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TB Case Management Guide and Checklist with Instructions

Purpose:

The Tuberculosis (TB) Case Management Guide and Checklist (TB CM Checklist) is designed to provide detailed guidance to Local Health Department and District (LHD) staff for the management of active or suspected TB disease cases reported to their jurisdiction.

For a comprehensive review of management of TB patients living in the State of Connecticut (CT), please refer to the Standards of Care for Patients with Suspected and Confirmed Drug-Susceptible Tuberculosis in Connecticut (CT TB Standards of Care).

For additional information about the TB Control Program, please visit our website.

 

Instructions:

1.     Underlined hyperlinks in this document lead to resources appropriate to specific steps in the process outlined in the TB CM Checklist. You may access the links by double-clicking on the link or by pressing the CTRL button and clicking on the link.

 

The steps outlined in this guide will not apply to all cases of TB. TB Case Management is part of Patient Centered Care, which is defined as individualized care and management for each patient diagnosed with active TB disease (see Clinical Practice Guidelines for Treatment of Drug Susceptible TB).

 

2.     Extrapulmonary TB that is confirmed to have no pulmonary involvement still requires directly observed therapy (DOT) and an initial interview, but some steps of this document will not apply. Please contact your assigned state TB case manager for more information on the management of these patients.

 

3.     Each row in the TB CM Checklist is considered a core component of CT TB Control activities. Note: Week 8 is a critical point in the case management of TB patients.

 

4.     For any clarifications or assistance in implementing these steps, please call the TB Control Program at 860-509-7722 and ask for your jurisdiction’s assigned state TB case manager.

 

Timeline

TB Case Management Activities

Date Done

Initial Notification via TB Surveillance Report

Review information on the TB Surveillance Report Form. Contact the person who filled out form (end of page 2) for labs, imaging, medication doses, and other results not provided.

If inpatient, request name and contact information for case coordinator/discharge planner on the floor in which the patient is admitted.

 

 

If inpatient, contact case coordinator/discharge planner on the floor to discuss completing a discharge and treatment plan (see sample template: Connecticut Tuberculosis Patient Discharge and Treatment Plan).

· Explain that the purpose of the discharge plan is to ensure a collaborative effort of the inpatient provider, the patient, and the local health department to ensure a safe and smooth transition from the inpatient facility to a community setting. The discharge plan requires that signatures from the provider and patient must be obtained on the discharge plan prior to submission to the local health department. The local health department must approve the plan prior to the discharge.

· Request that prescriptions be faxed to TB Control Program (860-730-8271) to avoid delay in discharge due to medication procurement. The dosing should be consistent with the Clinical Practice Guidelines for Treatment of Drug Susceptible TB (see pp. 5-6 and 26).

· Sputa need to be collected if there is any abnormality consistent with TB on radiography or if site of disease is pleural or laryngeal TB. Sputa should also be collected with HIV positive patients who have even if CXR findings are normal.

 

If not inpatient, contact provider to ensure patient was told to quarantine and verify medications prescribed. Contact patient and reiterate quarantine until deemed not infectious. Arrange date and time for interview. Do not start medications until all drugs are available to start at the same time.

 

 

Day 1-3:

from initial notification

Interview the patient. The interview should be done in person. A phone or video interview can be performed if the patient is hospitalized. If the preferred language of the patient is a language other than the interviewer speaks, the interviewer should ensure certified medical interpretation services will be available at the interview.

 

 

 

Interview should include the following:

· Introduction and explanation of the health department in the management of the care of the patient.

· Verify demographics and insurance status (including eligibility for TB Medicaid, CADAP, etc.).

· Explain the TB Billing Program for uninsured, insured, and underinsured patients.

· Confirm symptom onset. Elicit contacts 3 months prior to patient’s symptom onset and document contact information on TB Contact Investigation Worksheet. For tips, see TB Interviewing for Contact Investigation.

· Explain DOT and electronic/video DOT (eDOT) and arrange for times/locations once patient is discharged.

· Assess how patient is tolerating the medications. A sample DOT log listing common side effects is located in Appendix 6 of the CT TB Standards of Care.

 

· Assess community setting into which the patient will be discharged to determine whether it is safe for infectious patient to be discharged. Some factors to consider for safe discharge include ensuring no young children or immunocompromised persons in the household and the patient’s willingness and ability to quarantine until deemed not infectious.

 

 

For both Inpatient and outpatient settings, release from isolation/quarantine when patient is considered not infectious is appropriate if the patient meets three (3) criteria: Fourteen (14) days of ingestion and tolerating anti-TB medications, AND three (3) consecutive negative sputum smears, AND clinical improvement. The three sputa must be collected 8 hours apart with one being an early morning specimen.

 

 

Extrapulmonary TB:

· If CXR/Chest CT normal and HIV negative, no isolation is needed.

· If CXR/Chest CT normal and HIV positive, collect 3 sputum and isolate (follow above criteria for

determining infectiousness).

· If CXR/Chest CT abnormal, collect 3 sputum and isolate (follow above criteria for determining

infectiousness).

 

 

Update state TB case manager with any new information and provide contact information for contacts that live outside of your jurisdiction.

 

 

Week 1

Contact the individuals in your jurisdiction discovered during the patient interview. Schedule TSTs/IGRAs either through the local health department or the primary care physician. Contact providers for any updates for the TB Contact Investigation Worksheet.

 

 

 

If inpatient, obtain current smear results and updates on patient’s course of treatment. Continue working with discharge planner on getting prescriptions and planning outpatient services. Local health department or designee for DOT should have medications in hand prior to discharge.

 

 

If outpatient, collect sputum and submit to state lab using the State Public Health Laboratory: Clinical Test Requisition form. Remember to label the specimen bottle with the patient’s name and date of birth. These must match the Clinical Test Requisition form or the lab cannot process the specimen. If NAAT has not been done and culture result is not known, and less than 3 days of anti-TB meds have been ingested, request a NAAT on the sputum using the NAAT Test Requisition form.

· If patient was initially smear positive, collect 1 sputum per week until you get smear negative. Collect 2 more sputa after one smear negative result received.

· If more than 1 sputum is submitted at one time, date and time should also be on label of bottle and lab requisition.

 

 

Week 2

Continue contact identification and scheduling of testing until first round of testing is complete. Ensure all contacts with positive screening results are referred for chest x-rays and treatment.

 

 

 

For both inpatient and outpatient settings, release from isolation/quarantine is appropriate if the patient meets three (3) criteria: 1) Fourteen (14) days of ingestion and tolerating anti-TB medications, AND 2) three (3) consecutive negative sputum smears, AND 3) clinical improvement.

 

 

If inpatient, obtain current smear results and updates on patient’s course of treatment. Continue working with discharge planner on getting prescriptions and planning outpatient services. Determine whether the patient is still infectious and needs continued isolation based on public health standards (the 3 criteria listed above).

 

 

If outpatient, determine if release of quarantine is appropriate at the end of week 2.

 

 

Week 3

Collect sputum if still in quarantine.

 

 

 

Continue contact investigation, elicit additional contacts if necessary.

 

 

Assess for refills and ensure medications obtained.

 

 

Continue DOT/eDOT; give incentives as needed.

 

 

Week 4

Enter first round of contact testing information on the TB Contact Investigation Worksheet and submit to the state TB case manager.

 

 

 

Determine end of infectious period for second round of contact testing. The end of the infectious period is the date of the last exposure of the contact while the TB patient was still infectious. The contact should have a test 8-10 weeks after the last exposure. (See TB Contact Investigation for more information).

 

 

Remind patient of follow up appointments and/or testing. Request TB Treatment and Follow-Up Care Report Form from provider.

 

 

Continue DOT/eDOT. Give incentives if patient is adherent with DOT and follow up appointments/tests.

 

 

Submit incentive logs and billing for Contact Investigation and DOT services using the TB Billing Vendor Invoice (CO-17).

 

 

Week 5-7

Continue DOT/eDOT.

 

 

 

Schedule contacts for second round of testing 8-10 weeks after the last exposure to TB patient if they were negative on the first round.

 

 

☆ Week 8

CRITICAL CLINICAL ITEMS

 

 

Collect a sputum BEFORE the 60th day of treatment. Contact state TB case manager to determine the date.

If culture positive around 60 days after the initiation of treatment and initial imaging was cavitary, nine (9) months of treatment is needed. (Guidelines for Treatment of Drug Susceptible TB, p. 21).

 

 

Drug susceptibilities should be finalized. Changes to medications should be based on susceptibility pattern. Ensure patient has appropriate and adequate medications.

 

 

Repeat imaging is recommended. Clinical decision: if culture negative and imaging is improving, continue medications for two (2) additional months. (Guidelines for Treatment of Drug Susceptible TB, p. 33). If no improvement, consider treatment for LTBI.

 

 

Remind patient of follow up appointments and/or testing. Request TB Treatment and Follow-Up Report Form from provider.

 

 

Give incentives if patient is adherent with DOT and follow up appointments/tests.

 

 

Submit incentive logs to TB Control Program. Submit billing for DOT services using the TB Billing Vendor Invoice (CO-17).

 

 

Month 3

Complete second round testing of all negative contacts.

 

 

 

Submit completed Contact Investigation Worksheet to state TB case manager.

 

 

Obtain request TB Treatment and Follow-Up Report Form from physician visit.

 

 

Continue DOT. Give incentives if patient is adherent with DOT and follow up appointments/tests.

 

 

Months 4-6 (or 9)

Obtain TB Treatment and Follow-Up Report Form from physician visit every month.

 

 

 

Continue DOT. Give incentives if patient is adherent with DOT and follow up appointments/tests.

 

 

Submit incentive logs and billing for DOT services using the TB Billing Vendor Invoice (CO-17).

 

 

Notify state TB case manager of the final date of treatment. Discuss any outstanding items so all parties can close case as completed adequate treatment.