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 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)