Transcript Tenets of Public Health Nursing

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 multidisciplinary 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
1st 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
2nd 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
3rd 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 multidisciplinary 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
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
4th 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
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
5th Element
Implementation - 2
Requires:
educating
coordinating
monitoring
locating
brokering
referring
negotiating
documenting
decision-making
advocating 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
6th 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
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
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
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
7th Element
Evaluation - 2
• Is an ongoing process
• Important for future policy development or
policy changes
7th 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?
7th 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
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
8th 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