SUCCEEDING IN PATIENT ADHERENCE TO THERAPY

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1 CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE SUCCEEDING IN PATIENT ADHERENCE TO THERAPY OBJECTIVES Upon completion of this session, participants will be able to: 1. List factors that influence adherence to therapy/ treatment 2. Identify interventions that can help improve treatment completion 3. Describe how to manage a DOT program INDEX OF MATERIALS 1. slide outline Presented by: Jenny Hernandez, RN, BSN PAGES 1-13 SUPPLEMENTAL READING MATERIALS 1. County of San Bernardino Department of Public Health - DOT Billing Record 2. County of San Bernardino Department of Public Health - Home Isolation Agreement, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510)

2 CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE ADDITIONAL REFERENCES Mitruka K, Winston CA, Navin TR. Predictors of failure in timely tuberculosis treatment completion, United States. Int J Tuberc Lung Dis Aug;16(8): Moonan PK, Quitugua TN, Pogoda JM et al. Does directly observed therapy (DOT) reduce drugresistant tuberculosis? BMC Public Health. 2011; 11(1):19. World Health Organization. Adherence to long-term therapies. Evidence for action. Geneva: World Health Organization, Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J. Patient Adherence to Tuberculosis Treatment: A Systematic Review of Qualitative Research. PLoS Med 2007;4(7): e238. Liu Q, Abba K, Alejandria MM, Balanag VM, Berba RP, Lansang MAD. Reminder systems and late patient tracers in the diagnosis and management of tuberculosis. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD Lutge EE, Wiysonge CS, Knight SE, Volmink J. Material incentives and enablers in the management of tuberculosis. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD M Imunya JM, Kredo T, Volmink J. Patient education and counseling for promoting adherence to treatment for tuberculosis. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD Toczek A, Cox H, ducros P, Cooke G, Ford N. Strategies for reducing treatment default in drugresistant tuberculosis: systematic review and meta-analysis. Int J Tuberc Lung Dis. 2013;17(3): , UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510)

3 Jenny Hernandez RN, BSN San Bernardino County Department of Public Health Nurse Supervisor May 28, 2015 Upon completion of this session, participants will be able to: List factors that influence adherence to therapy/treatment Identify interventions that can help improve treatment completion Describe how to manage a DOT Program 1

4 I don t have TB. You re killing me You re going to cause me to lose my kidney I m not sick anymore. Homelessness, substance abuse, mental health, and other issues Failure to complete TB treatment may lead to: Prolonged infectiousness Poor outcomes Acquired drug resistance Additional exposures Multi-disciplinary care Build a positive rapport with the patient and their family Appropriate drug regimen Adequately addressing any psychosocial barriers to treatment 2

5 All patients should receive a patientcentered approach that is based on: Patient needs Mutual respect Webster s definition (v): To take notice of, to regard with special attention; to regard as worthy of special consideration; hence, to care for How do we get there? Relationships aren t built in a day. Fostering Adherence to Treatment (2) A central element treatment adherence is taking measures. Use measures to: Assess adherence Promote adherence Address adherence issues Measures should be: Tailored to patient circumstances Mutually acceptable 3

6 Examples of measures: Assess adherence- documentation, periodic reviews, dose counts Promote adherence- incentives and enablers, directly observed therapy (DOT) Address adherence issues- policies and procedures Interventions must be tailored to the patient s particular situation and cultural needs Approaches developed in collaboration with the patient are more successful Important: Treatment support measures, not the treatment regimen itself, must be personalized to suit the unique needs of the patient Important elements of case conference: A multi-disciplinary environment to identify patient barriers to adherence Develop interventions to address barriers to treatment adherence Document barriers and interventions Meetings held weekly to evaluate the effectiveness of interventions 4

7 Health system/ HCT-factors Social/economic factors Condition-related factors Therapy-related factors Patient-related factors HCT = healthcare team WHO. Adherence to Long-term Therapies: Evidence for action. WHO Age Race Gender Poverty Illiteracy/Education level Substance abuse Unstable living conditions/homelessness Distance from treatment centers Costs related to care WHO. Adherence to Long-term Therapies: Evidence for action. WHO Factors that affect adherence: Lack of awareness and knowledge about adherence Lack of skills/resources to assess adherence and address poor adherence Lack of skills/resources to assist with patient behavioral change Poor communication between healthcare team and patients Lack of access to care WHO. Adherence to Long-term Therapies: Evidence for action. WHO

8 Factors that affect adherence: Therapy Length of treatment Dosing frequency Side effects Condition Positive view Lack of symptoms Negative view Effects of symptoms Effects on patients Functional status Associated depression WHO. Adherence to Long-term Therapies: Evidence for action. WHO Adherence: Age, gender Race/ethnicity Migration Understanding of disease and effects of treatment Cultural belief systems Altered mental status (substance abuse, mental illness, other illnesses) WHO. Adherence to Long-term Therapies: Evidence for action. WHO Social/Economic Factors and Interventions 6

9 Housing Food Transport to treatment settings Cooperation between/among services Education of the community and providers to reduce stigma Family and community support WHO. Adherence to Long-term Therapies: Evidence for action. WHO Access and continuity Coordination of care between/among settings Opportunities for patients to participate in their care 7

10 Providing information to patients in a manner they can understand Support from local patient organizations/ groups Management of disease and treatment plan in conjunction with the patient Multidisciplinary care Intensive staff supervision and training Use of directly observed treatment (DOT) WHO. Adherence to Long-term Therapies: Evidence for action. WHO Developing a patients first attitude in the clinic Staff training, motivation, and supervision Policy/procedures Reminders in advance of appointments Train staff to identify patient-specific incentives and enablers Provide information to comprehensive primary care Therapy and Condition- Related Factors and Interventions 8

11 Education on use of medications adverse effects, and treatment adherence Use of bi-weekly medication if the patient is an option Agreements (written or verbal) to return for an appointment or course of treatment Continuous monitoring and reassessment Tailor treatment support to needs of patients Patient-Related Factors and Interventions Develop a relationship of mutual trust and respect Mutual goal setting Memory aids and reminders Home visit/track down when no show Provide education to the patient and patient s family with the goal of successful completion of therapy Modified from WHO. Adherence to Long-term Therapies: Evidence for action. WHO

12 Provide medication directly observed (DOT) Use enablers Use culturally appropriate resources and supportive measures Together with the patient, develop a contract or plan that details steps to be taken if patient does not follow care plan Definition: Direct observation of therapy (DOT) involves providing the anti-tuberculosis drugs directly to the patient and watching as he/she swallows the medications. ATS/ CDC. Treatment of Tuberculosis. MMWR 2003; 52(no.RR-11) Definition (continued) ATS/CDC - DOT is the preferred core management strategy for all TB patients 5 out of 7 doses are observed each week for daily regimen Intermittent regimen every dose must be observed 10

13 When implementing any new strategy it is essential to establish a means for monitoring and evaluating the intervention Effective implementation of DOT will require: Development of protocols Education provided to the patient about DOT procedures Training of personnel A process of monitoring and supervision Agree on time and place Allow for flexibility Help patients keep appointments Maintain confidentiality Be on time and consistent Adopt and reflect a nonjudgmental attitude Consider alternate DOT options such as Video DOT 11

14 Patient s needs can t be met with traditional DOT Patient s have a functioning landline Patient s have proven to be adherent Patient s are able to correctly identify medication and dosages Patient s are able to maintain effective communication Promotes patient autonomy Treatment interruptions, treatment completion, and hospitalizations similar Costs were much lower than in-person More convenient for patient and provider Follow cases closely with staff and stay informed about difficult cases Don t let a lot of time pass before taking action (document, document, document) Employ the least restrictive measures first Notify the patient in writing of impending action (make sure you have grounds to take legal action) 12

15 Assess patient s needs Consider all factors that may influence adherence Use all resources and tools available to individualize care Include the patient in their plan of care 13

16 DIRECTLY OBSERVED THERAPY MEDICATION BILLING RECORD Medications Day Mo Tu We Th Fr Sa/Su Mo Tu We Th Fr Sa/Su ISONIAZID RIFAMPIN 300mg 100mg 300mg 150mg tabs tabs caps caps RIFAMATE (INH+RM) caps Ethambutol 400mg 100mg tabs tabs PYRAZINAMIDE 500mg PYRIDOXINE 25mg/50mg tabs tabs DOT by (initial each day) F= field DOT C= clinic DOT D=denies side effects M= missed/failed dose H= held dose S= Self Administered P=Packet/delivery X=special circumstances POSSIBLE SIDE EFFECTS: a. headache b. weakness c. fever d. nausea e. vomiting f. jaundice g. dark urine h. skin rash i. numbness j. impaired visual vision k. impaired color vision l. vertigo m. ataxia n. tinnitus o. impaired hearing p. abdominal pain (REPORT SIDE EFFECTS OR PROBLEMS TO CASE MANAGER AND RECORD IN COMMENTS SECTION USING LETTER CODE) REPORT ALL FAILED DOSES TO CASE MANAGER WITHIN ONE WORKING DAY & EXPLAIN BELOW DATE COMMENTS INITIALS SIGNATURE/TITLE Patient Name: D.O.B. Case # Address: City: Zip: Phone # Insurance type Case Manager: Route: Notes: County of San Bernardino Department of Public Health TBC 2/11

17 County of San Bernardino Department of Public Health Tuberculosis Control Program 1(800) Fax (909) TUBERCULOSIS HOME ISOLATION AGREEMENT 1. Take your medicine. The medicine will kill the TB germs. If you don t take the medicine or don t take it correctly, you will stay longer in isolation and it will take you longer to return to your normal activities. 2. Stay home. Do not leave the house unless you are coming to your TB appointments or medical appointments that your TB case manager knows about. If you have other appointments you are concerned about, talk to your TB case manager. The case manager may be able to help you make other arrangements. If you will be unable to work for more than a month, your case manager may help you apply for disability. 3. Do not have visitors while you are infectious. When you are infectious, you breathe the TB germ out into the air around you. Others may catch TB even if you are wearing a mask, because the air in your home has TB germs in it. This is especially important for young children and those with serious medical conditions as the TB germ is more harmful to them. 4. Wear the mask your TB case manager gave you when you come to your TB appointments. Please be sure to put the mask on so that it covers your nose and mouth and fits close to your face. If the mask is not on properly, it will not protect other people from becoming infected. 5. Cover your mouth and your nose when you cough and sneeze, even when you have your mask on. This helps keep the bacteria from escaping into the air and is one of the best ways to keep the TB germs from spreading. 6. Go outside or away from others when you are coughing up your sputum specimen. Many germs are put into the air when you do this. If you must do this, go outside or go to a place in the house where there is the freshest air and open the windows. 7. Employees of the Department of Public Health, law enforcement and emergency medical personnel are permitted to enter the place of isolation. 8. Special instructions: ACKNOWLEDGEMENT OF UNDERSTANDING OF HOME ISOLATION FOR TB I have read this document and have had its contents explained to me. I have had an opportunity to have my questions answered. I have received a copy of this document. Name of person being isolated: Name of person being isolated: Witnessed/Translated by: Witnessed/Translated by: (Signature) (Print) (Signature) (Print) Date: Date: Rev. 8-09

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