Key Elements of Case Management Charlton Wilson MD SDPI Competitive Grant Program Cardiovascular Disease Risk Reduction Group Planning Year – Meeting 1.

Key Elements of Key Elements of Case ManagementCase Management

Charlton Wilson MDCharlton Wilson MD

SDPI Competitive Grant ProgramSDPI Competitive Grant Program

Cardiovascular Disease Risk Reduction GroupCardiovascular Disease Risk Reduction Group

Planning Year – Meeting 1Planning Year – Meeting 1

November 18-19, 2004November 18-19, 2004

Denver, CODenver, CO

OutlineOutline

DefinitionsDefinitions Experience in American Indian and Experience in American Indian and

Alaska Native communitiesAlaska Native communities ModelsModels Issues to addressIssues to address ResourcesResources

To improve diabetes care, To improve diabetes care, Task Force on Community Preventive Task Force on Community Preventive

ServicesServicessupports the following interventions:supports the following interventions:

Self management   Self management   Self Management EducationSelf Management Education

Health-care system level Health-care system level interventions interventions Disease ManagementDisease Management Case ManagementCase Management

TThe Task Force on Community Preventive Services he Task Force on Community Preventive Services is a 15-member non-Federal Task force is a 15-member non-Federal Task force supported by the Centers for Disease Control and Prevention (CDC).supported by the Centers for Disease Control and Prevention (CDC).

Diabetes Self-Diabetes Self-Management EducationManagement Education

Structured education programs Structured education programs self-monitoring of blood glucoseself-monitoring of blood glucose education about diet and exerciseeducation about diet and exercise treatment planstreatment plans motivation for patients to use the motivation for patients to use the

skills for self-management of diabetes.skills for self-management of diabetes.

Disease ManagementDisease Management

Organized, proactive, multi-component Organized, proactive, multi-component approach for all members of a approach for all members of a population with a specific diseasepopulation with a specific disease identify the target population in the identify the target population in the

community or organization community or organization implement care plans proven to be effective implement care plans proven to be effective track, measure, and manage health track, measure, and manage health

outcomes outcomes

Case ManagementCase Management

Assignment of a case manager toAssignment of a case manager to PlanPlan CoordinateCoordinate Integrate care for people with a disease Integrate care for people with a disease

or conditionor condition

ModelsModels

ModelsModels

ModelsModels Position RequirementsPosition Requirements

Often Nursing backgroundOften Nursing background Key ActivitiesKey Activities

Identification and outreach to patientsIdentification and outreach to patients AssessmentAssessment Care plan developmentCare plan development Care plan implementationCare plan implementation Follow upFollow up

A Case Management OutcomeA Case Management Outcome Defined areas of empowermentDefined areas of empowerment

Outreach EffectivenessOutreach Effectiveness

0

20

40

60

80

100

4 month 8 Month 12 month

Time interval from project start

% o

f p

atie

nts

in

th

e ca

se

load

No response tooutreach/refused

Receiving careelsewhere

Addressunknown

Face-to-face visit

PIMC, Case Management Pilot Project, ADA 2001Chi2 for trend 9.6, p = 0.002

IssuesIssues

Roles and ResponsibilitiesRoles and Responsibilities Professional relationshipsProfessional relationships AccountabilityAccountability

Space, toolsSpace, tools LocationLocation Registry AccessRegistry Access

Case Load ManagementCase Load Management Continuous healing relationships vs Continuous healing relationships vs

dynamic patient populationsdynamic patient populations Those issues unique to your communityThose issues unique to your community

Process measure documentation in past year

Not Case Managed

N=277

Case Managed

N=793

Odds Ratio (95%

confidence interval)

p-value

Percent Percent

Eye examination 60 80 2.9 (2.1,4.0) 0.0001

Diet Instruction by a registered Dietician

12 28 3.0 (2.0,4.5) 0.0001

Self Monitor Blood Glucose 79 89 2.2 (1.5,3.3) 0.0001

Dental Examination 30 43 1.7 (1.2, 2.2) 0.0002

Comprehensive Foot examination 59 68 1.5 (1.1, 2.0) 0.005

Screening for nephropathy 64 73 1.4 (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

Selected adjusted treatment pattern differences among patientsincluded in the evaluation cohort at PIMC, IHS, 2001-2002.

Treatment pattern documentation in past year

Not Case Managed

N=277

Case Manage

dN=793

Odds Ratio (95%

confidence interval)

p-value

Percent Percent

Hyperglycemia Treatment Type*

diet 12 7 0.5 (0.3, 0.9) 0.008

oral 59 65 1.0 (0.8, 1.4) 0.94

insulin/insulin +oral 29 28 1.0 (0.7, 1.3) 0.92

Treatment of Hypertension with ACEi or ARB $

88 85 1.2 (0.8, 1.8) 0.28

Treatment of elevated LDLc with Lipid lowering agents &

32 35 0.8 (0.5, 1.3) 0.41

Use of daily Aspirin # 44 24 0.4 (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

ResourcesResources Norris SL, Nichols PJ, Caspersen CJ, Glasgow Norris SL, Nichols PJ, Caspersen CJ, Glasgow

RE, Engelgau MM, Jack L, Isham G, Snyder RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and McCulloch D: The effectiveness of disease and case management for people with diabetes. A case management for people with diabetes. A systematic review. systematic review. Am J Prev Med Am J Prev Med 2002; 22:15-2002; 22:15-38.38.

Wilson, C, Curtis J, Lipke S, Bochenski C, Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Managers in a Large Clinical Practice: Implications for Workforce Development, Implications for Workforce Development, Diabetic MedicineDiabetic Medicine 2005, (in press) 2005, (in press)

SummarySummary

DefinitionsDefinitions Experience in American Indian and Experience in American Indian and

Alaska Native communitiesAlaska Native communities ModelsModels Issues to addressIssues to address ResourcesResources