A Proposal for a Case Management Program for Chronic Disease at Touro University’s Student Run Health Clinic
By Sarah Rose NewTouro University- California
Advisor: Dr. Thairu
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
• 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
Background and Significance
Rogers et al., (2012)Heindenreich et al. (2011)
• 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
Background and Significance
National Diabetes Education Program, (2007)National Diabetes Information Clearinghouse, (2011)
• 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
Background and Significance
Center for Disease Control and Prevention [CDC], 2011)Keenan & Rosendorf, (2011)Heindenreich et al., (2011)Rogers et al., (2012)Lloyd-Jones, Evans, & Levy, (2005)
• 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
Background and Significance
Rogers et al., (2012)
• 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
Background and Significance
California Healthcare Foundation, (2006)CDC, (2008)
• 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
Background and Significance
Case Management Society of America [CMSA], (2010)Bosshart & Vienna, (2008)
• 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
Background and Significance
CMSA, (2010)
• 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
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
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
Background and Significance
Meah, Smith, & Thomas, (2009)Simpson & Long, (2007)National Research Counsil, (2002)
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
• 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
Touro University’s SRHC
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
• 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
– 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
Proposed Case Management Program
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
• 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
• Designed with six interrelated system changes– Increase patient centered, evidence based care
Bodenheimer et al., (2002)Coleman et al., (2009)
• 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
Conceptual Framework
Fiore et al., (2000)Glasgow et al., (2006)The Quality Indicator Study Group, (1995)
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
• 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 Process
Acceptance to Case Management Program
• Begins after triage and medical assessment
• Only enrolled if they fit criteria
Assignment to Case Manager
• Brief intro to Case Management Program
• Begin Health Literacy Test and Healthy Lifestyle Questionnaire
Health Literacy Test
• Designed to rate patients knowledge on diabetes, hypertension, obesity, and cardiovascular risk factor and disease.
• 20 questions exam• Self administered• The higher the
score, the more competent the patient is on the disease or risk factors related to the disease.
Case Management Process
Healthy Lifestyle Questionnaire
• Used to access self perceived views on health, diet, and exercise habits.
• Interview patient• Consist of two
different scores• Healthy Lifestyle
Score• Health Risk Score
Healthy Lifestyle Score
• Used to assess the number of healthy choices one makes
Health Risk Score
• Used to assess the amount of sugar and fat one consumes
EXAMPLE
• 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
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
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 Process
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
• 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 = 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
Case Managers Job
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
• 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
• 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
• 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
• 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• 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 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
• 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
• 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
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REFERENCESHeidenreich, 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 from http://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.
Triage: get BMI, BP, Random Glucose test, recent weight loss, thirst +FH (DM, CVD, HTN)
Prehypertensive>130/85
Hypertensive>140/90
BP 2X
Random BS >126
SD/PA: Evaluate, discuss with Dr. Lopes after H and P and Refer to case manager if BS> 126 0r BMI>25 0r BP >130/85, and/or by Dr. Lopes’s discretion
BMI>25Overweight and no other risk
County referral (per Dr. Lopes) and Case Management Program
Identify risks for metabolic syndrome
1 Case
Management Program only
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).
If more than 1 Risk Factors, if not please refer to box 1
1. Cigarette smoking2. Obesity (body mass index ≥30 kg/m2)3. Physical inactivity4 .Dyslipidemia5. Diabetes mellitus6. Age (older than 55 for men, 65 for women)7. Family history of premature cardiovascular disease8. Sleep apnea
Identify other risks for CVD
Responsibilities:EMERGENCY PROTOCALTriageH and PCase manager
Diabetes risk1. Age >452. High BP3. At risk weight BMI>254. FH of DM5. High cholesterol6. Acanthrosis nigrcans7. Physically inactive8. High blood sugar
CP, SOB, BP>180/120 Notify Dr. Lopes to access urgency
Typical patient coming in for screening physical, OMM treatment etc. PROTOCOL FOR RISK ASSESSMENT
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