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Follow-up after training and Follow-up after training and supportive supervisionsupportive supervision
The IMAI District Coordinator The IMAI District Coordinator CourseCourse
Strengthening Health SystemsStrengthening Health Systems
District focus: Fills gaps and complements District focus: Fills gaps and complements existing training/modules for specialized doctors, existing training/modules for specialized doctors, higher resource settings; for home-communityhigher resource settings; for home-community
Builds on and strengthens routine health Builds on and strengthens routine health servicesservices
Focus on building a district system withFocus on building a district system with Clinical teamsClinical teams Referral, backReferral, back--referral; improved communication referral; improved communication
Regional Referral Hospital
District Hospital
District Hospital
District Hospital
Health Centre
Health Centre
Health Centre
Health Centre
Health Centre
Health Centre
Health Centre
Health Centre
Health Centre
First-level health workers
Clinical team may include nurse and ART Aid at first-level and doctor at second-level
Second-level health workers
DISTRICT HOSPITAL
Doctors/medical officers/inpatient RN
HEALTH CENTRE Clinical care—nurses, medical assistants;
ART counsellors (ART Aids)
COMMUNITY Treatment supporters, community health workers, peer support
groups, CBOs, advocates
CENTRAL / PROVINCIAL Specialised referral (physicians,
pediatricians, subspecialists)
Referral, back-referral, clinical mentoring
Patient monitoring
Drugs, diagnostics,
commodities, logistics support
National, Regional and District ART Management
Individualised care for patients
A Public Health approach facilitates broad coverage and enables the majority to access care and ART
Some patients will develop complex problems and need specialist input to their clinical or psychosocial management
Mentoring: Specialists in apex or tertiary centres linked with district generalist clinicians
Referral: complex cases referred upwards for specialist care and management
It is not either specialist services or a public health approach – it is both together
Planning for scale up Planning for scale up Preparing the community Preparing the community Establishing collaboration with partnersEstablishing collaboration with partners Planning capacity buildingPlanning capacity building Establishing distance communication for clinical team Establishing distance communication for clinical team
supportsupport Follow-up support and supervision after trainingFollow-up support and supervision after training Medicines, diagnostics and health suppliesMedicines, diagnostics and health supplies Patient monitoring Patient monitoring Orienting and optimizing entry pointsOrienting and optimizing entry points Prevention accelerationPrevention acceleration
The IMAI district coordinator course:The IMAI district coordinator course:
Administrative and managerial tasksAdministrative and managerial tasks
Preparation before training
Training
Follow-up after training:•District/regional management-
supportive supervision to sites: clinical, drug supply managementpatient monitoring
•Clinical supervision •Facility accreditation•Health worker certification•Team to team exchange•Other QA methods
Community/PLHA/stakeholder/other programme involvement
Setting targets and choice of sites for
HIV Care/ART
Preparation IMAI training
Choose clinical teams, plan training by cadres
Logistics: maintaining the supply of drugs, diagnostics, equipment
Establish good communication for clinical team support
Patient monitoring system: registers, reports, data use
IMAI Training by cadre
and team
On-site visits after trainingMentorship
Team to team support
Prevention acceleration
Orient and optimize entry points
Evaluation
Patient MonitoringPatient Monitoring
Supportive supervisionSupportive supervisionCollection/aggregation of reportsCollection/aggregation of reports
Regional Office
District Coordinator
Hospital
HC HC HC
Monthly report, cohort analysis
Aggregate data
Aggregate data
National Office
Aim of Clinical MentorshipAim of Clinical Mentorship
As part of emergency HIV care/ART scale-up, As part of emergency HIV care/ART scale-up, mentorship is aimed tomentorship is aimed to:: Support decentralized delivery of HIV care, ART and Support decentralized delivery of HIV care, ART and
prevention with quality of care at all levelsprevention with quality of care at all levels Build capacity of primary-care providers to manage Build capacity of primary-care providers to manage
unfamiliar or complicated cases by consultation and unfamiliar or complicated cases by consultation and on-site management where appropriateon-site management where appropriate
Promote and facilitate ongoing learning, skill Promote and facilitate ongoing learning, skill development and quality promotiondevelopment and quality promotion
Health Centre
Health Centre
Health Centre
Regular mentoring visits provided by experienced clinicians at the regional level
Regional Referral Hospital
Regular supportive supervision provided by the existing district management team (e.g. district medical officer, district matron)
Basic administrative subunit: the district
External mentors (e.g. expatriate) paired with local mentors on initial visits if sufficient expertise does not exist at regional level
District Hospital
Observe case management and reinforce skills
Observe case management and reinforce skills
Clinical case review
Clinical case review
Clinical team meeting
Clinical team meeting
Review patient monitoring system
Review patient monitoring system
Document the visit Document the visit
Sequence of steps in the clinical mentoring visitSequence of steps in the clinical mentoring visit
Agreed minimum essentialdata elements
What happens to the data
Indicators or other aggregated data
1.Entry point 2.Why eligible for ART 3.Reasons for:Substitution within first-lineSwitch/Substitution to or within second-line STOP ART1.Number and weeks of each ART treatment interruption2.Pregnancy status 3.Start/stop dates of prophylaxis: •Cotrimoxazole•Fluconazole•INH•TB treatment •Adherence on ARTSource: II. HIV Care, III. ART Summary, IV. Patient Encounter and Family Status
Transferred to pre-ART or ART register but used only by clinical team /district ART coordinator—not transferred to quarterly report or cohort analysis
Indicators for patient and programme management at the facility/district level:Distribution of entry points in patients enrolled in HIV careWhy eligible for ART: clinical only, CD4 or TLCDistribution of patients not yet on ART by clinical stage•Distribution of reasons for substitute, switch, stop to investigate problems; whether substitutions and switches are appropriate (use in context reviewing medical officer log)•ART treatment interruptions:
Number/Percentage of patientsNumber weeks
Percentage of pregnant patients linked with PMTCT interventions (or simply use to generate lists to assure linkage)Number on cotrimoxazole, fluconazole, INH prophylaxis at end of quarter (for ordering prophylaxis drugs)Number/Percentage of patients on both TB treatment and ART3b. % patients with good adherence to ART