Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

Establish the treatment plan, ensuring that all the components are included. The case
manager should ensure that the treatment plan is useful and meaningful. It becomes the
internal standard of care for the patient as well as the performance standard for the case
manager. 30 DOT is the standard of care for all TB cases and suspects.
Establish time frames in the treatment plan to monitor the plan and patient
response. Monitoring should be done at least monthly at the patient’s home, ambulatory
clinic, health department, or health care provider’s office. When itinerant PHNs provide
case management for patients in villages, monthly monitoring can be done by
teleconference in conjunction with the CHAP or DOT aide, phone, or may be done by
the patients’ provider. Each component of the plan should be reviewed to ensure that it
is an accurate accounting of the patient’s problems, required tests, and interventions. To
track progress toward outcomes, document all treatment activities and their dates:
medications taken, tests and results, patient visits, monitoring activities, side effects,
adverse reactions, education sessions, social service referrals, incentives, enablers,
isolation status changes, and patient problems. 31
Adjust the treatment plan as needed, to meet new realities. Since patient
circumstances are usually fluid and personnel resources often change over time, it is
essential that the plan be negotiated with the patient and changed to adjust to new
situations. The adjusted plan should be discussed with the team members, as well as
the patient. 32
A L A S K A T B P R O G R A M M A N U A L Case Management 10. 16
R e v i s e d N o v e m b e r 2 0 1 2