Serving the Underserved: Using the Chronic Care Model when you have absolutely no idea what is wrong

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Serving the Underserved Using the Chronic Care
Model when you have absolutely no idea what is
wrong with your patient

• Brandon Cornejo Ph.D., MS III
• Family Medicine Clerkship
• Feb. 2, 2007

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Overview

• City Fort Lupton
• Site Salud Clinic
• Clinics History
• Fort Lupton Clinic
• Typical Patient
• Unique patient with difficult diagnosis of
  chronic disease
• In the context of the Chronic Disease Model

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How did I end up in Ft. Lupton?
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Fort Lupton, Colorado
www.yahoomaps.com
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Fort Lupton, Colorado

• General Stats
• Population in July 2005 7,121
• Median resident age 28.9 years
• Median house value 131,900

www.city-data.com
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Fort Lupton, Colorado

• Demographics
• 21.8 Foreign born (20.3 Latin America).
• White Non-Hispanic (49.9)
• Hispanic (47.4)

www.city-data.com
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Fort Lupton, Colorado

• Education
• High school or higher 67.3
• Bachelor's degree or higher 12.2
• Graduate or professional degree 4.5
• Unemployed 4.3

www.city-data.com
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Fort Lupton, Colorado
Median household income 40,917
www.city-data.com
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Salud Clinics

• 501 (c) 3 Non-profit
• Established 1970
• Farmworkers and families

• Medically indigent, the uninsured,
• and the under-insured
• Federally Qualified Migrant and
• Community Health Center

www.saludclinic.org
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Salud Clinics

• Primary medical and dental care
• Obstetrics and out-patient care
• 66,000 residents and migrant and seasonal
  farmworkers
• Northcentral and northeast Colorado.
• Mobile clinic

www.saludclinic.org
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Salud Clinics
www.saludclinic.org
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Salud Clinics

• Payment
• Medicaid 30
• Medicare 4
• Private Insurance 12
• Other Public Insurance 4
• Sliding Fee Scale 50

www.saludclinic.org
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Salud Clinic Fort Lupton

• Opened in 1970 (First Clinic)
• Administration
• 65 of clients are Latino
• Board of Directors, the majority of whom are
  Salud clients, governs the organization
• Largest grantee from the U.S. Bureau of Primary
  Health Care

www.saludclinic.org
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Patient H.M. A typical patient

• 43 year old G3P3103
• CC Heart palpitations
• Social No SS , No insurance
• Meds Fluoxetiene 20 mg PO daily
• Vitals HR 80 BP 130/100 Weight 170 lbs
  Height 55

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Patient H.M.s mom
By the way

• 58 year old female
• 212 lbs, 5 feet tall
• Metabolic Syndrome
• Hypertension
• Dyslipidemia
• DM Type 2

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Salud Clinic Fort Lupton

• Most Common Diseases
• Diabetes Mellitus Type 2
• Hypertension
• Dyslipidemia
• Obesity
• Depression/Anxiety (Psychosocial)
• High-risk Pregnancy

• Especially late care

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Salud Clinic Fort Lupton
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The Chronic Care Model
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Scott

• 19 year old male
• CC Stomach pain
• Vitals HR 62 BP 110/80 Weight 112 lbs Height
  510

• HPI 7 year history of lower abdominal pain. Now
  with diarrhea for
• 8 months. Difficulty eating and primarily
  subsisting on fruit the only
• thing he can tolerate. No melena or frank blood
  in stool. No fevers.
• Med/Surg Hx none
• Fam Hx Mother has Celiac Disease(?) Paternal
  grandfather w/ HTN
• Social No insurance, living with mother, prefers
  his computer to
• social interactions, does not go out much, quit
  ITT Tech
• Meds None, denies ETOH and drug use

• Exam
• Benign except mild diffuse guarding and TTP LQs
  during Abdominal exam chews his fingernails
  mildly pale/jaundiced
• Labs WNL except elevated TBili and Albumin

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The Chronic Care Model

• How does this guy fit into this model?

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The Chronic Care Model
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The Chronic Care Model

• Health Care System
• Delivery System Design
• 1st issue what are the possible diagnoses
• Celiac Disease
• Psychiatric Disorder
• (Eating Dx vs. Anxiety Dx?)
• Irritable Bowel Disease
• Hyperthyroidism

Prepared, proactive team

• Decisional Support
• Scotts course of treatment based on
  differential diagnosis

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The Chronic Care Model

• Scotts Most likely problem ? (Being prepared and
  proactive)
• Celiac Disease (CD)
• Chronic Diarrhea
• Maternal history of disease
• 10-20 of probands have 1st degree relative with
  CD
• Karinen, et. al. Scand. J. Gastroenterol. 2006
  Nov41(11)1299-304
• CBC, B12, iron, LFT, Metabolic abnormalities
• Tierney, et. al. Curr Med Diag and Treatment,
  2006
• Negative Stool guiac
• Sudan test(steatorrhea)

• Treatment/testing Withdraw Gluten (wheat, rye)
  from diet
• 94 recovery after 12 mo.
• Annibale, B. et. al. Am. J. Gastroenterol. 2001
  Jan96(1)132-7
• Practice Guidelines Journal of Pediatric
  Gastroenterology and
• Nutrition, 40 1-19, 2005

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The Chronic Care Model
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The Chronic Care Model

• Organization of Health Care and Community
• Organization of Health Care
• Psychotherapist on staff
• GI specialist in clinic for support
• Referral to Brighton Hospital for imaging
• University Hospital for more complex cases
• Nutritionist on staff that may be able to assist

• Community
• Support groups available in Fort Lupton (Not
  specific for CD)
• Often for English speakers with more resources
• Celiac Disease Foundataion
• Family
• State/Federal Government for financial support
  (SK is a citizen)

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The Chronic Care Model

• Salud Clinics
• Often the only source of medical delivery and
  support for many individuals

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The Chronic Care Model

• Self-Management
• Not as simple as a DMII (HA1C, BG, Cholesterol)
• No firm diagnosis but each has self-management
  potential
• Celiac disease altering diet gluten free
• SK may be pro-active
• 8 year history of doctors visits with little
  improvement
• Why?
• Reliably reporting symptoms?
• Finding foods that he can tolerate

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The Chronic Care Model
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The Chronic Care Model

• Clinical Information System
• Celiac Disease Awareness Campaign (NIH)
• Information
• Disease News
• Fact Sheets
• Registry?
• Clearinghouse
• Registration for clinical studies
• Stats

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Review

• Salud Clinics serve an underserved and indigent
  population
• Typically located in a less affluent and rural
  area
• These clinics are often the only source of health
  care and support
• Despite this, the clinics can offer the support
  of a chronic disease management

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Acknowledgements
Kelet Robinson, MD Tillman Farley, MD Roberto
DeNegri, MD Esteban Gaido, MD Stephanie Miller,
PA Ed Hendrickson, PhD, PA Brian Boley, PA All
the Medical Assistants