Transcript 99DOTS

Using Mobile Phones to Monitor and
Improve Adherence to Tuberculosis Medications
In collaboration with:
Central TB Division
Topics Covered
• What is 99DOTS
• Features and Benefits of 99DOTS
• Benefit to Patient
• Benefit to Field Staff
• Benefit to District Supervisors
• 99DOTS Workflow in TB-HIV collaborative
intervention of ART and RNTCP department
• 99DOTS Dashboard Workflow
• Overview of ART and RNTCP Responsibilities in
99DOTS
• Detail Task Breakup of ART and RNTCP
Responsibilities
• 99DOTS Video
What is 99DOTS?
Strengthening DOTS monitoring through real-time adherence monitoring
What is 99DOTS?
Goal: to provide 99% of the benefits of DOTS at a
fraction of the cost and inconvenience to patients
• Anti-TB drugs are wrapped in
envelopes which are printed with
hidden numbers behind the pills
• When patients dispense a dose,
they reveal a hidden TOLL FREE
number which they call
• This call gets reflected on the
99DOTS dashboard immediately as
a taken dose
99DOTS: Accurate Monitoring at Very Low Cost
5
How can the Patient data be
accessed?
Different ways of accessing the patient data –
• Web dashboard (www.99dots.org)
• Every center will be given their own login ID and Password
to access their patients
• Different logins for ART center, DTC and field staff (with
limited permissions)
• SMS Alerts for Staff and Treatment Supporters to take
immediate action
Calendar View of Adherence
SMS Alerts from 99DOTS
Alerts to Staff
Reminders to Patients
SMS Message:
[0000] Please
take pills
[0000]
Please
take pills
Notification of new patients
SMS Message:
[0000] Please
take pills
New patient
(740XXXXXX)
enrolled,
Yelahanka district
SMS Message:
Two of your
patients have
missed doses
today: Raj &
Om
Two of your
patients have
missed doses
Raj (979XXXXXX)
& Om (812XXXXXX)
Analytics and Reports for
Program
Features of 99DOTS
• Calls are completely free for patients
• Calls can be made even when the patient has no
pre paid balance or the mobile is in roaming area
• Any call from a registered patient number is
marked as a dose taken (personal, shared, land
line)
• Numbers are not unique, but appear in an
unpredictable sequence – ensures pill-in-hand
adherence
• When patients call, they hear “Thank you”
• Calls immediately show up in the dashboard as
taken doses
• Automatic alerts and reminders to patients and
supervisors for non-adherent patients
• Adherence records available to field staff, medical
officers, district staff and all other stakeholders in
the program
SMS Message:
Two of your
patients have
missed doses
today: Raj &
Om
Two of your
patients have
missed doses
Raj (979XXXXXX)
& Om (812XXXXXX)
Benefits of 99DOTS
Patients
• Less travel
• Increased convenience
Field
Staff/Supervisors
• Focused and more
efficient care
Program Officers
• Easy monitoring
• Accurate reports
99DOTS Workflow for TBHIV Co-Infected Treatment
99DOTS: Workflow - Summary
Patient at ART Centre with
symptoms of TB
Cough, Fever, Night sweats, Weight loss
Continuous
monitoring and
follow up by
RNTCP staff
Patient’s sputum is
sent for testing to
the RNTCP center
Patient is counseled at ART
Centre to take medication in
the 99DOTS packaging and
registered on 99Dots website
CBNAAT testing for
rapid microbiological
diagnosis
Patient
identified
positive for TB
TB Medication Regimen
• Most patients undergo treatment for 6 months
• Intensive Phase (IP): 2 months
(Isoniazid, Rifampicin, Ethambutol, and Pyrazidamide) – 4FDC
• Continuation Phase (CP): 4 months
(Isoniazid, Rifampicin, and Ethambutol) – 3FDC
• FDC
• Pills/Day based on weight band
• Daily regime – easy with FDC
• If patient takes full course, near certain-cure
• After 2-3 weeks: feeling better
• After 6 months: negligible chance of
relapse/resistance
4FDC
3 FDC
FDC Drugs by Weight
WEIGHT CLASS
# OF PILLS
# STRIPS FOR 28 DAYS
< 25 kgs
Does not receive FDCs or 99DOTS
0
30 – 39 kgs
2 pills per day
2
40 – 54 kgs
3 pills per day
3
55 – 70 kgs
4 pills per day
4
> 70 kgs
5 pills per day
5
FDCs wrapped in custom 99DOTS envelopes based on weight
(diagrams to follow)
99DOTS Envelopes
2 pills
4 pills
3 pills
5 pills
Patient counseling of 99DOTS
ART Center staff nurses/counselors
• Explain 99DOTS, and importance of
adherence (how many pills, every
day, make free call)
• 6 months medication
• Call is free, even without balance
and can be done free even when
roaming
• Patient should follow path of pills
• Patient should come back every 28
days when pills are finished
• If patient has phone, administer first
dose and make first call
99DOTS Website
Workflow
NOTE:
For detailed information on how to use the
99DOTS Website to perform various tasks, see
the 99DOTS Dashboard User Guide
Snapshots of 99DOTS Website Dashboard
18
Step 1
Step 2
Step 3
• RNTCP – District Login : Maintain Staff Details at District and TU level using the Staff
Details menu in the 99DOTS Website
• ART Center Login: – Register Patient using the Add Patient menu in the 99DOTS
Website
• RNTCP – District Login: Assign correct TU for all new patients using the Treatment
Center tab under patient details page in 99DOTS Website
Step 4
• RNTCP – District Login: Add treatment supporters (relatives, community workers)
under district and TUs using the Treatment Supporters menu in the 99DOTS
Website and link them to individual patients from patient details page. Do not add
staff as Treatment Supporters
Step 5
• RNTCP – District and TU Login – Monitor patients for adherence using the Calendar
menu in the 99DOTS website. Add Notes/Tags after interacting with patients, and
perform various patient management tasks from the patient details page.
19
STEP 1: Staff Details
Using the District Login,
add District and TU staff
details. These staff will
get SMS alerts for
patients listed under
their district and TUs.
This is mandatory and
extremely important.
STEP 2: Add Patient
STEP 3: Assign Patients to TU
Register Patient on 99DOTS
(using ART login) – When
registering patient, select the
correct District to which the
patient belongs. This allows the
relevant district to see the
patient.
From the list of Patients under
District, select the required
patient and allocate him/her to a
TU within the district. Once
patients are allocated a TU, TU
Staff will start receiving alerts
about the patient and see them
from the TU login.
STEP 5: Patient Management
Perform various on-going patient management tasks
such as: Edit Patient Details, Edit Attention Required,
Adding Notes and Tags, Editing Treatment Center,
Marking Manual Dosage, Closing and Reopening a
Case, Downloading Treatment Cards, Reports
STEP 4: Add & Link Treatment
S
Supporters
Add list of Treatment Supporters
under district and TUs. The Treatment
Supporters won’t be automatically
linked to patient. You have to go to
individual patient details page and link
Treatment Supporters to the patient.
Staff like DPS / STS / TBHV should not
be added here.
20
Patient monitoring by RNTCP
• Login to 99dots.org to see patient adherence/notes
• Follow up with patients with low adherence
• Respond to SMS alerts, and 99DOTS requests to follow
up with patients
• DOTS+ Supervisor/RNTCP team to review adherence at
regular meetings
• Add notes on patient behavior to log follow ups
99DOTS – Adherence scenario
Patient
ID
Patient name
1423
Rahul K.
1
2
3
4
5
6
7
Today is the 8th day of Rahul’s treatment and he has not called in
two days
Rahul gets a message reminding him to take his daily dose
The RNTC staff (STS, TBHVs, DPS, field staff) also gets a message
alerting them that Rahul has not[0000]
taken medication in 3 days
Please
takeimportance
pills
They call Rahul, and counsels him
on the
of taking
drugs
every
day
Rahul
K. (740XXXXXXX)
has not taken pills.
Rahul takes his medication, and calls the hidden number, so his
adherence can be logged
8
Roles and Responsibilities of ART and RNTCP
staff for TB-HIV Co-Infected treatment
99DOTS TB-HIV Co-infected Treatment Responsibility Matrix
Task
Responsible Department
Ensuring that drugs are sent to ART Centers
RNTCP – District TB Office
Adding Staff Details at District and TU Level in 99DOTS
website. These staff will get SMS when a patient is
added and when the patient misses to call the toll free
number
RNTCP – DPS, or any other staff designated by DTO
Adding relatives or other persons close to the patient,
RNTCP – DPS, or any other staff designated by DTO
community workers, etc. who would like to be intimated
by SMS on non adherence and liking them to patients.
Registering Patients on 99DOTS website (selecting
correct district, adding phone numbers, and assigning
correct weight band)
ART Center – Data Manager
Assigning Patients to the correct TU under the district
RNTCP - DPS, or any other staff designated by DTO
Counseling Patients about 99DOTS and how to make a
call after each dosage
Initially by ART Center Counselors/nurses/doctors while
giving medicines. Later by RNTCP staff (for example,
DPS, STS, TBHVs) who is responsible for monitoring
patients adherence on 99DOTS website and responding
to SMS alerts
Task
Responsible Department
Handing over 99DOTS wrapped drugs to patients
ART Center – Pharmacist
Ensuring that drugs are available, maintaining
inventory, and issuing refills to patients
ART Center - Pharmacist
Editing Patient Details, like adding additional
phone numbers, updating address change
ART Center – Data Manager and RNTCP - DPS, or any
other staff designated by DTO
Monitoring patient list for adherence
RNTCP - DPS, or any other staff designated by DTO
Follow up with patience once non adherence
SMS is received by the linked staff/provider
RNTCP – STS, TBHVs, DPS, Field workers, or any other
staff designated by DTO
Adding Notes and Tags, marking manual doses,
closing a case, downloading reports
RNTCP - DPS, or any other staff designated by DTO
Changing Treatment Center details, for example
in the case of change of TU/District/ART Center
of patient.
RNTCP - DPS, or any other staff designated by DTO
The DOTS Plus Supervisor (DPS) or any other staff designated by the District
TB Officer (DTO) is accountable for all patients in his/her district. He/she can
call patients directly after going through the dashboard and/or delegate this
to the relevant field staff like STS, TBHVs, field workers, etc.
Detail Task Breakup of ART and RNTCP
staff for TB-HIV Co-Infected treatment
TASKS TO BE DONE BY ART CENTER STAFF FOR HIV-TB CO-INFECTED TREATMENT
UNDER THE 99DOTS TREATMENT PLAN USING FDC PILLS WRAPPED INSIDE 99DOTS
BLISTER PACKS
Sr. No.
Task Description
Details
1.
EVALUATE HIV PATIENTS FOR TB
SYMPTOMS
Check for:
 Fever
 Cough
 Weight Loss
 Night Sweats
2.
COLLECT SPUTUM
Collect sputum even if any one of the four symptoms are
seen in the patients
3.
CBNAAT TEST
Send the sputum sample to CBNAAT Lab for testing
4.
DRUG PRESCRIPTION
If the test result is positive and the patient is diagnosed for
TB the doctor at ART centre prescribes appropriate FDC pills
as per the weight band of the patient.
Sr. No.
Task Description
Details
5.
REGISTER PATIENT ON 99DOTS
WEBSITE
6.
HANDING OVER THE MEDICINES
The Data Manager at ART registers the new patient on the
99dots website.
IMPORTANT:
The Data Manager should select the correct district the
patient belongs too. It is important because monitoring of the
adherence will be done by RNTCP staff linked to that district
or TU.
Correct primary mobile number should be added without
adding 0, 91, or +91.
Use only 10 digits mobile number.
There is a provision to add multiple phone numbers as
secondary numbers. It is advisable that the Data Manager
checks with the patient and accompanying relatives. These
secondary numbers can also be used to give free call.
The Data Manager should advise the patient to update the
ART centre in case the mobile number changes in the future.
The Pharmacist hands over the prescribed FDC blister pills for
28 days wrapped in the correct 99DOTS envelopes.
Sr. No.
Task Description
7.
COUNSELLING PATIENT ON USAGE The medical counsellor explains how 99dots FDC pills are to be
consumed by the patient.
OF 99DOTS FDC PILLS AND
IMPORTANT:
GIVING MISSED CALL
The counsellor explains the importance of taking daily doses by
following the arrows marked on the 99DOTS Envelop and also
giving miss call to the toll free number provided.
The counsellor should emphasise that the call is free of cost
and can be made even if the patient does not have balance
amount in the mobile.
The counsellor should emphasise the importance of adherence
and why it is important not to stop taking daily dose and to
give the miss call. If the patient is accompanied by a relative or
friend, the counsellor can counsel them too.
DAY ONE DOSE AT THE ART
Once the patient in counselled on the usage of the pills, the
CENTER
counsellor/nurse should ensure that the day one dosage is
taken at the ART centre followed by which the patient also
gives a miss call to the revealed toll free number after
dispensing the first day dose from the blister pack. The
counsellor/nurse should advise the patient to repeat the
procedure daily. If the patient is accompanied by friends or
relatives they should also be shown the method.
MAINTAIN INVENTORY AND
The Pharmacist should ensure that indent to get stock is sent
ENSURE THAT MEDICINES ARE
to District TB office before the stock gets over.
AVAILABLE
8.
9.
Details
TASKS TO BE DONE BY RNTCP CENTER STAFF FOR HIV-TB CO-INFECTED TREATMENT
UNDER THE 99DOTS TREATMENT PLAN USING FDC PILLS WRAPPED INSIDE 99DOTS
BLISTER PACKS
Sr. No.
Task Description
1.
UPDATE STAFF DETAILS ON THE 99DOTS The DOTS Plus Supervisor (DPS) and other health staff designated by
DTO can add multiple staff members to receive SMS whenever:
WEBSITE
A new patient is added in the district
A patient fails to give miss call indicating that he/she is not adhering to
the treatment plan
So when a new patient is added in a particular district or TU, the
corresponding staff (for example DPS, DTO, STS, TBHV, etc.) who is
added to the 99DOTS under the district or TU receives an SMS.
Similarly when the patient fails to adhere to the treatment an SMS is
sent.
ASSIGN PATIENTS TO THE CORRECT TU The DPS, or any other staff designated by the DTO should ensure that
UNDER THE DISTRICT
all patients are assigned to the correct TU under the district in 99DOTS
website.
MONITORING OF PATIENT ADHERENCE The DPS, or any other staff designated by DTO can login to the 99DOTS
ON THE 99DOTS WEBSITE
website and see the list of patients registered under his/her district or
TU and can check if the patient is adhering to the treatment. This will
help the staff to concentrate on high risk patients and follow up with
only those patients. They do not have to spend time in following up
with each individual patient’s.
2.
3.
Details
NOTE:
The DOTS Plus Supervisor (DPS) or any other staff delegated by the District TB Officer (DTO) is
accountable for all patients in his/her district. He/she can call patients directly after going through
the dashboard and/or delegate this to the relevant field staff like STS, TBHVs, field workers, etc.
Sr. No.
Task Description
4.
If any patient does not call the toll free number after consuming pills in a
FOLLOWUP WITH NON ADHERING
PATIENTS UPON RECEIVING SMS ALERT day, the alert SMS is sent to the staff linked to the district or the TU of
the patient. The staff (STS, TBHVs, and Field Staff) can immediately act
upon the alert and make arrangements to either do a telephonic follow
up or a home visit to the patient.
5.
ADDING AND LINKING TREATEMMENT
SUPPORTERS TO PATIENTS
The DPS or any other health staff designated by DTO can also add and
link relatives, community workers, or any other non-staff as treatment
supporters at the district and TU level so that the non- adherence SMS
can be sent to them. It is necessary to link these treatment supporters to
individual patient.
6.
MODIFY DETAILS BASED ON
FOLLOWUP – PATIENT DETAILS,
MEDICAL DETAILS, ADDING NOTES
AND TAGS, MARKING MANUAL DOSES
ADHERENCE, ALTERING ATTENTION
REQUIRED, TRANSFERRING PATIENTS
BETWEEN DISTRICTS, CLOSING CASES
DOWNLOADING RNTCP TREATMENT
CARDS AND REPORTS
Based on the interaction and follow up with the patients the DPS or any
other health staff designated by DTO staff can update details regarding
patient, medication, add notes or tags, alter attention required, update
manual doses in case there were issues with mobile connectivity, closing
case after completion of treatment, reopening cases, transferring
patients between districts etc.
7.
Details
Using the 99DOTS website DPS, DTO, or any other staff designated by
DTO can download RNTCP Treatment cards for patients and also
download various reports for analysis.
99DOTS Training Video
http://bit.ly/99DOTS-ENGLISH
http://bit.ly/99DOTS-HINDI