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TB Nurse Care Management

Clinicians, not the patient, are responsible for successful treatment of active tuberculosis (TB) disease. Nurse care management helps ensure adherence to the overall treatment plan. The CDC (Centers for Disease Control and Prevention) 2016 guidelines for treatment of drug-susceptible TB recommend care management for all patients with active disease. This is to ensure successful treatment and safety of the patient and public. Care management for TB is complex. Nurse case managers connect patients with needed clinical and social services throughout treatment. TB care management includes:

  • Providing ongoing patient education.
  • Providing directly observed therapy (DOT).
  • Creating a plan for treatment that takes into consideration a patient's values, needs, culture, and beliefs.
  • Appropriately using available resources, including enablers and incentives, to help patients complete treatment.
  • Determining the risk of infectiousness to others and evaluating those who are at risk for infection and disease.
A smiling nurse check a patient's blood pressure.

Please watch "TB 101" webinar, part of the Wisconsin TB Program's TB Tuesday training series, for an introduction to TB and LTBI concepts.

Public health nurses at local health departments usually perform the nurse case management role.

They coordinate care between the treating physician, the health department, social service workers, infection control nurses, and other specialists involved in the care of the patient.

DOT is the standard of care for treatment of all forms of active TB disease. DOT increases the number of patients cured and completing treatment, as well as increasing the likelihood that the patient’s bacterial load, especially the number of live bacteria in the patient’s respiratory specimens, will decrease over time. Wisconsin statutes and Wis. Admin Code § DHS 145.10(6)(b) state that the local health officer or the health department may require a person to receive DOT.

WTBP recommends performing DOT seven days a week for two weeks at the initiation of treatment. After two weeks, DOT can be decreased to five days a week during the intensive phase (first two months of treatment). During the continuation phase (after first two months of treatment), DOT can be further decreased, if necessary and appropriate for the patient. See Table 2 in the 2016 CDC guidelines for more information.

Electronic or video DOT (eDOT or vDOT) is the use of electronic technologies to remotely monitor TB patients ingesting their medication, either in real time or recorded. There are multiple technologies available to administer vDOT. Some patients will use their own personal device, as long as the technology is compatible with the health department’s technology and patient security and privacy are not compromised. Depending on the resources of the local health department (LHD) and patient, smartphones, tablets, or computers with webcams can be used.

See Wisconsin Electronic Video Directly Observed Therapy (eDOT) P-03325 (PDF) for the Wisconsin TB Program recommendations for use of eDOT. Some reimbursement through the TB Dispensary is available for vDOT, see Attachment F TB Dispensary Policies and Procedures. Eligibility for vDOT will depend upon LHD legal approval, experience in TB case management, and overall nursing experience.

There are important criteria that patients should meet before considering medication administration by vDOT:

vDOT inclusion criteria

Treatment history must include:

  • Completed intensive phase (for active TB); vDOT may be started earlier if all inclusion criteria (below) are met an all exclusion criteria are ruled out.
  • Demonstrated medication adherence while on in-person DOT (100% adherent).

Other inclusion criteria

  • Motivated to have vDOT.
  • At least 18 years of age.
  • Ability to effectively communicate with the patient without language barriers.
  • Patient is able to identify each medication accurately and describe possible side effects.
  • Patient is able to demonstrate proper use of technology used for vDOT.
  • Privacy guaranteed (other people not able to see or hear) or waiver form signed.
  • Reliable internet or telephone connection.

Exclusion criteria

Patients meeting the criteria below should NOT be considered for a vDOT regimen:

  • Regimen includes intermittent dosing for active TB disease (i.e., doses are given three or fewer times per week).
  • Adherence issues with DOT or related issues (missing appointments, dishonesty, inappropriate use of technology)
  • Less than 18 years old (minor)
  • Language barrier
  • Medical condition that puts patient at increased risk for adverse reaction (for example, AIDS, poorly controlled diabetes, cancer, dialysis)
  • Substance abuse, incarceration, homelessness, unstable housing
  • Memory impairment or psychiatric concerns
  • Medication intolerance or adverse reaction
  • Risk for hepatic complications (alcohol or liver disease)
  • Disabled or unable to fully participate in vDOT, such as vision impairment or other physical challenges
  • Court-ordered therapy

For more information on eDOT, see the CDC eDOT Toolkit.

Resources

Questions about TB?

Email dhswitbprogram@dhs.wisconsin.gov
Phone: 608-261-6319
Fax: 608-266-0049

Glossary

 
Last revised October 1, 2024