1 / 17

Expanding Diabetes Yearly Clinics to Include Case Management

Muscogee (Creek) Nation Healthy Heart Program Johnnie Brasuell, APRN, CNP; Michele Crawley, RN, BSN; Kristen Colbert, RN, BSN. Expanding Diabetes Yearly Clinics to Include Case Management. Muscogee (Creek) Nation Division of Health. Muscogee (Creek) Nation.

toyah
Download Presentation

Expanding Diabetes Yearly Clinics to Include Case Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Muscogee (Creek) Nation Healthy Heart Program Johnnie Brasuell, APRN, CNP; Michele Crawley, RN, BSN; Kristen Colbert, RN, BSN Expanding Diabetes Yearly Clinics to Include Case Management

  2. Muscogee (Creek) Nation Division of Health Muscogee (Creek) Nation • 8 full counties and 3 partial counties • 72,000 Tribal Members

  3. Muscogee Creek Nation Division of Health Healthy Heart Program • Each of the five MCNDH Clinics provides a full range of primary care and through the SDPI program a Diabetes Program team was added: • Nurse Educator/Coordinator • Dietitian • Diabetes Case Manager/Healthy Heart • Exercise Programs Manager • Diabetes Program Clerk

  4. MCN Diabetes Program Teamsat each of the five clinics • Provides: • ADA Recognized DSME • Healthy Heart Programs • Community prevention programs in 21 schools, and 11 Elderly Nutrition Programs • Tribal walking programs in 25 communities • Annual MCN Citizens’ Summit • Coordinate standards of diabetes care in clinics through the yearly clinic and assess self-management support needs

  5. Sustaining Healthy Heart Through Primary Care and Yearly Clinics Goal: To partner with primary care providers to improve Best Practices in diabetes care. • To initiate less intensive case management to all patients • Track appropriate and timely complication care • To identify risk factors on a routine basis • To facilitate access to available resources • To provide Healthy Heart intensive case management to a subgroup.

  6. What Are We Doing Differently? Recruitment from DSME Graduates Recruitment from Yearly Clinic. • This clinic serves the total diabetes population and is already familiar to patients. From Demonstration Project To Sustainable HH Initiative

  7. What Are We Doing Differently? Continued • Three HHP case managers at five clinics to provide HHP only • Five case managers (One at each clinic) to provide: • Less intensive diabetes case management • HHI From Demonstration Project To Sustainable HH Initiative

  8. What Are We Doing Differently? Continued • HHP required time lines not in Sync with clinical schedules • Physical Exam and lab required for HHI participants are accomplished without separate scheduling From Demonstration Project To Sustainability HH Initiative

  9. What Are We Doing Differently? Continued • Honoring the Gift of Heart Health was provided once a year over a 3-month period for new enrollees • HGHH will be scheduled by DSME coordinators year round From Demonstration HHP To Sustainabile HHI

  10. What are We Doing Differently? Continued • Access to enrollment once a year • Provides access to enrollment year round From Demonstration Project To Sustainable HH Initiative

  11. Pre Assessment • Detailed chart audit • Lab, immunizations, EKG, wellness care • History of self-management education • History of clinical appointments

  12. Assessment During Yearly • Start with motivational interviewing • How have been doing with your diabetes this year? • What are concerns about your health? • What changes have been thinking about? • Summarize: • This is what I hear you saying: • Could I offer you some suggestions or services that are available to you?

  13. Assessment During Yearly • Review self-assessment forms: • Healthy Behaviors • RAPA (Rapid Assessment of Physical Activity) • Medical History Update • Review objective information and update patient • Assess readiness for lifestyle changes • Offer resources

  14. Assessment During Yearly • Inform patients that full review of their results will be completed in the next few days • Case manager will contact them by phone for their approval of final follow up plan.

  15. Follow Up Yearly Clinic • Final review of the total assessment includes: • Eye, foot, and dental exams • Laboratory values • Other clinical measurements • Healthy Behaviors • Staging of complications • Readiness level • Recommendations from interdisciplinary professionals

  16. Follow Up Yearly Clinic Continued • Provide patient with yearly health status report • Propose individualized recommendations to patient • Discuss patient accepted plans to provider • Obtain required referrals from provider

  17. Patient Collaboration After Yearly • Inform patient of approved plan and progress of referrals through appropriate channels • Patient will be responsible for following up with case manager if they have concerns involving the referral process and appointments.

More Related