1. Case Management and Diabetes Mellitus Charlton Wilson, Jeff Curtis, Suzanne Lipke, Robin Thompson, Susan Dethman

2. Outline: Case Management Role Role Process Process Experiences Experiences

3. To improve diabetes care, Task Force on Community Preventive Services supports the following interventions: Self management Self management Self Management Education Self Management Education Health-care system level interventions Health-care system level interventions Disease Management Disease Management Case Management Case Management The Task Force on Community Preventive Services is a 15-member non-Federal Task force supported by the Centers for Disease Control and Prevention (CDC).

4. Diabetes Self-Management Education Structured education programs Structured education programs self-monitoring of blood glucose self-monitoring of blood glucose education about diet and exercise education about diet and exercise treatment plans treatment plans motivation for patients to use the skills for self- management of diabetes. motivation for patients to use the skills for self- management of diabetes.

5. Disease Management Organized, proactive, multi-component approach for all members of a population with a specific disease Organized, proactive, multi-component approach for all members of a population with a specific disease identify the target population in the community or organization identify the target population in the community or organization implement care plans proven to be effective implement care plans proven to be effective track, measure, and manage health outcomes track, measure, and manage health outcomes

6. Case Management Assignment of a case manager to Assignment of a case manager to Plan Plan Coordinate Coordinate Integrate care for people with a disease or condition Integrate care for people with a disease or condition Case Management, Care Management, Care Coordination Case Management, Care Management, Care Coordination

7. Models

8. Models

9. Steps For Diabetes Case Management Assessment Assessment Analysis of assessment findings Analysis of assessment findings Outcome identification Outcome identification Planning Planning Diabetes Self Management Education Diabetes Self Management Education Evaluation Evaluation Follow up Follow up Program effectiveness Program effectiveness

10. Assessment Determine the priority of information obtained by the client’s immediate condition or need Determine the priority of information obtained by the client’s immediate condition or need Include the client’s family Include the client’s family Collect the information in a systematic manner Collect the information in a systematic manner Document findings in a retrievable format Document findings in a retrievable format

11. Assessment Integrate the assessment process with data from other members of the health care team to ensure continuity and collaboration Integrate the assessment process with data from other members of the health care team to ensure continuity and collaboration Include information related to client’s knowledge of diabetes and current diabetes self- management behaviors. Include information related to client’s knowledge of diabetes and current diabetes self- management behaviors.

12. Analysis of Assessment Identify actual or potential problems and/or challenges and barriers Identify actual or potential problems and/or challenges and barriers Identify interpersonal, cultural, psychosocial and environmental conditions that affect the client Identify interpersonal, cultural, psychosocial and environmental conditions that affect the client Validate findings with the client, family and health care team Validate findings with the client, family and health care team Document findings in a manner that identifies outcomes Document findings in a manner that identifies outcomes Incorporate findings into an individualized care plan Incorporate findings into an individualized care plan

13. Outcome Identification Formulate outcomes from assessment findings Formulate outcomes from assessment findings Determine that outcomes are realistic, attainable and measurable Determine that outcomes are realistic, attainable and measurable Ensure that outcomes reflect scientific knowledge of diabetes care Ensure that outcomes reflect scientific knowledge of diabetes care Use outcomes to evaluate goal attainment Use outcomes to evaluate goal attainment

14. Planning Assist client with developing goals Assist client with developing goals Patient selected plan - Individualize the plan to meet the client’s needs Patient selected plan - Individualize the plan to meet the client’s needs Identify priorities in relation to expected outcomes Identify priorities in relation to expected outcomes Document the plan Document the plan Collaborate with other team members about the plan Collaborate with other team members about the plan

15. Diabetes Self-Management Training Provide diabetes education that is pertinent to the client’s assessed needs and health values Provide diabetes education that is pertinent to the client’s assessed needs and health values Use appropriate teaching methods Use appropriate teaching methods Allow opportunities for the client to demonstrate skills Allow opportunities for the client to demonstrate skills Incorporate empowerment strategies Incorporate empowerment strategies Document understanding of education Document understanding of education

16. Evaluation Evaluate outcomes on a systematic and on-going basis Evaluate outcomes on a systematic and on-going basis Document client’s response to implementing the care plan Document client’s response to implementing the care plan Evaluate the effectiveness of interventions in relation to outcomes Evaluate the effectiveness of interventions in relation to outcomes Revises plan as needed Revises plan as needed Documents revisions Documents revisions Collaborates with team on evaluation Collaborates with team on evaluation

17. Follow - Up Determine frequency of follow-up Determine frequency of follow-up Use a systematic approach for each follow up visit Use a systematic approach for each follow up visit Provide client with feed back Provide client with feed back Incorporate a tracking system to avoid “lost to follow-up” status Incorporate a tracking system to avoid “lost to follow-up” status

18. Case Management Interventions Treatment Strategies Treatment Strategies Medical Nutrition Therapy Medical Nutrition Therapy Exercise prescriptions Exercise prescriptions Coping Behaviors Coping Behaviors Medication adjustment Medication adjustment Diabetes Self Management Training Diabetes Self Management Training 10 core content areas 10 core content areas ADA National Standards for Diabetes Self- Management Education ADA National Standards for Diabetes Self- Management Education

19. Case Management Interventions Supportive Counseling Supportive Counseling Readiness for Change Readiness for Change Motivational Interviewing Motivational Interviewing Problem Solving Problem Solving Skills building Skills building Monitoring Monitoring Individualized Care Plans Individualized Care Plans Coordination of Resources Coordination of Resources

20. Things to Consider Age-appropriate, culturally, ethically and spiritually sensitive care and support Age-appropriate, culturally, ethically and spiritually sensitive care and support Educate patients, families and support systems Educate patients, families and support systems Continuity of care Continuity of care Coordination of care for various settings Coordination of care for various settings Managing information Managing information Effective communication with diabetes team Effective communication with diabetes team Non-judgmental approach Non-judgmental approach

21. Reimbursement Case management at this point in time is not a reimbursable item, however, the professional expertise of the individual can be billed for third party. Case management at this point in time is not a reimbursable item, however, the professional expertise of the individual can be billed for third party. Case management is generally used as a patient management tool and a current and future cost containment utilization. Case management is generally used as a patient management tool and a current and future cost containment utilization.

22. Scheduling Time slots typically provided to the case manager normally are 2 to 4 times greater than time allocation for the Primary Care Provider. This allows for a more in-depth interview and analysis of the patient and their understanding of the current care plan and disease process. Time slots typically provided to the case manager normally are 2 to 4 times greater than time allocation for the Primary Care Provider. This allows for a more in-depth interview and analysis of the patient and their understanding of the current care plan and disease process.

23. Scheduling Scheduling will also reflect case load. Scheduling will also reflect case load. A benchmark has not been established as to the number of patients a diabetes case manager can effectively be responsible for. A benchmark has not been established as to the number of patients a diabetes case manager can effectively be responsible for.

24. Case Load At the Wewoka Service Unit, 75 patients to be effectively managed by the case manager utilizing a 32 hour work week was initially suggested. At the Wewoka Service Unit, 75 patients to be effectively managed by the case manager utilizing a 32 hour work week was initially suggested. Each individual organization will have to determine case load for their case managers. This will vary with severity of patient and their disease process, including learning barriers. Each individual organization will have to determine case load for their case managers. This will vary with severity of patient and their disease process, including learning barriers.

25. Issues Roles and Responsibilities Roles and Responsibilities Professional relationships Professional relationships Accountability Accountability Space, tools Space, tools Location Location Registry Access Registry Access Case Load Management Case Load Management Continuous healing relationships vs dynamic patient populations Continuous healing relationships vs dynamic patient populations Those issues unique to your community Those issues unique to your community

26. Case Management in Indian Health Settings A poll of participants in the Diabetes Summer Institutes Portland Session

27. A poll of case management services in Indian Health settings Voluntary, self reported poll (written survey) of participants in the case management class Voluntary, self reported poll (written survey) of participants in the case management class Returned N= 22 (out of 27) Returned N= 22 (out of 27) Completed on day 1of the institute Completed on day 1of the institute

28. Professions in Attendance

29. Type of Organization

30. Location

31. Patient Education Program Of those who had a program

32. Do you currently have a case management program?

33. How many case managers in your program? Of those who had a case management program

34. What percent of full time is the case management program? Of those who had a case management program

35. What additional duties does the case manager have? Of those who had a case management program

36. Professions of the case manager Of those who had a case management program

37. How many patients/case manager? 95-100 95-100 176 176 300 300 348 348 50% - Unknown 50% - Unknown Of those who had a case management program

38. Case Manager Support Of those who had a case management program

39. Pilot Evaluation # 1: Aim To evaluate the effectiveness of a Nurse Care Coordinator who provided active outreach, education, and care coordination to American Indian and Alaskan Native people with diabetes in an IHS primary care system To evaluate the effectiveness of a Nurse Care Coordinator who provided active outreach, education, and care coordination to American Indian and Alaskan Native people with diabetes in an IHS primary care system

40. Pilot Project Location Location Phoenix Indian Medical Center Phoenix Indian Medical Center Nurse Care Coordinator (NCC) Nurse Care Coordinator (NCC) RN, CDE RN, CDE 295 people selected by “lottery” from the registry 295 people selected by “lottery” from the registry Outreach Outreach letters, phone calls, opportunistic notification letters, phone calls, opportunistic notification Education Education Individual consultation Individual consultation Coordination Coordination Scheduling, follow up, reinforcement Scheduling, follow up, reinforcement

41. Evaluation Measures Outreach effectiveness Outreach effectiveness Quarterly accounting of face-to-face consultation Quarterly accounting of face-to-face consultation Visits Visits Education and coordination effectiveness Education and coordination effectiveness Adherence with IHS standards of care Adherence with IHS standards of care IHS diabetes care and outcomes audit performed at baseline, 4, 8 and 12 month intervals IHS diabetes care and outcomes audit performed at baseline, 4, 8 and 12 month intervals Comparison population Comparison population 290 people from the active diabetes registry who did not have a nurse care coordinator 290 people from the active diabetes registry who did not have a nurse care coordinator

42. Outreach Effectiveness Chi 2 for trend 9.6, p = 0.002

44. * * * * Difference between groups p < 0.05 by Chi 2

45. * * * * * * *

46. * * * * * * *

47. Evaluation # 1: Conclusions For American Indian and Alaskan Native people with diabetes the addition of a Nurse Care Coordinator to the primary care health system results in: For American Indian and Alaskan Native people with diabetes the addition of a Nurse Care Coordinator to the primary care health system results in: Effective outreach Effective outreach An increased adherence with the IHS Diabetes Standards of Care An increased adherence with the IHS Diabetes Standards of Care

48. Pilot Evaluation # 2: Aim To evaluate the ability of a nurse care coordinator to affect utilization of ambulatory health care services by American Indian and Alaskan Native people with diabetes in an IHS primary care system To evaluate the ability of a nurse care coordinator to affect utilization of ambulatory health care services by American Indian and Alaskan Native people with diabetes in an IHS primary care system

49. Pilot Project Location Location Phoenix Indian Medical Center Phoenix Indian Medical Center Nurse Care Coordinator (NCC) Nurse Care Coordinator (NCC) RN, CDE RN, CDE 295 people selected by “lottery” from the registry 295 people selected by “lottery” from the registry Outreach Outreach letters, phone calls, opportunistic notification letters, phone calls, opportunistic notification Education Education Individual consultation Individual consultation Coordination Coordination Scheduling, follow up, reinforcement Scheduling, follow up, reinforcement

50. Evaluation Measures 295 people with a nurse care coordinator (NCC) were compared to 290 people without a nurse care coordinator 295 people with a nurse care coordinator (NCC) were compared to 290 people without a nurse care coordinator Visits were classified into 4 categories: Visits were classified into 4 categories: Combined ambulatory health care encounters Combined ambulatory health care encounters Emergency department encounters Emergency department encounters Primary health care encounters Primary health care encounters Pharmacy encounters Pharmacy encounters

51. Evaluation Measures The number of visits during the project year were divided by the number of visits during the preceding year so that each group served as its own control The number of visits during the project year were divided by the number of visits during the preceding year so that each group served as its own control The attributable difference was calculated as the difference of the % change between the cohort with and the cohort without a nurse care coordinator The attributable difference was calculated as the difference of the % change between the cohort with and the cohort without a nurse care coordinator Attributable difference = %  NCC group - %  without NCC group Attributable difference = %  NCC group - %  without NCC group 100 100

52. Selected Ambulatory Utilization Data Location Visits by people with NCC (N) Visits by people without NCC (N) Year prior Year during Year prior Year during Combined visits 2364250525322602 Primary care 1133128010351094 Pharmacy476549525591 Emergency department 685610869851

53. Ambulatory Health Care Utilization Differences Attributable to Nurse Care Coordination for People With Diabetes

54. Evaluation # 2: Conclusions For American Indian and Alaskan Native people with diabetes the addition of a nurse care coordinator to the primary care health system results in: For American Indian and Alaskan Native people with diabetes the addition of a nurse care coordinator to the primary care health system results in: An increased total number of health care encounters An increased total number of health care encounters But, more use of primary care and pharmacy services and less use of emergency department encounters suggesting a more efficient and effective utilization of ambulatory services But, more use of primary care and pharmacy services and less use of emergency department encounters suggesting a more efficient and effective utilization of ambulatory services

55. Evaluation of Full Project: Aim To evaluate the effectiveness of a team of four Nurses providing education and case management to American Indian and Alaskan Native people with diabetes in an IHS primary care system To evaluate the effectiveness of a team of four Nurses providing education and case management to American Indian and Alaskan Native people with diabetes in an IHS primary care system

56. Pilot Project Location Location Phoenix Indian Medical Center Phoenix Indian Medical Center Registry 4,112 patients seen in the year Registry 4,112 patients seen in the year Nurse Care Coordinator (NCC) Nurse Care Coordinator (NCC) Four RNs, three had CDE at the time Four RNs, three had CDE at the time 1,461 different patients (1:365) 1,461 different patients (1:365) 2,580 in-person encounters (1.8 encounters) 2,580 in-person encounters (1.8 encounters) Evaluation Cohort Evaluation Cohort Patients with patient education documentation and 2 HbA1c’s within a year Patients with patient education documentation and 2 HbA1c’s within a year Compared those with and those without Case management encounter Compared those with and those without Case management encounter

57. Process measure documentation in past year Not Case Managed N=277 Case Managed N=793 Odds Ratio (95% confidence interval) p-value Percent Eye examination60802.9 (2.1,4.0)0.0001 Diet Instruction by a registered Dietician 12283.0 (2.0,4.5)0.0001 Self Monitor Blood Glucose79892.2 (1.5,3.3)0.0001 Dental Examination30431.7 (1.2, 2.2)0.0002 Comprehensive Foot examination59681.5 (1.1, 2.0)0.005 Screening for nephropathy64731.4 (0.9, 2.0)0.002 Adjusted for age, sex, treatment type, BMI Selected adjusted* process measure outcomes of interest among patients included in the evaluation cohort at PIMC, IHS, 2001-2002

58. Selected adjusted treatment pattern differences among patients included in the evaluation cohort at PIMC, IHS, 2001-2002. Treatment pattern documentation in past year Not Case Managed N=277 Case Manage d N=793 Odds Ratio (95% confidence interval) p-value Percent Hyperglycemia Treatment Type* diet1270.5 (0.3, 0.9)0.008 oral59651.0 (0.8, 1.4)0.94 insulin/insulin +oral29281.0 (0.7, 1.3)0.92 Treatment of Hypertension with ACEi or ARB $ 88851.2 (0.8, 1.8)0.28 Treatment of elevated LDLc with Lipid lowering agents & 32350.8 (0.5, 1.3)0.41 Use of daily Aspirin #44240.4 (0.3, 0.6)0.0001 * Adjusted for age, sex $ Analysis restricted to 736 of the patients in the evaluation cohort with a clinical diagnosis of hypertension & Analysis restricted to 594 of the patients in the evaluation cohort with a low density lipoprotein cholesterol of > 2.58 mmol.L (100mg.dL) # Adjusted for age, sex, treatment type

60. Qualitative Experiences Developing inter-personal relationships helps to build trust Developing inter-personal relationships helps to build trust Persistence is required and rewarded Persistence is required and rewarded Individual assessment facilitates the development of a care and education plan Individual assessment facilitates the development of a care and education plan

61. Resources Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande- Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002; 22:15-38. Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande- Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002; 22:15-38. Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Implications for Workforce Development, Diabetic Medicine 2005, (in press) Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Implications for Workforce Development, Diabetic Medicine 2005, (in press)

62. Models