1. CVD Risk Reduction Group Case Management Core Elements May 2005

2. Case Management Core Elements Draft Case Management Core Elements Reviewed at March Planning Meeting Input Sessions – Strengths/Challenges Review of Comments Individual, Group Priorities Common Themes Final Case Management Core Elements In Binder

3. Case Management Core Elements Review of Comments – Case Management Team Strengths Team Approach Lead Case Manager Past experience, build on existing team, already in place Monthly meetings good Involvement of community Challenges Motivation of team over time, staff turnover, retention Monthly meetings too much Don’t have staff yet, hiring problems, qualified staff Coordinating care among several sites a challenge

4. Case Management Core Elements Review of Comments – Individual Case Management Strengths Diabetes Registry, structure, services already in place Flexibility, One on one visits Challenges Difficulty finding adequate space History of poor patient retention, compliance

5. Case Management Core Elements Review of Comments – Disease Management Strengths Following IHS guidelines, already in place Goals consistent with existing programs Registry, DMS, Flowsheets already in place Already do Diabetes Audit Challenges RPMS inaccurate Need paper data collection – don’t have RPMS Provider turnover, buy in to follow standards Data sharing an issue

6. Case Management Core Elements Review of Comments – Self Management Education Strengths Reference materials available Will help increase knowledge about diabetes Have existing education Challenges Qualified staff, hiring No smoking cessation program in place Patient readiness, behavior change, motivation Mental health issues

7. Case Management Core Elements Final Core Elements Document Case Management Team No changes Individual Case Management No changes Disease Management Tracking of outcomes/goals – need options for those without RPMS Self-Management Education Add Balancing Your Life With Diabetes Curriculum Make it clear that materials are references – encouraged to use

8. Case Management Core Elements Documentation of Care Plans Discussion 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