Jenny Walker

TB Specialist Nurse

Liverpool Community Health

Enhanced Case Management for TB patients

The RCN define standard case management as care which is: “co-ordinated by a named case manager and is appropriate for any non-clinically complex patient who is able to self-medicate and have monthly follow-up in a hospital or community setting”

For SCM patients the recommended ratio is 1 nurse to 40 cases per annum

(RCN, 2012)

Standard Case Management (SCM)

ECM applies to any case where more than the usual amount of TB Nurse time as outlined by the RCN is required for their management

Level 0 (zero) refers to SCM ECM levels ranged from 1-3 depending on their

complexity For ECM patients the recommended ratio is 1 nurse to

20 cases per annum RCN (2012)

What is Enhanced Case Management (ECM)?

In year 1 there was anecdotal discussion at the cohort reviews around what the specialist nurses consider to be enhanced case management. 30% of all cases presented required ECM

Understanding the complexity of TB cases is fundamental to assessing the manpower needed to provide effective care

To assist the specialist nurses to effectively categorise their patients a series of levels have been agreed with guidance provided for each level. All cases required scoring including post-mortem cases

So why bother with a complexity score for ECM?

Other specialities use complexity scoring systems but the majority of these focus on physical and psychological aspects of patient care (Brady et al, 2012).

TB patient’s often have complex problems that extend far beyond the physical and social issues that other illness and diseases affect .

Access to property / language barriers / stigma / contact tracing are issues that can dramatically effect TB care

Why use ECM scoring?

After reviewing the effectiveness of ECM complexity scoring the percentage of cases requiring ECM has doubled overall in the NW in year 2 from 30% to 61%

The overall increase is that TB specialist nurses had previously been underestimating the workload of the lower level ECM cases and had not categorised them as ECM

Has ECM Complexity Scoring Guidelines Helped

Percentage of cases requiring ECM levels comparing 2011/12 and 2012/13

A systematic review of a current case load that was on-going was undertaken.

The areas that the patients lived in consisted of low and moderate incidences of TB cases

Key areas that caused concern for patients and / or extended workload for TB teams these included– Social– Physical– Access issues– Stigma– Contact tracing

How Did ECM Complexity Scoring Happen?

Examples of complexity levels Level 1 Level 2 Level 3

Fortnightly visits Interpreter for first visit but some

English Elderly - monitor side effects Children - concordance of child and

parent / adult Requires medications from GP /

community pharmacy due to blister packs - to check correct doses

Requires signposting for benefits / financial issues

Contact tracing from various areas / setting i.e. patient out of area, workplace, community group settings

Difficult access. Eg no front door bell, >1 address, problems getting time off work/college, those who refuse home visits etc.

Stigma that can be dealt with through 1:1 education

Complex meds / co-infection meds i.e. TB meds given when on ARV’s already

Disease site eg smear positive pulmonary or central nervous system disease

 

Weekly visits Having complex side effects so requires

regular LFT etc. Needs more regular prompting with

medications – blister packs / Isoscreen regularly / tablet counts

Financial difficulties prevent treatment compliance i.e. attending clinic apt / poor nutrition / heating

Stigma that requires more formal education i.e. community centres / work places

Transmission within contacts / children who are contacts

Language barriers throughout treatment requiring easily accessible interpreter either face to face or phone interpretation at each visit

Alcohol and/or drug dependency without LFT derangement

Difficult to reach – DNA at clinics / home for reviews

HIV and TB co-infection starting both ARV and TB meds at the same time

Single drug resistance  

Difficult language to access throughout treatment

DOT Homelessness or housing issues due to

finance Illegal immigrants – difficult to access

funding / benefits Drug resistance More than one drug resistance Needs reintroduction of medications i.e.

deranged LFT’s Complex contact tracing – transmission

within children / vulnerable groups / extensive transmission

Involvement of PHE for workplace / community screening

Potentially dangerous patients where more than one person is required to visit

Children who DNA and social service involvement is required

 

 

Fortnightly visits Clinical issues - Complex medication / HIV co-infection

already on ARV’s / blister packs / child on treatment / elderly pt’s / disease site (smear +ve PTB / CNS)

Social issues – difficult access / no doorbell / requires signposting to benefits

TB Specific – contact tracing, out of area / education to workplace etc. / Stigma dealt with on 1:1

Sections of ECM Level 1

Weekly visits Clinical issues – complex side effects / regular LFT’s etc. /

HIV & TB co-infection starting ARV’s at same time / requires extensive prompting (blister packs / tablet counts) / single drug resistance

Social issues – financial difficulties leading to poor nutrition / language barriers requiring interpreter for initial visits & diagnosis / alcohol &/or drug dependency which is manageable / difficult to reach (no phone) / DNA at clinics & visits

TB Specific – contact tracing with transmission / child contacts / education to workplace etc. / Stigma requiring formal education i.e. community centres

Sections of ECM Level 2

DOT Clinical issues – Multiple drug resistance / reintroduction

of medications / multiple co-morbidity Social issues – language barriers throughout treatment /

homelessness / illegal immigrant / no access to benefits or funding / dangerous pt’s requiring risk assessments and extra resources

TB Specific – contact tracing (transmission within children, children who DNA, vulnerable groups, extensive transmission) / involvement of PHE for workplace screening etc.

Sections of ECM Level 3

Percentage of ECM cases categorised as level 1, 2 and 3

  ECM 1 ECM 2 ECM 3Greater Manchester 55% 31% 14%Cheshire Warrington Wirral 36% 27% 36%Merseyside 37% 21% 42%Lancashire 25% 37% 37%Cumbria 33% 42% 25%North West 45% 32% 23%

Table 13: Percentage of cases categorised as levels 1-3 by Area Team

North Central London (NCL) began using cohort review in 2010

Approx. 500 cases (pre cohort review) & 750 cases (during cohort review) were notified in NCL

– 38% required DOT(pre cohort)

– 57% required DOT (during cohort review) 1515 cases notified during first 2 years of cohort review

– 30% of North West patients needed ECM prior to complexity scoring

– 61% required ECM after complexity scoring introduced(Anderson et al 2013)

Comparative review of another area

Cohort Review Data Collection Form

GB – 46 year old, Smear +++ PTB, paranoid schizophrenic, housing issues, no social support, drug and alcohol dependent, defaulted on treatment after discharge as unable to contact him / did not turn up for OPA

Prior to scoring for ECM he triggered for ECM

After scoring he triggered a 3

Case Scenario

SK – 52 year old Smear + PTB, alcohol abuse (not disclosed) Polish immigrant. Extensive transmission amongst family (2 active & 3 latent), difficult to contact, non-English speaking.

Relatively easy to manage clinically so would not need ECM if contact tracing / access to property / language barrier where not taken into consideration

With the use of ECM he scored 3.

Case Scenario

JD – 64 year old, referred on post mortem, patient had extended social life! Wife and mistress!

Due to post mortem referral would not need ECM as no clinical issues

Scored a 2 as there was complex communication issues with social services / investigation work related to symptoms / tracing contacts / dealing with the deceased family and ‘friends’

Case Scenario

RCN (2012) Tuberculosis case management and cohort review. RCN: London

Anderson C, White J, Abubakar I et al (2013) Raising Standards in UK TB Control: Introducing Cohort Review. Thorax

Brady N, Fleming K, Thiemann-Bourque K, Olswang L, Dowden P, Saunders M and Marquis J (2012) Development of the communication complexity scale. American Journal of Speech and Language Pathology. Vol. 21(2) pages 16-28

Reference