Infectious Disease Case Management

Introduction

The goal of population-based disease case management is to optimize the self-care capabilities of individuals and families, including the capacity of systems and communities to coordinate and provide health and human services. This training will present a brief introduction to infectious disease case management principles. The primary goal of local public health officials, as infectious disease case managers, is to ensure individuals complete an appropriate and effective course of treatment in the shortest time possible with the least restrictive measures indicated, and to identify all high-risk contacts and refer them to evaluation and treatment.

Learning Objectives

After completing this training, you will be able to:

  

What is Case Management?

Case management is a collaborative process, following public health principles, that coordinates an individual's medical needs over an entire episode of illness or response process. Case management includes a range of activities specific to the needs of the individual and the needs of the community.

According to Public Health Interventions - Applications for Public Health Nursing Practice (PDF), developed by the Minnesota Department of Health in 2001, case management is characterized by its:

With disease case management, you have two patients - the community and the patient you are working with. Your job is to quickly interrupt the disease transmission and engage and retain the patient in care.

Goals and Levels

If performed in a timely manner, case management provides an effective framework for the public health nurse to stop the spread of disease.

 

 

Role of Health Departments

The case manager (commonly a Local Board of Health (LBOH) public health nurse or MDPH employee) is directly responsible for an individual's case management for specific infectious diseases in the community in which they serve.

The case manager:

  • Follows up on identified cases
  • Assesses each individual's situation
  • Formulates a plan
  • Builds relationships with patients to ensure they are receiving the medical care and other services they need in order to recover from their disease.

The LBOH is often the link between the state health department and the person with the infectious disease in the community. The LBOH ensures appropriate actions are taken in alignment with state guidance to monitor disease and stop the spread of infection.

One of the ways it does this is by using MDPH's MAVEN system. MAVEN is a surveillance tool used to inform cities and towns of disease events. It provides a system for information tracking, disease investigation, and case management efforts and is shared with the state health department.

Note: Some LBOH outsource case management to visiting nurse associations or other external organizations.

 

Disease case management is a preferred strategy for infectious diseases to ensure diagnosed individuals are able to get optimal care, as well as to stop the spread of the disease.

Regardless of the disease, case management includes steps such as assessment, assurance and planning.

 

The components of the case management process include:

  1. Case identification
  2. Case investigation
  3. Engagement and retention of care
  4. Case management completion

Each will be described on the following pages.

Remember, for some infectious diseases, case management by the LBOH is required under Massachusetts regulations.

Complete the knowledge check below. Note: this is unscored so you will see a group quiz score of 0/0.

    

Case Identification

Timely disease notification is an essential first step in initiating infectious disease case management. When a person is diagnosed with certain infectious diseases, their healthcare professional is required to report it to MDPH.

Reports are then entered as "events" into MAVEN. Using MAVEN enables MDPH and local health officials to capture and transfer appropriate public health, laboratory, and clinical data efficiently and securely over the internet in real-time. The system interfaces with Electronic Laboratory Reporting (ELR) efforts, and automatically notifies state and local officials 24/7/365 of any event requiring their attention.

For many infectious diseases, the diagnosis and public health interventions may require collection of clinical, laboratory, demographic, and social data. The type of disease will determine the type and frequency of interventions that are needed.

Interventions must be culturally appropriate, and must provide continuity of care from the acute stage through to either completion of therapy (if indicated) or support during the chronic phase of illness.

Depending on the disease, the LBOH's role may be to investigate and manage the case. Although related, case investigation and case management should be considered two separate activities.

Infectious Disease Examples

One common infectious disease managed by LBOH nurses is tuberculosis (TB). LBOH nurses also play a role in perinatal Hepatitis B follow-up.

Throughout this training, these two diseases will be used as examples illustrating case management in action.

 

TB

Under regulation 105 CMR 365.200, people with suspected and/or confirmed TB are assigned a nurse case manager from the LBOH.

Perinatal Hepatitis B

Regulations allow for follow up of Hepatitis B-positive pregnant women and their infants:

  • Regulation 105 CMR 130.627 requires that all pregnant women be tested for Hepatitis B during each pregnancy
  • Regulation 105 CMR 300.000 requires that all Hepatitis B-positive labs be reported to MDPH, requires that providers report Hepatitis B diagnoses in pregnant women, and outlines how cases and contacts must be managed

Perinatal case management in Massachusetts uses MAVEN. Hepatitis B-positive labs are reported to MDPH through Electronic Laboratory Reporting (ELR).

Pregnancy status is then determined for Hepatitis B-positive women between the ages of 14-50.

  • Those women who are pregnant and Hepatitis B-positive are entered into case management
  • Case management includes interaction with both patients and providers

 

  

Case Investigation

Case investigation is an integral part of infectious disease case management.  Case investigation takes place after a case has been identified.

While this training will not go into much detail about case investigation, thorough investigation is required to develop an effective individual plan of care (required as part of case management).

The goals of the investigation process are to interrupt the disease transmission, find and treat exposed individuals, and gather enough information to be able to develop an effective individual plan of care from which the case will be managed.

Have you had experience developing an individual plan of care? 


In order to develop an effective individual plan of care that ensures interruption of disease transmission, the case manager must consider the case presentation, his/her knowledge of the microorganism, and how the disease is transmitted.

  • Some infectious diseases may have a higher risk of transmission, depending on the mode of transmission (i.e., blood/body fluids, airborne, droplet)

The LBOH should consult with the state health department when faced with a disease that they are unfamiliar with. State level resources can guide the LBOH through a proper investigation and the creation of an appropriate care plan.

 

Review the examples below.

 

TB

Those who present with pulmonary symptoms of active TB can be infectious.

  • TB is transmitted through the air; thus, people who shared the same breathing space with the individual during their infectious period must be identified and evaluated

Given that TB is an airborne disease, the case manager must identify where the individual has been during that time.

  • Exposure sites could include school or work, as well as many others  

Perinatal Hepatitis B

When a pregnant woman tests positive for Hepatitis B, she is entered into case management by MDPH nurses, by the MDPH Refugee and Immigrant Health Program, or by the Boston Public Health Commission (BPHC).

  • BPHC performs all components of perinatal Hepatitis B case management for Boston residents
  • LBOH in other parts of the state take part in case investigation by assessing household and sexual contacts for infection and vaccination status

Vaccinating contacts will prevent further transmission, especially to the newborn who will soon be coming into the household.

 

Interruption of Disease Transmission

To protect the community, LBOH must ensure proper actions are in place to interrupt disease transmission to others. The steps required vary significantly based on the disease and modes of transmission.

In some cases, it is necessary to determine who the patient has been in contact with prior to diagnosis. This is referred to as a contact investigation.

As part of disease containment, if it has been determined that a contact investigation needs to be performed based on communicability of the infecting microorganism, individuals prioritized for testing and referral will be identified by the infectious disease case manager.

Think about your setting. How would you go about evaluating and communicating with affected individuals?


The evaluation method for those who test positive depends on the mode of transmission and includes education about the disease.

  • Applying the public health practices below is instrumental to interrupting disease transmission

 

  

Review the examples below.

 

TB

Contact investigations of those identified to have come into contact with suspected TB patients are managed in a variety of ways.

  • LBOH work collaboratively with the state health department and a variety of partners depending on the exposure site
  • Patient and community education is provided by the team, which may include the local public health nurse, state TB nurse, state epidemiologist, and community health worker team to ensure every contact is identified, tested, evaluated, and referred for follow-up care (if needed)
  • Diagnostic testing such as tuberculin skin test or blood assay for is arranged through this collaboration and done in a systematic fashion

 

Perinatal Hepatitis B

Hepatitis B is a liver infection caused by the Hepatitis B virus (HBV). Hepatitis B is transmitted when blood, semen, or other body fluids from a person infected with HBV enters the body of someone who is not infected and not immune.

This can happen through sexual contact, sharing of needles or syringes, or birth (from mother to baby).

For some people, Hepatitis B is an acute short-term illness, but, for others, it can become a long-term chronic infection. The risk for chronic infection is related to age at infection.

  • Approximately 90% of infected infants become chronically infected, compared to 2–6% of adults

Because of the high risk of becoming chronically infected with HBV if exposed at a young age, perinatal Hepatitis B case management plays an important role in protecting these infants against chronic Hepatitis B.

Chronic Hepatitis B can lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis B is by getting vaccinated. (CDC 2015).

 

 

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:

 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.

 

 

 

 

 

Case Management Completion

Case management is completed when the patient meets a variety of milestones. These milestones may include a combination of direct oversight and regular reviews of the patient's progress with the care continuum specific to the infectious disease.

Clinical improvement, laboratory monitoring, and compliance with an established plan of care can provide clear indicators that case management activities have been successful and may be coming to a close.

Review the examples below.

TB

As previously noted, TB therapy can be as short as six months, or it can be much longer.

Factors that influence the length of therapy include:

  • Site of disease
  • Response to therapy
  • Drug resistance
  • Medication tolerance
  • Adherence to treatment
  • Documented laboratory or radiographic improvement

Collaboration with the clinical team provides incremental evidence of the patient's success with treatment. By meeting regularly with the treatment team, it is easier to see when milestones have been reached.

During the patient's last clinical appointment, the clinical provider will project the last day medications need to be taken. Patients who have completed TB therapy will be given a letter of completion from the clinical provider for their records, and will be instructed to return if TB symptoms recur. 

Perinatal Hepatitis B

Perinatal hepatitis B case management comes to a close once the infant has completed his/her hepatitis B vaccine series and has a blood test (PVST) that shows protection against hepatitis B.

As previously described, PVST should take place once the baby has completed their hepatitis B vaccine series, at 9-12 months of age, and at least 1-2 months after the final dose of vaccine.

If the baby's blood test shows they are HBsAg negative, and anti-HBs positive, then they are considered protected against hepatitis B and case management is complete.

  • Occasionally, PVST results may show that a baby is not protected, and the case manager will follow up with the pediatrician to determine the best course of action

 

Summary

Infectious disease case management is a collaborative process with many partners, components, and activities.

Keeping the patient central in the process, viewing them in a holistic way, ensuring their medical and psycho-social needs are met, and preserving autonomy are the keys to successful case management.

 

Conclusion and Additional Resources

Congratulations! You have completed the training.

Print or save this Job Aid (PDF) that summarizes the key points.

Review the Learning Objectives

You are now able to:

If you feel you need additional exposure to this material, you may repeat the training or return to any of the pages at any time.

Additional Resources

If you would like further information about this topic, please consult the following websites and materials:

 

Post-Test and Certificate of Completion

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