Core Elements: Case Management

Recruitment

Yvette Roubideaux, MD, MPH

The CVD Risk Reduction Demonstration Project

We know “what” but we don’t know “how”

The CVD Risk Reduction Demonstration Project

Core elements – “what” Development of intensive

intervention– “how” (details) Collaborative process

The CVD Risk Reduction Demonstration Project

8 Core elements - Intensive Intervention – “the what”

Identify eligible individuals with Diabetes Recruit individuals with diabetes to participate Initial physical exam and baseline measures Case Management approach to clinic visits

The CVD Risk Reduction Demonstration Project

8 Core elements – Intensive Intervention – “the what”

Treat CVD risk factors to recommended target levels Education on diabetes and CVD risk reduction – group or

individual Gather data on required evaluation measures Target number of participants per year (minimum) = 50

Core Elements: Collaborative Process

Determining the “how” – so far: Planning Meeting Presentations/Training Sessions Grantee Panel Discussions/Questions Breakout Sessions/Input Comments during breaks, email communication Homework follow-up questions Idea maps IHS Advisory Committees - notes CGP Steering Committee IHS programmatic issues/direction

Core Elements: Collaborative Process – Big

Picture

Initial Presentations Training

Input, Breakout Sessions, Grantee PanelsIdea Maps

Draft Protoc

olReview

Committees Refine,

Clarify

Final ReviewGrantee

s

Final Decision

IHS DDTP

Core Elements: Draft Draft Protocol/Required

Activities Review the 1st Draft today

• Questions

Breakout Session• Identify strengths, challenges

• Potential training needs

Core Elements: Draft Case Management - components

Case Management Team• Membership, Meetings

Intensive Activities• Screening for Individuals with Diabetes• Eligible Participants - Diabetes• Individual Case Management – assessment, care plans• Disease Management – standards/goals, treatment, tracking• Self-Management Education - components• Motivational Activities• Monitoring/Follow-up of CVD Risk Factors

Core Elements: Draft Recruitment - components

Recruitment Goals• Minimum numbers

Recruitment Activities• Recruitment Team• Settings for Recruitment

• Community, Clinical• Methods of Recruiting individuals to participate• Materials for Recruitment• Process to help individuals participate in screening• Invitation for eligible to participate – informed consent process• Entry process – instructions, appointments• Tracking of recruitment activities

Core Elements: Draft Draft Protocol/Required

Activities Review the 1st Draft today

• Questions

Breakout Session• Identify strengths, challenges

• Potential training needs