Engagement and Retention of Care

One of the most important roles for the infectious disease case manager is to ensure the patient is linked to care. In some cases, the individual might be referred to the case manager from the care setting during the acute phase of an illness, or as a result of laboratory report notification.

Linking the patient to community-based care for continuity of services is vital to the patient's recovery. An individual may receive care at a public health clinic or with a private provider. The case manager must support the patient's continuation of care from early notification throughout the course of therapy.

An effective case manager builds a relationship with the patient and actively works to ensure the patient is engaged in the plan. This includes constantly looking for early warning signs that the patient may be getting off track.

It is important to recognize that many patients are faced with difficult issues beyond their illness such as:

  • Limited family support
  • Housing
  • Transportation
  • Socioeconomic factors
  • Language barriers
  • Access to care challenges

 Review the tabbed activity to learn more about what happens when patients are engaged and retained in care.

 

  Review the examples below. 

 

TB

Discharges

Discharges from a facility for persons with suspected TB are regulated per 105 CMR 365.000. Individuals are required to have an approved discharge plan in place within 72 hours of anticipated discharge. The individual is to have a follow-up clinic visit scheduled and enough anti-TB medications on hand to last until that first follow-up appointment. Discharge planning during the acute phase is based on collaboration between the discharging facility, the state health department, and the LBOH nurse.

Continuation Phase of Care

The ongoing collaboration between local and state case managers ensures that the individual is continually linked to care throughout therapy. Lab tests, vision and hearing screenings, as well as routine sputum collection are ways of monitoring the individual throughout the duration of therapy.

Adherence Support and Completion of Therapy

TB therapy can be long and drawn out for the individual. Supportive monitoring is provided by the local case manager and assigned community health workers by providing directly observed therapy (DOT). Therapy can be at a minimum 6 to 24 months (or more). Supporting individuals in a variety of ways is crucial to keeping him/her engaged in care. Keeping individuals in care in the least restrictive way is the key to curing TB.

Compulsory Hospitalization

In some cases, if the individual has demonstrated that they are unable or unwilling to comply with TB treatment and poses a threat to the community, mandated hospitalization may be required. According to MGL Ch 111 94A-C: Compulsory hospitalization of a person with infectious TB may be requested by either the local public health department of the facility where the individual may be hospitalized. Clear documented evidence or vocalized noncompliance from the individual along with clear clinical suspicion of infectious TB is required to start this process. Compulsory hospitalization is done collaboratively with MDPH and the local entity. 94A and 94B petitions support a 15-day hospitalization.

Perinatal Hepatitis B

Interaction with Families

Once a Hepatitis B-positive pregnant women is entered into case management, case managers will make initial contact with the patient to introduce themselves and the case management process. They also usually send a brochure that outlines Hepatitis B and the importance of vaccinations for the baby.

Once the baby is born, letters are also sent to the mother reminding her when the second and third doses of the Hepatitis B vaccine are due. When the baby has received all three doses of the Hepatitis B vaccine, the case manager will send a letter to the mother about the need for post vaccination serological testing (PVST) for the baby, which will determine if he/she is immune to Hepatitis B.

Interaction with Providers

Another role of the case manager is to interact with the providers involved in the care of the mother and baby. For the pregnant woman who is Hepatitis B-positive, this includes:

  • Contacting her OB and recommending that additional Hepatitis B screening tests be performed (HBeAg, HBV DNV, ALT), and referral to a specialist (if needed) in accordance with the CDC's Screening and Referral Algorithm for Hepatitis B Virus (HBV) Infection among Pregnant Women (PDF)
  • Notifying the hospital where the woman plans to deliver of her Hepatitis B status so the hospital is aware and can provide the baby the recommended post-exposure prophylaxis at birth (which is the first dose of the Hepatitis B vaccine and HBIG)

Once the baby is born, the case manager also has interaction with the baby's pediatrician, including:

  • Writing a letter to the pediatrician introducing themselves as the case manager, and outlining the plan of care the baby should receive because the mother was Hepatitis B-positive
  • Sending reminder letters to the pediatrician for the second and third doses of the Hepatitis B vaccine, and post-vaccination serologic testing (PVST). PVST should take place once the baby has completed the Hepatitis B vaccine series (9-12 months of age), and at least 1-2 months after the final dose of the vaccine
  • Following up with the pediatrician to obtain PVST lab results on the baby and assist with interpretation (if needed)

The LBOH nurse also has a role in perinatal Hepatitis B case management. It is their responsibility to follow up on household and sexual contacts to the Hepatitis B-positive pregnant woman, to determine their vaccination status.

If it is determined that there are contacts that are not vaccinated, the LBOH nurse will either vaccinate the contacts, or refer them for vaccination. This will help protect the newborn once he/she is born and returns home.

The LBOH also helps in finding a patient if they are deemed "lost to follow-up" and can also educate parents who do not want to vaccinate their child about the importance of vaccines. 

Education

Education is an ongoing process in case management. From the initial diagnosis to outcome, the case manager must use every opportunity to educate the patient, the family, possible contacts to infectious patients, and the community. 

Can you think of some information you might need to share with your patient?


Patients need to be informed about their disease, medications, diagnostic tests, and risk for transmission.