Transcript Who completes the Care and Treatment plan

THE CARE AND TREATMENT
PLAN
• PART OFTHE FIRST STEPS TOWARDS
PLANNING SCALE UP OF ART AT
TREATMENT FACILITY.
• IT IS DEVELOPED DURING SITE
PREPARATION.
• It is part of the components of the
sequence that eventually empower a
facility to provide care and treatment for
clients. partnership commences.
• The Care and Treatment Plan will also
help you design services in line with the
goal, objectives and guiding principles of
the Project .
• The facility should design a plan that is
appropriate for it’s capacity and patient
population.
• Developing this plan will assist you to write
a budget, identify areas for capacitybuilding, make quality improvements to
your program throughout the year, and
coordinate activities.
• Who completes the Care and Treatment
plan ?.
• Development of the Care and Treatment
Plan requires a collaborative effort of
personnel from many sectors of your
treatment facility.
• Thus, it may be useful for the site to have
a leader or key representative from the
following areas as appropriate:
• (1) clinical; (2) laboratory; (3) counseling
and/or adherence support; (4) communitybased health programs; (5) pharmacy; (6)
medical records; and (7) finance and
administration.
• IHVN Members of staff are available to
provide technical and programmatic input
during the process.
• The C and T plan consists of 8(eight parts)
as listed on the next slides
• Part 1: Project Overview: Structure and
Management of Care
• 1.1 Treatment delivery model
• 1.2 Human Resource Management
• 1.3 Identifying target populations for ART
• 1.4 Patient Enrollment Projections
• 1.5 Continuity of Care
• Part 2: Medical Care under the ART Program
• Part 3: Strengthening your adherence
program
• Part 4: Community Mobilization and Support
for ART
• Part 5: Preparing your Laboratory for ART
• Part 6: Preparing your Pharmacy for ART
• Part 7: Strategic Information planning
• Part 8: Financial systems preparation
• How to complete ?:
• While some sections of the Care and
Treatment plan are crucial for planning the
site annual budget, other sections can be
developed on an on-going basis
throughout implementation.
• It is recommended that a team of key
personnel discuss part 1 in detail before
completing the budget
• Then, the key personnel should familiarize
themselves with the section that pertains
to their specialty (e.g. laboratory),
identifying essential activities that will
impact the site budget
• Key personnel can continue leading ongoing discussions with other relevant staff
to complete the Care and Treatment Plan
over time.
• Resources: The following documents may
assist you in planning:
• Existing site policies and procedures
• National and international ART guidelines
and strategy documents
• IGT (the site assessment tool)
• Part 1: Project Overview: Structure and
Management of Care
– Treatment Delivery Model
we recognize that no single ART delivery model
has been validated as optimal for universal use in
resource-constrained countries Therefore, the
project supports treatment delivery modalities
and solutions identified by the site that integrate
into existing health care infrastructure, operate
within national/international guidelines, and can
achieve long-term programmatic success
Examples of treatment delivery models used
include:
• Hospital-based services provided through the
out-patient department.
• Home-based care centers.
• Mobile VCT programs.
Throughout the duration of the project,
measured program success of individual
approaches will be linked to prioritization for
program replication, expansion, and broader
scale.
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Planning questions:
Identify your Treatment Delivery Model:
Please discuss with your team the treatment
delivery model that your site plans to
implement and write a brief description. We
also recommend drawing a framework (e.g.
with boxes and arrows) of your program to
illustrate how the components will integrate
into the existing health care infrastructure.
Please include entry points to care as well as
community support services in the description
and framework.
• 1.2 Human Resources Management:
• Human resource capacity is a major constraint to scaling
up comprehensive HIV/AIDS care and treatment. An
ARV treatment plan that calls for significant additions in
physician or nursing staff to expand the healthcare
system capacity in order to provide quality care and
treatment to PLWHA by definition will not be scalable.
• It will be especially challenging to ensure that the
necessary HIV/AIDS clinic workers are found without
weakening the healthcare structure for other diseases by
pulling workers out of existing programs.
• Therefore, to strengthen the ART program,
local community members will need to be
recruited and trained in the details of
adherence to antiretroviral and recognition
of medication side effects. Once
adequately trained, these new ancillary
healthcare workers from local communities
can dramatically increase the potential of a
single physician or clinical officer to deliver
ARV to their surrounding communities
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Planning questions:
1.Identifying the ART Team:
Please describe the structure of the ART team
in full detail, defining the roles and
responsibilities of each member.IHVN
encourages the site to make an organizational
chart.
*Please refer to the programmatic budget
guidance for additional information
regarding staff structures.
• Members of the team
• Name of the person who will be coordinating
activities Responsibilities with regards to ART
• Project Coordinator
• Medical Officers and/or Clinical Officers.
• Nurse.
• Adherence counselors/Treatment Support Specialists
• Community Volunteers
• Pharmacy Staff.
• Strategic Information staff (M&E, data entry staff, etc)
• Laboratory staff
• Finance
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2 Human Resource Management:
Describe the LPTF plan for hiring, retaining, and
training site and community staff.
How will you recruit new staff?
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Advertise and call for interviews not at present but as the
programme expands.
How will you retain existing staff?
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What is your plan for training current and new staff, including
community volunteers?
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Integration into hospital scheme
E.g. Capacity building from donors
E.g. In-house training by hospital
Step down training from those who have benefited. *Please
refer to the programmatic budget guidance on training for
information about the types of training that IHVN will provide.
• 1.3 Identifying target populations for
ARTPlanning question:
1.Target population:
Please list the sub-groups of the
population targeted by the site for
ART care and Treatment.
• Sub-groups of population that ART
program will targetExample:HIV positive
children,Youths,Pregnant Women, People
Living with HIV / Support Group.
• Inclusion Criteria :
• Please discuss with your team the
medical and non-medical inclusion
criteria that your site plans to implement .
Please ensure that your criteria operate
within the National HIV/AIDS guidelines
and strategy for Nigeria.
• Items to consider for medical criteria:
clinical criteria, immune staging criteria,
asymptomatic pregnant women, etc.
• Items to consider for non-medical
criteria: demonstrated motivation to enter
care, disclosure status, substance abuse,
family support, geographic criteria, socioeconomic criteria, etc.
3.Patients on waiting lists for ART
• If your site has a waiting list of patients
eligible for ART, what determines the
order that patients are moved off the
waiting list and placed on ART (assuming
that all patients cannot be started on ART
at once)?
• 1.4 Patient Enrollment Projections
• Please complete a table for patient
enrollment per month for the next year.
• To achieve and maintain these outcomes,
consider the human resource capacity at
the site, the number of ART clinic days, the
number of outreach days, and the
community capacity for follow-up and
adherence monitoring.
• Months
• Number of adult patients initiated on
ART per month of the year.
• Number of pediatric patients initiated
on ART per month of the year.
• Eg,10 for jan,15 for feb,25 for march etc
• 1.5 Continuity of Care
• Antiretroviral therapy for AIDS has the ability to
transform AIDS from a fatal acute infection to a
long-term chronic condition. This transformation
requires a programmatic shift from provision of
acute care to a model of chronic care at many
sites. Several components of the treatment
model will directly support continuity of care,
such as integrating the ART program into holistic
HIV/AIDS approach, strengthening health care
networks, expanding community mobilization.
• Regular ART team meetings
• Sites are strongly encouraged to hold regular (e.g. twice
monthly) coordination meetings with key ART staff
involved in patient care, including clinical officers,
treatment support specialists, pharmacists, home-based
care coordinators, etc.
• At the meeting, the team discusses patient cases one by
one in order to coordinate care plans specific to each
patient. Due to time constraints, the team may decide to
discuss only certain patients, such as patients in a
specific catchment area, patients with adherence
problems, patients preparing to start or to re-start ART,
etc.
• For each patient, the staff makes a clear follow-up plan
based on the following:
• What are the causes of any adherence problem that this
patient is experiencing?
• how can the team help this patient succeed on ART?
• Is the problem serious enough to consider either
changing the patient’s regimen or stopping the ARVs
altogether until the problem is resolved?
• What follow up actions are necessary? Who is
responsible? By when?
• The team also provides oversight of equitable access to
care, including selection of patients who will commence
ART according to criteria and specific target groups
• 1.5.1 Patient flow: Monitoring patients on ARVs
• Please describe all of the steps that will be followed in
the first year to support a patient on ARV therapy to
ensure continuity of care by making a flowchart
illustrating the care of one patient over the course of
a year.
• Include the following details in the patient flow:
• Entry of the person into care (what departments or
organizations refer patients to AIDS care and treatment
services—e.g. VCT, PMTCT, TB clinic, etc)
• Initial clinical evaluation (where and by whom)
• Eg:next slide
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VCT, PMTCT, TB Clinics
Medical Officer’s evaluation
CD4 Test
Medical Officer’s evaluation criteria for
ART
• Treatment preparations (A/O, Counsellors)
• 1.5.2. Coordination of patient care and
communication flow
• Please plan how staff will communicate patient
appointments and follow up. Consider the
protocol to be followed in specific situations,
such as four examples outlined below:.
A clinician decides to switch a patient’s regimen.
How will this decision be communicated to the
rest of the ART team, in particular to the
adherence counselors (treatment support
specialists)? Who will inform the community
volunteer that supports the patient?
a. How will the ART team track what patients
have missed appointments? How will the team
follow up patients who have missed medical or
adherence appointments? Please give a
specific answer (e.g. who, when, how).
b. The ART team at the site discovers that a
patient has adherence problems and needs
more support. How and when will the ART
team inform a community volunteer to followup with this patient?
a. A community volunteer discovers that a
patient has adherence problems. How
and when will the community volunteer
inform the site staff about the problems
faced by this patient? Who on the ART
team will the community volunteer
inform?
• Part 2: Medical Care under the ART
Program
• Please follow your country’s National ART
Guidelines when completing this section.
IHVN clinical technical officers will work
with the site to complete this section.
• 2.1 Treatment Regimens
• How do you determine if someone is
clinically eligible.eg CD4<350.
• Regimens :
1st line regimen.
Alternate 1st line.
regimen for pregnant women.
regimen for TB patients.
• 2.2 Safety Monitoring:
• Please describe how the program will
monitor for toxicity in patients who
recently initiated ART. e.g. weekly
appointments for the first two weeks.
• How often will patients be monitored for
toxicity in the short term?
e.g. weekly appointment for the first 2
weeks.
• How often will patients be monitored for
toxicity over the long term?.
• Who will monitor the patient for toxicity?
E,g pharmacist.
• Please describe how the program will
monitor and address side effects of
specific drugs, including nevirapine, d4T
(stavudine), Alluvia, and efavirenz
• 2.3 Laboratory Monitoring
• Detail a proposed schedule for immunological and
other laboratory tests required for enrollment and
monitoring.
•
Refer to programmatic budget guidelines for
information about what kinds of laboratory tests
should be included in your site budget. Viral load
testing is not readily available in many sites.IHVN
will conduct viral load measurements to validate
programmatic success and to determine some
individual patient response to therapy.
2.4 Linking ART to PMTCT
•
Many sites are currently providing
PMTCT services, which are natural
starting points for initiating ART to
women in the 3rd trimester of pregnancy,
to newborns, and to their families. Plan
with members of your site team how the
ART program will coordinate care of
women and families between the PMTCT
and ART programs.
• Questions to discuss include the following:
• How will the site screen and enroll pregnant
women into the ART program?
• How will care be coordinated for pregnant
women participating in both the PMTCT and
ART programs?
• How will staff communicate with one another
about patient care? (e.g. Will the patient medical
record contain information from both services?)
• How will the mother receive follow-up care after
delivery (where, how often, who follows up?)
• How will the child receive follow-up care
after delivery? (where, how often, who
follows up?)
• Part 3: Strengthening your Adherence
program (preamble)
• Giving the patients the best chance to achieve
success on their first line regimen is critically
important, especially in light of limited viral load
monitoring and limited second line treatments. In
order to achieve and maintain durable viral
suppression, patients must take their ARV
regimen greater than 95% of the time.
• Several psychological, social, and physical
factors can influence patient adherence
behavior. To address these factors, the
site can strengthen specific components of
the adherence program that have been
shown to impact patient adherence :next
slide
• implementing on-going patient treatment
preparation and adherence education
• increasing the technical competence of ART
program staff regarding adherence monitoring
• promoting positive interpersonal relations
between the patient and the ART program staff
• integrating adherence support services into
other services
• ensuring continuity of care
• expanding community participation in adherence
support activities.
• Multiple strategies to support adherence can be
utilized depending on each site’s and
community’s needs. Developing human
resources as “adherence specialists” can be
accomplished through the training of community
members, hospital staff, or even patients’ family
members or guardians. Once adequately
trained, these new ancillary health workers can
dramatically increase the potential of a single
physician or clinical officer to deliver ARVs to
their surrounding communities.
• Site Planning Questions
• 3.1 Treatment Preparation
• Please outline the treatment preparation
plan, listing specific steps that a patient will
need to fulfill before starting ARVs. The
treatment preparation plan should prepare
the patient to adhere to ARVs and should
allow the staff to determine if the patient is
able to be adherent to ARVs.
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Specifically address how the following
activities will be conducted and by whom:
Patient education about ART, adherence,
and resistance
Patient education about side effects and
toxicity
Identification of treatment supporters
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Adherence “trials” with non-ART
medication (e.g. OI prophylaxis, vitamins,
etc)
Discussion of the patient’s daily schedule
and identification of a dosing schedule
-Find out about occupation, social life
and find out any limiting factor
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3.2 Monitoring adherence of patients
on ARVs
Who will be responsible for monitoring
patient adherence ?
What methods will be used to monitor
adherence levels of patients?
What materials or tools will be used to
record patient adherence?
• 3.3Patient Education:
• Please identify how your site can
establish or strengthen existing patient
and community education opportunities.
eg support group,TSS,Pharmacist.
• Part 4: Community Mobilization and Support for ART
(preamble)
• By integrating ART services into treatment networks and
community activities on the continuum of HIV/AIDS
prevention, care, and treatment, sites are positioned to
take a holistic approach to addressing HIV/AIDS.
• To obtain buy-in from the community, the site should
consider holding meetings with general community
members, People Living with HIV/AIDS, and community
leaders to plan the community component together.
Facilities may form a Community Advisory Board, which
provides important feedback to the
site from the community regarding
implementation and planning of programs.
• Site Planning Questions
• 4.1 Community responsibilities:
How aware is the community about the
AIDS services at your site, including
ART?
What role does the community see
themselves filling to support the ART
program?
How will your site support the community
in their responsibilities? (e.g. resources,
education, training, incentives, recognition,
etc)
What other roles does the site hope to
build within the community in supporting
the ART program, specifically the
adherence support component?
4.2 Community mobilization and stigma
reduction
• Please outline the steps that your site
will take this year to achieve the
Crosscutting issue of:
“Community mobilization promotes
an increased awareness of
accessible and affordable programs
and reduces stigma”
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4.3 Monitoring your community
program :
Please discuss how you will monitor and
evaluate the following :
Quality of adherence counseling and
follow-up by community volunteers
Quality and impact of community
mobilization activities,eg by doing comm.
surveys to assess stigma etc.
4.4Creation of treatment networks:
• Please outline the steps that your site
will take to achieve the objective :
“Health care treatment networks are
created and strengthened to support
capacity building within country and
communities.”
e.g. hiring of network coordinators.
• Part 5: Preparing your Laboratory for
ART
• Where will ART-related lab tests be
conducted?:
• on-site
• off-site laboratory not located at the facility.
• For site conducting labs on-site at the
facility:
• Have guidelines for infection control and
waste management been implemented at
your site? Establish sop for waste
management.
• Have you identified a referral or back-up
lab for CD4 and other tests? Establish one
• Do you have a forecasting and
procurement plan for obtaining the
necessary reagents? (Help site with
forecasting tool and attach to C and T
plan.)
• Have you implemented a quality
assurance protocol for laboratory
procedures and testing? IHVN lab to
support this.
• Are there any physical resource needs identified
during site assessment that need to be
addressed (e.g. electricity, space, etc)? If there
are,establish a mechanism to address this.
• * Quality assurance protocol for laboratory
protocol and testing should include an
equipment maintenance plan for laboratory
equipment, quality control
procedures/proficiency testing for staff, quality
control procedures/routine maintenance for
laboratory tests, and specimen tracking and
accountability plan(IHVN lab to assist)
• Part 6: Preparing your Pharmacy for
ART :
• Where will patients refill their AIDS
medications:
• on-site at the facility
• off-site pharmacy not located at the facility.
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Pharmacy capacity-building activities:
If applicable, have you made formal
linkages to referral pharmacies offsite ?
Are key staff working in the site
pharmacy trained in ARV supply chain
management ?
• Are there Standard Operating Procedures
for drug procurement? If No link up with
IHVN pharm. To develop one.
• Is there system for drug forecasting and
supply chain management? If no IHVN
pharm to assist.
• Is there a system for tracking drugs
dispensed to patients enrolled in the ART
program ? Dispensing tool.
• Is there a system for monitoring and
reporting adverse drug
reactions(pharmacovigillance).
• Does the site need to strengthen key
Standard Operating Procedures (SOPs)?
.If yes, link up with IHVN for support.
• Please list any skills-building topics
required from IHVN to help your pharmacy
staff .
• Part 7: Strategic Information Planning
(preamble)
• The monitoring and evaluation component of an
ART program provides accurate and timely data
to measure the effectiveness of the ART
program in producing optimal patient outcomes,
to measure the site’s contribution to the national
ART response, and to measure IHVN project’s
contribution to the goals of the President’s
Initiative.
• The general requirements of an HMIS system are the
following:
• The system captures the data needed to provide
monitoring reports to the various stakeholders, including
the Ministry of Health and PEPFAR reports required by
the donor representative and the Office of the Global
AIDS Coordinator (OGAC).
• The system can be easily re-programmed to
accommodate any changes in these donor reporting
requirements
• The system can capture, or be programmed to capture,
the clinical data needed byIHVN for quality
assurance/quality improvement purposes
• Site Planning Questions:
• What kind of HMIS system does your
site prefer to use?
Paper-based system
Computer-based system
Other (specify) --------------
• What paper forms will the site use? Does your
site plan to use any of the IHVN paper M&E
forms? (The IHVN clinical encounter forms are
encouraged, but not required. If other forms are
used, they must be able to fulfill reporting
requirements. )
• How will patient (paper) files be stored to
ensure confidentiality? Do you have enough
storage capacity to accommodate patient
(paper) files.
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Please outline the plan for
harmonization of the forms to capture
information required for:
monitoring reports to the various
stakeholders
clinical data needed by IHVN for quality
assurance/quality improvement purposes
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Please discuss plans for an automated
patient management system, if available
or supported through IHVN. In
answering this question, please consider
the issues below if applicable:
Plans to obtain administrative or political
buy-in
Plans to hire data manager or
administrator
• Plans to train data entry staff to use
electronic patient management system;
• Computers designated for M&E with
hardware specifications ;
• Other IT Capacity, Policies, and
Procedures
• Local IT vendor service
• Part 8: Financial systems preparation
• Have corrective actions been taken in
response to findings from the last audit of
the site? (Audit should have occurred
within the last 12-18 months.)
• Does the site have a method for
separately tracking funds from different
donors? (e.g. has specific donor codes
and/or separate bank accounts)
• Have the site finance and administrative
staff been trained on the reporting
requirements and accounting procedures
of the project?
• Does the site have an accounting system
that allows it to track/aggregate expenses
based on type of expense?
• Does the site have a chart of accounts that
enables the tracking of specific project
cost categories used for the ART project
(ie. Lab supplies, CD4 tests, specific lab
equipment, HIV tests, training).
• Does the site have a system that enables
the tracking of staff effort based on
activity/project( use of time sheet)
• Does the site have an accounting system
that enables the tracking of interest
income (interest earned on funds when
they are in the bank)?
• Does the site have an accounting system
that allows it to track fees for service
(program income) directly related to the
ART project?
• Does the site have a system to track/
manage inventory, including medical
inventory such as drugs and lab
equipment as well as other equipment and
supplies such as computers?
• Does the site have a written procurement
policy that ensures competitive bidding,
adequate support documentation, and
appropriate approval/oversight?