overviewtb nurse case management

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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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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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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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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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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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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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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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

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