TB Case Management

1. TB Case Management Magic Happens

2. TB Case Management – Defining the Magic • Series of 4 videoconferences • Initial steps - Today • Monitoring and ongoing activities – 2/26/09 • Contact investigation – 3/31/09 • Additional resources and activities – 4/29/09 • February 26th, March 31st and April 29th will be joint polycoms with Kentucky From the Atlantic to the Mississippi !

3. X-ray Targeted testing/ LTBI treatment Inpatient care Clinical Services Pharmacy Medical evaluation and follow-up Non-TB medical services Social services Laboratory Interpreter/ translator services HIV testing and counseling Patient education Data collection Coordination of medical care Epidemiology and Surveillance DOT Home evaluation Contact investigation Case Management Outbreak Investigation Data analysis Housing Program evaluation & planning Follow-up/treatment of contacts Isolation, detention QA, QI for case management Consultation on difficult cases Data for national surveillance report Training Federal TB Control Program State TB Control Program Guidelines Information for public State statutes, regulations, policies, guidelines Funding National surveillance Training Technical assistance Funding Elements of a Tuberculosis Control Program

4. Definition • Primary responsibility for coordination of patient care to ensure that the patient’s medical and psychosocial needs are met through appropriate utilization of resources

5. Responsible and accountable to ensure: • The case • Completes a course of therapy • Is educated about TB and its treatment • Has documented culture conversion • Has a contact investigation completed, if appropriate

6. Primary goals of case management • Render the patient non-infectious by ensuring treatment • Prevent TB transmission and development of disease • Identify and remove barriers to adherence • Identify and address other urgent health needs

7. I got a new case!!! What do I do now?

8. TB Control Priorities • Deal with the case • Diagnosis • Isolation • Treatment • Deal with the contacts • Identification • Evaluation • Treatment • Targeted Testing and treatment

9. Initial steps to the reported TB case or suspect • Receive the case report • Gather as much info as possible from report source • Intake Form • Demographics • Patient weight • Diagnostic work-up to date • REQUEST COPIES OF EVERYTHING!!!! • Current treatment, if any • Risk factors • Other important facts • Family/living situation • Work place/school

10. Initial steps to the reported TB case or suspect • Case manager assigned • Virginia Standard – each identified case/suspect is assigned to a nurse case manager for follow-up, preferably within 1 day of report • Report to VDH TB Control • Timothy Epps – 804-840-5057 • William White – 804-840-5079 • Central Office – 804-864-7906

11. Initial steps to the reported TB case or suspect • Virginia Standard – all new cases/suspects contacted within 3 days of initial report • Consult with medical provider to gather additional information and treatment plan, if needed • Conduct initial interview with patient • Recommend first visit in hospital, if hospitalized • Recommend home visit early in initial follow-up period • Assess home environment • Space, ventilation, presence of high-risk persons

12. Initial steps to the reported TB case or suspect • Additional forms • General and TB Health History • Medication profile • TB Treatment/Discharge Plan (2005A-TB-004) • Required for all institutionalized patients • Requires Health Director or designee signature • Health Director may require for outpatients • Tuberculosis Service Plan • Your guide to what you need to do

13. Initial steps to the reported TB case or suspect • Assess completeness of diagnostic work-up • CXR, TST, sputum, histology, HIV, blood work, other • Obtain copies of all relevant test results for HD chart • Obtain additional hospital records, if applicable • Discharge summary • MARs • Double check susceptibility order immediately • Arrange for additional testing/medical care as needed • TST, CXR, sputum, HIV, baseline biochemistry tests • Baseline vision, color vision, hearing, etc.

14. Initial steps to the reported TB case or suspect • Assessment of the treatment plan • Re-calculate dosages • Enough meds? • Right meds? • Assess for potential drug-drug/food/herbal interactions • Health director involvement/legal action

15. Initial steps to the reported TB case or suspect • Assessment of infectiousness • Sputum reports/collection • Determination of period of infectiousness • Isolation instructions and agreement • Isolation Form

16. Initial steps to the reported TB case or suspect • If infectious, begin additional information gathering and interview for contact investigation • Identify and screen/test high priority contacts • Household and other close contacts • Small children • Immune compromised contacts

17. Initial steps to the reported TB case or suspect • Initial patient education • Disease vs. Infection • Transmission, signs & symptoms, treatment and importance of completion, diagnostic procedures, monitoring and follow-up, meaning of test results. • Role of patient in treatment plan, role of case manager, role of health department • Treatment plan – Direct Observed Therapy (DOT Agreement form) • Handling side effects, change in symptoms • Disease of public health significance • Consequences for failure to follow treatment plan

18. Initial steps to the reported TB case or suspect • Assess for barriers to care • Lack of knowledge • Cultural • Linguistic • Substance abuse • Homelessness • Payer source for care • Arrange for resources and make referrals to assist and overcome barriers

19. Assistance with nursing case management • Jane Moore – 804-864-7920 804-382-3351 • Brenda Mayes – 804-864-7968 804-356-3998 • Assistance with medical management • Margaret Tipple, MD – 804-864-7916