GETTING STARTED: PLANNING SUPPORTIVE CARE FOR PEOPLE WITH DR-TB AT NATIONAL LEVEL

1. GETTING STARTED: PLANNING SUPPORTIVE CARE FOR PEOPLE WITH DR-TB AT NATIONAL LEVEL PHOTO: FHI 360

2. Webinar topics • Quick review of the comprehensive supportive care framework • Steps in planning implementation at the national level • Considerations for monitoring & evaluation of supportive care • Keys to success—advice from pilot countries • Resources • Q&A PHOTO: PATH

3. Four Thematic Areas 13 comprehensive care elements • Monitoring/treatment of side effects • Patient nutritional support • Monitoring/treatment of co-morbid conditions • Physical rehabilitation • Palliative & end-of-life care for people who cannot be cured • Patient assessment & care plan • Education/treatment literacy • Treatment at location of choice • Respectful, compassionate communication • Monitoring/treatment of mental illness • Address social isolation and need for emotional support • Protection from stigma and discrimination • Financial assistance

4. Global level Agreement on four key thematic areas for comprehensive supportive care for DR-TB and the elements of supportive care for each area Local or facility level Adapt the national package to local circumstances; develop a local implementation plan with clear roles and responsibilities for delivering services Individual patient level Assess patient for needs in each thematic area and work in partnership with the patient to develop an individual care plan incorporating the available services that best meet that person's specific needs and preferences Operationalizing the Package National or regional level Assess the current status of patient support; decide what interventions are feasible for the program to implement to cover each element for each thematic area and create an appropriate package of supportive services

5. Operationalizing in-country

6. Steps in implementation planning at national level • Identify your stakeholders, orient them to the supportive care framework, and get their buy-in • Identify a Task Force to develop, revise, and finalize the national supportive services package and get stakeholder agreement on the package • Analyze your policy, human resource, and material needs to prepare for implementation • Incorporate supportive care in national guidance documents and legal frameworks, as appropriate, and assign responsibility for implementation oversight • Choose locations where package implementation will begin or expand • Develop an implementation plan and budget • Identify funding sources • Plan how to monitor and evaluate your supportive services • Use the lessons learned to continue improving upon the services delivered • Develop an advocacy strategy and plan for sustainability of the supportive care package from the beginning

7. 1. Identify stakeholders, orient to the framework and get buy-in • NTP • Other MOH divisions, other government entities • Technical partners • Local implementing organizations • Other community partners • Private health services • Professional organizations • Academic institutions • Corporations or other for-profit entities • Donors • Affected community representatives

8. 2. Task force/working group to develop the package of services to be offered, based on country epidemiology, patient needs, feasibility • What is the epidemiology of DR-TB in your country? • How are you performing on finding people with DR-TB? • Once they are found, how many are initiated on treatment? • How many are completing their treatment successfully? • What are your targets and how far are you from them? • Where are the gaps, and can supportive care help fill them?

9. Philippines 2015

10. Now what do we do? • Identify the factors that are contributing to low treatment success for MDR/RR-TB • Analyze and interpret your data • TALK to people or use studies if they have been done (like in the Philippines) • Frontline providers • Community-based organizations and implementers • People with MDR/RR-TB • Decide which factors are amenable to intervention, what is feasible, and which of those will have the greatest impact for the most people • Identify which factors can be addressed by implementing elements of supportive care

11. Quality care for people with DR-TB • DR-TB prevention through adequate treatment of DS-TB • DR-TB prevention through infection control and contact evaluation and treatment • Quality rapid diagnostics • Trained clinicians and health workers • Free, high-quality drugs with new and shortened regimens • aDSM and prompt treatment of side effects • Supportive care until cure • Ongoing monitoring following cure

12. 3. Analyze your policy, human resource, and material needs to prepare for implementation • Are there any policy or legislative changes needed for implementation? • What human resources will be required to implement, and are they already available and trained, available but need training, or need to be hired and trained? • What resources will be necessary to deliver supportive care (e.g. rooms, nutritional supplements, bicycles for home visits, phone cards, etc.)

13. 4. Incorporate supportive care into national guidance/legal frameworks • Supportive care included in NSP and legal frameworks as appropriate • National guidance defines: • Who should receive – eligibility criteria for supportive services • What they should receive – elements that are highest priority at country level • Who should deliver – roles and responsibilities • How services should be delivered – In-patient vs outpatient vs community-based • Funding streams available/to be used for implementation • Training and materials required/available to support implementation

14. 5. Choose locations to begin or expand supportive care services • Develop criteria for site selection, for example: • Interest/commitment from site • Readiness for implementation in terms of staffing, training, supplies, capacity for monitoring • Burden of DR-TB • Past performance

15. 8. Plan how to monitor and evaluate supportive services • Improvements in DR-TB patient clinical outcomes as a result of supportive care by comparing baseline/historical outcomes to post-implementation outcomes • Improvements in patient satisfaction by comparing baseline patient survey results to post-implementation patient survey results  • The feasibility and acceptability of the comprehensive care package in your setting by surveying frontline clinicians and health managers  • Other indicators relevant to your specific interventions • Indicators that can help you with advocacy (e.g., cost of services/patient)

16. 9. Use the lessons learned to improve delivery of supportive services • Multidisciplinary approach – HCW input to encourage buy-in and continuous quality improvement • Real-time review of data to make ongoing course corrections • Focus on quality and outcomes • Share results with policy makers and funders to advocate for allocation of support when benefits are demonstrated

17. 10. Plan for advocacy and sustainability • Do so EARLY in the process • Engage key decision-makers from the outset • Gather the data that can make a compelling argument for funding • Provide updates throughout the process, not just at the end • China CDC endorses patient-centered care in their TA and guidance for the national TB programming • NCTB has highexpectationsfor the NAP pilot’s contribution to field experiences to inform an evidence-based, China-specific MDR-TB patient care model • NCTB plans to expand the approach nationwide with domestic funding Patient-Centered Care Endorsed by NTP

18. Keys to success – advice from pilot countries • Time and patience! • Spending time getting the needed approvals and buy-in at all levels • Participatory orientation and planning • Adequate training of frontline staff in key areas, particularly counseling • Clear, written instructions and SOPs • Ongoing supportive supervision by the country team • Being flexible, listening to feedback and adapting as needed to meet local needs • Seeing tangible benefits in terms of improvements in performance and patient satisfaction • Feedback and celebration of successes

19. Keys to success – advice from pilot countries (2) • Common understanding of the issues and the need for supportive care, based on experience • Considering local needs as the primary starting point for developing services • Being realistic but ambitious about what is feasible • Adapting and finding short-cuts for the Patient Assessment and Care Plan • Using a multidisciplinary team approach to service provision • Training and partnering with community organizations to deliver care package interventions • Using an electronic case-based information management system • Ongoing monitoring and analysis of data for real-time improvements • Starting small and learning what works and what doesn’t before expanding

20. Care Package guidance document • Part 1: Delivering Comprehensive Supportive Care to People with Drug-resistant Tuberculosis (Practical Guide) • Part 2: Operational Toolkit • Step-by-step instructions • How-To guides for each element of supportive care • Service Status Assessment and Planning template • Rapid Systems Assessment tool • Local Operational Plan template • Patient Assessment and Individual Care Plan template • M&E Guide http://ghpro.dexisonline.com/resource/delivering-comprehensive-supportive-care-people-drug-resistant-tuberculosis-0

21. How the Practical Toolkit can help

22. How the Practical Toolkit can help (2)

23. How the Practical Toolkit can help (3)

24. “…we had our own dreams about how to provide patient care and to address…stigma and the high interruption rate…now, the patient-centered DR-TB package has made those dreams a reality…” Doctor at Matlala Hospital, Limpopo Province, South Africa