pharmaceutical treatment of dyslipidemia Core Elements: Case Management and Intensive Activities

12 SDPI Healthy Heart Project RECAP Case Management Core Elements – Intensive Activities  Case Management Visits – More Intense!  Healthy Heart Curriculum – What works for your site What do we really need to DO? Retention Core Elements – Intensive Activities  Retention Plan and Activities Things to think about when planning/scheduling Intensive Activities Intensive Activities materials/information Core Elements: Case Management and Retention Activities


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