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A Proposal for a Case Management Program for Chronic Disease at Touro University’s Student Run Health Clinic. By Sarah Rose New Touro University- California Advisor: Dr. Thairu. Capstone Objectives.

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slide1

A Proposal for a Case Management Program for Chronic Disease at Touro University’s Student Run Health Clinic

By Sarah Rose New

Touro University- California

Advisor: Dr. Thairu

capstone objectives
Capstone Objectives

To present a proposal for a Case Management Program that monitors hypertension, diabetes, obesity, and cardiovascular disease at the Touro University’s Student Run Health Clinic

background and significance
Background and Significance
  • Cardiovascular Disease (CVD)
      • Broad term for all diseases specific to the heart and cardiovascular system
    • 2,200 Americans die of CVD every day
      • Average of 1 every 39 seconds
    • Forecasted by 2030= 40.5% of U.S. will have some form of CVD

Rogers et al., (2012)

Heindenreich et al. (2011)

slide4

Background and Significance

  • Diabetes
    • Major risk factor of CVD is diabetes
    • CVD is a major complication of diabetes and leading cause of premature death of those with diabetes
    • Diabetes effects 25.8 million people= 8.3% of U.S. population
    • 81.5 million adults have prediabetes= 37% of U.S. population

National Diabetes Education Program, (2007)

National Diabetes Information Clearinghouse, (2011)

slide5

Background and Significance

  • Hypertension
    • clinically defined as high blood pressure readings two separate occasions
    • Contributes to 1 in 7 deaths and nearly half of all CVD related deaths
    • Effects 30% of U.S. adults
    • Forecasted to increase by 9.9% from 2010 to 2030
    • Prehypertension
      • 29.7% U.S. adults >20

Center for Disease Control and Prevention [CDC], 2011)

Keenan & Rosendorf, (2011)

Heindenreich et al., (2011)

Rogers et al., (2012)

Lloyd-Jones, Evans, & Levy, (2005)

slide6

Background and Significance

  • Obesity
    • Increasing rise of obesity leads to increase rise in hypertension, CVD, and diabetes
    • 149 million U.S. adults are overweight or obese
      • 67.3% of the U.S. population
      • 33.7% are only obese

Rogers et al., (2012)

slide7

Background and Significance

  • Disease Burden on California
    • 57% of Californians over 65 have high blood pressure
    • 33% of males and 39% of females will be diagnosed with diabetes in their lifetime
    • Solano County:
      • 9.5% adults have diagnosed diabetes, largest figure when compared to other Counties in California
      • 22.8% are obese

California Healthcare Foundation, (2006)

CDC, (2008)

slide8

Background and Significance

  • Case Management Programs
    • Defined as collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy options and services to meet individual and family needs
    • Evolution:
      • 1900s- began as sanitation and immunization practices
      • 1981- case management is integrated into Medicaid

Case Management Society of America [CMSA], (2010)

Bosshart & Vienna, (2008)

slide9

Background and Significance

  • Six Components
    • Client identification and selection,
    • Assessment and problem/opportunity identification
    • Development of the case management plan
    • Implementation and coordination of care activities
    • Evaluation of the case management plan and follow up
    • Termination of the case management process

CMSA, (2010)

slide10

Background and Significance

  • Evidence of Case Management Effectiveness
    • Weingarten et al. (2002) reported:
      • that case management programs were associated with provider adherence to guidelines and patient disease control
    • Gilmer et al. (2007) found:
      • association with cost effective improvements in quality-adjusted life expectancy and a decrease in incidence of diabetes-related complications
      • that case management programs are cost effective for low income populations
slide11

Background and Significance

  • California Medi-Cal Type 2 Diabetes Study Group (2004)
    • found that case management improved glycemic control when added to primary care
    • reduced disparities in diabetes health status among low income ethnic populations
slide12

Background and Significance

  • Student Run Clinics
    • Student initiated endeavors with commitments to underserved communities
    • First appeared in various cities in the mid 1960s
      • Currently widespread among U.S. medical schools
    • Provide training to face healthcare crises
    • Considered impressive, realistic learning methods for preparing young physicians

Meah, Smith, & Thomas, (2009)

Simpson & Long, (2007)

National Research Counsil, (2002)

touro university s student run health clinic srhc
Touro University’s Student Run Health Clinic (SRHC)
  • Opened in October 2010
  • Located in Vallejo, California at Norman C. King Community Center
  • Open from 4:30-8:00pm every Thursday
  • Opened under the supervision of Dr. Lopes
  • Mission: to create an interprofessional clinic that focuses on improving access to health care in the surrounding areas while improving clinical and education skill of students at Touro University
touro university s srhc1
Touro University’s SRHC
  • Offers the following services:
    • Screening exams and health education
    • Medication review
    • Blood pressure check
    • Osteopathic manipulative medicine
    • Immunizations
  • As of October 2011= 192 patients
  • As of February 2012= 235 patients
specific aims and objectives of proposed case management program
Specific Aims and Objectives of Proposed Case Management Program
  • Increase volunteer positions for MPH students
  • Decrease diabetes, hypertension, high BMI, and cardiovascular disease within Student Run Health Clinic (SRHC) patient population
  • Increase health literacy and adherence to healthy behaviors for the community
proposed case management program
Proposed Case Management Program
  • TU-SRHC Case Management Program is unique
    • Use a public health approach by providing services to reduce the burden of disease on the community
      • through outreach and advocacy in addition to reducing individual barriers to health
proposed case management program1
Proposed Case Management Program
  • If successful, the proposed program
    • Will help the SRHC to strengthen their mission to overcome individual and environmental barriers to health
    • Will reduce risks and outcomes that can be maintained under the SRHC’s current scope of practice
preliminary studies progress report
Preliminary Studies/Progress Report
  • Program implementation began in November 2011 but patients are currently not enrolled
  • Program currently in final stages of development with an anticipated launch date of May 31st, 2012
  • I have played an important role in the program since its inception
  • Pilot Program will be launched with 6 case managers
  • Jocelyn Lee DO/MPH
  • Ghazal Ghafari MPH
  • Kyle Severinsen MPH
  • John Suchland MPH
  • Michael Phorth MPH
  • Katie Ho MPH
  • New Public Health Coordinator- Kristoffer Chin MPH
proposed design of case management program
Proposed Design of Case Management Program
  • Held simultaneously with SRHC at the Norman C. King Community Center in Vallejo, CA
  • Section of clinic will be allocated for Case Management
  • Case Management Services:
    • offered from 4:30-5:00pm
    • followed by Community Education from 5:00pm-6:00pm
    • Case Management again from 6:00-8:00pm
  • Community Walking Program:
    • 6:00-7:00pm (seasonal based)
    • Offered via the Lifestyle Medicine Club
chronic care model conceptual framework
Chronic Care Model Conceptual Framework
  • Designed with six interrelated system changes
    • Increase patient

centered, evidence

based care

Bodenheimeret al., (2002)

Coleman et al., (2009)

slide23

Conceptual Framework

Tsai et al., (2005)

slide24

Conceptual

Framework

Tsai et al., (2005)

slide25

Conceptual Framework

  • Use the 5A’s Model of Behavioral Change Counseling.
    • This is an evidence-based approach appropriate for a broad range of different behaviors and health conditions

Fiore et al., (2000)

Glasgow et al., (2006)

The Quality Indicator Study Group, (1995)

patient inclusion criteria
Patient Inclusion Criteria
  • Patient attends Touro University’s Student Run Health Clinic
  • Systolic blood pressure measurement >130
  • Diastolic blood pressure measurement >85 on two separate occasions (hypertension)
  • Fasting plasma glucose >126 mg/dl or 100 md/dl – 125mg/dl (pre-diabetes)
  • Casual plasma glucose concentration >200 mg/dl
  • BMI >25
  • Pre-diagnosis of hypertension, diabetes mellitus type II, and/or cardiovascular disease
  • This criteria has been approved by Dr. Lopes
data collection
Data Collection
  • Electronic Disease Registry
    • Record all vitals taken at SRHC, outside clinics, and own monitoring capabilities
  • Perceived Individual and Environmental Barriers to Health
    • Assist in future program improvement and developing future community initiatives
  • Satisfaction Surveys
    • Allow for improvements in quality of care and services offered
case management process2
Case Management Process
  • Treatment Tier Placement
    • Case managers will place patients into two treatment plan tiers
      • Limited or advanced proficiency
      • Low or high risk
    • Placement will assist in recognition of the severity of disease or other risk factors.
    • Allows assessment of the severity of environmental barriers
    • Will indicate where to begin in terms of health education
slide32

Case Management Process

  • Assessment with 5A’s
    • Assess, Advisement, Agree, Assist, and Arrange
    • Includes:
      • recording individual and environmental barriers to better health
      • case manager recommendations to behavior change.
      • creating collaborative goals with the patient
      • develop strategies to achieve these goals
      • giving referrals to outside resources, a diet prescription, and exercise guidelines
      • planning of a follow up visit
slide33

Case Management Process

  • Follow up appointments
    • All patients will return in 2 weeks for a follow up
    • Follow up appointments after pilot will be set up by treatment plan tiers
    • Appointments will involve triage and patient specific treatment
      • New readings will be recorded in patient’s registry
    • Reassessment of the Healthy Lifestyle Questionnaire
case management process3
Case management process
  • Follow up appointments
    • Patients will be given more educational tools
    • The 5A’s will be updated
    • Alterations to treatment plans will be made
    • The case manager will ensure that outside resources are being utilized
case manager s job
Case Manager’s Job
  • Work in bi-weekly, two hour shifts
    • Must also be flexible according to patients’ schedule
    • Follow up with patient between appointments via email address to provide motivation and consultation
  • If not assigned a patient, they will work to update Public Health Library
    • Primary purpose is to keep staff at SRHC and case managers up to date in chronic disease
    • Only accessible to registered Touro members
case managers job
Case Managers Job
  • Case managers = community health advocate
    • Program identifies personal environmental barriers to resolve local health problems
    • Managers use these to create community initiatives, outreach, and increase access to resources
  • Will be working with the Solano County Coalition for Better Health
srhc and touro community education
SRHC and Touro Community Education
  • Case Management Program brown bag series
    • Topics will include diabetes, hypertension, obesity, CVD, cultural health differences, and health disparities
    • Open to all students and strongly recommended to those who plan to volunteer at the clinic
  • Protocol created by Jocelyn Lee and Dr. Lopes
    • Protocol print out given to all staff
      • Aide in better identification of patients with these specific diseases or risk factors
      • Allow staff to correctly utilize the Case Management Program
exit criteria for case management program
Exit Criteria for Case Management Program
  • No limit on length in program
  • Released upon criteria of graduation
  • Outcomes or goals are as follows:
    • Patient becomes self sufficient in this or her own recovery or rehabilitation
    • Patient reduces test results, controls disease, or is undiagnosed with disease
case manager limitations
Case Manager Limitations
  • No contact with patients via cell phones
    • Will contact via email address
  • Limitation to scope of practice of SRHC
    • SRHC only has the ability to monitor the diseases chosen by the Case Management Program
  • Cannot diagnose patients or suggest medication
    • Will refer to on staff student pharmacist
proposed pilot for program
Proposed Pilot for Program
  • During pilot, maximum patient load of 8 and minimum of 6
  • Will allow case managers to assess the proper patient load ratio for full launch
potential challenges for implementing the case management program
Potential Challenges for Implementing the Case Management Program
  • Limited human resources as the program will depend on volunteer students from Touro
    • This may place limitations on patient load
    • It is possible that the program will only accept those patients who require immediate assistance as directed by student physician
ethical considerations
Ethical Considerations
  • Patient authorizes treatment
  • Patient will sign form allowing contact via email
    • Explain risk and benefit of e-mail communication
  • Training for case managers
    • Specific Case Management Training
    • New managers will shadow mentor 2 times
  • Flash drive keeps all data and patients information
    • Locked up at clinic
    • Case managers will have access to flash drive during clinic hours
    • SRHC staff will also have access
budget and personnel
Budget and Personnel
  • Budget only requires funds for printing materials
    • Estimated $100 dollars
    • All other items supplied by Touro University or SRHC
  • Personnel includes:
    • MPH Coordinator
    • Case Management Program Director
    • Volunteers from the MPH Program
future implications
Future Implications
  • Expand in both size and materials
    • Develop two volunteer tiers:
      • Case managers who advocate for individuals
      • Case managers who advocate for environmental needs
      • Allow to keep a public health approach as the need for individual monitoring increases with patient load
  • More disease specific training to replace manual
  • Additional cultural sensitivity training
  • Expansion of services: women's health, dental, etc.
conclusion
Conclusion
  • Student run health clinics are increasing in number in the United States and they provide an opportunity to provide healthcare in low income populations
  • Case Management Programs may effectively reduce health disparities
  • The proposed Case Management Program has the potential to improve health outcomes in surrounding areas low income and minority population
references
REFERENCES

Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. [Research Support, Non-U.S. Gov't]. The Journal of the American Medical Association, 288(14), 1775-1779.

Bosshart, J., & Vienna, M. (2008). Recommendations for case management collaborations and coordination in federally funded HIV/AIDS programs. U.S. Department of Health and Human Services. Retrieved from http://www.cdcnpin.org/scripts/features/CaseManagement.pdf

California HealthCare Foundation. (2006). Chronic disease in California: facts and figures. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ChronicDiseaseFactsFigures06.pdf

California Medi-Cal Type 2 Diabetes Study Group. Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study. (2004). Diabetes care, 27(1), 95-103. http://www.ncbi.nlm.nih.gov/pubmed/14693973

Case Management Society of America. (2010). Standards of practice for case management. Retrieved from http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf

Center for Disease Control and Prevention. (2008). Diabetes data and trends. [Data file]. Retrieved from http://apps.nccd.cdc.gov/DDT_STRS2/CountyPrevalenceData.aspx?StateId=6&mode=OBS

Center for Disease Control and Prevention. (2011). Vital signs: prevalence, treatment, and control of hypertension—United States, 1999-2002 and 2005-2008. Morbidity and Mortality Weekly Report, 60(4), 103-108.

Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the Chronic Care Model in the new millennium. Health Affairs, 28(1), 75-85. doi: 10.1377/hlthaff.28.1.75

Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., et al. (2000). Treating tobacco use and dependence: clinical practice guideline. U.S. Department of Health and Human Services. Retrieved from http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf

Gilmer, T. P., Roze, S., Valentine, W. J., Emy-Albrecht, K., Ray, J. A., Cobden, D., Nicklasson, L., Philis-Tsimikas, A., & Palmer, A. J. (2007). Cost-effectiveness of diabetes case management for low-income populations. [Research Support, Non-U.S. Gov't]. Health Services Research, 42(5), 1943-1959. doi: 10.1111/j.1475-6773.2007.00701.x

Glasgow, R. E., Emont, S., & Miller, D. C. (2006). Assessing delivery of the five 'As' for patient-centered counseling. [Research Support, Non-U.S. Gov't]. Health Promotion International, 21(3), 245-255. doi: 10.1093/heapro/dal017

references1
REFERENCES

Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., . . . Woo, Y. J. (2011). Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. [Consensus Development Conference]. Circulation, 123(8), 933-944. doi: 10.1161/CIR.0b013e31820a55f5

Keenan, N. L., & Rosendorf, K. A. (2011). Prevalence of hypertension and controlled hypertension - United States, 2005-2008. Morbidity and mortality weekly report. Surveillance Summaries,60(01 Suppl), 94-97.

Lloyd-Jones, D.M., Evans, J.C., & Levy, D. (2005). Hypertension in adults across the age spectrum: current outcomes and control in the community. Journal of the American Medical Association, 294, 446-472. doi: 10.1001/jama.294.4.466

Meah, Y. S., Smith, E. L., & Thomas, D. C. (2009). Student-run health clinic: novel arena to educate medical students on systems-based practice. [Review]. The Mount Sinai Journal of Medicine, New York, 76(4), 344-356. doi: 10.1002/msj.20128

National Diabetes Education Program. (2007). The link between diabetes and cardiovascular disease. Retrieved from http://ndep.nih.gov/media/CVD_FactSheet.pdf

National Diabetes Information Clearinghouse. (2011a, December 6). National diabetes statistics, 2011. Retrieved fromhttp://diabetes.niddk.nih.gov/dm/pubs/statistics/#fast

National Research Counsil. (2002). Fostering rapid advances in health care: learning from system demonstrations. [Executive Summary]. Washington DC: The National Academies Press.

Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E. J., Berry, J. D., Borden, W. B., . . . Turner, M. B. (2012). Heart disease and stroke statistics--2012 update: a report from the American Heart Association. [Comparative Study]. Circulation, 125(1), e2-e220. doi: 10.1161/CIR.0b013e31823ac046

Simpson, S. A., & Long, J. A. (2007). Medical student-run health clinics: important contributors to patient care and medical education. Journal of General Internal Medicine, 22(3), 352-356. doi: 10.1007/s11606-006-0073-4

The Quality Indicator Study Group (1995) An approach to the evaluation of quality indicators of the outcome of care in hospitalized patients, with a focus on nosocomial infection indicators. Infection Control and Hospital Epidemiology, 16, 308–316.

Tsai, A.C., Morton, S.C., Mangione, C.M., & Keller, E.B. (2005). A meta-analysis of interventions to improve care for chronic for chronic illnesses. American Journal of Managed Care, 11(8), 478-88.

slide50

Typical patient coming in for screening physical, OMM treatment etc.

PROTOCOL FOR RISK ASSESSMENT

CP, SOB, BP>180/120 Notify Dr. Lopes to access urgency

Triage: get BMI, BP, Random Glucose test, recent weight loss, thirst +FH (DM, CVD, HTN)

Responsibilities:

EMERGENCY PROTOCAL

Triage

H and P

Case manager

SD/PA: Evaluate, discuss with Dr. Lopes after H and P and Refer to case managerif BS> 126 0r BMI>25 0r BP >130/85, and/or by Dr. Lopes’s discretion

BP 2X

Prehypertensive

>130/85

Hypertensive

>140/90

BMI>25

Overweight and no other risk

Random BS >126

Identify risks for metabolic syndrome

Identify other risks for CVD

RF 1: abdominal obesity (waist circumference >40 inches in men or >35 inches in women) *

RF 2: glucose intolerance (fasting glucose >100 mg/dL), *

RF 3: BP >130/85 mmHg, *

RF 4: high triglycerides (>150mg/dL)

RF 5: low HDL (<40 mg/dL in men or <50 mg/dL in women).

1. Cigarette smoking

2. Obesity (body mass index ≥30 kg/m2)

3. Physical inactivity

4 .Dyslipidemia

5. Diabetes mellitus

6. Age (older than 55 for men, 65 for women)

7. Family history of premature cardiovascular disease

8. Sleep apnea

Diabetes risk

Age >45

High BP

At risk weight BMI>25

FH of DM

High cholesterol

Acanthrosisnigrcans

Physically inactive

High blood sugar

1

Case Management Program only

County referral (per Dr. Lopes) and Case Management Program

If more than 1 Risk Factors, if not please refer to box 1