Nurse Case Management Phoenix, Arizona

February 20-22, 2008

Nurse Case Management Techniques, Treatment Adherence and DOT

Millie Blackstone, RN, MPH February 21, 2008

Nurse Case Management Techniques,Nurse Case Management Techniques, Treatment Adherence and DOTTreatment Adherence and DOT

Millie Blackstone, RN, MPH TB Nurse Coordinator

Arizona Department of Health Services February, 2008

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ObjectivesObjectives

• Describe the elements of case management

• Identify potential barriers to completing TB therapy

• Discuss the use of directly observed therapy, enablers and incentives to insure treatment adherence in TB patients

TB Nurse Core FunctionsTB Nurse Core Functions

• Assessment • Policy Development • Assurance

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AssessmentAssessment

• Community assessment to identify available resources

• Collect and interpret data on TB in the community

• Participate in TB case finding • Monitor trends • Evaluate outcomes (direct care, education,

research)

Policy DevelopmentPolicy Development

• TB skin test training for school nurses, nurses in providers offices and hospitals as needed

• Informing local government of needs for support services

• Encourage community involvement

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AssuranceAssurance

• Develop standards for DOT • Provide health promotion activities for

families/individuals • Provide physicians with current TB

treatment guidelines

ASTDN: Association of State and TerritorialASTDN: Association of State and Territorial Directors of Nursing ModelDirectors of Nursing Model

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Elements of CMElements of CM

• Case finding • Assessment • Problem identification • Development of a plan • Implementation • Variance analysis • Evaluation • Documentation

Activities of Case FindingActivities of Case Finding

• Communication with healthcare providers • Tracking patients • Reporting • Completion of contact investigation • Education

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Case Management InitialCase Management Initial AssessmentAssessment

The case manager should make an initial hospital visit within one business day of a referral or case report to assess the condition of the patient and begin the contact investigation.

Initial Assessment ActivitiesInitial Assessment Activities • Review demographic information • Determine the extent of the illness • Obtain and review the patient’s previous health history • Determine infectiousness • Evaluate knowledge and beliefs • Monitor the TB medications (also need to know other

medications patient is taking • Identify barriers • Review psychosocial status • Obtain a list of possible contacts

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Ongoing CM Assessment ActivitiesOngoing CM Assessment Activities

• Monitor clinical response to treatment • Determine HIV and other risk factors • Review treatment regime • Identify positive and negative motivational

factors • Determine unmet educational needs • Review the status of the contact investigation

(Evaluation should be done within 7 days of identification – continue if not complete)

Problem IdentificationProblem Identification

• Assessment data (lack of education) • Nursing diagnosis (knowledge deficit)

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Activities to identify problemsActivities to identify problems

• Assess existing health problems • Coordinate team meeting • Monitor the nursing diagnosis (Assessment -

Patient verbalizes little understanding of TBdisease; Nursing diagnosis - Knowledgedeficit related to lack of understanding of TBdisease) Has this problem been solved? If so,is there other issues that need to be addressed?

Develop a Treatment PlanDevelop a Treatment Plan

• When you have gathered enough information assess the patient’s needs and problems, including confirmed and suspect cases

• Develop a plan based on assessment data and problems identified

• The CM is responsible for the overall plan including documentation, monitoring the patient’s response, interventions, outcomes and initiating changes in the plan

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Treatment Plan ComponentsTreatment Plan Components

• Address and contact information • Assignment of responsibilities • Patient educator’s name and dates of

education • Method for prevention of transmission (no

isolation, home isolation, legal orders) • Planned course of therapy • Estimated date of therapy completion

Treatment Plan ComponentsTreatment Plan Components ConCon’’tt

• Review of test results from initial medical evaluation

• Medical history • Diagnosis • Monitoring activities and schedule appointments

to assess response to therapy • Baseline tests and monitoring activities and

schedule to detect potential side effects/adverse reactions

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Treatment Plan ComponentsTreatment Plan Components ConCon’’tt

• Potential drug interactions • Potential treatment adherence obstacles • Personal service needs • Referrals for social services • Means of ensuring successful completion of

treatment • Location of DOT • Approvals and signatures • Intermediate and expected outcomes

Ongoing Assessment andOngoing Assessment and MonitoringMonitoring

For ongoing assessment the followingactivities are recommended:

• Monitor the clinical response to treatment • Determine HIV status and risk factors

(refer for treatment if needed) • Review the treatment regimen • Ensure correct medications are ordered

and given at the correct time and in thecorrect dosage

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Ongoing Assessment andOngoing Assessment and MonitoringMonitoring ConCon’’tt

• Monitor the side effects of the medications and any adverse reactions

• Assess adherence to treatment program • Determine unmet educational needs (educate

regarding the TB disease process) • Advocate for the patient • Review the status of the contact investigation • Monitor bacteriologic improvement

Variance AnalysisVariance Analysis

• Looks at the difference between the anticipated and the actual patient care outcomes and the reasons for the difference to identify changes that need to be made.

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EvaluationEvaluation

• Were the TB treatment plan and control activities implemented in a timely manner?

• Were intermediate and expected outcomes achieved?

• Was the patient satisfied with the care? • Was the staff satisfied with the plan and

outcomes?

Evaluation ActivitiesEvaluation Activities

• Monitor the treatment plan monthly • Identify strengths and weaknesses • Conduct a cohort analysis at least every

month (review of cases to ensure everything has been or is being done)

• Monitor reports

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Directly ObserveDirectly Observedd TheraTherappy (DOT)/Direy (DOT)/Directlyctly Observed Preventive Therapy (DOPT)Observed Preventive Therapy (DOPT)

Candidates for DOT include: • All patients being treated for active TB

disease • Patients with multidrug-resistant TB Candidates for DOPT include: • Immunocompromised persons on LTBI • Pediatric contacts on treatment for LTBI • Household contacts on treatment for LTBI

IncentivesIncentives vsvs EnablersEnablers Incentives act as an immediate reward and patients can

choose to use them in any way and may include: • Gift certificates to a grocery store for $5.00 if the

adherence rate is 100%

Enablers help the patient adhere to the treatment plan andmay include:

• Transportation if a patient has difficulty getting to anappointment. There should be a written policy/procedureregarding what conditions the enabler is given.

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Progressive InterventionsProgressive Interventions

Progressive interventions include: • Learning possible reasons for non-

adherence • Address identified problems • Patient should be told orally and in writing

the importance of adherence (include the consequences for failing to do so, along with potential legal actions)

Progressive InterventionsProgressive Interventions ContinuedContinued

• Have a DOT agreement form and homeisolation form or voluntary formscompleted

• Next step if patient doesn’t adhere to DOTmay be a court order (Step of last resort)

• If a patient with infectious TB refusestreatment and voluntary isolationemergency detention to isolate isappropriate.

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Documentation Needed at theDocumentation Needed at the StateState

If you know it is a case • Complete and send to ADHS the RVCT form • Pay attention to the information you are filling

out on the form so it makes sense (bronchoscopy wash is not a sputum)

• Complete the Addendum Form (Supplemental Form) at the same time as the RVCT

• If the case is from a provider who diagnosed thepatient or there is an unusual case, senddocumentation to show that this is really a case.

DocumentatDocumentation Needed Continuedion Needed Continued

Once susceptibilities are known • Complete and send to the state the

Follow-up 1 Drug Susceptibilities within 10 days of finding out the drug susceptibilities

Once treatment is completed • Complete and send to the state the

Follow-up 2 Completion of Treatment within 10 days of completion of treatment

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Additional Issues RegardingAdditional Issues Regarding DocumentatDocumentationion

Additional items of concern • Write so we can read it (press hard as copies are faxed) • Review the forms for accuracy prior to sending it to the

state • Make every effort to obtain complete information (need

everything on the forms filled out) • If you update any of the forms, send it in again. • If you don’t know how to answer the blanks on the form

call the state • If it is decided the patient is no longer a case, explain the

reason and fax the information to the state so this information is in writing.

More Issues RegardingMore Issues Regarding DocumentatDocumentationion

If a case/suspect/LTBI moves to or lives in another county, state, or country then we need an Interjurisdictional TB Notification Form completed and sent to the state. If there is no address of phone number contact ADHS.

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RememberRemember

• All referrals to TB Net (for countries other than Mexico) or Cure TB (for Mexico) should be sent through the state. This way everybody knows the status of the patient.

• Please complete the TB Net or Cure TB forms (copies of each form will be provided)

Laboratory IssuesLaboratory Issues

• Any laboratory that obtains a TB test result or receives a specimen for detection of an infectious agent shall, submit a report and, if applicable, an isolate to the state laboratory.

• Encourage your laboratories to submit isolates to the state laboratory (this is required in Arizona Rules)

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Documentation if Not a CaseDocumentation if Not a Case

For all others that are not a case including contacts:

• Complete an ADHS Prevention Registry Form and make sure it is entered into STAR

• For those who don’t have STAR ensure the information is given to ADHS

Why is TreatWhy is Treatment Adherence soment Adherence so ImportImportant?ant?

• Prevention of multi-drug resistant TB • Ensure people around the patient is not

exposed to infectious TB • Ability to decrease the incidence of TB, by

perseverance and DOT (this has been proven by the Navajo Nation)

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Health Insurance Portability andHealth Insurance Portability and Accountability Act (HIPAA)Accountability Act (HIPAA)

Some HIPAA guidelines • Don’t send patient identifiers via regular e-

mail. Send by Siren or fax or a password protected file

• Only give information on patients to people who need to know

DeathsDeaths

Just a few reminders regarding deaths • Try to determine if the death is a result of

TB • Obtain a death certificate and send this to

ADHS • If you don’t have a culture or information

contact ADHS. You still need to do a contact investigation for suspects

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Contact InformationContact Information

Millie Blackstone, RN, MPH 602-364-4676

e-mail: Blacksm@azdhs.gov

Fax: 602-364-3267

Questions/CommentsQuestions/Comments

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