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TB Nurse Case ManagementLisle, Illinois

April 27 28 2010April 27-28, 2010

Principles of Case Management

Alisha Blair LVNAlisha Blair, LVN

April 27, 2010

TB Nurse Case Management

Why Are We Here?

Ali h l iAlisha Blair, LVNTB Nurse Consultant/Educator

Lisle, IllinoisApril 27th 2010

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Objectives

• Define Case ManagementDefine Case Management

• Goals of Case Management

• Discuss The Role of Public Health in Case Management

• Describe Eight Elements of Case Management Process

• Discuss Standards of Care in Regards to Tuberculosis

What Is Case Management ?

• Case Management Is – a system of healthcare in which a– a system of healthcare in which a

treatment plan for a patient is

developed by a multidisciplinary

team to achieve established

patient care outcomes.

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Nurses Are “ideal” Case Managers

• Case management and nursing process are similar and many

times interchangeable

• Patient care always takes place in a system of health care

Goals of TB Case Management

• Treat TB patient according with CDC Guidelines

• Complete treatment in appropriate time frames

• Prevent progression of TB and drug resistance

• Prevent transmission of TB by means of effective Contact Investigation (CI)Investigation (CI)

• Educate patient, family and community about TB

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Who Are The Members of The Case Management Team?

•Nurse Case Manager

•Physician

•DOT worker

•Contact investigator

O h i•Other caregivers

Primary Responsibility of Nurse Case Manager

• Partner with Case Management Team– Develop treatment plan where patient is assessed p p p– interviewed – treated

• Implement appropriate and continuous therapy

• Monitor response to treatment p

• Educate each patient about its TB and its treatment

• Ensure each contact is appropriately evaluated

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Elements of TB Nurse Case Management

Case Finding

Patient Assessment

Problem Identification

Evaluation

Documentation

Development of Plan

Implementation

Variance Analysis

Case Finding

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Element #1: Case Finding/Reporting

•Once Case/Suspect Reports are R i dReceived

•24 hours to conduct 1st

interview•Interview In Person

Obtain locating information for patient

Obtain name of the lab if other than State Lab

Assessment

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Case Management Initial Assessment

• The case manager or other trained individual should

make an initial hospital visit within one business day of

case report to assess the condition of the patient and

begin the contact investigation.

– Hospital

– Patient’s Home

– Other Location Patient Specifies

• Minimum of Two Interviews– 1-2 weeks after Initial

Element # 2: Assessment

•Interview patient

•Obtain demographics

• Review Psychosocial

•Review past medical history

Cultural and language background

Social behaviors

• Evaluate pt’s knowledge of TB

Identify barriers to adherence

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Element # 2: AssessmentMedical Evaluation

• Use baseline tests for initial evaluation:

• Conduct Medical Assessment

• Establish priorities for• Establish priorities for contact investigation

Additional Assessment and Data Gathering

• Assess completeness of diagnostic work-upCXR TST sputum histology HIV blood work other– CXR, TST, sputum, histology, HIV, blood work, other

• Insure three SPUTUM specimens are collected

– Obtain copies of all relevant test results

• Arrange for additional testing/medical care as needed– Baseline vision, color vision, hearing, etc.

• Obtain additional hospital records, if applicable– Discharge summary, MARS

• Check/request susceptibilities

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Psychosocial issues

• Assess for potential problems/needs that h di t i t TBmay have direct impact on TB care

– Substance abuse – referral to recovery program

– Homelessness

– HIV status – testing and referral if neededg

– Pregnancy – referral and coordination of care

– Language barriers/cultural beliefs –interpreters, education

Problem Identification

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Element # 3: Problem Identification

• Assess existing and/orAssess existing and/or potential health problems

• Coordinate team meetings to discuss pt’s assessment

• Monitor outcomes and identify new problems.

Develop a Plan

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Element # 4: Initial Plan of Care

• Establish Plan of Care

• Monitor plan and patient response

• Negotiate and adjust the plan

Implementation

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Element #5: Four Steps of Implementation

• Treatment / Monitoring• Treatment / Monitoring

• Referral

• DOT Administration Evaluation

• Patient /Family Education

Elements of CM Process:Ongoing Assessment Activities

• Monitor the clinical response to treatment

• Review the treatment regimen

• Identify positive and negative motivational factors

influencing adherence

• Determine the unmet educational needs of the patientDetermine the unmet educational needs of the patient

• Review the status of the contact investigation

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Ongoing Assessment and Monitoring

• Monitor the clinical response to treatment

– Cough

– Night Sweats

– Hemoptysis

• 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 the correct dosage

Element #5 Implementation:Step One:Treatment/Monitoring Plan

The NCM should ensure that:

• TB treatment progressingaccording to physician’s plan

• Patient shows signs of improvement

• Patient informed about consequences of non adherence

• TB treatment provided according with standards, if pt hospitalized

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Element #5 ImplementationStep Two: Which Referrals Are Needed?

• Social services – Housing food utilities substance– Housing, food, utilities, substance

abuse counseling

• Translators

• Specialty Services relating with TB treatmentTB treatment– CT-Scan

• Other physicians for evaluation of medical problems

Element # 5 Implementation Step Three: Negotiate Plan for DOT

• Appropriate & Achievable Plan

• Time and place of DOT– Assures Adherence

St t i f dh• Strategies for adherence– Incentives

– Enablers

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Element # 5: ImplementationFinal Step: Education

• Assess pt’s knowledge & awarenessawareness– Cultural and language

appropriate

• Teaching Materials

• Ensure Patient’s family or care giver if involved in care are also educated about disease process

Red Flags

• Missed DOT Doses

• Non-adherence to isolation orders

• Non-adherence to physician orders

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Variance Analysis

Element # 6 Variance Analysis

Di b t• Discrepancy between

anticipated outcomes and

actual patient care outcomes

– Make changes if necessary

– Document changesDocument changes

• Assess cause of variance

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Ongoing Case Management“Failure to Adhere to the Treatment Plan”

• Non Adherence• Non-Adherence

– Case manager must document

• Attempts to provide care at patient’s convenience

• Interventions such as enablers/incentives to improve

adherence

• Patient education

• Referrals to social services for assistance

Evaluation

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Element # 7: Evaluation

Obtain answers to these questions :

• Was TB treatment plan implemented in a timely manner?

• Were expected outcomes achieved?– Toxicity– Treatment Completed

• Was patient satisfied with services?

• Were nurse and TB members satisfied with plan and outcome?

Ongoing Evaluation Activities

• Monitor the treatment plan monthly

• Identify strengths and weaknesses in treatment plan

• 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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Evaluating Reports

• Susceptibilities

– Advise treating physician immediately of any resistanceAdvise treating physician immediately of any resistance

• Monthly Labs

– Elevated Liver Enzymes, Low WBC

• Report to MD

• DOT Log

– Missed Doses

• Evaluate Social Issues

Ongoing Evaluation

• Case management evaluations – Periodic / routine case management meeting

• local nurse case managers provides a snap shot of cases at the time of the meeting

– Real-time problem solving avoid the Tortoise Syndrome• barriers to treatmentbarriers to treatment

• isolation adherence

• contact investigation problems.

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Documentation

Element # 8 Documentation

M it t’ di l d• Monitor pt’s medial record

• Document CM activities

• Assure patient confidentiality

“if isn’t documented, it wasn’t done”

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Completion of Therapy

E l t d i f t t t ith• Evaluate and review course of treatment with provider or TB expert physician consultant

• Appropriate regimen, number of DOT doses, uninterrupted therapy

• Bacteriology results to support culture i d tibiliticonversion, drug susceptibilities

• Chest x-rays have improved

Completion of Therapy Follow-Up Plan

• If possible, collect 3 sputa for AFB smear/cultureposs b e, co ect 3 sputa o s ea /cu tu e

• Final CXR to document response and serve as future

baseline study

• Document additional follow-up, sputum collections or

CXR frequencyCXR frequency

• Patient education and instructions

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Important Reminders• It is the responsibility of the treating physician private or

public health for the successful treatment of the TB

Patient

• It’s Important to view TB from a Holistic Standpoint

– We are treating the patient and not only the disease

• We must be Culturally Sensitivey

• State laws/local customs

• Education is Key

Challenges in TB Case Management Activities

• Time

• Staffing/resources

– Forced Furloughs

• Funding

– Forced 4 day work weeks

• Learning curve

– Lost Expertise

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Key Themes and Concepts

• We are all committed to ensuring TB exposures are

minimal

• We are all determined to ensure the patient with TB is

appropriately treated

• We are committed to ensuring contact investigations are

completed as thoroughly as possible

• We are all committed to evaluation and follow up

Public Health Responsibilities

• Completes a course of therapy

• Is educated about TB and its treatment

• Has documented culture conversion

• Has a contact investigation completed if appropriateHas a contact investigation completed, if appropriate

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Why We’re Here???

• Learn best practices from the experts

• Collaborate to get the job done when we alone don’tCollaborate to get the job done when we alone don t

have the resources

• Learn from each others’ experiences

• Combine our different experiences and knowledge to

create a better waycreate a better way……

• Keep on top of what’s new and figuring out how to apply

it to our practice