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TB Notes 1, 2003

TB Nurse Case Management Model 2002 for Ensuring Completion of Therapy: Care Practice and Standard Terminology

In TB control, case management is the gold standard for providing quality care for patients and ensuring they complete therapy. It can be performed by a variety of health care staff, including physicians and outreach workers, but is most frequently carried out by nurses. Depending on the patient and his or her needs, case management can be fairly simple or quite complex. Typically, the methods, terms, and tools used by case managers in recording, describing, and evaluating their activities are informal and nonstandardized. As a result, case managers are unable to document their impact on patient completion of therapy (COT). Standardizing the language that describes the work performed by nurse case managers would make the efforts of nurses more visible and improve communication within nursing and with other disciplines.

As a part of a multitask project to address this lack of standardized terms and procedures for describing the efforts of nurses, a team consisting of public health nursing consultants from CDC, the National TB Controllers Association (NTCA), and the National TB Nurse Consultant Coalition (NTNCC), as well as a CDC evaluation specialist, developed the TB Nurse Case Management Model 2002. The team presented the model in October 2002 at the International Union Against Tuberculosis and Lung Disease (IUATLD) 33rd World Conference on Lung Health. This logic model describes the somewhat unique elements of the TB nurse case management decision-making and care process using standard nursing terms, so that TB nursing practice can be conceived, developed, and implemented using terms and action plans that can be supported and evaluated.

The team used as their framework the Case Management Care Model 2001, a model of TB case management that had been previously developed and presented by two members of the team based on a model of health from Johns Hopkins and which was used for a pilot evaluation of one site’s TB nurse case management program. The 2001 model identifies factors that affect the patient’s health: patient characteristics; cues to action (role models, reminders, mandates); causal factors (access to care, health knowledge, past experiences, beliefs, self efficacy); mediators (provider characteristics, system characteristics); and outcomes (completion of therapy). This model suggests categories of factors for nurses to consider.

The 2002 model is a conceptual template from which hands-on tools (e.g., patient encounter forms) will be developed. The model describes, in sections, the decision-making process that TB nurses use in selecting individual-level interventions that support adherence to treatment plans. This decision-making process includes 1) developing assessment profiles of patient needs, 2) tailoring interventions to remove identified barriers, and 3) monitoring patients’ outcome indicators with standard data elements.

To develop the 2002 model, the authors first described the elements of an assessment profile of patient needs by identifying the interacting multiple factors that may interfere with the patient’s adherence to therapy. The factors may be patient-related, such as conflicting health beliefs, alcohol or drug dependence, or mental illness. They may be provider-related, such as vague provider explanations, or failure to encourage, reassure, and support the patient in the treatment process. Factors may be related to the clinic setting or location, transportation services, the availability of child care, and the hours and availability of interpreters who speak the language. They may be related to the disease severity, which may cause physical and cognitive limitations, loss of belief in the efficacy of treatment, and loss of social services. Factors can also be associated with the TB treatment regimen, which involves a large number of drug treatments in a long, complex therapeutic regimen.1

In the next section of the model, the team showed how, through patient-tailored interventions, nurses attempt to remove these assessed barriers to treatment adherence. The interventions are most effective when used in combination rather than as single approaches, and should include convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy, and supervision and attention (i.e., enhanced DOT).2 Tailored interventions should be safe, effective, patient-centered, timely, efficient, and equitable.3 They should be respectful of and responsive to individual patient preferences, needs, and values, and ensure that patient values guide all clinical decisions.

In the final section of the 2002 model, the authors showed how the nurse monitors the case management process and its outcome via indicators concerned with patient health states, behaviors, or perceptions. The indicators yield accurate, meaningful information and enhance understanding of patient barriers and the health care quality, costs, outcomes, and opportunities. Nursing care interventions and their outcomes are the least well documented activities in the existing health care databases.4

The standard data elements used in this project are approved and recognized by the American Nurses Association and are described in the following classification guides: the Nursing Outcomes Classification (NOC),5 the Nursing Intervention Classification (NIC),6 and the Nursing Diagnosis Association (NANDA).7 The use of indicator measurement scales (described in the NOC) is a reliable and valid method of measuring the process and outcomes so that the effect of nursing interventions can be examined. A five-point Likert-type scale is used to demonstrate the variability in the patient described by the outcome. The fifth or end-point scale (very strong) reflects the most desirable condition relative to the outcome.5

To describe TB treatment needs and patient factors associated with barriers to COT, the authors used deductive methods to identify nursing diagnoses and intervention activities based on current practice as reflected in TB nursing and treatment documents (8,9). For each patient factor and treatment need, the authors, experts in the fields of TB nurse case management and in evaluation, brainstormed and identified care activities through consensus. Finally, standard terminology was applied.

This work resulted in the two-part Case Management Care Model 2002. This expansion of the 2001 model identifies standard terminology for nursing diagnoses, interventions, and outcomes associated with completion of TB treatment. Selected indicators of the success of an intervention include patient’s communication ability, TB knowledge, supporting beliefs for recommended actions, participation in health care decisions, control of disease fear, coping with social relationships and role performance, compliance behavior, engagement in treatment, access to health care, medication response, and well-being. This model helps nurses conduct ongoing evaluation of the impact of selected interventions.

Future project work will include 1) piloting the patient assessment profile and outcome indicator tool for predicting COT barriers and resource needs; 2) identifying standard terminology for selected interventions and activities to remove treatment and care barriers; 3) tracking the quality of recorded data; and 4) evaluating how the theoretical model has been implemented in a field setting.

The standardization of case management practice and terminology will help in expanding nursing knowledge, developing health information systems, determining costs for nursing services, planning for resource needs, and improving nursing education. The ultimate goal of this process of evaluating and standardizing case management practice and terminology is to improve the outcome of TB patient treatment.

-Submitted by Judy Gibson MSN, RN
Div of TB Elimination

References

1. Ickovics JR, Meisler AW. Adherence in AIDS clinical trials: A framework for clinical research and clinical care. Clinical Epidemiology 1997; 50(4), 385-91.

2. Haynes RB, McKibbon DA, Danani R. Systematic review of randomized trials of interventions to assist patients to follow prescriptions for medications. Lancet 1996; 348, 383-86.

3. Institute of Medicine. Crossing the quality chasm. A new health system for the 21st century. National Academy Press: Washington, D.C.; 2001.

4. Saba V. National committee on vital and health statistics (HCVHS): work group on computer-based patient records. Written testimony for Home Health Care Classification System (HHCC); at http://www.ncvhs.hhs.gov/990517t7.htm, accessed on 3/26/01.

5. Johnson M, Maas M, Moorhead S. Iowa Outcomes Project: Nursing Outcomes Classification (NOC), 2nd edition. St. Louis, Mo: Mosby; 2000.

6. McCloskey JC, Bulechek GM. Nursing Interventions Classification (NIC), 3rd Edition. St. Louis, Mo: Mosby; 2000.

7. NANDA. Nursing Diagnoses: Definitions and Classification, 2001-2002. Philadelphia, Pa: North American Nursing Diagnosis Association; 2002.

8. National TB Nurse Consultant Coalition (NTNCC). Tuberculosis Nursing: A Comprehensive Guide to Patient Care. Atlanta, Ga: The National Tuberculosis Controllers Association; 1977.

9. American Thoracic Society, Infectious Diseases Society of American, Centers for Disease Control and Prevention. Treatment of tuberculosis. Am J Respir Crit Care Med 2003;167: 603-662.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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