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

1 st 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

2 nd 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

3 rd 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

4 th 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

4 th 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

5 th 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

5 th 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

6 th 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

6 th 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

7 th 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

7 th Element
Evaluation - 2
• Is an ongoing process
• Important for future policy development or policy changes

7 th 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?

7 th 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

8 th 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

8 th 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