1. Key Elements of Case Management Charlton Wilson MD SDPI Competitive Grant Program Cardiovascular Disease Risk Reduction Group Planning Year – Meeting 1 November 18-19, 2004 Denver, CO

2. Outline Definitions Definitions Experience in American Indian and Alaska Native communities Experience in American Indian and Alaska Native communities Models Models Issues to address Issues to address Resources Resources

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.

6. 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

8. 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

10. Models

11. Models

12. Models Position Requirements Position Requirements Often Nursing background Often Nursing background Key Activities Key Activities Identification and outreach to patients Identification and outreach to patients Assessment Assessment Care plan development Care plan development Care plan implementation Care plan implementation Follow up Follow up A Case Management Outcome A Case Management Outcome Defined areas of empowerment Defined areas of empowerment

13. Outreach Effectiveness PIMC, Case Management Pilot Project, ADA 2001 Chi 2 for trend 9.6, p = 0.002

14. 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

15. 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

16. 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

17. 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)

18. Summary Definitions Definitions Experience in American Indian and Alaska Native communities Experience in American Indian and Alaska Native communities Models Models Issues to address Issues to address Resources Resources