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7/28/2019 OverviewTB Nurse Case Management
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An Overview ofTuberculosis Case Management
For Nurses
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Definition of Case Management
A system of health care delivery designedto facilitate achievement of expected
outcomes within an appropriate length ofstay. ANA, 1998
A practice model that uses a systematic
approach to identify specific patients andmanage patient care to ensure optimaloutcomes. Ignatavicius and Hausman, 1995
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Role of the TB Nurse Case
Manager
The role of the nurse in TB includes
providing and managing care of the patient
with TB and is directed towards achieving
specific goals
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Goals and Principles of Case
Management - 1 Providing quality health care along a
continuum
Consistently coordinating care to reducefragmented services across multi-
disciplinary settings
Enhancing quality of life
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Goals and Principles of Case
Management - 2
Achieving anticipated outcomes
Utilizing resources effectively
Providing cost-effective health care
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Standards and Competencies
In order to achieve these goals, the RN mustutilize the theoretical framework and
standards of practice from:
science of nursing
public health practice
treatment of TB and TB infection in adults andchildren
case management concepts and competencies
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1st Element
Case Finding Early identification of TB case/suspect to
ensure public health reporting regulations areupheld and TB control activities initiated
Familiarity with facilities and organizations thatprovide services to persons at high risk of
infection and disease
Developing liaisons with these facilities is key
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Activities of Case Finding-1
Communication with health care providers
Development of a system to track patients who arehospitalized during outpatient TB treatment
Early identification of TB cases/suspects byhospital discharge planning and networking with
community providers
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Activities of Case Finding - 2
Ensure that a TB interview is conducted as soon as
the case is identified
Complete the contact investigation in accordance
with national, state, and local policies
Provision of education about TB infection and
diseases to health care providers
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2nd Element
Assessment Gathering objective and subjective data from all
possible sources
Assessment and reassessment continue throughout
the patients course of TB treatment
Initial assessment should occur during the
patients hospitalization
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Initial Assessment Activities
Ascertain extent of the TB illness
Obtain and review previous health history
Determine actual or potential infectiousness
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Initial Assessment - 2
Evaluate patients knowledge/beliefs about TB
Monitor the TB medication regimen Is patient taking medication?
Has anyone altered the meds?
Identify barriers or obstacles to adherence
Review psychosocial status
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Ongoing Assessment - 1
Monitor the clinical response to treatment
Determine the HIV status or the risk factors
for HIV disease
Review the treatment regimen
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Ongoing Assessment - 2
Identify positive and negative motivational
factors influencing adherence
Determine patients unmet educational
needs
Review status of the contact investigation
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3rd Element
Problem Identification Identification ofexisting or potential problems is
derived from the assessment
Problems may be stated as a nursing diagnosis oras a problem statement
Problems/needs should be identified by the multi-disciplinary team and the patient/family/significant others/parent or guardian when patientis a child
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Nursing Diagnosis
A statement of a human response to an
actual or potential health problem
Statement of nursing judgment
Conclusion based on nursing assessment
Reference to a health experience
Two-part statement that includes etiology
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Nursing Diagnosis - 2
Part One: Modifiers
Contains functional behaviors that can be
improved through nursing actions/interventions
Modifiers for the first part may be:alteration in
potential alteration of
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Nursing Diagnosis - 3
Part Two: Etiology
Identifies causes/factors the nurse works to
improve or influence
Describes factors that contribute to the
current healthcare situation.Example: Potential alteration in health
maintenance related to multiple drugregimen
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Problem Identification Activities
Assess existing and/or potential health
problems
Document using nursing diagnosis orproblem statement
Coordinate team meeting
Monitor the nursing diagnosis or problem
statement at periodic intervals
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4th Element
Development of a Plan - 1 Planning begins when sufficient information is
gathered
Based on assessment data and problems identified
by all team members, patient, family, parent/
guardian
Requires critical thinking and decision making
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4th Element
Development of a Plan - 2 Plan should include intermediate and
expected outcomes
Plan should be flexible and able to bechanged to meet new realities
Once written, plan becomes an internalstandard of nursing care
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Activities of Plan Development
Establish the plan of care ensuring that all
components are included
Monitor the plan of care and patient response
according to established time frames
Negotiate and adjust the plan of care, as needed, to
meet new realities
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5th Element
Implementation -1 Includes all interventions required to move
the TB patient along a coordinated,
sequenced health care continuum
Implementation includes all team members,
private providers/community agencies
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5th Element
Implementation - 2Requires:
educating referring
coordinating negotiating
monitoring documenting
locating decision-making
brokering advocating for patient
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Implementation Activities - 1
Provide/coordinate interventions needed forpatient to complete TB treatment as planned
Refer patient to other health care providers,social service agencies as needed
Broker and locate needed services relatingto TB treatment
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Implementation Activities - 2
Negotiate a plan for DOT or self-administeredtherapy
Design and coordinate strategies to improveadherence
Educate patient and caregivers about the TBdisease process
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Implementation Activities - 3
Advocate for the patient with team members andother service providers
Conduct (or ensure) a contact investigation
Provide/monitor delinquency control activities
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6th Element
Variance Analysis - 1 Looks at discrepancies between anticipated
and actual patient care outcomes
Variances may arise from changes in the
patients personal situation, medical
condition, or health care resources
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6th Element
Variance Analysis - 2 Variances should not be considered failures
but rather opportunities to improve
A flexible plan can be easily adapted to
accommodate variances
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Variance Analysis Activities - 1
Identify variances in care plan at specified
intervals:
Were intermediate and expected outcomesachieved?
If not, why not?
Describe reason(s) for the variance
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7th Element
Evaluation - 1 Looks at outcomes of care plan,
interventions, variances, and roles/
responsibilities of each team member
Important in measuring intermediate and
expected goals
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7th Element
Evaluation - 2 Is an ongoing process
Important for future policy development or
policy changes
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7th Element
Evaluation - 3Evaluation answers the following questions:
Were the TB treatment plan and control
activities implemented in a timely manner?
Were intermediate and expected outcomes
delineated and achieved?
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7th Element
Evaluation - 4Evaluation answers the following questions:
Was the patient satisfied with the services and
care during his/her TB treatment?
Were the nurse case manager and team
members satisfied with the plan and outcomes?
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Evaluation Activities - 1
Monitor multidisciplinary care plan
monthly or more frequently; depends on
complexity of treatment, patient variables
Develop a problem ID list tracking
logistical issues (e.g. number of bus ticketspatient receives per visit)
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Evaluation Activities - 2
Identify strengths/weaknesses in the health caresystem; community resources thatnegatively/positively affect expected outcomes
Conduct cohort analysis quarterly to identifyvariances or common elements among the group
Monitor the regulatory mechanisms to ensure thatTB case reports are accurate/updated according tostate standards
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Evaluation Activities - 3
Review the contact investigation for
completeness, accuracy, and timeliness
according to state standards
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8th Element
Documentation Chronicles patient care outcomes
Used to facilitate positive changes for
patient and team members
Is an integral part of all elements of the case
management process
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8th Element
Documentation - 2 Vital component of nursing practice
Must be consistent with internal and
external standards of care
If it isnt documented.
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Documentation Activities
Document nursing care and case managementactivities
Assessments
Nursing diagnoses or problems identified
Plans
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Documentation Activities - 2
Document nursing care/case managementactivities
Interventions
Intermediate and expected outcomes
Individual variances
Evaluations
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Documentation Activities - 3
Monitor patient medical records monthly toensure that all members of the
multidisciplinary team have:
Documented information, interventions, andservices
Provided care in a timely manner
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Documentation Activities - 4
Assure patient confidentialitydont forget
HIPAA guidelines:
Inform patient that medical record and information is
kept confidential within healthcare setting
Obtain written consent to obtain/provide any part of
patients medical record to/from other providers
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Documentation Activities - 5
Protect patient records:
Ensure that medical records are not easily
accessible to others during the day
Lock medical records in a file cabinet at the
end of the day