A Proposal for a Case Management Program for Chronic Disease at Touro University’s Student Run Health Clinic

1. A Proposal for a Case Management Program for Chronic Disease at Touro University’s Student Run Health Clinic By Sarah Rose New Touro University- California Advisor: Dr. Thairu

2. Capstone Objectives To present a proposal for a Case Management Program that monitors hypertension, diabetes, obesity, and cardiovascular disease at the Touro University’s Student Run Health Clinic

3. Background and Significance • Cardiovascular Disease (CVD) • Broad term for all diseases specific to the heart and cardiovascular system • 2,200 Americans die of CVD every day • Average of 1 every 39 seconds • Forecasted by 2030= 40.5% of U.S. will have some form of CVD Rogers et al., (2012) Heindenreich et al. (2011)

4. Background and Significance • Diabetes • Major risk factor of CVD is diabetes • CVD is a major complication of diabetes and leading cause of premature death of those with diabetes • Diabetes effects 25.8 million people= 8.3% of U.S. population • 81.5 million adults have prediabetes= 37% of U.S. population National Diabetes Education Program, (2007) National Diabetes Information Clearinghouse, (2011)

5. Background and Significance • Hypertension • clinically defined as high blood pressure readings two separate occasions • Contributes to 1 in 7 deaths and nearly half of all CVD related deaths • Effects 30% of U.S. adults • Forecasted to increase by 9.9% from 2010 to 2030 • Prehypertension • 29.7% U.S. adults >20 Center for Disease Control and Prevention [CDC], 2011) Keenan & Rosendorf, (2011) Heindenreich et al., (2011) Rogers et al., (2012) Lloyd-Jones, Evans, & Levy, (2005)

6. Background and Significance • Obesity • Increasing rise of obesity leads to increase rise in hypertension, CVD, and diabetes • 149 million U.S. adults are overweight or obese • 67.3% of the U.S. population • 33.7% are only obese Rogers et al., (2012)

7. Background and Significance • Disease Burden on California • 57% of Californians over 65 have high blood pressure • 33% of males and 39% of females will be diagnosed with diabetes in their lifetime • Solano County: • 9.5% adults have diagnosed diabetes, largest figure when compared to other Counties in California • 22.8% are obese California Healthcare Foundation, (2006) CDC, (2008)

8. Background and Significance • Case Management Programs • Defined as collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy options and services to meet individual and family needs • Evolution: • 1900s- began as sanitation and immunization practices • 1981- case management is integrated into Medicaid Case Management Society of America [CMSA], (2010) Bosshart & Vienna, (2008)

9. Background and Significance • Six Components • Client identification and selection, • Assessment and problem/opportunity identification • Development of the case management plan • Implementation and coordination of care activities • Evaluation of the case management plan and follow up • Termination of the case management process CMSA, (2010)

10. Background and Significance • Evidence of Case Management Effectiveness • Weingarten et al. (2002) reported: • that case management programs were associated with provider adherence to guidelines and patient disease control • Gilmer et al. (2007) found: • association with cost effective improvements in quality-adjusted life expectancy and a decrease in incidence of diabetes-related complications • that case management programs are cost effective for low income populations

11. Background and Significance • California Medi-Cal Type 2 Diabetes Study Group (2004) • found that case management improved glycemic control when added to primary care • reduced disparities in diabetes health status among low income ethnic populations

12. Background and Significance • Student Run Clinics • Student initiated endeavors with commitments to underserved communities • First appeared in various cities in the mid 1960s • Currently widespread among U.S. medical schools • Provide training to face healthcare crises • Considered impressive, realistic learning methods for preparing young physicians Meah, Smith, & Thomas, (2009) Simpson & Long, (2007) National Research Counsil, (2002)

13. Touro University’s Student Run Health Clinic (SRHC) • Opened in October 2010 • Located in Vallejo, California at Norman C. King Community Center • Open from 4:30-8:00pm every Thursday • Opened under the supervision of Dr. Lopes • Mission: to create an interprofessional clinic that focuses on improving access to health care in the surrounding areas while improving clinical and education skill of students at Touro University

14. Touro University’s SRHC

15. Touro University’s SRHC • Offers the following services: • Screening exams and health education • Medication review • Blood pressure check • Osteopathic manipulative medicine • Immunizations • As of October 2011= 192 patients • As of February 2012= 235 patients

16. Specific Aims and Objectives of Proposed Case Management Program • Increase volunteer positions for MPH students • Decrease diabetes, hypertension, high BMI, and cardiovascular disease within Student Run Health Clinic (SRHC) patient population • Increase health literacy and adherence to healthy behaviors for the community

17. Proposed Case Management Program • TU-SRHC Case Management Program is unique • Use a public health approach by providing services to reduce the burden of disease on the community • through outreach and advocacy in addition to reducing individual barriers to health

18. Proposed Case Management Program • If successful, the proposed program • Will help the SRHC to strengthen their mission to overcome individual and environmental barriers to health • Will reduce risks and outcomes that can be maintained under the SRHC’s current scope of practice

19. Preliminary Studies/Progress Report • Program implementation began in November 2011 but patients are currently not enrolled • Program currently in final stages of development with an anticipated launch date of May 31st, 2012 • I have played an important role in the program since its inception • Pilot Program will be launched with 6 case managers • Jocelyn Lee DO/MPH • Ghazal Ghafari MPH • Kyle Severinsen MPH • John Suchland MPH • Michael Phorth MPH • Katie Ho MPH • New Public Health Coordinator- Kristoffer Chin MPH

20. SRHC Population

21. Proposed Design of Case Management Program • Held simultaneously with SRHC at the Norman C. King Community Center in Vallejo, CA • Section of clinic will be allocated for Case Management • Case Management Services: • offered from 4:30-5:00pm • followed by Community Education from 5:00pm-6:00pm • Case Management again from 6:00-8:00pm • Community Walking Program: • 6:00-7:00pm (seasonal based) • Offered via the Lifestyle Medicine Club

22. Chronic Care Model Conceptual Framework • Designed with six interrelated system changes • Increase patient centered, evidence based care Bodenheimeret al., (2002) Coleman et al., (2009)

23. Conceptual Framework Tsai et al., (2005)

24. Conceptual Framework Tsai et al., (2005)

25. Conceptual Framework • Use the 5A’s Model of Behavioral Change Counseling. • This is an evidence-based approach appropriate for a broad range of different behaviors and health conditions Fiore et al., (2000) Glasgow et al., (2006) The Quality Indicator Study Group, (1995)

26. Patient Inclusion Criteria • Patient attends Touro University’s Student Run Health Clinic • Systolic blood pressure measurement >130 • Diastolic blood pressure measurement >85 on two separate occasions (hypertension) • Fasting plasma glucose >126 mg/dl or 100 md/dl – 125mg/dl (pre-diabetes) • Casual plasma glucose concentration >200 mg/dl • BMI >25 • Pre-diagnosis of hypertension, diabetes mellitus type II, and/or cardiovascular disease • This criteria has been approved by Dr. Lopes

28. Data Collection • Electronic Disease Registry • Record all vitals taken at SRHC, outside clinics, and own monitoring capabilities • Perceived Individual and Environmental Barriers to Health • Assist in future program improvement and developing future community initiatives • Satisfaction Surveys • Allow for improvements in quality of care and services offered

29. Case Management Process

30. Case Management Process EXAMPLE

31. Case Management Process • Treatment Tier Placement • Case managers will place patients into two treatment plan tiers • Limited or advanced proficiency • Low or high risk • Placement will assist in recognition of the severity of disease or other risk factors. • Allows assessment of the severity of environmental barriers • Will indicate where to begin in terms of health education

32. Case Management Process • Assessment with 5A’s • Assess, Advisement, Agree, Assist, and Arrange • Includes: • recording individual and environmental barriers to better health • case manager recommendations to behavior change. • creating collaborative goals with the patient • develop strategies to achieve these goals • giving referrals to outside resources, a diet prescription, and exercise guidelines • planning of a follow up visit

33. Case Management Process • Follow up appointments • All patients will return in 2 weeks for a follow up • Follow up appointments after pilot will be set up by treatment plan tiers • Appointments will involve triage and patient specific treatment • New readings will be recorded in patient’s registry • Reassessment of the Healthy Lifestyle Questionnaire

34. Case management process • Follow up appointments • Patients will be given more educational tools • The 5A’s will be updated • Alterations to treatment plans will be made • The case manager will ensure that outside resources are being utilized

35. Case Manager’s Job • Work in bi-weekly, two hour shifts • Must also be flexible according to patients’ schedule • Follow up with patient between appointments via email address to provide motivation and consultation • If not assigned a patient, they will work to update Public Health Library • Primary purpose is to keep staff at SRHC and case managers up to date in chronic disease • Only accessible to registered Touro members

36. Case Managers Job • Case managers = community health advocate • Program identifies personal environmental barriers to resolve local health problems • Managers use these to create community initiatives, outreach, and increase access to resources • Will be working with the Solano County Coalition for Better Health

37. SRHC and Touro Community Education • Case Management Program brown bag series • Topics will include diabetes, hypertension, obesity, CVD, cultural health differences, and health disparities • Open to all students and strongly recommended to those who plan to volunteer at the clinic • Protocol created by Jocelyn Lee and Dr. Lopes • Protocol print out given to all staff • Aide in better identification of patients with these specific diseases or risk factors • Allow staff to correctly utilize the Case Management Program

38. Exit Criteria for Case Management Program • No limit on length in program • Released upon criteria of graduation • Outcomes or goals are as follows: • Patient becomes self sufficient in this or her own recovery or rehabilitation • Patient reduces test results, controls disease, or is undiagnosed with disease

39. Case Manager Limitations • No contact with patients via cell phones • Will contact via email address • Limitation to scope of practice of SRHC • SRHC only has the ability to monitor the diseases chosen by the Case Management Program • Cannot diagnose patients or suggest medication • Will refer to on staff student pharmacist

40. Proposed Pilot for Program • During pilot, maximum patient load of 8 and minimum of 6 • Will allow case managers to assess the proper patient load ratio for full launch

41. Potential Challenges for Implementing the Case Management Program • Limited human resources as the program will depend on volunteer students from Touro • This may place limitations on patient load • It is possible that the program will only accept those patients who require immediate assistance as directed by student physician

42. Ethical Considerations • Patient authorizes treatment • Patient will sign form allowing contact via email • Explain risk and benefit of e-mail communication • Training for case managers • Specific Case Management Training • New managers will shadow mentor 2 times • Flash drive keeps all data and patients information • Locked up at clinic • Case managers will have access to flash drive during clinic hours • SRHC staff will also have access

43. Time Table for Project

44. Budget and Personnel • Budget only requires funds for printing materials • Estimated $100 dollars • All other items supplied by Touro University or SRHC • Personnel includes: • MPH Coordinator • Case Management Program Director • Volunteers from the MPH Program

45. Future Implications • Expand in both size and materials • Develop two volunteer tiers: • Case managers who advocate for individuals • Case managers who advocate for environmental needs • Allow to keep a public health approach as the need for individual monitoring increases with patient load • More disease specific training to replace manual • Additional cultural sensitivity training • Expansion of services: women's health, dental, etc.

46. Conclusion • Student run health clinics are increasing in number in the United States and they provide an opportunity to provide healthcare in low income populations • Case Management Programs may effectively reduce health disparities • The proposed Case Management Program has the potential to improve health outcomes in surrounding areas low income and minority population

47. REFERENCES Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. [Research Support, Non-U.S. Gov't]. The Journal of the American Medical Association, 288(14), 1775-1779. Bosshart, J., & Vienna, M. (2008). Recommendations for case management collaborations and coordination in federally funded HIV/AIDS programs. U.S. Department of Health and Human Services. Retrieved from http://www.cdcnpin.org/scripts/features/CaseManagement.pdf California HealthCare Foundation. (2006). Chronic disease in California: facts and figures. Retrieved from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ChronicDiseaseFactsFigures06.pdf California Medi-Cal Type 2 Diabetes Study Group. Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study. (2004). Diabetes care, 27(1), 95-103. http://www.ncbi.nlm.nih.gov/pubmed/14693973 Case Management Society of America. (2010). Standards of practice for case management. Retrieved from http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf Center for Disease Control and Prevention. (2008). Diabetes data and trends. [Data file]. Retrieved from http://apps.nccd.cdc.gov/DDT_STRS2/CountyPrevalenceData.aspx?StateId=6&mode=OBS Center for Disease Control and Prevention. (2011). Vital signs: prevalence, treatment, and control of hypertension—United States, 1999-2002 and 2005-2008. Morbidity and Mortality Weekly Report, 60(4), 103-108. Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the Chronic Care Model in the new millennium. Health Affairs, 28(1), 75-85. doi: 10.1377/hlthaff.28.1.75 Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., et al. (2000). Treating tobacco use and dependence: clinical practice guideline. U.S. Department of Health and Human Services. Retrieved from http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf Gilmer, T. P., Roze, S., Valentine, W. J., Emy-Albrecht, K., Ray, J. A., Cobden, D., Nicklasson, L., Philis-Tsimikas, A., & Palmer, A. J. (2007). Cost-effectiveness of diabetes case management for low-income populations. [Research Support, Non-U.S. Gov't]. Health Services Research, 42(5), 1943-1959. doi: 10.1111/j.1475-6773.2007.00701.x Glasgow, R. E., Emont, S., & Miller, D. C. (2006). Assessing delivery of the five 'As' for patient-centered counseling. [Research Support, Non-U.S. Gov't]. Health Promotion International, 21(3), 245-255. doi: 10.1093/heapro/dal017

48. REFERENCES Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., . . . Woo, Y. J. (2011). Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. [Consensus Development Conference]. Circulation, 123(8), 933-944. doi: 10.1161/CIR.0b013e31820a55f5 Keenan, N. L., & Rosendorf, K. A. (2011). Prevalence of hypertension and controlled hypertension - United States, 2005-2008. Morbidity and mortality weekly report. Surveillance Summaries,60(01 Suppl), 94-97. Lloyd-Jones, D.M., Evans, J.C., & Levy, D. (2005). Hypertension in adults across the age spectrum: current outcomes and control in the community. Journal of the American Medical Association, 294, 446-472. doi: 10.1001/jama.294.4.466 Meah, Y. S., Smith, E. L., & Thomas, D. C. (2009). Student-run health clinic: novel arena to educate medical students on systems-based practice. [Review]. The Mount Sinai Journal of Medicine, New York, 76(4), 344-356. doi: 10.1002/msj.20128 National Diabetes Education Program. (2007). The link between diabetes and cardiovascular disease. Retrieved from http://ndep.nih.gov/media/CVD_FactSheet.pdf National Diabetes Information Clearinghouse. (2011a, December 6). National diabetes statistics, 2011. Retrieved fromhttp://diabetes.niddk.nih.gov/dm/pubs/statistics/#fast National Research Counsil. (2002). Fostering rapid advances in health care: learning from system demonstrations. [Executive Summary]. Washington DC: The National Academies Press. Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E. J., Berry, J. D., Borden, W. B., . . . Turner, M. B. (2012). Heart disease and stroke statistics--2012 update: a report from the American Heart Association. [Comparative Study]. Circulation, 125(1), e2-e220. doi: 10.1161/CIR.0b013e31823ac046 Simpson, S. A., & Long, J. A. (2007). Medical student-run health clinics: important contributors to patient care and medical education. Journal of General Internal Medicine, 22(3), 352-356. doi: 10.1007/s11606-006-0073-4 The Quality Indicator Study Group (1995) An approach to the evaluation of quality indicators of the outcome of care in hospitalized patients, with a focus on nosocomial infection indicators. Infection Control and Hospital Epidemiology, 16, 308–316. Tsai, A.C., Morton, S.C., Mangione, C.M., & Keller, E.B. (2005). A meta-analysis of interventions to improve care for chronic for chronic illnesses. American Journal of Managed Care, 11(8), 478-88.

49. Thank you! I would be happy to answer any questions you may have!

50. Typical patient coming in for screening physical, OMM treatment etc. PROTOCOL FOR RISK ASSESSMENT CP, SOB, BP>180/120 Notify Dr. Lopes to access urgency Triage: get BMI, BP, Random Glucose test, recent weight loss, thirst +FH (DM, CVD, HTN) Responsibilities: EMERGENCY PROTOCAL Triage H and P Case manager SD/PA: Evaluate, discuss with Dr. Lopes after H and P and Refer to case managerif BS> 126 0r BMI>25 0r BP >130/85, and/or by Dr. Lopes’s discretion BP 2X Prehypertensive >130/85 Hypertensive >140/90 BMI>25 Overweight and no other risk Random BS >126 Identify risks for metabolic syndrome Identify other risks for CVD RF 1: abdominal obesity (waist circumference >40 inches in men or >35 inches in women) * RF 2: glucose intolerance (fasting glucose >100 mg/dL), * RF 3: BP >130/85 mmHg, * RF 4: high triglycerides (>150mg/dL) RF 5: low HDL (<40 mg/dL in men or <50 mg/dL in women). 1. Cigarette smoking 2. Obesity (body mass index ≥30 kg/m2) 3. Physical inactivity 4 .Dyslipidemia 5. Diabetes mellitus 6. Age (older than 55 for men, 65 for women) 7. Family history of premature cardiovascular disease 8. Sleep apnea Diabetes risk Age >45 High BP At risk weight BMI>25 FH of DM High cholesterol Acanthrosisnigrcans Physically inactive High blood sugar 1 Case Management Program only County referral (per Dr. Lopes) and Case Management Program If more than 1 Risk Factors, if not please refer to box 1