Jenny Walker
TB Specialist Nurse
Liverpool Community Health

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The RCN define standard case management as care which is: “co-ordinated by a named case manager and is appropriate for any non-clinically complex patient who is able to self-medicate and have monthly follow-up in a hospital or community setting ”

For SCM patients the recommended ratio is 1 nurse to
40 cases per annum
(RCN, 2012)


ECM applies to any case where more than the usual amount of TB Nurse time as outlined by the RCN is required for their management

Level 0 (zero) refers to SCM

ECM levels ranged from 1-3 depending on their complexity

For ECM patients the recommended ratio is 1 nurse to
20 cases per annum
RCN (2012)


In year 1 there was anecdotal discussion at the cohort reviews around what the specialist nurses consider to be enhanced case management. 30% of all cases presented required ECM

Understanding the complexity of TB cases is fundamental to assessing the manpower needed to provide effective care

To assist the specialist nurses to effectively categorise their patients a series of levels have been agreed with guidance provided for each level. All cases required scoring including post-mortem cases


Other specialities use complexity scoring systems but the majority of these focus on physical and psychological aspects of patient care
(Brady et al, 2012).
 TB patient’s often have complex problems that extend far beyond the physical and social issues that other illness and diseases affect .

Access to property / language barriers / stigma / contact tracing are issues that can dramatically effect TB care


After reviewing the effectiveness of ECM complexity scoring the percentage of cases requiring ECM has doubled overall in the NW in year 2 from 30% to 61%

The overall increase is that TB specialist nurses had previously been underestimating the workload of the lower level ECM cases and had not categorised them as ECM

Percentage of cases requiring ECM levels comparing
2011/12 and 2012/13
80%
70%
60%
50%
40%
30%
20%
10%
0%
Greater
Manchester
CWW Merseyside Lancashire Cumbria North West
Year 1 11/12
Year 2 12/13


A systematic review of a current case load that was ongoing was undertaken.

The areas that the patients lived in consisted of low and moderate incidences of TB cases

Key areas that caused concern for patients and / or extended workload for TB teams these included
– Social
– Physical
– Access issues
– Stigma
– Contact tracing

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Level 1
Fortnightly visits
Interpreter for first visit but some English
Elderly - monitor side effects
Children - concordance of child and parent
/ adult
Requires medications from GP / community pharmacy due to blister packs to check correct doses
Requires signposting for benefits / financial issues
Contact tracing from various areas / setting i.e. patient out of area, workplace, community group settings
Difficult access. Eg no front door bell, >1 address, problems getting time off work/college, those who refuse home visits etc.
Stigma that can be dealt with through 1:1 education
Complex meds / co-infection meds i.e. TB meds given when on ARV’s already
Disease site eg smear positive pulmonary or central nervous system disease
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Level 2
Weekly visits
Having complex side effects so requires regular LFT etc.
Needs more regular prompting with medications – blister packs / Isoscreen regularly / tablet counts
Financial difficulties prevent treatment compliance i.e. attending clinic apt / poor nutrition / heating
Stigma that requires more formal education i.e. community centres / work places
Transmission within contacts / children who are contacts
Language barriers throughout treatment requiring easily accessible interpreter either face to face or phone interpretation at each visit
Alcohol and/or drug dependency without LFT derangement
Difficult to reach – DNA at clinics / home for reviews
HIV and TB co-infection starting both ARV and
TB meds at the same time
Single drug resistance
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Level 3
Difficult language to access throughout treatment
DOT
Homelessness or housing issues due to finance
Illegal immigrants – difficult to access funding / benefits
Drug resistance
More than one drug resistance
Needs reintroduction of medications i.e. deranged LFT’s
Complex contact tracing – transmission within children / vulnerable groups / extensive transmission
Involvement of PHE for workplace / community screening
Potentially dangerous patients where more than one person is required to visit
Children who DNA and social service involvement is required


Fortnightly visits

Clinical issues - Complex medication / HIV co-infection already on ARV’s / blister packs / child on treatment / elderly pt’s / disease site (smear +ve PTB / CNS)
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Social issues – difficult access / no doorbell / requires signposting to benefits

TB Specific – contact tracing, out of area / education to workplace etc. / Stigma dealt with on 1:1


Weekly visits

Clinical issues – complex side effects / regular LFT’s etc. /
HIV & TB coinfection starting ARV’s at same time / requires extensive prompting (blister packs / tablet counts) / single drug resistance

Social issues – financial difficulties leading to poor nutrition / language barriers requiring interpreter for initial visits & diagnosis / alcohol &/or drug dependency which is manageable / difficult to reach (no phone) / DNA at clinics & visits

TB Specific
– contact tracing with transmission / child contacts / education to workplace etc. / Stigma requiring formal education i.e. community centres

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DOT
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Clinical issues – Multiple drug resistance / reintroduction of medications / multiple co-morbidity
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Social issues – language barriers throughout treatment / homelessness / illegal immigrant / no access to benefits or funding / dangerous pt’s requiring risk assessments and extra resources

TB Specific – contact tracing (transmission within children, children who DNA, vulnerable groups, extensive transmission) / involvement of PHE for workplace screening etc.

60%
50%
40%
30%
20%
10%
0%
Greater
Manchester
Greater Manchester
Cheshire Warrington Wirral
Merseyside
Lancashire
Cumbria
North West
CWW Merseyside
ECM 1
Lancashire
ECM 2 ECM 3
Cumbria
ECM 1
55%
36%
37%
25%
33%
45%
ECM 2
31%
27%
21%
37%
42%
32%
North West
Table 13: Percentage of cases categorised as levels 1-3 by Area Team
ECM 3
14%
36%
42%
37%
25%
23%


North Central London (NCL) began using cohort review in
2010

Approx. 500 cases (pre cohort review) & 750 cases (during cohort review) were notified in NCL
– 38% required DOT(pre cohort)
– 57% required DOT (during cohort review)

1515 cases notified during first 2 years of cohort review
– 30% of North West patients needed ECM prior to complexity scoring
– 61% required ECM after complexity scoring introduced
(Anderson et al 2013)


GB – 46 year old, Smear +++ PTB, paranoid schizophrenic, housing issues, no social support, drug and alcohol dependent, defaulted on treatment after discharge as unable to contact him / did not turn up for
OPA

Prior to scoring for ECM he triggered for
ECM
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After scoring he triggered a 3

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SK – 52 year old Smear + PTB, alcohol abuse (not disclosed) Polish immigrant.
Extensive transmission amongst family (2 active & 3 latent), difficult to contact, non-
English speaking.

Relatively easy to manage clinically so would not need ECM if contact tracing / access to property / language barrier where not taken into consideration

With the use of ECM he scored 3.

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JD – 64 year old, referred on post mortem, patient had extended social life! Wife and mistress!

Due to post mortem referral would not need
ECM as no clinical issues

Scored a 2 as there was complex communication issues with social services / investigation work related to symptoms / tracing contacts / dealing with the deceased family and
‘friends’


RCN (2012) Tuberculosis case management and cohort review.
RCN: London

Anderson C, White J, Abubakar I et al (2013) Raising Standards in
UK TB Control: Introducing Cohort Review. Thorax

Brady N, Fleming K, Thiemann-Bourque K, Olswang L, Dowden P,
Saunders M and Marquis J (2012) Development of the communication complexity scale. American Journal of Speech and
Language Pathology. Vol. 21(2) pages 16-28