ART/TB Initiation Counseling Patient-centered ART Initiation and Adherence counseling model
Transcript
ART/TB Initiation Counseling
Patient-centered ART Initiation and Adherence counseling model
ObjectivesAt the end of the training you will be able to:
– Know the structure of the adapted ART/TB Initiation counseling model
– Know what all the tools are, and use them appropriately– Understand the importance of the Adherence Plan and
how to complete it with the client– Apply the 14 steps to assist the client to complete the
counseling sessions– Perform ART/TB initiation counseling and PMTCT
counseling
How many squares do you see?
Presenter
Presentation Notes
Notes for presenter: There is no one right answer. This activity is called Perspective Squares. It shows you how we all see things differently. This shows us also that we as healthcare workers may see things differently to how our patients see them. We are all a product of our own life experiences and lessons. Understanding that everyone experiences and sees things differently is important. It can help you have an open mind when dealing with different people. This is the approach we want to keep in mind through the training, and as we offer counseling.
Rationale for a adapted counseling model
Think about your counseling at the moment:
• What counseling support do your patients need?- Post-initiation support- Challenging social circumstances- Problem-solving- Co infection with HIV/TB (or other conditions)
• What do you think are the qualities of a good counselor?
Presenter
Presentation Notes
NOTE this is an animated slide Have participants brainstorm answers to questions
Overview of adapted modelwith a new approach toward patients, putting them at centre in
order to find solutions to their problems
Structure Approach Tools Training Mentoring
Overview Assist in integrating
treatment into their lives
Focus on encouraging
patient ownership of
treatment process
Supportive not prescriptive
Acknowledges practical
barriers to adherence
Assist patient in addressing barriers to adherence
Take home messages clear
Presenter
Presentation Notes
Wanted to create a model that shifts the way we think about being on treatment, A model that is SUPPORTIVE, that it focused on…. (give overview of each point) Lets understand how each of the 5 key areas have been revised…
Structure
Limit number
of preparat
ion sessions
Strengthen post-initiation
support (active
learning on treatment)
Allows for fast
tracking without compromising
content
Presenter
Presentation Notes
We kept 4 sessions, Limited preparation sessions Strengthened post initiation support Allowing for fast tracking without compromising content
Session 1A-B-(C)Pre-ART
Day of diagnoses
Day of eligibility
Day of initiation
HIV testing and counselling
Session 2: ART initiation
Month 1 on treatment
Month 6on treatment
Session 3: 1st adherence FU
Session 4: 2nd adherence FU
Detectable VLEnhancedAdherenceCounseling
Adherence counselling Standard track
4 to 7 days
3 to 7 days
Clinical Management
CD4 count
Consultation By MA/CO forTB screening &Staging
ARTInitiation
ARV Refill
ARV Refill
Viral Load (6M)
30 days
M2/M3/M4/M5
Presenter
Presentation Notes
We kept 4 sessions The timing of the sessions is different – less pre ART prep and more post ART initiation support We wanted to improve post initiation support Encourage active learning while on treatment Above diagram is an example of timing between the sessions in this model – adapt to suit your setting.
Approach
Limit time spent on repeated treatment
literacy
Patient centered
readiness to initiate
14 simple specific
adherence support steps to address
Presenter
Presentation Notes
We are now going to review the approach adopted in this counseling model – a patient centered approach This model introduces a more structured approach to cover 14 of the most common adherence challenges patients face while integrating treatment into their life – NOT going to go through each content point now.
Approach: ABC’s of adherence
Identify the GOAL
Identify the BARRIERS to achieving the goal
Work on making a PLAN to
overcome the barriers
Presenter
Presentation Notes
How do we adopt this NEW approach to counseling? We are using an updated strategy to look at adherence Trying to shift the thinking about being sick and on treatment to investing in health and well-being. We use the ABCs of adherence – Goal, Barriers, Plan Aim is to empower the patient by encouraging them to create their own solutions/plans
ABC’s of adherence in practiceAdherence Step 7 - Storing medication and extra dosesReview adherence goal
“It is important to identify a convenient place to store medication so that you have easy access and are easily reminded”
Identify barriers
“Where could you keep your medication at home?”
“How could you carry your medication when you go out?”
Make a concrete plan
Identify safe and convenient place to store drugs at home or at place where patient usually takes his/her drugs
Identify a place to carry extra doses of drugs, what to keep them in - in case patient does not make it in time to usual storage place (e.g. envelope in pocket of woman’s bag, plastic bag in man’s backpack or jacket he usually wears)
Presenter
Presentation Notes
Use an example like “storing medicines” to show how ABCs of adherence – Goal, Barriers, Plan – can be used to aid adherence planning
Tools
• Simplified flipchart (HIV/ART, TB, PMTCT)
• Session guide (for lay counselors)
• Adherence plan (put in patient file)
ARV Patient Education Flipchart
• Simplified flipchart for group/individual educational session• Limited to treatment literacy for Session 1A only
Presenter
Presentation Notes
Not to go through details now – just to show the tool
TB Flipchart
Presenter
Presentation Notes
Not to go through details now – just to show the tool Provides simplified messages for patients initiating TB treatment
Flipchart for PMTCT ART Initiation
• Covers general PMTCT information in addition to routine ART adherence messages
• For group/individual educational session
Presenter
Presentation Notes
1min - Not to go through details now – just to show the tool
Adherence Plan
• For patient file
Presenter
Presentation Notes
Not to go through details now – just to show students where they can find the tool in their training pack
Session guide for counselors
• Step by step guide
• Structured in ABC approach (goal, barrier, plan)
Presenter
Presentation Notes
Not to go through details now – just to show students where they can find the tool in their training pack
1. I want to be alive for my children
2. I need to be able to earn3. I want to see my children
grow older
Adherence steps
• Adherence steps are associated with 3 reasons to stay healthy and alive
• Move away from treatment focus, but rather on why…
Presenter
Presentation Notes
Activity: close your eyes, think about what is important in your life – think about the goals you would want to achieve, people who you’d like to support. When you think of these things, put together 3 reasons why you would want to stay healthy and alive.
Mentoring tools
Counselor observation tool
• Who is responsible for this?– MSF Patient Support Officers are responsible for
providing mentorship to the lay counselors at the facilities
• How is this completed?– Observation of sessions– Feedback on sessions– Develop goals with counselor to strengthen/improve
counseling
Overview complete!
Presenter
Presentation Notes
Stop here for Counseling Model Overview Prestentaion
Building Session 1A
ART/TB Initiation and Adherence Counseling Model
Brainstorm!
What is the most important information a patient
should learn and know about HIV?
Presenter
Presentation Notes
Definition of HIV, CD4, viral load, healthy living, adherence, etc. Let’s see if all that information fits into our literacy session…
Session 1
• 3 parts to session 1 (A + B + C - All done on same day)
Notes for presenter: Ask class to go to the overview of counseling sessions table in their Counseling Manual Show how Session 1 has 3 parts Take class through the content of session 1 (main headings) in the detailed session plan section of their Counseling Manual
Review flipchart
• In pairs read through Flipchart together
Presenter
Presentation Notes
Notes for presenter: Split class into pairs with one ART/TB flipchart between 2 – Ask each pair to review the flipchart together and ask questions to facilitators as required – 2 facilitators go round the room to answer queries and check teams are progressing Instruction for students: Remember to start from the very cover page – overview of the colours and what they stand for – this is your first introduction to the components of the flipchart AND the patients learning Encourage the class to just focus on carefully reading through the information on the flipchart for this exercise – to ensure they don’t miss any new/updated information and to familiarize themselves with the details before they have to do it in front of patients.
End of Building Session 1A
Next time to Role Play Session 1A
Presenter
Presentation Notes
Stop here
Session 1 A: Review • When do we do Session 1A?
– As soon as eligible patient referred to counseling
• What tools are needed?– Flipchart
• Remember to start from the cover page.
• Start with overview of the colours/images and what theystand for – this is your first introduction to the components ofthe flipchart AND the patient’s learning
Presenter
Presentation Notes
Notes for the presenter: Remind the participants to READ READ READ! They must try for the training, to just focus on reading, we know they know the information, but we want them to give the training a chance.
Notes for presenter: 60 minutes – 5mins for instructions, 40mins for role play, 15mins for feedback and discussion on session1A Instruction to the class: Go into pairs Tools you will need to complete this session: flipchart, counseling manual. Turn to the page in your counseling manual with the detailed session plan for session 1A - You will see instructions on use of the flipchart throughout this session. Remember the use of the flipchart in this session ends BEFORE the Viral Load part. Viral Loads are not discussed in session 1A – this is discussed in Session 4. In your pairs, decide who will be the counselor and who will play the patient for this exercise. Take your time to read through the steps in your session plan Role Play: Facilitators go round the room to answer queries and check teams are progressing Feedback session: Ask each group in turn to share what they found helpful/not with Session 1A As you move from group to group for feedback ask for additional points – to avoid repetition Ask class to comment on each feedback given – does anyone agree or disagree
End of Role Play Session 1A
Next Building Session 1B
Presenter
Presentation Notes
Stop here
Building Session 1B
ART/TB Initiation and Adherence Counseling Model
Brainstorm!
What should a patient know or learn about their treatment journey?
What are the most common challengesthat a patients faces when learning to
take their treatment?
Presenter
Presentation Notes
Notes for presenter: Encourage the group to all participate Exercise is designed to help the class build the adherence steps included in session 1B Encourage participation by asking: What do you think is important to know about taking your own treatment (no matter what its for)? Write all points on the board
Overview of Adherence Plan
Presenter
Presentation Notes
Notes for presenter Present the Adherence Plan sections applicable to Session 1B - My 3 reasons to stay healthy and alive & Session 1 after ART education session Tick off each point the group raised that coincides with the topic covered in the Adherence Plan Congratulate and thank the class for their participation - Now you have ‘built’ the Adherence Plan
End of Building Session 1B
Next time to Role Play Session 1B
Presenter
Presentation Notes
Stop here
Session 1B Role Play
– When do we do Session 1B? • Immediately after 1A
– Work through session with your partner (each person has a turn at being the counselor)
– Use your manual -READ, READ, READ !!
Presenter
Presentation Notes
Notes for presenter: 60 minutes – 5mins for instructions, 40mins for role play, 15mins for feedback and discussion on Session1B Same as with Session 1A role paly Tools: Adherence plan, counselor session guide Role play working through the session Encourage the class to simply read the manual at this stage – do not go “off script” – familiarize yourself with the manual 1st, once you know it, you can then improvise.
End of Role Play Session 1B
Next Session 1C Discussion
Presenter
Presentation Notes
Stop here
Session 1C
• How soon after patient says ‘they are not ready to start ART’ do we do Session 1C?Immediately
• Why do we need session 1C? Give the patients time and space to share the
reasons why they are not ready to start treatmentAllows us to better understand their reasons for
non-readiness
Presenter
Presentation Notes
Notes for presenter: Explain that Session 1C is for patients that say they are not ready to start ART Give 1-2 mins for students to offer answers to the questions before presenting them Main points to stress: Never allow the patient to leave after they say they are not ready – go immediately into session 1C If after the session they say they still need time to decide, try to fix an appointment for them to come to you again
Session 1C
• How do we do this? – Allow the patient to share– Give a listening ear to the patient– Share other patients stories (testimonies) of
having overcome barriers to starting treatment– Work together to make a plan to overcome their
reasons for non-readiness
Presenter
Presentation Notes
Notes for presenter: Encourage discussion around each of these points Ask class: do you agree or disagree Can you give examples of how you would do this
Session 1C
• GROUP or INDIVIDUAL : why?• Tools: session guide, testimonies, • Overview of session:
– Invite the patient to share why they don’t feel ready– Choose the testimony that best fits their needs/reasons– Read the testimony– Discuss the way forward to overcoming these reasons
Presenter
Presentation Notes
Notes for presenter: Discuss the reasons for individual or group sessions: if you put two or more people in a group they often have compatible traits (same reasons for non readiness, age, gender, language etc.). commonalities help people share openly
Day 1 complete!
Welcome to Day 2
Recap of Day 1
• How many sessions are in the model?
• What is the order of the sessions?
• Name 4 adherence steps
• What are the ABCs of Adherence?
• Name tools!
Recap of Day 1ART/ TB Treatment Counseling Model contains:
• Sessions: 4 sessions- 1 education session, 1 day initiation, 2 post initiation follow-up
• Tools: flipchart (2), counselor session guide, adherence plan
• Approach: patient-centered, supportive, address the common adherence challenges, focus on reasons to be healthy and alive
• ABCs of Adherence: Goals, Barriers, Plans
Building Session 2
ART/TB Initiation and Adherence Counseling Model
Session 2
• When do we do Session 2? - On the day of treatment initiation
• Which tools are needed? – Session guide, Adherence Plan
• Review all content covered in: Adherence Steps 5-9- Medication schedule- Managing missed doses- Reminder strategies- Storing medication- Dealing with side effects
Presenter
Presentation Notes
Notes for presenter: 60min Exercise Take class through the content of Session 2 as detailed in the Counseling Manual – Read out the steps Emphasize use of Adherence ABCs (Goal, Barriers, Plan) in each step Update the counselors on new information Medication schedule – if taking BD meds, the duration between the doses doesn’t have to be 12hrs – can simply pick morning and evening times that suit your schedule best Managing missed doses: regardless of when you remember – take your treatment, why? Its about having enough ARVs in your body to prevent multiplication of virus – no calculation of hours needed Reminders strategies: do the activity, ask counselors where would THEY put the stickers to remind them – (stickers can be replaced by a piece of fabric or any item readily available in your setting) Storing medication – plan for energencies Dealing with side effects: important thing to remember is, communicate with your treatment team at facility, DON’T stop your treatment
Session 2 Role Play
• Introducing Observation and Feedback (discussion)• In groups of 3 role-play the session:
• 1 counselor• 1 patient• 1 observer
– Observer asks counselor: how did the session go? What went well, what could improve?
– Observer report back: give your own feedback, make goals with the counselor to work on progress.
Presenter
Presentation Notes
90 minutes 5mins for instructions 60mins for role play (each student gets 30mins) 20mins for feedback and discussion on Session 2 (10 mins after each round out role play) Instruction to the class: Go into pairs (different from pairs used in day 1) Tools you will need to complete this session: Counseling manual and Adherence Plan – ideally use same adherence plan as you used in day 1 Turn to the page in your counseling manual with the detailed session plan for session 2 Each person should get a chance to be the counselor with session 2 lasting 25mins Role Play: Facilitators go round the room to answer queries and check teams are progressing Feedback session: Ask each group in turn to share what they found helpful/not with Session 2 As you move from group to group for feedback ask for additional points – to avoid repetition Ask class to comment on each feedback given – does anyone agree or disagree Discuss the value of feedback and its importance for counselor professional development and quality assurance in counseling
End of Role Play Session 2
Next Building Session 3
Presenter
Presentation Notes
Stop here
Session 3
• When is session 3 completed? – First adherence follow-up appt.
• Which tools are used? – Session guide, Adherence Plan
• Content covered in: Adherence Steps 10-12• Planning for trips• Dealing with substance use• Communicating with Treatment Team
Presenter
Presentation Notes
Notes for presenter: 60min exercise Take class through the content of Session 3 as detailed in the Counseling Manual – Read out the steps Point out use of Adherence ABCs (Goal, Barriers, Plan) in each step Main points to stress: Planning for trips: planned and unplanned travel. You (patient) can prepare to ensure you remain on treatment while travelling Dealing with substance use: remember the difference between substance USE and substance ABUSE. We are talking about USE – there is no interaction between alcohol and ARVs, the issue is about remembering to take your treatment and to making a plan to ensure you take your treatment when you plan on using substances. BUT if you asses the patient to have a problem or suspect ABUSE, seek out resources to available in your setting to support these patients - refer and talk to clinicians at facility Communicating with team: we want to enable the patients to ask anyone in their treatment team the questions they have
Session 3 Role play
• Go into pairs
• Different pairs from those in Day 1
• Each person should get a chance to be the counselor – Session 3 lasts approx. 20mins
Presenter
Presentation Notes
90 minutes 5mins for instructions 60mins for role play (each student gets 30mins) 20mins for feedback and discussion on Session 3 (10 mins after each round out role play) Instruction to the class: Go into pairs (different from pairs used in day 1) Tools you will need to complete this session: Counseling manual and Adherence Plan – ideally use same adherence plan as you used for Session 2 Turn to the page in your counseling manual with the detailed session plan for session 3 Each person should get a chance to be the counselor with session 2 lasting 20mins Role Play: Facilitators go round the room to answer queries and check teams are progressing Feedback session: Ask each group in turn to share what they found helpful/not with Session 3 As you move from group to group for feedback ask for additional points – to avoid repetition Ask class to comment on each feedback given – does anyone agree or disagree
Day 2 Feedback
• What are your overall thoughts on the sessions practiced today (session 2 and 3)?
• Did you like the structured session plan?
• What would you do differently?
Presenter
Presentation Notes
Notes for presenter: Congratulate class for their participation so far Now time to have an informal discussion on how they found the day Facilitators take notes for their own learning – can be applied to adapting the course/counseling in the future
Day 2 complete!
Welcome to Day 3
Recap of Day 2
Presenter
Presentation Notes
30mins Open up to the class to shout out what they remember from day 2. Write points on the white board and clarify any errors or points of confusion Key points to recall: Medication schedule Managing missed doses Reminder strategies Storing medication Dealing with side effects Planning for trips Dealing with substance use Communicating with Treatment Team
Session 4
• When is session 4 completed? – Final adherence follow-up appt.
• Which tools are required? – Session guide, Adherence Plan, Flipchart
• Content covered in: Adherence Steps 13-14• Preventing any future problems with taking treatment• Education on Viral Load • Continuation Phase (TB)
Presenter
Presentation Notes
Notes for presenter: Take class through the content of Session 4 as detailed in the Counseling Manual – Read out the steps Point out use of Adherence ABCs (Goal, Barriers, Plan) in each step Main points to stress: Preventing future problems: its normal to have negative feelings and thoughts when you make a mistake or forget to take your treatment, how would you work through those feelings to try again Viral load section has accompanying pages in the ART/TB Flipchart
Session 4 Role play
• Go into pairs
• Different pairs from those in Day 1
• Each person should get a chance to be the counselor – Session 4 lasts approx. 20mins
Presenter
Presentation Notes
90 minutes 5mins for instructions 60mins for role play (each student gets 30mins) 20mins for feedback and discussion on Session 4 (10 mins after each round out role play) Instruction to the class: Go into pairs (different from pairs used in day 1) Tools you will need to complete this session: Counseling manual and Adherence Plan – ideally use same adherence plan as you used for Session 2 Turn to the page in your counseling manual with the detailed session plan for session 3 Each person should get a chance to be the counselor with session 2 lasting 20mins Role Play: Facilitators go round the room to answer queries and check teams are progressing Feedback session: Ask each group in turn to share what they found helpful/not with Session 3 As you move from group to group for feedback ask for additional points – to avoid repetition Ask class to comment on each feedback given – does anyone agree or disagree
Feedback
• What are your overall thoughts on the sessions practiced today (session 4) ?
• Did you like the structured session plan?• What would you do differently?
Presenter
Presentation Notes
30mins Congratulate class for their participation so far Now time to have an informal discussion on how they found the day Facilitators take notes for their own learning – can be applied to adapting the course/counseling in the future
Recap!
• How many sessions are in the model?
• What is the order of the sessions?
• Name 4 adherence steps
• What are the ABCs of Adherence?
• Name tools!
Recap: patient flow
Counseling is
IMPORTANT
How do patients move in your facility?
How are they referred to counseling
What can we do to make
sure they come to counseling?
Session 1A-B-(C)Pre-ART
Day of diagnoses
Day of eligibility
Day of initiation
HIV testing and counselling
Session 2: ART initiation
Month 1 on treatment
Month 6on treatment
Session 3: 1st adherence FU
Session 4: 2nd adherence FU
Detectable VLEnhancedAdherenceCounseling
Adherence counselling Standard track
4 to 7 days
3 to 7 days
Clinical Management
CD4 count
Consultation By MA/CO forTB screening &Staging
ARTInitiation
ARV Refill
ARV Refill
Viral Load (6M)
30 days
M2/M3/M4/M5
Presenter
Presentation Notes
We kept 4 sessions The timing of the sessions is different – less pre ART prep and more post ART initiation support We wanted to improve post initiation support Encourage active learning while on treatment Above diagram is an example of timing between the sessions in this model – adapt to suit your setting.
Role Play Session 1 to 4
Presenter
Presentation Notes
60mins Opportunity for class members to role play on front of others and receive constructive feedback Options for how to structure this session: Have class split into groups of 3 – one is the observer, one is the patient, and one is the counselor. After each session is complete, the group gives feedback to the person playing the counselor role in that session. Class members volunteer to role paly the session in front of the rest of the class. Whole class gives feedback on their session on completion. Facilitators stage an ‘ideal counseling session’ for the class – class gives critical feedback and asks questions on completion of the session Encourage the class to give feedback to each session by answering the following: How do you think it went? What was good? What was challenging? Ways it can be improved?
Day 3 complete!
Welcome to Day 4!
Brainstorm!
What is the most important information a pregnant patient
should learn and know about HIV?
Review our PMTCT Guidelines
Presenter
Presentation Notes
Replace with PMTCT Guidelines for your setting as required
Key messages for PMTCT
• Start ART early!
• Breast is still best! Exclusive breastfeeding for first 6 months
• Give your baby ARVs after birth
• Deliver in a health facility
• Stay on ART for life to protect mom, baby and partner!
Questions?
Presenter
Presentation Notes
Allow the class to ask questions – clarify points of confusion
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