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

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

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

SRHC Population

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)

Conceptual Framework

Tsai et al., (2005)

Conceptual Framework

Tsai et al., (2005)

• 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

Time Table for Project

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

REFERENCESBodenheimer, 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.xGlasgow, 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

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.

• Thank you! I would be happy to answer any questions you may have!

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