by Judith King, HSS Copy and Content Editor
"A commitment to quality patient care and to my own wellbeing as a Nurse fuels my passion for case management – not only as a clinical protocol, but also as a calling," says Nurse Clinician Sr Zama Ntuli, who is a Case Manager based at Pietermaritzburg's Central City Clinic.
Sr Ntuli is a Professional Nurse who is trained in Nurse-initiated Management of Antiretroviral Therapy (NIMART). She took up her post with HST in 2020, joining the SA SURE PRO Project, which partners with the Department of Health (DoH) in adopting case management as a compassionate approach to maintaining patients living with chronic conditions – such as tuberculosis (TB), non-communicable diseases (NCDs) and HIV – in care.
She also serves part of the Outreach Team, and recently joined a team that supports the implementation of case management in hospitals in uMgungundlovu District.
What is case management, and what does a Case Manager do?
Through close and regular communication with individual patients, Case Managers build trust to ground enduring relationships that support them in receiving and staying on treatment ‒ from the point of diagnosis for those with HIV and NCDs, and from a presumptive TB screening until voluntary discharge from managed care and 2.5 years after cure for patients with TB.
Such patients encounter many milestones in their treatment journey, so case management lays strong foundations for the clinical and psychological care of newly diagnosed patients who are beginning their treatment, and for those brought back into care after treatment interruption.
Recognising that simply providing medication cannot resolve patients' obstacles to adherence – such as stigma, pain, fatigue, depression, transport, nutrition, sleep disturbances, finances and family circumstances ‒ Case Managers guide patients through these issues with a comprehensive care plan, supporting them in their own care planning, and referring them for specialist attention if needed.
Sr Ntuli's daily activities
"My role is to provide care for patients who are on chronic treatment for communicable and non-communicable diseases. Newly diagnosed patients need pre- and post-test counselling to help them accept their status, and to understand their treatment journey, so I also assess their readiness to start treatment. I explain why it's important to take the medication, how to take it, the possible side-effects, and the goal of achieving viral suppression. Together, we create a treatment plan that best suits their personal circumstances."
Over a period of six months, Sr Ntuli checks on their progress either fortnightly or monthly, and once they are clinically stable, she registers them on the Central Chronic Medicine Dispensing and Distribution (CCMDD) programme for medicine collection on scheduled dates from convenient external pick-up points. They return to her once a year for viral load blood tests and clinical review.
"HIV-positive patients who miss their appointment dates, despite the reminders that we send them, are of great concern, because interrupted treatment carries the risk of drug resistance and HIV-associated illness," she says. "Once they return to the clinic after being traced telephonically or physically, I provide intense adherence counselling, and re-initiate them on treatment. Thereafter, two-weekly monitoring includes conducting a pill count to ensure that they are taking the medication correctly, with regular viral load tests."
Sr Ntuli also provides pre-exposure prophylaxis (PrEP) to HIV-negative clients, with the required counselling and education to ensure that they stay uninfected.
How case management supports patients' and healthcare workers' wellbeing
"As a Clinician, case management has enabled me to maintain regular consultation with the same patients for a holistic continuum of care," Sr Ntuli explains. "Patients feel well taken care of, because we build a trusting bond through which they are known and heard as individuals."
The case management process benefits the health service provider as well as the patient. "I can schedule my caseload to tend to 15 to 20 patients a day while making room for un-booked (walk-in) patients," she notes. "This shortens patients' waiting time and improves their health outcomes, and also makes my day run smoothly."
"In the clinic, the model helps us to close gaps in the care process, such as blood test results not being viewed, actioned, explained to the patient, or filed. This creates a working environment that supports my own wellbeing as a Nurse."
Active case management therefore strengthens health system efficiency by rationalising clinic flow, and decongesting the Chronic Stream area. "Case management helps to bond all facility staff within a shared value system, and provides managers with specific goals and sound direction in decision-making," says Sr Ntuli.
Addressing challenges
"The best way of dealing with the challenge of patients missing appointments and being clinically ill on their return," she says, "is empowering them with health education. It is critical to regularly test their viral load, and rapidly re-initiate them on treatment and monitor their appointment-keeping if they are virally unsuppressed ‒ this is the basis of case management. It can be difficult to trace some patients telephonically or physically, but we strive to find them, welcome them back to care, and provide counselling to boost their treatment adherence."
Sr Ntuli also notes the problem of patients seeking care at multiple facilities, which affects the care continuum, and the challenge of patients not having or bringing proper identification documents.
She addresses these issues by promoting patients' understanding of why things are done a certain way and why certain systems are put in place. "We also empower them on new health discoveries and why certain treatment solutions are changing," she says. "A respectful and kind manner goes a long way when explaining things to patients, so that they are open to receiving the information. They need reassurance that no matter what happens, we will face challenges together until the finish line, and as a Case Manager I am available to my patients 24/7."
A typical work-day
Sr Ntuli's day begins with check the appointment book to note how many patients' missed their appointment the previous day, and sending that list to the Tracing Team for telephonic and physical tracing. She also prepares and submits any required performance data and reports.
She draws up her daily schedule of patient consultations, reviews their individual blood-test results, and ensures that she has enough treatment supplies for all the patients expected.
Before embarking on the individual patient consultations, she gathers those who are already at the clinic for group health education, including a question-and-answer session.
At the end of each consultation for clinical review and support, she books the patient's next review date. Before the close of day, she compiles and submits her statistical reports, retrieves files for patients booked for the following day, and replenishes the required treatment stocks.
Future aspirations
"I want to further my studies by specialising in Midwifery and undertaking advanced HIV and TB care," says Sr Ntuli. "I'd also love to rove through our supported sub-districts to observe how the Case Management Model is being implemented in all facilities, and to mentor on how this model changes the lives of health service providers and patients.
She counts her family a blessing from God. "My inspirations are my mother, Busisiwe Ntuli and my son Melokuhle Ntuli, who have been extremely supportive throughout my career and always shown pride in even my smallest achievements. They have been there through the most difficult moments and my best days. I didn't get to where I am on my own, as I've had great mentors along the way: Mr Nkululeko Zulu, Sr Nokukhanya Ngcobo, Sr Qaqamba Mlambo and my Operational Manager, Sr Mancici Mlambo; I'm humbled by them seeing something in me which I sometimes fail to see in myself."
Sr Ntuli loves spending her leisure time with close family and friends, especially going on adventurous trips in the outdoors. On some weekends, though, she will be indoors binge-watching movies.
"I believe in working hard and persevering every day, not only because I want my supporters to be rewarded by what they have accomplished within me, but also so that my patients take part in their own success, and live full and healthy lives," she concludes.
---------------------------------------------------------------------------------------------------------
'Case management' is defined as:
"A collaborative process of assessment, planning, facilitation, care co-ordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes."
(Source: http://www.cmsa.org/who-we-are/what-is-a-case-manager/)
---------------------------------------------------------------------------------------------------------
The Case Management Model (CMM) – innovated by HST's uMgungundlovu District team – was highlighted at the March 2019 PEPFAR Country Operational Plan (COP) review meeting as a good practice for ensuring that patients achieve viral suppression.
Ignited by a 'change idea' for quality improvement to serve the Siyenza drive, the uMgungundlovu project team had developed and implemented a case management initiative which markedly boosted continuity of treatment among patients attending the district's focus clinics.
Based on these results, PEPFAR recommended that all its District Support Partners DSPs include this model in their districts, and all DSPs requested benchmark visits to observe application of the CMM in uMgungundlovu. The Health Minister instructed all DoH facilities to case-manage newly diagnosed HIV-positive patients for the first year of treatment.
As case managing is a role rather than a job title, every staff member in a facility has some responsibility for contributing to and supporting case management.