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IMAI Sequence of Care

IMAI Sequence of Care. Task shifting, division of labor, and the role of non-clinicians on the care team. The Care Team. COMMUNITY SERVICES. Patient. Designated MD with substantial ART experience (first months). Health centre. District Outpatient Clinical Team. Consult, refer,

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IMAI Sequence of Care

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  1. IMAI Sequence of Care Task shifting, division of labor, and the role of non-clinicians on the care team

  2. The Care Team COMMUNITY SERVICES Patient Designated MD with substantial ART experience (first months)

  3. Health centre District Outpatient Clinical Team Consult, refer, back-refer, visit MD, MO ART Aid RN, medical aid (CO) RN, medical aid (CO) ART Aid

  4. Nurse Offer HIV testing and provide pre-test counselling ANC and PMTCT Clinical review of symptoms and signs Determine HIV clinical stage and functional status Assess adherence to medications Drawing and processing of blood samples Manage symptoms according to Acute Care guidelines Pre-screen for ART eligibility; refer for ART initiation Completion of HIV Care/ART Follow-up Form Community Counsellor HIV testing and post-test counselling Register new patients in the Pre-ART register Discuss disclosure Explain treatment, follow-up care Support chronic HIV care Assess and support adherence to prophylaxis and ART Prevention education (safer sex, condoms) Link with community services Update Pre-ART and ART registers Who does what at the clinic?

  5. Triage Education and support Assess Review pregnancy status Review TB status Provide clinical care Give prophylaxis ART Manage chronic problems Arrange Prevention Sequence of Care—11 steps

  6. Non-clinicians Clinicians Sequence of care

  7. Clinicians Doctor Health Officer Nurse Non-clinicians (potentially filled by PLHA) ART Aid Triage/receptionist Data clerk Members of the Care Team

  8. Triage/Data Clerk • When patients come to the clinic, someone greets them, locates their HIV Care/ART card, finds out why they have come, and weighs them. After the evaluation, this person can transfer the relevant data from the HIV Care/ART Card to the register.

  9. Triage/Receptionist Sequence of care

  10. ART Aid • Given the importance of patient education and the time required for effective adherence support, it is advisable to have one or more additional team members who can work as ART Aids. A specialized counsellor is not necessary; an ART Aid can be a nursing assistant or PLHA or other lay provider who has gone through the IMAI ART Aid course.

  11. ART Aid Sequence of care

  12. Nurse/midwife • In the IMAI approach, these cadres do clinical staging, monitor adherence, provide patient education, and recommend or initiate first-line treatment in uncomplicated patients under the supervision of a health officer/clinical officer or a doctor.

  13. Nurse/midwife Sequence of care

  14. Doctor • Even if not stationed at the facility, a doctor needs to take responsibility for the care, make frequent visits to supervise, be a clinical mentor (reviewing cases, answering questions, etc), be available for consultation on cases, and be responsible for substitutions and for switches to second-line treatment.

  15. Health Officer/Clinical Officer • Provides supervision to the rest of the care team, initiate first-line treatment and manage adverse effects under the supervision of the doctor.

  16. Sequence of care Doctor or Health Officer/Clinical Officer

  17. Dispenser • In a small health centre, dispensing may be done by a clinician. In a larger health centre or a district hospital, dispensing is often done by a pharmacist technician, supervised by a pharmacist.

  18. Sequence of care Dispenser

  19. ART Aid • Increased need of HR in the context of scale up • ART Aids (counsellors, health educators, PLWA) are often more effective than doctors and health officers/clinical officers at patient education and adherence support. • Basic ART Aid Course is designed for people with little or NO clinical background—LAY PROVIDERS can become ART Aid • Can provide important insights during team meetings about "difficult" patients.

  20. ART Aid • speaks the same language patient as the patient • comes from the community to the clinical team • is a link with the community • knows what is available at community level • progressively learns what is needed at community level for ART and HIV care scale up • inform patients and the rest of the clinical team on the community services • advocates with community stakeholders

  21. Roles of the Basic ART Aid • Adherence preparation (includes ART preparation and initiation) • Monitoring and supporting patients on ART • Post-test and on-going psychosocial support • Patient education on HIV/AIDS, disclosure, prevention, and positive living in the context of clinical care • Triage • Peer support • Community support

  22. What is needed to integrate community members more effectively? • Lay provider needs to "formally" integrated in the health system with regular jobs as trainers and ART Aid. • "Emergency" policy decisions to create new posts for LP in the context of the clinical team and for community support and education

  23. Task Shifting • Improves team efficiency, which: • Is more convenient for the patient • Increases the number of patients that can be cared for by one team • Decreases costs • For optimal team efficiency: # of non-clinicians > # of clinicians

  24. Acute Care vs. Chronic HIV Care Quick circuit vs. Regular circuit Triage

  25. Regular Circuit • For: • Patients with OI's • Patients starting or recently starting ART • Patients with ART toxicity • Triage → ART Aid → Nurse → [HO/CO if necessary] → Dispenser • 40-60 minutes

  26. Regular Circuit Sequence of care

  27. Quick Circuit • For: • Stable patients in Chronic HIV Care needing refills of cotrimoxazole • Stable patients with > 3 months of ART without toxicity or OI's • Triage → ART Aid → Dispenser • 10-15 minutes

  28. Quick Circuit Sequence of care

  29. Community-based Refills and Monitoring • For: • Stable patients in Chronic HIV Care or ART who live far away from the health facility. • Refill and counselling provided by a community health worker or community volunteer • Coordinated by someone at the health facility • Decrease patient load within health facility, but requires time and resources to train and coordinate community volunteers

  30. Community-based refills and monitoring Sequence of care

  31. Which cadre will be: • Providing first-level facility HIV care/ART- nurses, clinical officers, medical assistants, other…? Will they be initiating first-line ART or only recommending? • Providing patient education and support, adherence preparation and support (ART counselling)—lay providers on clinical team, nursing assistants, nurses, other… • District MD/MO on clinical team

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