TUBERCULOSIS CASE MANAGEMENT AND CONTACT … · FUNDAMENTALS OF TB CASE MANAGEMENT ... Core curriculum on tuberculosis: what the clinician should know, fourth edition, 2000:1-139

TUBERCULOSIS CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE

MARCH 19-22, 2019

FUNDAMENTALS OF TB CASE

MANAGEMENT

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 PAGES

1. Fundamentals of TB case management – slide outline Presented by: Ann Scarpita RN, BSN, MPH

17

SUPPLEMENTAL MATERIAL

1. Tuberculosis (TB) Treatment Contract (sample template)

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

Fundamentals of TB Case ManagementAnn Scarpita, RN, BSN, MPHColorado Department of Public Health and Environment

TB Case Management and Contact Investigation IntensiveMarch 19-22, 2019 1

Fundamentals of Tuberculosis

Case ManagementMarch 19, 2019

Ann Scarpita RN, BSN, MPHTB Nurse Consultant, Colorado

ObjectivesUpon 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 adherence

2



OverviewDefinition of Case Management

“Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes.”

~Case Management Society of America

3

Overview (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



Overview (3)Assignment of a trained professional to be primarily responsible and accountable to ensure that the patient:

• Completes an appropriate course of therapy

• Is educated about (and understands) 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 in a language 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



Key Components of TB Case Management (2)

Steps in TB case management

• Receive the case report: review and decide on urgency (prioritizing patient and public safety)

• Is the patient safe?

• Is the public safe?

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 and those of the local health department

• Educate the provider about TB control program services and oversight responsibility

8



Key Components of Tuberculosis Case Management

(4)

Steps in TB case management (continued)

• Make initial contact with patient by home visit (or in hospital) within one working day of report (recommended)

• Establish rapport

• Explain role of public health nurses/outreach staff

9


(5)Steps in TB case management

(continued)• Assess the home environment to

determine suitability

• Space

• Ventilation

• Presence of high-risk individuals

• Safety Concerns

10





(continued)

• Assess current status of the client• Physical * (assessment and weight)

• Psychological

• Financial

• Social

• Cultural

11

12




(7)Steps in TB case management (continued)

• Provide education about TB and TB management (using interpreter if appropriate)

• Assess for compliance with home isolation

• Assess for barriers to adherence and need for DOT

• Review medications and potential adverse reactions

13



(continued)

• Present contract or agreement documents for treatment (legal agreements in their language or interpreter as needed)

• Prepare the patient and nurse/community health outreach worker

• Initiate contact/source case investigation

14




(9)Steps in TB case management (continued)

• 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?

15

Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Disease Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible

Tuberculosis

16



Recognizing and ManagingAdverse Events

• Important to be familiar with potential adverse events related to the drug regimen

• Consider a standardized protocol for the management of adverse events

• Recognize when to consult a physician and document appropriately

17

Strategies to Promote Adherence: Enablers

An enabler is anything that helps the patient to more readily complete therapy

18

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



Strategies to Promote Adherence (2) Incentives

An incentive is used to encourage and reward adherence

19

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

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

20



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

21

Definition

Directly Observed Therapy (DOT) (2)

• ATS/CDC recommends that every TB patient is

considered for DOT

• DOT is the standard of care and is mandatory

for every person with active pulmonary TB (CO)

• 5/7 days are considered a full week for “daily”

regimen

• Daily is preferred as “more is better”

22

Definition (continued)



DOT Strategies• Maintain confidentiality

• Be flexible-meet the patient where they are

• Assign a case manager to each patient with TB

• Ensure that there are written procedures and adequate training if non-licensed staff delivers medication

• Partner with the private sector for DOT

• Use of Video DOT and other electronic means of the monitoring patients adherence with treatment.

23

Directly Observed Therapy

24



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 disease

• Educate patient about TB case management

25

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

• Monitor treatment response by collecting sputa every other week until culture negative x 2 (may vary per jurisdiction)

• Continue minimum of monthly assessments, including weight

• Address the patient’s psychosocial needs

26



Patient Outcome Criteria (3)

Specific indicators

• Sputum conversion (culture negative x 2)

• Clinical and radiological response

• Completion of therapy

• Resolution of symptoms

• Resolution of other health problems

27

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 within 24 hours

− For hospitalized cases, submitting discharge plans for review and approval by the responsible health department (California Gotch Law) (proposed in CO)

28



Co-management of TB Patients (2)

The private physician’s responsibilities (continued)

• Managing other illnesses and any reported problems with medications

• Providing a clinical updates at minimum of quarterly and as requested by the TB Control Program

• Writing scripts

29

Co-management of TB Patients (3)

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 fully and completely, when indicated

• Carrying out its mandated responsibility to protect the public health

30



Case Manager’s Responsibility

• To develop 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

31

Conclusion

32



QUESTIONS

Ann Scarpita, RN, BSN MPHTB Nurse Consultant

Colorado Department of Public Health and Environment Disease Control Branch

(303)[email protected]

https://www.colorado.gov/pacific/cdphe/tb

33

mailto:[email protected]

https://www.colorado.gov/pacific/cdphe/tb

1

Tuberculosis (TB) Treatment Contract

It has come to our attention based on current health records that you have active pulmonary tuberculosis,

which is a serious disease requiring medical treatment to keep it from spreading to other people. It is

important you read all the information contained in this contract and recognize the state of Colorado,

under the law CRS 25-4-501, requires you to

1. Keep all appointments with doctors and clinics as instructed;

2. Follow all medical instructions from clinic staff and/or your physician regarding treatment for

your tuberculosis;

3. Arrive on time when you have appointments for directly observed therapy at the Public Health

Department Clinic; with clinic outreach staff; or at another clinic that is approved under this

contract;

4. Not return to work or school until authorized by your public health agency;

5. Not allow anyone other than those living with you or health department staff into your home

until you receive permission from your public health agency;

6. Not leave your home except as authorized by your public health agency;

7. Follow any special orders on the backside of this contract.

You must understand, initial and follow the instructions on the back of this contract.

This contract shall be in effect until you no longer need treatment for tuberculosis.

If you fail to do what is required under this contract, you will receive spoken and/or written warnings

requesting that you receive your medical treatment. If you fail to follow this contract, you may receive a

written order to remain in isolation according to Colorado state law CRS 25-4-507 (see attachment A).

Failure to do what this written order requires you to do will result in a court order under Colorado laws

CRS 25-1-112 and 512, which you must obey or you will be charged with a misdemeanor criminal

offense under law CRS 25-1-114(4). The purpose of this contract is to protect the public health.

Name ___________________________________________________ Date _____/_____/_____

Street Address ________________________________ City _________________ Zip __________

Home Phone (____) ____-______Work Phone (____)____-______ Cell Phone (____) ____ -______

2

Tuberculosis (TB) Treatment Contract

Client's Name _____________________________________________ Date ______________________

Physician's Name__________________________________________

Please initial below where indicated.

1. I will keep all appointments given to me by clinical staff. I am aware the duration of treatment for

tuberculosis is typically for six or more months. I understand that ongoing appointments will be

necessary for the duration of treatment to ensure my treatment is working. ___________ (initial)

2. I will follow my tuberculosis treatment plan. This means I will (1) take all medications for the

treatment of tuberculosis as prescribed by my doctor or other clinic staff, (2) provide sputum,

urine or blood specimens as requested, (3) receive chest X-ray tests as requested, (4) report

changes in my health, (5) report any changes in my contact information, and (6) provide

information about the people with whom I spend a lot of time. ___________ (initial)

3. I will arrive as scheduled to the Public Health Department Clinic or another clinic that is approved

under this contract for directly observed therapy to make sure that I take all the medication needed

to cure my tuberculosis. Taking directly observed therapy means that a health care worker will

meet me at a scheduled time and place and give me the medication ordered by the doctor.

Participating in directly observed therapy will give me the best chance to cure my tuberculosis.

Alternate location for directly observed therapy / . (location) (initial)

4. I will not return to work or school until I have permission from my public health agency.

_________

(initial)

5. I will not allow anyone other than health department staff or those already living with me into my

home until authorized. ___________ (initial)

6. I will not leave my home until I have permission from my public health agency. ___________ (initial)

Because I could spread tuberculosis to others, I will remain in my home or in a place where I will

not expose others to the tuberculosis germs. When I take my tuberculosis medications, I will

decrease the chance of spreading tuberculosis to others. My public health agency will decide when

it is safe for me to return to school and/or work at my follow-up appointments.

___________/_____________________ (initial) (date)

I may attend school and/or go to work. ___________/_____________________ (initial) (date)

7. Special orders___________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

3

I hereby acknowledge that I received a copy of this contract and understand the requirements in it.

Signed _________________________________________________ Date _______________________ (Signature)

Witness ________________________________________________ Date _______________________

If interpreter was used:

Interpreter Name/ID number: _________________________________

Agency:_____________________________________________________

Documents

TUBERCULOSIS CASE MANAGEMENT AND CONTACT … · FUNDAMENTALS OF TB CASE MANAGEMENT ... Core curriculum on tuberculosis: what the clinician should know, fourth edition, 2000:1-139