July 31st, 2008 Task Shifting: Yvonne Konjore, MaryAnn Vitiello, Marcia Weaver, Debbie Winters

1. July 31st, 2008 Task Shifting: Yvonne Konjore, MaryAnn Vitiello, Marcia Weaver, Debbie Winters

2. Definition: Task Shifting • "Task shifting involves the rational redistribution of tasks among health workforce teams." • "Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of available human resources for health." -WHO. Task shifting: global recommendations & guidelines, 2008. Available online at: http://www.who.int/healthsystems/TTR-TaskShifting.pdf

3. Examples: Task Shifting • Specialist to general practice doctors • Doctors to non-physician clinicians and nurses • Clinicians to community counselors

4. Definition: Non-physician clinician -Mullen F, Frehywot S. Lancet, 2007.

5. Quality of care: U.S. Compare the quality of HIV care provided by nurse practitioners (NP) and physician assistants (PA) to doctors with 3 levels of training or expertise: • Infectious disease specialist • Generalist HIV experts • Generalist non-HIV experts -Wilson IB, et. al. Ann Intern Med, 2005.

6. Quality of care: U.S. • 68 HIV care sites • Sample of 75 patient records at each site • Sample of 5 providers at each site • Link patient record to the clinician "who makes most major decisions (e.g. changing antiretroviral regimen) regarding this patient's care."

7. Quality of care measures: U.S. • Use HAART at last visit, if eligible • Viral load controlled (HAART patients) • Pneumocystis carinii prophylaxis • Screened for tuberculosis • Hepatitis C status known • Papanicolaou smear (female patients) • Influenza vaccination • Outpatient visit during 3 of 4 quarters

8. Quality of care: U.S. • No significant difference between NPs or PAs and ID specialist or generalist HIV experts for 6 out of 8 measures • NP and PA significantly more likely to do TB and cervical cancer screening • NPs and PAs had significantly higher performance than generalist non-HIV expert for 6 out of 8 measures, including eligible patients on HAART and VL controlled.

9. "Practice makes perfect" Mortality among 43,325 hospital inpatients with HIV in 2002 at 392 hospitals in 5 states in U.S. The probability of dying in a hospital decreased by 1.8% (p<0.05) for each increase in 10 HIV-positive patients treated by the physician. Volume of HIV patients treated by physician was more important in explaining mortality than volume of HIV patients treated at hospital. -Hellinger F. J Acquir Immune Defic Syndr, 2008.

10. Quality of care: Zambia Clinical care protocols at 18 clinics (2005/6): 1st line regimens prescribed by clinical officers and nurses according to standard protocols Adherence counseling by nurses and pharmacy technicians Follow-up of patients who are more than 10 days late for scheduled appointment by community volunteers (n=12,369) -Stringer JSA. et. al. JAMA, 2006.

11. Quality of care: Uganda Home-based care by trained lay providers Baseline (2001) - follow-up for 5 months (n=466) Cotrimoxazole (CTX) prophylaxis - weekly follow-up for 18 months (n=399) CTX + HAART (2003) - weekly follow-up for 2 years to resupply medicine, ask standard questions about adherence, drug toxicity, hospital admissions and mortality (n=1045) -Mermin J. et. al. Lancet, 2008.

12. Policies: PEPfAR "The Emergency Plan and its host country partners support […] broadening of policies regarding the types of health care workers that can provide HIV/AIDS services." PEPfAR Report on workforce capacity and HIV/AIDS, 2006. Available online at: http://www.state.gov/documents/organization/69651.pdf

13. WHO - 22 recommendations & guidelines • Define the roles and associated competency levels. • Adopt systematic approach to harmonized, standardized, competency-based training. • Training programs and continuing education support for health workers should be tied to certification, registration and career progression. • Supportive supervision and clinical mentoring should be regularly provided. -WHO. Task shifting: global recommendations & guidelines, 2008. Available online at: http://www.who.int/healthsystems/TTR-TaskShifting.pdf

14. Training & task shifting: Uganda Methods • Key informant interviews with managers of HIV/ART clinics • Survey of clinicians - self report on tasks, HIV training, knowledge of HIV and ART National sample (2006) • 44 health facilities (randomly selected) • 6 regional referral hospitals (RRH) • 16 district hospitals • 22 health centre IV’s • 265 clinicians Lutalo I. et. al. manuscript under review, 2008.

15. Figure 1. Average number of registered people living with HIV/AIDS and ART patients at facility

16. Allocation of tasks in HIV/ART clinics by profession

17. Figure 2: Previous training in HIV care by profession

18. Figure 3. Percentage of clinicians who assessed overall knowledge of ART as less than “good”

19. Namibia health center/clinic model Before Staff: RN/EN Counseling/offer test Elisa HIV test Post-test counseling T I M E [ No contact with patient] Patient return with advanced stage of HIV (or patient tested at advanced stage for first time)

20. Namibia health center/clinic model • Key steps in task shifting: • Reclassify some medicines • on essential medicine list • Train community counselor • in HIV testing and IMAI • Train RN/EN in diagnosis & • treatment of minor OIs, • staging, monitoring ART, • and refills • RN/EN supervise additional • staff After RN/EN or community counselor RN/EN Counseling/offer test Rapid HIV test Post-test counselling Register for chronic HIV care Initial staging Continuing care to slow progression of HIV

21. Traditional Roles of the Nurse (Task Oriented) Taking blood Paperwork, completing forms Support/ Counselling Vital Signs & Weight Administrative Duties, Attending meetings Dispensing Medication with specific orders from the MD

22. HIV/AIDS Advanced Nurse Specialist (HANS) Example of a successful task shifting program Prepare nurses to expand their role in ART scale-up efforts. Includes but not limited to: • Initial assessment for newly diagnosed patients • Management of stable patients including ART refills • Leadership role within the clinic, throughout the hospital and in the community

23. The HANS Program In Ethiopia • 6 day Didactic/Classroom training, 7 day Clinical Practicum and 5 day on-site clinical mentoring and continued education • 400 nurses have completed program. As a result of the training: • Role is more active and central in ART scale-up and expansion of services to include nutrition, safe water and Prevention for Positives messages that address wellness strategies (smoking cessation, safer sex practices) • Provide leadership, essential resources and on-site training to nursing colleagues throughout the hospital

24. The HANS Program In Ethiopia • Outcome Evaluation conducted and results available from Quality Improvement team in Seattle • Opportunities for expanded role of HANS graduates including: • On-going mentoring and on-site training • TOT • Field-Based Nurse (FBN)

25. Rationale for development of the HANS training methodology Expanding the nurses’ role in HIV disease management will free up physicians’ time to focus on critically ill, complex HIV patients. Nurses have necessary skills and solid knowledge foundation, but need mentoring and confidence building to enhance professional self-esteem and increase learning. Empowering nurses to become active members of the multidisciplinary team will improve their clinical and leadership skills. Strong physician-nurse partnership is essential as shift from doctor-focused to “nurse intensive” staffing models develop.

26. Expanded Role of the Nurse Initiation and Refill of ART for stable patients ART readiness counselling Side Effect Management, Laboratory Testing & interpretation of results Comprehensive assessment of pre-ART patients Nursing Leadership role as a active member of the Multidisciplinary Team On-going ART Adherence Assessment and Counselling

27. Clinical Mentoring Toolkit:Basics of Clinical Mentoring Curriculum Module 1 • Introduction to Mentoring and Building a Mentor/Mentee Relationship • Distinguish mentoring from supportive supervision • Starting a Mentoring Assignment Module 2 • Clinical Mentoring Skills • Clinical Teaching Theory • Teaching Moments • Systems Strengthening Module 3 • Program Orientation • Overview of medical system/structure • Reporting • Logistical Issues

28. Clinical Mentoring Toolkit:Real Life Mentoring Scenarios • Includes adult ART, PMTCT and pediatric scenarios • Offers potential solutions to challenging scenarios • Compiles of tips provided by experienced Clinical Mentors • Organized by typical problematic scenarios • Includes references such as treatment guidelines

29. Clinical Mentoring Toolkit:Real Life Mentoring Scenarios Example: Not all eligible mothers placed on cotrimoxazole prophylaxis Potential Solutions: • Post Guidelines • Create a clinical checklist • Model with mentee – assess eligible mothers Example: Mentee does not recognize acutely ill patients Potential Solutions: • Reinforce importance of quick interim history including a rapid review of systems, targeted exam • Set up a triage system

30. Next session: August 21st, 2008 Listserv: itechdistlearning@u.washington.edu Email: DLinfo@u.washington.edu

31. Next session: August 14th, 2008 HIV and Hepatitis Chia Wang, MD, MS