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Teamwork You and Your Case Manager

Teamwork You and Your Case Manager. Robin John, RPh , CDE Yakama Healthy Heart Program Coordinator. Case Management Team Members. Clinical Pharmacists Pharmacy Technicians. Screening. Providers Nursing Nutrition DM Center Pharmacy Patient Registration Currently over 1100

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Teamwork You and Your Case Manager

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  1. Teamwork You and Your Case Manager Robin John, RPh, CDE Yakama Healthy Heart Program Coordinator

  2. Case Management Team Members • Clinical Pharmacists • Pharmacy Technicians

  3. Screening • Providers • Nursing • Nutrition • DM Center • Pharmacy • Patient Registration • Currently over 1100 active DM patients at YIHS

  4. Who Qualifies for Program? • Type II Diabetics • Over 18 years old • Not Pregnant • Not on Dialysis or have End Stage Renal Disease • No Substance Abuse Issues that may interfere with treatment plan • Chemotherapy

  5. Define Your Role • Education • Medication Management • Monitoring • Referrals • Physical Assessments • Procedure for Acute Care • Contact Information • Develop rapport

  6. Duties of Case Manager • Identifying Data • Name • Address & Phone • Family Contact/Support Person • Date of Birth • Chart Number • Assessments • Care Plan/ Problem List

  7. CMV at Yakama • First Appointment – 1 hour • Forms, HIPPA, • Prior Knowledge • Motivation • Follow-up Appointments (usually ½ hour long) • Review Problems • Set goals, Review goals • Standards of Care • Frequency

  8. Case Management • Individual Case Management • Disease Management • Self Management Education

  9. Concerns, Questions, Reports • Patient Directed Visits • Plan for the “Controlled Patient” • Focus on 1-2 issues per Appointment • Set at least one SMART goal per Appointment • specific, measurable, attainable, realistic and timely • DOCUMENT AND REVISIT

  10. Individual Case Management • Patient Directed • Needs • How can we meet that need • Other team members • Barriers to Care • Visits • Problem Solving • Communication and F/U

  11. Daily Living • Family/ Psycho-Social Issues • Work • Child Care • Transportation

  12. Family Affair

  13. Stress Factors • Domestic violence • Death in the Family • Unemployed • Divorce • Child Care Issues

  14. Disease Management • Each Visit • Physical Assessment • Medication Management • Treatment Goals • Main focus is ABC’s • cont. the alphabet as CM evolves • Treatment Strategies • Quality Improvement

  15. Vital Signs • Weight • Height • Waist • Hips • Blood Pressure Goal: under 130/80

  16. Diabetes Report Card

  17. Standards of Care Reminders

  18. Reminders EHR, Flow Sheets, Tracking Log, Reminders

  19. Medications • Name of Medication • What it is for? • How it works • Side Effects • Adverse Reactions • Monitoring • Dose Adjustments • How do you take your medications • Allergies • Medication Alignment

  20. Medications

  21. Mammograms Colon Cancer Screening Exercise (DM Center) Foot Problems Dental Optometry Mammograms Colon Cancer Screening Exercise (DM Center) Foot Problems Dental Optometry Referrals

  22. Immunizations • Flu – yearly • Td – booster every 10 years • PPD • Pneumovax

  23. Foot Exams

  24. Lab Values • Blood Sugar A1C (My 100 Day Test) Goal: less than 7% . Cholesterol Every 6-12 months Goals: Total cholesterol <200 LDL (Bad Guy) <70 or 100 HDL (Good Guy) over 40 Triglycerides: under 150

  25. Monitoring and Labs

  26. Other Necessary Labs • Liver Function Tests • Kidney Function Tests • Urinalysis • Thyroid • Complete Blood Count • Drug Levels

  27. Team Approach • Referrals to • Dental • Optometry • Physical Therapy • Medical Provider • Nutritionist • Exercise Educator • Mental Health

  28. Documentation

  29. Improvement of Health • Education • Plans for medical emergency • Plans for extended trips • Referrals • Consultations • Safety Issues • Medication Refills

  30. Self-Management Education • AADE accreditation • Follow AADE Self Behavior Goals • SMART Goals • Document • Develop Plan • Follow-up

  31. Review Goals • Results? • Barriers? • Accomplished? • Incentive

  32. Acknowledge Achievements

  33. Activity Level • GOAL: 150 minutes / week -walking -dancing -housework -swimming -take the stairs -park farther away from destination

  34. Graphs for Progress

  35. Nutrition & Diet • Portion Sizes • Meat Choices Fish, Deer, Bison, Chicken, Turkey, Lean Beef • Healthy Alternatives Grilled, Baked, Broiled . Processed Foods White Bread, Pasta, Flour

  36. Message of the Month

  37. TRACKING

  38. Staying Sustainable

  39. ANY QUESTIONS?

  40. Thank You Robin.John@ihs.gov Yakama Healthy Heart Program 509-865-2102 ext 299 or 509-865-1715

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