1. Healthy Heart Project Dataset Session 1 of 2 July 29, 2009 SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1

2. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 Overview New Forms Introduction C1 C2 P1 P2 3 Participant Groups - who uses which form?

3. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 C1 C1 Comprehensive Assessment Form (Baseline and Annual Assessments)

4. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Questions 1 - 5 Make sure these are complete: NDPID# and Site# Participant ID# Which program: DP or HH? Which assessment? Pregnant or on Dialysis? STOP! Do not fill out the form – Participant is not eligible/cannot have assessment at this time Medical Clearance Has a licensed provider cleared the individual for participation in your program based on their judgment?

5. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 General Information General information needed at Baseline ONLY: Year of Birth Gender Date of first Case Management Visit that the participant actually attended! HIPAA Tip Only list the year of birth – full date of birth is PHI

6. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Clinical Visit Measurements No major changes Weight Height Waist circumference Blood Pressure

7. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Lipid Profile No major changes HDL LDL Triglycerides Total cholesterol

8. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Urine Testing - NEW A/C Ratio If no A/C Ratio, Urine Dipstick For Protein Microalbuminuria

9. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Glycemic Measures - NEW 1 of 4 tests can be done for assessments 1.FBG 2.OGTT 3.A1c 4.Casual Sugar

10. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Clinical History - NEW Diagnosis of Diabetes If yes, enter date Diagnosis of Metabolic Syndrome If yes, enter date

11. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Metabolic Syndrome - NEW For the purposes of this project, Metabolic Syndrome is defined as having at least 3 of these 5 conditions: 1.Abdominal Obesity (Waist circumference > 40 inches in men, > 35 inches in women) 2.Hypertension* (Blood pressure ≥ 130/85 mm Hg) 3.Low HDL Cholesterol* (< 40 mg/dl in men, < 50 mg/dl in women) 4.High triglycerides* (≥ 150 mg/dl) 5.Elevated fasting plasma glucose (FBG ≥100 mg/dl)

12. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Clinical History continued Tobacco Use Current user or no? Referred for cessation counseling? Diagnosis of Hypertension Yes or No? If yes, list year

13. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Clinical History continued CVD Event or Diagnosis Baseline ONLY Previous diagnosis of CVD? Annual Assessment ONLY CVD diagnosis or event since the previous assessment?

14. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C1 Clinical History continued Diabetes Risk Factors New Family history of diabetes question is now split into two questions: 1.Parental history of diabetes 2.Sibling history of diabetes History of Proteinuria Medications ONLY give information for the medications listed; no other medication information is needed.

15. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 C2 C2 Comprehensive Participant Questionnaire (Baseline and Annual Questionnaire)

16. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: C2 Header must be complete! Date 3 Topics About the participant’s physical activity About what the participant eats About the participant’s health THE END

17. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 P1.H P1.H Participant Attendance Form

18. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: P1 Participants start with monthly CMVs and may change to quarterly visits if their status is stabilized. Begin tracking at the participant’s first CMV. Update this form immediately after each ATTENDED CMV or other HH Activity. Only ATTENDED CMVs and activities are tracked, not all scheduled CMVs or activities. Submit a copy of this form to the Coordinating Center (CC) with the Annual Assessment forms each year or with the Participant Retention Form (P2.H). Case Management and other HH Activities ATTENDED

19. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 P2.H P2.H Participant Retention Form

20. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 New Forms: P2 Fill out a new P2.H form when: An active participant becomes inactive; OR an inactive participant becomes active again. (Including women returning after pregnancy) Only fill out the “None of the Above” box if the primary reason the participant is dropping out does not fit anywhere in the 10 reasons listed. * Submit a copy of this form along with a copy of the Participant Attendance Form (P1.H)

21. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 Three Participant Groups: Who Uses Which Form? Transition Group Original Group New Group Participants enrolled prior to August 1, 2009, with at least one annual assessment by July 31, 2009, will use the new forms as of August 1, 2009. Participants enrolled prior to August 1, 2009, with no annual assessment by July 31, 2009, will remain on the old forms through the completion of their first year annual assessment, then switch to the new forms. Participants enrolled on or after August 1, 2009, will use the new forms only.

22. SDPI Demonstration Projects: Transition to the new datasets Year 5Year 6 July - Sept, 2009Jan - March, 2010Oct - Dec, 2009July - Sept, 2010April - June, 2010 ONE YEAR PILOT OF NEW DATASETS Implement new dataset, obtain grantee input, revise August 1, 2009July 31, 2010 New Participants: Transition Participants: Original Participants: Use new forms Switch to new forms after 1st annual assessment Switch to new forms Participant Groups: Enrolled on or after 8/1/2009 Enrolled prior to 8/1/2009 with no annual assessment by 7/31/09: Enrolled prior to 8/1/2009 with at least one annual assessment by 7/31/09: SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1

23. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 Urine Albumin Testing – Dipsticks (Is a 2 nd dipstick needed?) First DipstickResultNeed 2 nd dipstick? Protein +No (implies +/+) -Yes Microalbumin +Yes -No (implies -/-)

24. SPECIAL DIABETES PROGRAM FOR INDIANS Healthy Heart Project: Year 5 Meeting 1 Urine Albumin Testing – Dipstick Interpretation 1 st Dipstick2 nd DipstickInterpretation TestResultTestResult Protein + Not needed (implies +/+) n/amacro- and microalbuminuria (+/+) -Microalbumin +microalbuminuria (but not macro) -neither macro nor micro (-/-) Micro albumin +Protein +macro- and microalbuminuria (+/+) -microalbuminuria (but not macro) -Not needed (implies -/-) n/aneither macro nor micro (-/-)