FUNDAMENTALS OF TB CASE MANAGEMENT · Tuberculosis nursing: a comprehensive guide to patient care....

Curry International Tuberculosis Center, UCSF 2001 Center Street, Suite 700

Berkeley, CA; Office (510) 238-5100

FUNDAMENTALS OF TB CASE MANAGEMENT TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE

OCTOBER 8-11, 2019

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

Fundamentals of TB case management slide outline Presented by: Barbara Cole, RN, PHN, MSN

page 1-17

CD7 Letter page 18

CD7 Follow up page 19

Sample exclusion letter work page 20

Patient contract page 21

ADDITIONAL REFERENCES

California Department of Health Services, California Tuberculosis Controllers Association. TB Case Management: Core Components. November 2011; 1-24.

Curry International Tuberculosis Center. Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, 3rd edition. 2016. URL: http://www.currytbcenter.ucsf.edu/sites/default/files/tb_sg3_book.pdf

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.

Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, 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 Oct 1;63(7):e147-e195. doi: 10.1093/cid/ciw376. Epub 2016 Aug 10. URL: https://www.cdc.gov/tb/publications/guidelines/pdf/clin-infect-dis.-2016-nahid-cid_ciw376.pdf.

National Tuberculosis Controllers Association, National Tuberculosis Nurse Consultant Coalition. Tuberculosis nursing: a comprehensive guide to patient care. 2011; 1-160.

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.

http://www.currytbcenter.ucsf.edu/sites/default/files/tb_sg3_book.pdf

https://www.cdc.gov/tb/publications/guidelines/pdf/clin-infect-dis.-2016-nahid-cid_ciw376.pdf

TB Case Management and Contact Investigation Intensive

Oakland, CA

October 8-11, 2019 1

Barbara Cole, RN, PHN, MSN

Tuberculosis Controller, Riverside County

Barbara Cole, R.N., P.H.N., M.S.N.


Fundamentals of

Tuberculosis Case ManagementOctober 8, 2019

1

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 adherence2


Oakland, CA

October 8-11, 2019 2



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

3

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

4


Oakland, CA

October 8-11, 2019 3



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

5

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

6


Oakland, CA

October 8-11, 2019 4



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)

7

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

Educate the provider about TB control program services

and oversight responsibility

8


Oakland, CA

October 8-11, 2019 5



Key Components of

Tuberculosis Case Management (4)


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

9

Key Components of



Assess the home environment to determine

suitability

Space

Ventilation

Presence of high-risk individuals

Safety Concerns

10


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October 8-11, 2019 6



Key Components of



Assess current status of the client

Physical

Psycho/Social

Substance Abuse

Financial

11

Key Components of



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)12


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October 8-11, 2019 7



Key Components of



Terminate case management

Prepare the patient and nurse/community health

outreach worker (CHOW)

13

Key Components of



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?

Is there a concern for MDR-TB?14


Oakland, CA

October 8-11, 2019 8



Official American Thoracic Society/Centers for Disease

Control and Prevention/Infectious Disease Society of

America Clinical Practice Guidelines: Treatment of

Drug-Susceptible Tuberculosis

15

Recognizing and Managing

Adverse 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

16


Oakland, CA

October 8-11, 2019 9



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

17

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

18


Oakland, CA

October 8-11, 2019 10



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

19

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

20

Definition


Oakland, CA

October 8-11, 2019 11



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

21

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.

22


Oakland, CA

October 8-11, 2019 12



Directly Observed Therapy

23

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 guidelines24


Oakland, CA

October 8-11, 2019 13



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

25

Patient Outcome Criteria (3)

Specific indicators

Sputum conversion

Clinical and radiological response

Completion of therapy indices

Resolution of symptoms

Resolution of other health problems

26


Oakland, CA

October 8-11, 2019 14



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)

27

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

28


Oakland, CA

October 8-11, 2019 15




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 health29


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

30


Oakland, CA

October 8-11, 2019 16




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?

31

Case Manager’s Responsibility

Utilize 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

32


Oakland, CA

October 8-11, 2019 17



THANK YOU!

QUESTIONS


Director – Disease Control Branch

(951) 358-5107

[email protected]

www.rivco-diseasecontrol.org

33

Disease Control Branch

4065 County Circle Drive, Riverside, California 92503

Phone (951) 358-5107 - Fax (951) 358-5102 - TDD (951) 358-5124

www.rivcoph.org

Kim Saruwatari, MPH, Director Cameron Kaiser, MD, MPH, Public Health Officer


Phone (951) 358-5107 Tel. (951) 358-5107

Fax. (951) 358-5102

Date

Name

Address

City, State, Zip

Dear

Thank you for reporting your patient(s), _________________________, who is a tuberculosis suspect (TB5).

Early reporting facilitates the Department of Public Health’s (DOPH) efforts to prevent the spread of tuberculosis.

Tuberculosis continues to be a significant health problem in California. Locally in Riverside County, 65 new

active cases were reported in 2018, compared to 60 in 2017. It is important for the Health Department and private

physicians to work together to ensure optimum case finding, contact investigation, surveillance and follow-up.

Public Health nurses provide case management and assess all TB patients who are started on treatment for the risk

of non-adherence. It is important that patients who are assessed to be at risk, for non-adherence, to be enrolled in

the DOPH, Directly Observed Therapy (DOT) program.

The Department of Public Health is mandated to provide oversight of the management of all patients receiving

TB treatment. In order to comply with this mandate, we need periodic updates to assist us in monitoring your

patient for ongoing follow-up and completion of therapy. Prompt completion and return of the enclosed

Tuberculosis Update (CD007) would be greatly appreciated. You will receive a new request at least quarterly for

the duration of your patient’s treatment.

I have enclosed the current American Thoracic/CDC guidelines for the management of tuberculosis. Please note

that HIV testing is a CDC standard for TB patients. Information on HIV testing is attached for your reference.

It is hoped that the enclosed information will serve as a practical reference as you manage your patient’s disease.

Our physician is available upon request for consultation. Please feel free to contact me at (951) 358-5107, should

you have any questions.

Once again, thank you for your assistance in preventing the spread of tuberculosis in Riverside County.

Sincerely,


Director, Disease Control

BC:ym

Enclosure

CD-7

Letter #1 – Suspect Case

18


4065 County Circle Drive, Riverside, California 92503

Phone (951) 358-5107 - Fax (951) 358-5102 - TDD (951) 358-5124

www.rivcoph.org



Phone (951) 358-5107 Tel. (951) 358-5107

Fax. (951) 358-5102

TO: DATE: THE COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH REQUIRES THAT YOU PROVIDE THE FOLLOWING INFORMATION. THIS INFORMATION IS CONFIDENTIAL. YOUR COOPERATION IS APPRECIATED. CALIFORNIA HEALTH AND SAFETY CODE: CHAPTER 5 SECTION 3287: “THE DEPARTMENT MAY INSPECT AND HAVE ACCESS TO ALL RECORDS OF ALL INSTITUTIONS AND CLINICS, BOTH PUBLIC AND PRIVATE WHERE TUBERCULOSIS PATIENTS ARE TREATED.” PUBLIC HEALTH REPORTING IS EXEMPT FROM HIPAA. PATIENT CONSENT IS NOT REQUIRED FOR COMPLETION OF THIS FORM. The full text of the Privacy Rule is available at: https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/publichealth/publichealth.pdf PLEASE COMPLETE ALL QUESTIONS BELOW: A. Patient still under your supervision? Yes No Suspected TB Case Yes No Confirmed Active TB diagnosis? Yes No If no, presently being supervised by: ______________________________________________ Presumptive Active TB Diagnosis? Yes No Refused/Stopped Therapy Completed Therapy Moved Died Other (Specify) B. Therapy 1. Date you last evaluated patient___________________ Date treatment started_____________________ Date treatment completed__________________

2. Current therapy INH mg.____________ Rifampin mg.__________ Ethambutol mg.___________ Pyrazinamide mg.___________ Strep. mg.______________ Other______________________ 3. Drugs taken regularly? Yes No(Specify) Target/ Projected treatment completion date __________________ C. Bacteriology None Requested D. Sputum Conversion Type(s) of Specimen: 1. Date first positive specimen collected___________________ Sputum Smear Culture Pending Bronchial Washings 2. Date first negative specimen collected___________________ Other (Specify) _________________________ Smear Culture Pending 3. Date most recent specimen collected____________________ Smear-positive Negative Pending Culture-positive Negative Pending 4. Sputum specimens not done Culture Identification M. Tuberculosis (+) MTD/PCR (+) Yes No Not done E. Current X-Ray Status (Other) _________________________________ Latest X-Ray taken on ____________________________________(date) Susceptibility Testing Yes No Normal Stable Sensitive to current Rx Yes No Cavitary Worsening Resistant to: Non-Cavitary Improving *Please write any additional comments on the back of this form. ________________________________________ ____________________________________________________________________R.N./M.D. (Date) PATIENTS WITH PULMONARY TUBERCULOSIS SHOULD HAVE SPUTUM EXAMINATIONS PERIODICALLY. IT IS ESENTIAL THAT THE DEPARTMENT OF PUBLIC HEALTH BE PROVIDED WITH THIS PERIODIC INFORMATION TO EVALUATE THE CLINICAL STATUS OF PATIENTS BEING FOLLOWED FOR TUBERCULOSIS. Patient’s Name

PLEASE SEND COMPLETED FORM TO COUNTY OF RIVERSIDE Department of Public Health - TB Control

Date of Birth

P.O. Box 7600 Riverside, CA 92513-7600 or Fax: 951-358-5102

I.D. Number

19

https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/publichealth/publichealth.pdf

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 Kim Saruwatari, 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 work 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,


Director, Disease Control

BC:

cc:

20

PATIENT CONTRACT FOR THE TREATMENT OF TUBERCULOSIS

I, (PATIENT’S NAME), (DOB: 00/00/0000), agree to adhere to the following conditions of treatment

provided by the County of Riverside, Department of Public Health - TB Control.

1. I will continue treatment for the length of time recommended by the physician.

2. I will take all of my TB medications through Daily Directly Observed Therapy.

3. I will be available to meet with the Public Health worker at a predesignated date and time as

arranged by the worker.

4. I will provide sputum specimens and submit to a chest x-ray as requested.

5. I will notify the Department of Public Health should I decide to leave the area so that records

can be forwarded, with my consent, to the appropriate health care provider.

I have been informed of, and understand, the risk tuberculosis presents to my health. I have also

been informed that any person having the disease in an infectious stage is required by State Law to

observe the instructions issued by the local Health Officer. Failure to adhere to these instructions,

therefore needlessly exposing others to infection, is a misdemeanor, which is punishable by a fine

and/or imprisonment. Furthermore, I understand that the Department of Public Health may take

legal action if I do not follow the provisions of this contract.

Patient's

Signature:

Date:

Physician's Signature:

Date:

PHN's

Signature:

Date:

4065 County Circle Drive, Riverside, California 92503 Fax Nos.: (951) 358.5446 or (951) 358.7922, or (951) 358.5102, TDD (951) 358.5124



Phone (951) 358-5107 Tel. (951) 358-5107

Fax. (951) 358-5102

21

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