Expanding Diabetes Yearly Clinics to Include Case Management

1. Muscogee (Creek) Nation Healthy Heart Program Johnnie Brasuell, APRN, CNP; Michele Crawley, RN, BSN; Kristen Colbert, RN, BSN Expanding Diabetes Yearly Clinics to Include Case Management

2. Muscogee (Creek) Nation Division of Health Muscogee (Creek) Nation • 8 full counties and 3 partial counties • 72,000 Tribal Members

3. Muscogee Creek Nation Division of Health Healthy Heart Program • Each of the five MCNDH Clinics provides a full range of primary care and through the SDPI program a Diabetes Program team was added: • Nurse Educator/Coordinator • Dietitian • Diabetes Case Manager/Healthy Heart • Exercise Programs Manager • Diabetes Program Clerk

4. MCN Diabetes Program Teamsat each of the five clinics • Provides: • ADA Recognized DSME • Healthy Heart Programs • Community prevention programs in 21 schools, and 11 Elderly Nutrition Programs • Tribal walking programs in 25 communities • Annual MCN Citizens’ Summit • Coordinate standards of diabetes care in clinics through the yearly clinic and assess self-management support needs

5. Sustaining Healthy Heart Through Primary Care and Yearly Clinics Goal: To partner with primary care providers to improve Best Practices in diabetes care. • To initiate less intensive case management to all patients • Track appropriate and timely complication care • To identify risk factors on a routine basis • To facilitate access to available resources • To provide Healthy Heart intensive case management to a subgroup.

6. What Are We Doing Differently? Recruitment from DSME Graduates Recruitment from Yearly Clinic. • This clinic serves the total diabetes population and is already familiar to patients. From Demonstration Project To Sustainable HH Initiative

7. What Are We Doing Differently? Continued • Three HHP case managers at five clinics to provide HHP only • Five case managers (One at each clinic) to provide: • Less intensive diabetes case management • HHI From Demonstration Project To Sustainable HH Initiative

8. What Are We Doing Differently? Continued • HHP required time lines not in Sync with clinical schedules • Physical Exam and lab required for HHI participants are accomplished without separate scheduling From Demonstration Project To Sustainability HH Initiative

9. What Are We Doing Differently? Continued • Honoring the Gift of Heart Health was provided once a year over a 3-month period for new enrollees • HGHH will be scheduled by DSME coordinators year round From Demonstration HHP To Sustainabile HHI

10. What are We Doing Differently? Continued • Access to enrollment once a year • Provides access to enrollment year round From Demonstration Project To Sustainable HH Initiative

11. Pre Assessment • Detailed chart audit • Lab, immunizations, EKG, wellness care • History of self-management education • History of clinical appointments

12. Assessment During Yearly • Start with motivational interviewing • How have been doing with your diabetes this year? • What are concerns about your health? • What changes have been thinking about? • Summarize: • This is what I hear you saying: • Could I offer you some suggestions or services that are available to you?

13. Assessment During Yearly • Review self-assessment forms: • Healthy Behaviors • RAPA (Rapid Assessment of Physical Activity) • Medical History Update • Review objective information and update patient • Assess readiness for lifestyle changes • Offer resources

14. Assessment During Yearly • Inform patients that full review of their results will be completed in the next few days • Case manager will contact them by phone for their approval of final follow up plan.

15. Follow Up Yearly Clinic • Final review of the total assessment includes: • Eye, foot, and dental exams • Laboratory values • Other clinical measurements • Healthy Behaviors • Staging of complications • Readiness level • Recommendations from interdisciplinary professionals

16. Follow Up Yearly Clinic Continued • Provide patient with yearly health status report • Propose individualized recommendations to patient • Discuss patient accepted plans to provider • Obtain required referrals from provider

17. Patient Collaboration After Yearly • Inform patient of approved plan and progress of referrals through appropriate channels • Patient will be responsible for following up with case manager if they have concerns involving the referral process and appointments.