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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
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
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
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,
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;
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;
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.