An Overview of Tuberculosis Case Management For Nurses

Definition of Case Management “A system of health care delivery designed to facilitate achievement of expected outcomes within an appropriate length of stay.” ANA, 1998 “A practice model that uses a systematic approach to identify specific patients and manage patient care to ensure optimal outcomes.” Ignatavicius and Hausman, 1995

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

Goals and Principles of Case Management - 1 Providing quality health care along a continuum Consistently coordinating care to reduce fragmented services across multi- disciplinary settings Enhancing quality of life

Goals and Principles of Case Management - 2 Achieving anticipated outcomes Utilizing resources effectively Providing cost-effective health care

Standards and Competencies In order to achieve these goals, the RN must utilize the theoretical framework and standards of practice from: science of nursing public health practice treatment of TB and TB infection in adults and children case management concepts and competencies

1 st Element Case Finding Early identification of TB case/suspect to ensure public health reporting regulations are upheld and TB control activities initiated Familiarity with facilities and organizations that provide services to persons at high risk of infection and disease Developing liaisons with these facilities is key

Activities of Case Finding-1 Communication with health care providers Development of a system to track patients who are hospitalized during outpatient TB treatment Early identification of TB cases/suspects by hospital discharge planning and networking with community providers

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

2 nd Element Assessment Gathering objective and subjective data from all possible sources Assessment and reassessment continue throughout the patient’s course of TB treatment Initial assessment should occur during the patient’s hospitalization

Initial Assessment Activities Ascertain extent of the TB illness Obtain and review previous health history Determine actual or potential infectiousness

Initial Assessment - 2 Evaluate patient’s 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

Ongoing Assessment - 1 Monitor the clinical response to treatment Determine the HIV status or the risk factors for HIV disease Review the treatment regimen

Ongoing Assessment - 2 Identify positive and negative motivational factors influencing adherence Determine patient’s unmet educational needs Review status of the contact investigation

3 rd Element Problem Identification Identification of existing or potential problems is derived from the assessment Problems may be stated as a nursing diagnosis or as a problem statement Problems/needs should be identified by the multi- disciplinary team and the patient/family/ significant others/parent or guardian when patient is a child

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

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”

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 drug regimen

Problem Identification Activities Assess existing and/or potential health problems Document using nursing diagnosis or problem statement Coordinate team meeting Monitor the nursing diagnosis or problem statement at periodic intervals

4 th 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

4 th Element Development of a Plan - 2 Plan should include intermediate and expected outcomes Plan should be flexible and able to be changed to meet new realities Once written, plan becomes an internal standard of nursing care

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

5 th 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

5 th Element Implementation - 2 Requires: educatingreferring coordinatingnegotiating monitoring documenting locatingdecision-making brokeringadvocating for patient

Implementation Activities - 1 Provide/coordinate interventions needed for patient to complete TB treatment as planned Refer patient to other health care providers, social service agencies as needed Broker and locate needed services relating to TB treatment

Implementation Activities - 2 Negotiate a plan for DOT or self-administered therapy Design and coordinate strategies to improve adherence Educate patient and caregivers about the TB disease process

Implementation Activities - 3 Advocate for the patient with team members and other service providers Conduct (or ensure) a contact investigation Provide/monitor delinquency control activities

6 th Element Variance Analysis - 1 Looks at discrepancies between anticipated and actual patient care outcomes Variances may arise from changes in the patient’s personal situation, medical condition, or health care resources

6 th 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

Variance Analysis Activities - 1 Identify variances in care plan at specified intervals: –Were intermediate and expected outcomes achieved? –If not, why not? Describe reason(s) for the variance

7 th 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

7 th Element Evaluation - 2 Is an ongoing process Important for future policy development or policy changes

7 th Element Evaluation - 3 Evaluation 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?

7 th Element Evaluation - 4 Evaluation 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?

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 tickets patient receives per visit)

Evaluation Activities - 2 Identify strengths/weaknesses in the health care system; community resources that negatively/positively affect expected outcomes Conduct cohort analysis quarterly to identify variances or common elements among the group Monitor the regulatory mechanisms to ensure that TB case reports are accurate/updated according to state standards

Evaluation Activities - 3 Review the contact investigation for completeness, accuracy, and timeliness according to state standards

8 th 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

8 th Element Documentation - 2 Vital component of nursing practice Must be consistent with internal and external standards of care “If it isn’t documented….”

Documentation Activities Document nursing care and case management activities Assessments Nursing diagnoses or problems identified Plans

Documentation Activities - 2 Document nursing care/case management activities Interventions Intermediate and expected outcomes Individual variances Evaluations

Documentation Activities - 3 Monitor patient medical records monthly to ensure that all members of the multidisciplinary team have: Documented information, interventions, and services Provided care in a timely manner

Documentation Activities - 4 Assure patient confidentiality – don’t 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 patient’s medical record to/from other providers

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