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TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE March 27-30, 2017 Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100 FUNDAMENTALS OF TB CASE MANAGEMENT LEARNING OBJECTIVES Upon completion of this session, participants will be able to: 1. Describe several components of the tuberculosis case management model 2. Identify and prioritize the objectives of TB case management 3. Identify the components of a clinical evaluation of a patient with TB 4. Describe the core treatment regimen for TB and at least 3 strategies to promote adherence INDEX OF MATERIALS PAGES 1. Fundamentals of TB Case Management – slide outline Presented by: Barbara Cole, RN, PHN, MSN 1-17 SUPPLEMENTAL MATERIAL • Sample School Exclusion Letter
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TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE March 27-30, 2017
Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100
FUNDAMENTALS OF TB CASE MANAGEMENT
LEARNING OBJECTIVES
Upon completion of this session, participants will be able to:
1. Describe several components of the tuberculosis case management model
2. Identify and prioritize the objectives of TB case management
3. Identify the components of a clinical evaluation of a patient with TB
4. Describe the core treatment regimen for TB and at least 3 strategies to promote adherence
INDEX OF MATERIALS PAGES
1. Fundamentals of TB Case Management – slide outline Presented by: Barbara Cole, RN, PHN, MSN
1-17
SUPPLEMENTAL MATERIAL
• Sample School Exclusion Letter
TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE March 27-30, 2017
Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100
ADDITIONAL REFERENCES
• Nahid P, Dorman S, Alipanah N et al. Official American Thoracic Society/Centers for Disease
Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis. Clin Infect Dis 2016; 63:e147–95.
• Curry International Tuberculosis Center. Drug-resistant tuberculosis: a survival guide for clinicians, third edition. 2016. URL: http://www.currytbcenter.ucsf.edu/sites/default/files/tb_sg3_book.pdf
• California Department of Health Services, California Tuberculosis Controllers Association. TB case management: core components. November 2011; 1-24.
• National Tuberculosis Controllers Association, National Tuberculosis Nurse Consultant Coalition. Tuberculosis nursing: a comprehensive guide to patient care. 2011; 1-160.
• G. B. Migliori, P. C. Hopewell, F. Blasi, A. Spanevello and M. C. Raviglione. Improving the TB case management: the international standards for tuberculosis care. Eur Respir J 2006; 28:687-690.
• New Jersey Medical School National Tuberculosis Center. Tuberculosis case management for nurses: self-study modules. 2001.
• U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Core curriculum on tuberculosis: what the clinician should know, fourth
edition, 2000:1-139.
Fundamentals of Tuberculosis Case Management 1
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Barbara Cole, R.N., P.H.N., M.S.N.
Tuberculosis Controller, Riverside County
Fundamentals of Tuberculosis Case Management
March 27, 2017
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Objectives
Upon completion of this session you will be able to:
Describe several components of the tuberculosis (TB) case management model
Identify and prioritize the objectives of TB case management
Identify the components of a clinical evaluation of a patient with TB
Describe the core treatment regimen for TB and at least 3 strategies to promote adherence
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Fundamentals of Tuberculosis Case Management 2
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Overview of Case Management
Primary responsibility for the coordination of patient care to ensure that the patient’s medical and psychosocial needs are met through appropriate utilization of resources
Definition
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Overview of Case Management (2)
Primary goals
Render the patient non-infectious by ensuring an adequate course of treatment
Provide early intervention
Prevent TB transmission and development of disease
Identify and remove barriers to adherence
Identify and address other urgent health needs
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Fundamentals of Tuberculosis Case Management 3
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Overview of Case Management (3)
The assignment of an individual to be primarily responsible and accountable to ensure that the patient:
Completes an appropriate course of therapy
Is educated about TB and its treatment and management
Has a documented culture conversion
Has a contact investigation completed when indicated
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Key Components of TB Case Management
Role of a case manager
Ensure that care provided is culturally sensitive and acceptable to the patient
Use Non-Stigmatizing language
Set goals, monitor outcomes, and appropriately document interventions
Maintain contact not only with the patient but with the care provider and other individuals providing health related services to the patient
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Fundamentals of Tuberculosis Case Management 4
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Key Components of TB Case Management (2)
Steps in TB case management
Receive the case report: review and decide on urgency within one working day (prioritize workload)
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Key Components of TB Case Management (3)
Steps in TB case management (continued)
Contact the medical care provider: within one working day of receipt of report Establish rapport
Educate the provider about the case manager’s roles/responsibilities and those of the local health department
Educate the provider about TB control program services and oversight responsibility
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Fundamentals of Tuberculosis Case Management 5
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Key Components of Tuberculosis Case Management (4)
Steps in TB case management (continued)
Make initial contact with patient by home visit (or in hospital) within one working day of report (ideal) Establish rapport
Explain role of public health nurses/outreach staff
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Key Components of Tuberculosis Case Management (5)
Steps in TB case management (continued)
Assess the home environment to determine suitability Space
Ventilation
Presence of high-risk individuals
Safety Concerns
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Fundamentals of Tuberculosis Case Management 6
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Key Components of Tuberculosis Case Management (6)
Steps in TB case management (continued)
Assess current status of the client Physical
Psychological
Financial
Social
Cultural
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Key Components of Tuberculosis Case Management (7)
Steps in TB case management (continued)
Provide education about TB and TB management
Assess for compliance with home isolation, if required
Assess for barriers to adherence and need for DOT
Initiate contact/source case investigation, if indicated
Review medications and potential adverse reactions
Present contract or agreement documents for treatment (legal orders as last resort)
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Fundamentals of Tuberculosis Case Management 7
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Key Components of Tuberculosis Case Management (8)
Steps in TB case management (continued)
Terminate case management
Prepare the patient and nurse/community health outreach worker (CHOW)
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Key Components of Tuberculosis Case Management (9)
Steps in TB case management (continued)
Review and discuss any problems or concerns Is more clinical information needed?
Is the patient infectious? Is isolation needed?
Are there any other medical/social problems that need to be addressed?
Is the treatment regimen appropriate based on ATS/CDC Guidelines?
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Fundamentals of Tuberculosis Case Management 8
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Disease Society of America Clinical Practice Guidelines: Treatment of
Drug-Susceptible Tuberculosis
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Recognizing and ManagingAdverse Events
Important to be familiar with potential adverse events related to the drug regimen
Consider a standardized protocol for the management of adverse events – know when to consult a physician
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Fundamentals of Tuberculosis Case Management 9
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
An enabler is anything that helps the patient to more readily complete therapy
Strategies to Promote Adherence: Enablers
Examples of Enablers
Transportation assistance
Bus pass
Cab fare
Gasoline
Obtaining and transporting specimens
Assisting the patient with paperwork for general relief to obtain food/housing
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An incentive is used to encourage and reward adherence
Strategies to Promote Adherence (2) Incentives
Examples of Incentives
Food vouchers
End-of-treatment gift certificate for food, clothing, or “individual” gifts
Television set while hospitalized
Movie passes
Assistant to access drug/mental health treatment
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Fundamentals of Tuberculosis Case Management 10
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Strategies to Promote Adherence (3)
Staff who are knowledgeable, caring, and sensitive to cultural issues
Medical care that is accessible and acceptable
Directly observed therapy (DOT)
Utilization of legal interventions, which progress from least to more restrictive actions
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Directly Observed Therapy (DOT)
The direct observation of the patient ingesting anti-TB medication by a trained health worker to ensure that the patient ingests his/her prescribed medication consistently and completes the required course of therapy
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Definition
Fundamentals of Tuberculosis Case Management 11
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Directly Observed Therapy (DOT) (2)
ATS/CDC recommends that every TB patient be considered for DOT
5 out of 7 doses are observed each week for daily regimen
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Definition (continued)
DOT Strategies Maintain confidentiality
Be flexible
Assign a case manager to all patients on DOT
Ensure that there are written procedures if non-licensed staff delivers medication
Use DOT for patients managed in the private sector
Use of Video DOT and other electronic means of the monitoring patients adherence with treatment.
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Fundamentals of Tuberculosis Case Management 12
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Directly Observed Therapy
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Patient Outcome Criteria
Patient care standards
Make the initial visit within 1 working day of the receipt of a referral
Assess the patient’s home to determine suitability of the home environment
Assess and address barriers to adherence
Educate the patient about TB and its management according to ATS/CDC guidelines
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Fundamentals of Tuberculosis Case Management 13
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Patient Outcome Criteria (2)
Patient care standards
Ensure that the treatment regimen is appropriate based on ATS/CDC guidelines
Elicit and evaluate contacts within 3-7 days
Address the failure of sputum to convert within 3 months
Address the patient’s psychosocial needs
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Patient Outcome Criteria (3)
Specific indicators
Sputum conversion
Clinical and radiological response
Completion of therapy indices
Resolution of symptoms
Resolution of other health problems
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Fundamentals of Tuberculosis Case Management 14
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Co-management of TB Patients
Case management of a patient under the care of private providers
The private physician is responsible for: Reporting all suspected and confirmed TB cases to the local
health department
For hospitalized cases, submitting discharge plans for review and approval by the responsible health department (California Gotch Law)
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Co-management of TB Patients (2)
The private physician’s responsibilities (continued)
Managing other illnesses and any reported problems with medications
Providing a clinical update at least quarterly and as requested by the TB Control Program
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Fundamentals of Tuberculosis Case Management 15
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Co-management of TB Patients (3)
The local health department is responsible for:
Assigning a case manager
Conducting a risk assessment for non-adherence; providing DOT, if indicated
Maintaining ongoing surveillance
Ensuring that a contact investigation is completed, when indicated
Carrying out its mandated responsibility to protect the public health
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Co-management of TB Patients (4)
Case management under MediCal Managed Care Plan (MMCP) Option 1: provider oversight and follow-up with the private
physicians
Option 2: MMCP refers the patient to a local health department for management Memorandum of Understanding (MOU) established to define
roles and responsibilities of the local heath department and MMCP
MMCP maintains responsibility for other illnesses
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Fundamentals of Tuberculosis Case Management 16
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
Co-management of TB Patients (5)
Case management under MMCP option 2 (continued) Address legal issues:
Who is medically liable as the physician of record?
Who is responsible for monitoring for drug toxicity?
How is confidentiality handled?
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Case Manager’s Responsibility
To develop strategies and services for the individual who has TB. The goal is for the patient to complete an adequate course of treatment
To do everything possible to educate, support, influence, and encourage the patient to take the medications as prescribed through the last dose
Enlist the support of the physician, social worker, and outreach staff to solve problems which arise
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Fundamentals of Tuberculosis Case Management 17
TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center
THANK YOU!
QUESTIONS
Barbara Cole, RN, PHN, MSNDirector – Disease Control Branch
(951) [email protected]
www.rivco-diseasecontrol.org
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4065 County Circle Drive, Suite 219, Riverside, California 92503 Phone 951.358.5107 Fax 951.358.5446 TDD 951.358.5124
www.rivcoph.org
R.U.H.S. – Public Health – Disease Control Sarah S. Mack, M.P.H., Director Cameron Kaiser, M.D., M.P.H., Public Health Officer
CONFIDENTIAL (sample letter) Date Name Address City, Ca. zip Dear Ms. This is to inform you that ________________________ is suspected of having a communicable disease. This employee will be excluded from workl until it is determined by the Health Officer that s/he is free of such disease or not communicable according to Chapter 2, Section 120130 of the Health and Safety Code of the State of California which states: “The health officer may require isolation (strict or modified) or quarantine for any
case of contagious, infectious or communicable disease when such action is necessary for the protection of the public health.”
If you should have any questions, please call the Disease Control Staff at (951) 358-5107. Sincerely, Barbara Cole, RN, PHN, MSN Director, Disease Control BC: cc:
