Enhanced Case Management - Central Manchester University

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Enhanced Case Management
for TB patients
Jenny Walker
TB Specialist Nurse
Liverpool Community Health
Standard Case Management
(SCM)
 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)
What is Enhanced Case
Management (ECM)?
 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)
So why bother with a complexity
score for ECM?
 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
Why use ECM scoring?
 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
Has ECM Complexity Scoring
Guidelines Helped
 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%
Year 1 11/12
40%
Year 2 12/13
30%
20%
10%
0%
Greater
Manchester
CWW
Merseyside
Lancashire
Cumbria
North West
How Did ECM Complexity Scoring
Happen?
 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
Examples of complexity levels
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
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











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
Sections of ECM Level 1
 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)
 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
Sections of ECM Level 2
 Weekly visits
 Clinical issues – complex side effects / regular LFT’s etc. /
HIV & TB co-infection 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
Sections of ECM Level 3
 DOT
 Clinical issues – Multiple drug resistance /
reintroduction of medications / multiple co-morbidity
 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.
Percentage of ECM cases
categorised as level 1, 2 and 3
60%
50%
40%
30%
20%
10%
0%
Greater
Manchester
CWW
Merseyside
ECM 1
Greater Manchester
Cheshire Warrington Wirral
Merseyside
Lancashire
Cumbria
North West
Lancashire
ECM 2
ECM 1
55%
36%
37%
25%
33%
45%
Cumbria
North West
ECM 3
ECM 2
31%
27%
21%
37%
42%
32%
Table 13: Percentage of cases categorised as levels 1-3 by Area Team
ECM 3
14%
36%
42%
37%
25%
23%
Comparative review of another
area
 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)
Cohort Review Data Collection Form
Case Scenario
 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
 After scoring he triggered a 3
Case Scenario
 SK – 52 year old Smear + PTB, alcohol
abuse (not disclosed) Polish immigrant.
Extensive transmission amongst family (2
active & 3 latent), difficult to contact, nonEnglish 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.
Case Scenario
 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’
Reference
 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
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