Case Management: A comprehensive approach to quality care.

1. Case Management: A comprehensive approach to quality care. Presenter: Michele Crawley, RN, BSN Lead Case Manager/Data Coordinator Muscogee Creek Nation Health System

2. Our Case Management Team • Our program has 5 clinical sites located throughout the Muscogee Creek Nation boundaries. • 5 RN Case Managers guide Healthy Heart visits at each clinic site . • Johnnie Brasuell, ARNP, CDE, Diabetes Program Manager • Okemah- Michele Crawley, RN, BSN, Lead Case Manager • Eufaula- Patsy Wiseman, RN, BSN • Okmulgee- vacant position • Sapulpa- Nicole Peak, RN, BSN • Koweta- Garrica Bateman, RN, BSN

3. Tribal Jurisdictions in Oklahoma

4. Muscogee Creek Nation in Oklahoma

5. Muscogee Creek Nation Boundaries

6. Baseline Assessment • 1st ensure that possible participant meets screening criteria for HH • Assess for readiness to change • Completed by provider in Diabetes yearly clinic. • If recruitment of participant does not occur in yearly clinic then case manager assists Diabetes Provider with assessment. • Case manager ensures that all required assessment data is completed before initial case management visit.

7. Baseline Assessment Continued • Ensure Medical Clearance is obtained from provider. • May need to obtain from Cardiologist if primary provider states patient is high risk • Physical Assessment of patient • Weight, height, waist circumference, & blood pressure. • Labs needed: • Lipid profile (within 3 months of 1st case management visit) • A1C (within 1 month of 1st case management visit) • Micro Albumin (within 1 month of 1st case management visit) • Other • Health History • Social History

8. Components of Case Management 3 major components of case management consist of: • Individual Case Management • Disease Management • Self-Management Education

9. Individual Case Management • The patient needs assessment is completed through a nursing evaluation • Complete the Case Management visit Encounter form • During this case management visit: • Implementation of quality care must occur by: • Obtaining vital signs & measurements • View recordings on Glucometer and Blood Pressure monitor. • Address any problem or concerns the patient is experiencing. • Identification of most recent Biometric Behaviors and Labs • Current or updated list of Medications

10. Individual Case Management Continued • Coordination of care with other health care disciplines: • Providers (primary or specialist) • Pharmacists • Dietitian • ExerciseManager • Complete any referrals required for quality care

11. Example of Patient Encounter Form

12. What goals are we looking for? • Blood Pressure < 130/80 • LDL <100mg/dl or <70mg/dl for high risk or Dx of CVD • HDL >40mg/dl men & >50mg/dl women • TGL <150mg/dl • A1C < 7.0% • Weight loss: 7% body weight or BMI <30 • Waist circumference <40 men & <35 women • Physical Activity on a regularly work up to 150 minutes per week • Healthy Eating: lower fat, salt, & calories • Stop smoking • Daily use of aspirin unless contraindicated

13. How can we help patients reach these Goals? • Intensive Case Management visits monthly or quarterly • Collaboration of care • Medication intervention • Lab test: on baseline, annual, quarterly, and as needed • Education • Diabetes Self Management • Honoring the Gift of Heart Health

14. Creating the Care Plan • Care plan is based upon patient needs • Identification of most recent Biometric Behaviors and Labs • Current or updated list of Medications • Focus on Healthy Behaviors: • Healthy eating habits • Exercise • Home testing of Blood Sugar and Blood Pressure • Patient must be involved • Patient sets goals for the month or quarterly

15. Example of Blank Care Plan Page 1

16. Example of Blank Care Plan Page 2

17. Let’s practice by putting it all together! • Develop a Trusting Relationship • Remember to be empathetic • Offer the patient options • Most of all have patience when it seems like your options are not being accepted by the patient. • Motivate, motivate, motivate

18. Completed Care Plan Example Page 1

19. Completed Care Plan Example Page 2

20. Tracking Options • Coordinating Center forms: • Baseline & Annual Assessments: C1 & C2 • Case Management visits: P1 or P2 • MCN Individual Program related forms • Electronic Health Record • Excel Spreadsheet- Monitoring tool • Encounter forms (currently on paper but we are moving to EHR)

21. Education Offered Our main source of Education for HH participants within MCN: Group focused Education but can be One-on-One if needed • Honoring the Gift of Heart Health • EPIC (Educating Partners in Care) • Lipid Lowering class

22. Why is Education important? “Tell me and I'll forget; show me and I may remember; involve me and I'll understand.”—Author Unknown (Chinese Proverb) Involvement with the patient is essential: • Lifestyle Behavior education and changes • Management of Blood Glucose monitoring • Journal– Food and Exercise • Awareness of Risk Factors for CVD • Motivational– find what motivates your patient • Encouragement of Family involvement • Address any barriers of success • Knowledge , attitudes, beliefs, mental health, & ect…

23. Enjoy Case Management

24. The End • A Healthy Heart is a Happy Heart!