Chronic Care Management Plan

**Sleep Apnea OVERVIEW**

Sleep apnea is a common disorder that can become life-threatening. It
affects adults, adolescents, and children. The definition of an apnea
event includes cessation of breathing for a minimum interval of 10
seconds between breaths. Apnea literally means without breath - apnea is
characterized by pauses in breathing that typically last fifteen to
twenty seconds - these episodes may occur during sleep as often as
twenty to thirty times per hour. Furthermore, patients can be
asymptomatic and unaware that they have the disorder. If left untreated,
sleep apnea can lead to cardiac arrhythmia, congestive heart failure,
hypertension, and stroke. There are two forms of sleep apnea - Central
and Obstructive. The latter is by far the most common. In Mixed Sleep
Apnea, there is a transition from Central to Obstructive features during
the events.

# 

# Risk factors:for sleep apnea include:

-   Obesity

-   Snoring

-   Family history

-   Hypertension

-   Hypertrophic tonsils and/or adenoids

Pathologic Features of Sleep Apnea Include:

-   Decreased oxygenation of vital organs and tissues.

-   Collapse of the airway due to decreased muscle tone around the
    throat and neck.

-   Obstruction of airflow to the lungs via narrowing of the airway.

-   Respiratory receptors in the brain fail to respond to changing blood
    levels of respiratory gases.

Signs and Symptoms include:

-   Loud snoring.

-   Choking or gasping during sleep.

-   Tired or sleepy during the day.

-   Morning headaches.

-   Irritability.

-   Dry throat on awakening.

# 

# Diagnosis:

A definitive diagnosis can only be made by performing an overnight sleep
study with polysomnogram.

Treatment:

Most common therapeutic intervention is delivery of positive airway
pressure using machines to pump a controlled stream of air through a
mask worn over the nose, mouth, or both.

-   CPAP -- Continuous positive airway pressure is the most common
    treatment for obstructive sleep apnea.

-   VPAP -- Variable positive airway pressure.

-   APAP -- Automatic positive airway pressure.

Surgical Interventions:

-   Multiple surgical techniques to relieve obstruction of airway.

-   In children and some adults, tonsil and/or adenoid removal.

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-   Tonsillectomy

-   Adenoidectomy

Alternative Teatment:

Breathing techniques, such as yoga.

Pharmacological Interventions:

-   Not very successful and wrought with side effects.

-   Most commonly used drug is theophylline.

-   Anti-narcoleptic medications such as modafinil are used to assist in
    treating daytime somnolence.

REF: <http://www.nhibi.nih.gov/healthprf/sleep/slpaprisk.pdf>

CHRONIC CARE MANAGEMENT PLAN

### **SLEEP APNEA**

#### **OUTREACH AND ADMISSIONS PERIOD**

Please provide us with the following information.

1.  Classification of Sleep Apnea: \_\_\_\_ Obstructive sleep apnea
    \_\_\_\_ Central sleep apnea

2.  Date of diagnosis:

Please include report of sleep study if available.

3.  Age of symptom onset:

4.  List current medications and treatments including dose and
    frequency.

5.  Has applicant been compliant with medications and treatment? If no
    explain.

6.  List past hospitalizations including dates, reasons for admission
    and include discharge summaries if available.

7.  When was the last appointment?

> Weight Height BMI BP

8.  Will the applicant need to continue follow-up under your care? If
    yes, list the frequency of follow-up appointments.

9.  In your opinion, will the applicant be able to self-manage
    medications and/or treatments unsupervised and participate in a
    vocational training program? If no, please explain.

10. In your opinion, will the applicant be appropriate to reside in a
    dormitory-style residence with minimal supervision? If no, please
    explain.

11. Are there any restrictions or limitations related to this specific
    illness?

12. List any allergies for this applicant.

13. What is the applicant's smoking history?

14. Does the applicant have health insurance?

Please sign below and return the form in the attached addressed
envelope.

###### Print Name and Title Signature

###### Phone Date

For any questions, please call

### **Admission Counselor/Health and Wellness Staff** 

> **Phone**

**Chronic Care Management Plan**

**Sleep Apnea**

**Goals:**

1.  Maximize employability and optimize health by efficiently treating
    sleep apnea so that the student experiences few or no symptoms.

2.  Encourage student to participate in and follow prescribed treatment
    plan.

3.  Educate student regarding self-management and reporting of symptoms.

4.  Encourage student enrollment in Weight Improvement Program, if
    indicated.

+----+---+------------------------------------------------------------+
| ** |   |                                                            |
| CA |   |                                                            |
| RE |   |                                                            |
| ER |   |                                                            |
| P  |   |                                                            |
| RE |   |                                                            |
| PA |   |                                                            |
| RA |   |                                                            |
| TI |   |                                                            |
| ON |   |                                                            |
| PE |   |                                                            |
| RI |   |                                                            |
| OD |   |                                                            |
| ** |   |                                                            |
+----+---+------------------------------------------------------------+
| *  | * |                                                            |
| *Y | * |                                                            |
| ES | N |                                                            |
| ** | O |                                                            |
|    | * |                                                            |
|    | * |                                                            |
+----+---+------------------------------------------------------------+
|    |   | Establish a sleep apnea action plan                        |
+----+---+------------------------------------------------------------+
|    |   | Review treatment protocol and medication(s)                |
+----+---+------------------------------------------------------------+
|    |   | Assess vocational training match                           |
+----+---+------------------------------------------------------------+
|    |   | Mandatory TUPP/smoking cessation enrollment                |
+----+---+------------------------------------------------------------+
|    |   | Annual influenza vaccination in October or November        |
+----+---+------------------------------------------------------------+
|    |   | Mandatory enrollment in a weight management program if     |
|    |   | indicated (on or off center)                               |
+----+---+------------------------------------------------------------+
|    |   | Educate student on weight management as it relates to      |
|    |   | employment                                                 |
+----+---+------------------------------------------------------------+
|    |   | # Educate student about potential obesity complications    |
|    |   |                                                            |
|    |   | ## Ca                                                      |
|    |   | rdiovascular (hypertension, hyperlipidemia, cor pulmonale) |
|    |   |                                                            |
|    |   | -   Stroke prevention                                      |
|    |   |                                                            |
|    |   | ## Diabetes mellitus, type 2                               |
|    |   |                                                            |
|    |   | ## Pulmonary (sleep apnea)                                 |
|    |   |                                                            |
|    |   | ## Liver (steatohepatitis)                                 |
|    |   |                                                            |
|    |   | ## Gallbladder (gallstones)                                |
|    |   |                                                            |
|    |   | ## Reproductive (PCOS)                                     |
|    |   |                                                            |
|    |   | ## Orthopedic (SCFE)                                       |
|    |   |                                                            |
|    |   | ## Skin (acanthosis nigricans, striae)                     |
|    |   |                                                            |
|    |   | ## CNS (pseudotumor cerebri)                               |
|    |   |                                                            |
|    |   | -   Psychosocial/quality-of-life issues                    |
+----+---+------------------------------------------------------------+
|    |   | # Educate student about lifestyle choices                  |
|    |   |                                                            |
|    |   | ## Weight management                                       |
|    |   |                                                            |
|    |   | ## Encoura                                                 |
|    |   | ge whole fruits, vegetables, low fat milk, increased fiber |
|    |   |                                                            |
|    |   | ## Avoid soda and fruit juices                             |
|    |   |                                                            |
|    |   | -   Encourage aerobic physical activity (exercise 30       |
|    |   |     minutes per day, 5 days per week)                      |
|    |   |                                                            |
|    |   | ## Avoid sedentary lifestyle (limit TV)                    |
|    |   |                                                            |
|    |   | # Avoid smoking                                            |
|    |   |                                                            |
|    |   | # Limit alcohol use                                        |
+----+---+------------------------------------------------------------+

+----+---+------------------------------------------------------------+
| ** |   |                                                            |
| CA |   |                                                            |
| RE |   |                                                            |
| ER |   |                                                            |
| D  |   |                                                            |
| EV |   |                                                            |
| EL |   |                                                            |
| OP |   |                                                            |
| ME |   |                                                            |
| NT |   |                                                            |
| PE |   |                                                            |
| RI |   |                                                            |
| OD |   |                                                            |
| ** |   |                                                            |
+----+---+------------------------------------------------------------+
| ## | # | # Monitor adherence issues                                 |
| #  | # |                                                            |
|    | # | # Medication regimen                                       |
|    |   |                                                            |
|    |   | ## Medication refills                                      |
|    |   |                                                            |
|    |   | ## Routine medical care                                    |
|    |   |                                                            |
|    |   | ## Urgent medical care                                     |
|    |   |                                                            |
|    |   | ## Environmental control                                   |
|    |   |                                                            |
|    |   | ## Self-monitoring                                         |
|    |   |                                                            |
|    |   | ## Physiotherapy                                           |
|    |   |                                                            |
|    |   | ## Rest                                                    |
|    |   |                                                            |
|    |   | ## Exercise                                                |
|    |   |                                                            |
|    |   | ## Nutrition                                               |
|    |   |                                                            |
|    |   | -   Tobacco, alcohol, drug use                             |
+----+---+------------------------------------------------------------+
| ** |   |                                                            |
| CA |   |                                                            |
| RE |   |                                                            |
| ER |   |                                                            |
| TR |   |                                                            |
| AN |   |                                                            |
| SI |   |                                                            |
| TI |   |                                                            |
| ON |   |                                                            |
| PE |   |                                                            |
| RI |   |                                                            |
| OD |   |                                                            |
| ** |   |                                                            |
+----+---+------------------------------------------------------------+
|    |   | Conduct a wellness center exit interview approximately two |
|    |   | weeks prior to completion of program.                      |
+----+---+------------------------------------------------------------+
|    |   | Identify potential sources of primary health care, and     |
|    |   | specialty care if needed, in the work community.           |
+----+---+------------------------------------------------------------+
|    |   | ##### Ob                                                   |
|    |   | tain signed HIPAA authorizations for the transfer of the s |
|    |   | tudent health records to identified health care providers. |
+----+---+------------------------------------------------------------+
|    |   | Assist student in enrolling or maintaining enrollment in a |
|    |   | public or private health insurance program.                |
+----+---+------------------------------------------------------------+
|    |   | Provide the student with a copy of health records          |
|    |   | including copies of chronic care management plan           |
|    |   | flowsheets.                                                |
+----+---+------------------------------------------------------------+
|    |   | Provide the student with adequate follow-up plan,          |
|    |   | medications and necessary equipment at departure.          |
+----+---+------------------------------------------------------------+
|    |   | Provide the student with an appropriate emergency plan in  |
|    |   | the event of potential life-threatening symptoms.          |
+----+---+------------------------------------------------------------+

+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Student Name:**        |     |     |   | * |     |     |     |     |
|                          |     |     |   | * |     |     |     |     |
|                          |     |     |   | S |     |     |     |     |
|                          |     |     |   | e |     |     |     |     |
|                          |     |     |   | x |     |     |     |     |
|                          |     |     |   | : |     |     |     |     |
|                          |     |     |   | M |     |     |     |     |
|                          |     |     |   | o |     |     |     |     |
|                          |     |     |   | r |     |     |     |     |
|                          |     |     |   | F |     |     |     |     |
|                          |     |     |   | ( |     |     |     |     |
|                          |     |     |   | c |     |     |     |     |
|                          |     |     |   | i |     |     |     |     |
|                          |     |     |   | r |     |     |     |     |
|                          |     |     |   | c |     |     |     |     |
|                          |     |     |   | l |     |     |     |     |
|                          |     |     |   | e |     |     |     |     |
|                          |     |     |   | o |     |     |     |     |
|                          |     |     |   | n |     |     |     |     |
|                          |     |     |   | e |     |     |     |     |
|                          |     |     |   | ) |     |     |     |     |
|                          |     |     |   | * |     |     |     |     |
|                          |     |     |   | * |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Date of Birth:**       |     |     |   | * |     |     |     |     |
|                          |     |     |   | * |     |     |     |     |
|                          |     |     |   | D |     |     |     |     |
|                          |     |     |   | a |     |     |     |     |
|                          |     |     |   | t |     |     |     |     |
|                          |     |     |   | e |     |     |     |     |
|                          |     |     |   | o |     |     |     |     |
|                          |     |     |   | f |     |     |     |     |
|                          |     |     |   | E |     |     |     |     |
|                          |     |     |   | n |     |     |     |     |
|                          |     |     |   | t |     |     |     |     |
|                          |     |     |   | r |     |     |     |     |
|                          |     |     |   | y |     |     |     |     |
|                          |     |     |   | : |     |     |     |     |
|                          |     |     |   | * |     |     |     |     |
|                          |     |     |   | * |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **EVERY VISIT**          | **  | **  | * |   | **  | **  | **  | **  |
|                          | Dat | Dat | * |   | Dat | Dat | Dat | Dat |
|                          | e** | e** | D |   | e** | e** | e** | e** |
|                          |     |     | a |   |     |     |     |     |
|                          |     |     | t |   |     |     |     |     |
|                          |     |     | e |   |     |     |     |     |
|                          |     |     | * |   |     |     |     |     |
|                          |     |     | * |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
|                          | / / | / / | / |   | / / | / / | / / | / / |
|                          |     |     | / |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Snoring? Gasping?      |     |     |   |   |     |     |     |     |
| (Y/N)**                  |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Daytime fatigue?       |     |     |   |   |     |     |     |     |
| Headaches? (Y/N)**       |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Body mass index        |     |     |   |   |     |     |     |     |
| (BMI)**                  |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Blood pressure (BP)**  |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Smoking status (Y/N)** |     |     |   |   |     |     |     |     |
|                          |     |     |   |   |     |     |     |     |
| **If yes, cessation      |     |     |   |   |     |     |     |     |
| plan? (Y/N)**            |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **TREATMENT OPTIONS**    |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **CPAP / VPAP / APAP     |     |     |   |   |     |     |     |     |
| (circle one)**           |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Oxygen therapy (Y/N)** |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Smoking cessation aids |     |     |   |   |     |     |     |     |
| (Y/N)**                  |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Medication:            |     |     |   |   |     |     |     |     |
| \_\_\_\_\_\_\_\_\_\_\_   |     |     |   |   |     |     |     |     |
| \_\_\_\_\_\_\_\_\_\_\_** |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Other:                 |     |     |   |   |     |     |     |     |
| \_\_\_\_                 |     |     |   |   |     |     |     |     |
| \_\_\_\_\_\_\_\_\_\_\_\_ |     |     |   |   |     |     |     |     |
| \_\_\_\_\_\_\_\_\_\_\_** |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **EDUCATION**            |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Nutrition**            |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Exercise**             |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Treatment adherence**  |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **ANNUAL OR AS           |     |     |   |   |     |     |     |     |
| INDICATED**              |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Overnight sleep        |     |     |   |   |     |     |     |     |
| study**                  |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **ENT evaluation --      |     |     |   |   |     |     |     |     |
| tonsils/adenoids**       |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Cardiac evaluation**   |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Spirometry**           |     |     |   |   |     |     |     |     |
|                          |     |     |   |   |     |     |     |     |
| **(FEV1 or FVC%          |     |     |   |   |     |     |     |     |
| predicted norm)**        |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Pulse oximetry (%      |     |     |   |   |     |     |     |     |
| saturation)**            |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| #### **PREVENTIVE**      |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+
| **Influenza vaccine      |     |     |   |   |     |     |     |     |
| (annual)**               |     |     |   |   |     |     |     |     |
+--------------------------+-----+-----+---+---+-----+-----+-----+-----+