2. CVD Risk Factor Reduction Kelly Moore, MD, FAAP IHS Division of Diabetes Treatment & Prevention

3. Overview Standards of Care Current Quality of CVD Care Purpose of Competitive Grant Program Case Management Tools

4. Standards of Care  IHS Standards of Care for Patients with Type 2 Diabetes (August 2003) Includes recommendation for treatment of CVD Risk Factors Target BP < 130/80 mm Hg LDL < 100 mg/dl Antiplatelet Therapy Tobacco cessation Self-Management Education

5. Standards of Care  IHS Best Practice Models Cardiovascular Disease and Diabetes Suggested practice models, levels of service and components of care Additional information on standards, target for treatment

6. Impact of CVD  Number 1 cause of death in AI/ANs  People with diabetes are 3-4 times more likely to develop CVD  Prevalence, mortality increasing  Level of awareness of the link between diabetes and CVD needs to be raised

7. Quality of Care - CVD Risk Reduction in AI/ANs with Diabetes  Evidence/Data IHS Diabetes Care and Outcomes Audit

8. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 A1C, % Mean A1C, 1994-2004 *p<0.0001 comparing mean HbA1 levels in FY94 and FY04

9. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 A1C, % Glycemic control, 1994-2004 *p<0.0001 comparing mean HbA1 levels in FY94 and FY04

10. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Performance Measure: Dyslipidemia Assessment 1998-2004 Percent

11. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Mean Lipid Values 1994-2004 mg/dl

12. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Blood Pressure Control 1994-2004 Percent

13. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Blood Pressure Control 1994-2004 Percent

14. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Tobacco Use 1998-2004 Percent

15. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Aspirin Therapy 1999-2004 Percent

16. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Self Management Education 1999-2004 Percent

17. Diabetes Care & Outcomes Audit Source: IHS National Diabetes Program Statistics 1994-2004 Self Management Education 1994-2004 Percent

18. CGP CVD Risk Reduction Demonstration Project  Purpose: To implement an intensive, clinic based case management approach to CVD Risk Reduction in individuals with Diabetes Demonstration Project - Intensive treatment to target goals based on standards of care  Eligibility for Intensive Activities Adults with Diagnosis of Diabetes With or without CVD Exclusions (pregnant, ESRD, alcohol/substance abuse)

19. Core Elements: Case Management  Case Management Team  Case Management Strategy Individual case management Disease management Self-management education  Tools for Case Management Diabetes Registries Diabetes Management System/RPMS Integrated Case Management System

20. Role of Data Systems in Improving Patient Care in Diabetes  Individual Patient Level  Track one or many patients  Identify specific clinical information  Reminders/prompts  Population Level  Calculate rates  Measure performance  Improve systems

21. Diabetes Management System  DMS Package in RPMS  Several applications to view individual patient data  Screen access for direct data entry  “Integrated” e-mail, recall

22. Diabetes Management System  Diabetes Registry  Data Items Maintained in the Diabetes Registry  - Patient Status  - Type of Diabetes  - Complications  - Register Provider and Case Manager  - Facility Where Patient is Routinely Followed  - Family Members  - Last and Next Case Review Dates  - Recall Date (Optional)

23. Diabetes Management System  Diabetes Registry Lists  Patient Status  Active, Inactive, Transient, Lost to Followup, Unreviewed, Deceased, Non-IHS Care  Diagnosis  Type 1, Type 2, Gestational, IGT  Complications  CVA (Stroke), Myocardial Infarction, End Stage Renal Disease, Hypertension, Retinopathy, Laser Treatment for Retinopathy, High Risk Foot, Minor Amputation, Major Amputation(s)

24. Diabetes Management System  Diabetes Patient Care Summary  Used by provider to manage/update care during clinical encounter  “Electronic” flowsheet – to do lists for recommended care  A part of Adult Health Summary  Electronic Audits using DMS/RPMS  Nationally defined audit elements  Integrated Case Management Package  Documentation of care plans, in development

27. Capacity to Use DMS in CGP  RPMS Survey – CGP CVD Grant Programs QuestionPercent Sites using RPMS92 Sites with DMS Package installed90 Sites using DMS76 Sites conducting electronic audits45

28. Next Steps  Treatment of CVD Risk Factors  As a part of intensive case management strategy  Grantee Panel discussion/questions  Core Elements: Case Management  Draft protocol/required elements for discussion  Explore DMS as an option  May need to schedule additional training  Use of paper tracking until everyone using  Need to consider those not on RPMS