6) Getting patients successfully through treatment for ... · Provide patient education at each encounter ... Translated Patient Ed Materials 10. Getting Patients Successfully Through

Getting Patients Successfully Through Treatment for LTBI1

Tuberculosis in Nursing: Prevention, Treatment, and Infection ControlJune 27-28, 2018Curry International Tuberculosis Center

GETTING PATIENTS SUCCESSFULLY THROUGH TREATMENT FOR LTBI:A CASE MANAGEMENT APPROACH

Ann Raftery, RN, BSN, MSCurry International Tuberculosis Center

Objective

Upon completion of this session, participants will be able to: incorporate case management (CM) approaches

to improve LTBI treatment completion outcomes in your practice

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On average, what percentage of patients receiving treatment for LTBI complete treatment in your setting?

1. <30%

2. 30-59%

3. 60-80%

4. > 80%

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Top 4 LTBI Treatment Confounders

1. Side effects or adverse reactions

2. Not convinced

3. Competing priorities

4. Insufficient support

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Peoplecology – a new term to ponder

“Peoplecology is about interacting with people in a way they feel better about themselves.”

The study of how to build interpersonal skills to: connect with people from all walks of life

overcome and bridge social and cultural barriers

listen, hear, and respond appropriately

engender a sense of being trustworthy and genuine

My interpretation

Tom Stuebner

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Case Management - Treating LTBI

Conduct an initial assessment Provide patient education at each encounter Ensure monthly face-to-face visit with a clinician

Assess adherence Assess for side effects/adverse affects

Refer for further clinical evaluation when indicated Coordinate care including referral for other support

services as indicated Outreach between visits to encourage adherence

with clinic appointments and for follow-up

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Initial Assessment

Potential barriers to adherence are identified

Rapport established

Education initiated related to LTBI and treatment

Baseline lab tests obtained

Interventions identified

Linkage to supportive services initiated

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Patient Education

Use a variety of methods Communicated verbally

Through printed material

Other media (e.g., video)

Patient should know: what they are being treated for and the expectations

surrounding treatment (e.g., how long, what monitoring or follow-up is necessary, etc.)

what the potential side effects are and what to do should he/she experience any

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What Adults Remember

90

70

50

30

20

10

0 20 40 60 80 100

Read

Hear

See

Hear & See

Say

Say & Do

% of What Adults Remember

Moreparticipation

equalsmore

remembered

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Translated Patient Ed Materials10



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Case 1

32 year old man, migrant agricultural worker is referred to your clinic for treatment of LTBI.

Reports he was born in Mexico but has lived in the U.S. since age 13.

States he had the TB skin test after his uncle was diagnosed with TB recently and adds that he feels fine and is not sick.

Q: What information do you want to gather and/or discuss with him before starting treatment for LTBI?

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But I had BCG!

My tuberculin skin test is positive because I had BCG vaccination.

1. Agree

2. Disagree

3. Maybe yes, maybe no

4. Not sure

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Useful LTBI Resources for Providers

The On-line TST/IGRA Interpreter:http://www.tstin3d.com/index.htmlMcGill University & McGill University Health Center Montreal Quebec, Canada; Supported by the Public Health Agency of Canada and Stop TB Partnership

The BCG World Atlas:http://www.bcgatlas.org/index.phpMcGill University & McGill University Health Center Montreal Quebec, Canada; Supported in part by the Public Health Agency of Canada

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Case 1 – Month 1

Came in for medication refill

He has no complaints, no rash, itching, fatigue, nausea, vomiting or jaundice

Reports he missed a few doses…pill count shows five doses missed

Q: What information do you want to emphasize during this visit?

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Addressing Competing Priorities

Discuss the situations when doses are missed and together determine a few strategies to improve

Examples… Forgetting to take dose in the morning Take dose at bedtime

Memory aids - pill box; cell phone/watch alarm; notice on bathroom mirror

Attach pill taking to a daily routine

Likes to party on weekends Can intermittent DOPT be arranged?

Negotiate an acceptable solution

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Case 1 – Month 3

Came in two weeks late for medication refill Reports his truck broke down and had to find a

way in to the clinic Has cut back on weekend drinking Feeling tired but attributes this to long hours and

heavy labor (digging ditches and planting trees)

Q: What questions would you have as Case Manager?

Q: What further actions or interventions would you discuss?

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Establishing Supportive Measures

Follow-up calls to check in on patient’s status when needed

Know the resources and contacts available in your community

Establish a referral system that expedites access to priority support services (e.g., mental health and substance abuse services, services for homeless, etc.)

For children, be creative and have multiple suggestions handy in terms of tips for medication administration and incentives (age appropriate)

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Case Management Approaches Aimed at Quality Improvement (QI)

Appointment reminder letters, phone calls, text messages

No shows – call patient same day to reschedule Evaluate LTBI treatment outcomes periodically and

report on them Educate staff who will have a role to play in

interacting with the patient

“Before [QI] changes, our adherence rate was 27%. After making these changes, it went up to 80% compliance with the treatment plan with an actual completion rate of 67%”

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Preparing Community Clinics

Health Departments might consider:Providing comprehensive training for clinic staff on

the diagnosis, treatment and management of patients on treatment for LTBI

Providing template assessment and monitoring tools

Serving as a resource to answer questions clinic staff may have during period knowledge and experience is growing

Periodic quality assessment visits to monitor treatment outcomes and to provide supportive guidance

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Summary

When adequately applied, a case management approach to LTBI treatment can positively impact treatment outcomes

Work with both staff and individual patients to problem solve barriers to treatment completion

Routinely track and report on your treatment outcomes to monitor effectiveness of strategies that you implement

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Documents

6) Getting patients successfully through treatment for ... · Provide patient education at each encounter ... Translated Patient Ed Materials 10. Getting Patients Successfully Through