sdpi healthy heart project sdpi competitive grant program technical assistance meeting october...

SDPI Healthy Heart ProjectSDPI Healthy Heart Project

SDPI Competitive Grant ProgramSDPI Competitive Grant Program

Technical Assistance MeetingTechnical Assistance Meeting

October 23-24, 2006October 23-24, 2006

Tucson, AZTucson, AZ

Core Elements: Case Management and Retention – Required ActivitiesCore Elements: Case Management and Retention – Required Activities


OVERVIEW – What we will cover in this sessionOVERVIEW – What we will cover in this session

Case Management Core Elements – Intensive ActivitiesCase Management Core Elements – Intensive Activities Case Management Core Elements as related to ongoing activitiesCase Management Core Elements as related to ongoing activities

Case Management VisitsCase Management Visits

Healthy Heart CurriculumHealthy Heart Curriculum

What do we really need to DO?What do we really need to DO?

Retention Core Elements – Intensive ActivitiesRetention Core Elements – Intensive Activities Retention Plan and Activities Retention Plan and Activities

Things to think about when planning/scheduling Intensive ActivitiesThings to think about when planning/scheduling Intensive Activities

Overview of materials/information available to assist you with Intensive Overview of materials/information available to assist you with Intensive ActivitiesActivities

Core Elements: Case Management and Retention Activities

SDPI Healthy Heart ProjectSDPI Healthy Heart ProjectCore Elements: Case Management – Protocol/Required Activities II

Case Management Core Elements - Intensive ActivitiesCase Management Core Elements - Intensive Activities

Components of Case Management for CVD Risk Components of Case Management for CVD Risk Reduction:Reduction:

• Individual Case ManagementIndividual Case Management

• Disease ManagementDisease Management

• Self-Management EducationSelf-Management Education

Individual Case ManagementIndividual Case Management• AssessmentAssessment

• Care planCare plan

• Implementation/coordination of careImplementation/coordination of care

• Care plan/referralsCare plan/referrals

• Follow-upFollow-up


Disease ManagementDisease Management

Reduction of CVD Risk in Patients with Reduction of CVD Risk in Patients with DiabetesDiabetes

• Standards/GuidelinesStandards/Guidelines

• Baseline Physical ExamBaseline Physical Exam

• Treatment GoalsTreatment Goals

• Treatment StrategiesTreatment Strategies

• Tracking Risk factors/goalsTracking Risk factors/goals

Core Elements: Case Management – Protocol/Required Activities II


Self-Management EducationSelf-Management Education

Standards/Guidelines– Reference Materials/OptionsStandards/Guidelines– Reference Materials/Options• Honoring the Gift of Heart Health CurriculumHonoring the Gift of Heart Health Curriculum• Balancing Your Life and Diabetes CurriculumBalancing Your Life and Diabetes Curriculum• Nationals Standards for Diabetes Self-management Nationals Standards for Diabetes Self-management

EducationEducation

Components of EducationComponents of Education• Individual or GroupIndividual or Group• Lifestyle: Nutrition, Activity, Stress Reduction, Motivation, Lifestyle: Nutrition, Activity, Stress Reduction, Motivation,

Mental Health, etc.Mental Health, etc.• Involvement of familyInvolvement of family• Awareness of risk of CVD for AIANsAwareness of risk of CVD for AIANs



Motivational ActivitiesMotivational Activities

Project sponsored activitiesProject sponsored activities

Involve family and youthInvolve family and youth

Combine with Community Based ActivitiesCombine with Community Based Activities

Document ParticipationDocument Participation

Monitoring/Follow-up of CVD Risk FactorsMonitoring/Follow-up of CVD Risk Factors

Testing for Clinical CareTesting for Clinical Care

Evaluation of Project/Reporting to CCEvaluation of Project/Reporting to CC



Intensive Activities Intensive Activities

What do we really need to DO?What do we really need to DO? Monthly Case Management Visits – Monthly Case Management Visits – HIGHER LEVEL OF CARE HIGHER LEVEL OF CARE

• Clinical componentClinical component• Lifestyle componentLifestyle component

Case Management Team Meetings – Provider Case Management Team Meetings – Provider Involvement Involvement

Teach Teach Honoring the Gift of Heart HealthHonoring the Gift of Heart Health curriculum curriculum

Retention Activities – See Retention Core ElementsRetention Activities – See Retention Core Elements



Things to think about when scheduling Things to think about when scheduling intensive activitiesintensive activities

TimelinessTimeliness Scheduling/convenience for participant (visits and Scheduling/convenience for participant (visits and

classes)classes) Case Manager scheduleCase Manager schedule Scheduling team meetings – provider availability?Scheduling team meetings – provider availability? Team meeting Class site/instructor availabilityTeam meeting Class site/instructor availability Time to complete paperworkTime to complete paperwork



More things to think about when scheduling More things to think about when scheduling intensive activitiesintensive activities

Keeping people interested/involved – Keeping people interested/involved – RETENTIONRETENTION• Brainstorm the same way you did for recruitment activitiesBrainstorm the same way you did for recruitment activities

• Identify and remove (or reduce) barriers to participationIdentify and remove (or reduce) barriers to participation

• Be diligent with your tracking so no one “falls between the cracks”Be diligent with your tracking so no one “falls between the cracks”

Remember – Remember –

This is INTENSIVE CASE MANAGEMENT – it means a This is INTENSIVE CASE MANAGEMENT – it means a higher level of care than regular case management, so higher level of care than regular case management, so you need to be diligent and creative you need to be diligent and creative



Tracking Intensive ActivitiesTracking Intensive Activities

The following forms are used to track the activities The following forms are used to track the activities of your project and the progress of your of your project and the progress of your participants throughout the duration of the grantparticipants throughout the duration of the grant

• Case Management Team Meetings Form (I1)Case Management Team Meetings Form (I1)• Participant Attendance Form (I2)Participant Attendance Form (I2)• Individual Retention Form (I3) Individual Retention Form (I3)

These forms should be updated monthly/regularly and These forms should be updated monthly/regularly and submitted to the Coordinating Center annually in submitted to the Coordinating Center annually in December.December.



Information to assist with intensive activitiesInformation to assist with intensive activities Each of the documents listed below can be found on the Each of the documents listed below can be found on the

Coordinating Center Website under Resources/Clinical Coordinating Center Website under Resources/Clinical Guidelines: Guidelines: http://www.uchsc.edu/ai/sdpi/sdpi_login.htmhttp://www.uchsc.edu/ai/sdpi/sdpi_login.htm, or in , or in “Appendix N. Clinical Guidelines” of the SDPI Operations Manual“Appendix N. Clinical Guidelines” of the SDPI Operations Manual

• IHS Standards of Care for patients with Type 2 DiabetesIHS Standards of Care for patients with Type 2 Diabetes

• *Care Plan Sample (only on website)*Care Plan Sample (only on website) The following additional resources can be found on the The following additional resources can be found on the

Coordinating Center Website under Resources/Clinical Coordinating Center Website under Resources/Clinical Guidelines: http://www.uchsc.edu/ai/sdpi/sdpi_login.htmGuidelines: http://www.uchsc.edu/ai/sdpi/sdpi_login.htm

• Guidelines for diagnosis and treatment of hypertensionGuidelines for diagnosis and treatment of hypertension

• Guidelines for pharmaceutical and lifestyle treatment of hypertensionGuidelines for pharmaceutical and lifestyle treatment of hypertension

• Guidelines for diagnosis and treatment of dyslipidemiaGuidelines for diagnosis and treatment of dyslipidemia

• Guidelines for pharmaceutical treatment of dyslipidemiaGuidelines for pharmaceutical treatment of dyslipidemia

Core Elements: Case Management and Intensive Activities


RECAPRECAP

Case Management Core Elements – Intensive ActivitiesCase Management Core Elements – Intensive Activities

Case Management Visits – More Intense!Case Management Visits – More Intense!

Healthy Heart Curriculum – What works for your siteHealthy Heart Curriculum – What works for your site

What do we really need to DO?What do we really need to DO?

Retention Core Elements – Intensive ActivitiesRetention Core Elements – Intensive Activities Retention Plan and Activities Retention Plan and Activities

Things to think about when planning/scheduling Intensive ActivitiesThings to think about when planning/scheduling Intensive Activities

Intensive Activities materials/informationIntensive Activities materials/information


sdpi healthy heart project sdpi competitive grant program technical assistance meeting october...

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