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IMAI Sequence of CareIMAI Sequence of Care
Task shifting, division of labor, and Task shifting, division of labor, and the role of non-clinicians on the the role of non-clinicians on the
care teamcare team
The Care Team The Care Team
Clinical Officers , nurses and midwives
Medical Doctor
ART Aids(NAs, Counsellors, Health assistants
CO
MM
UN
ITY
SE
RV
ICE
S
Patient
Designated MD with substantial ART experience (first months)
ARTAid
MD, MO
District Outpatient Clinical Team
RN, medical
aid(CO)
RN, medical
aid(CO)
ARTAid
Consult, refer, back-refer, visit
Health centre
Who does what at the clinic? Who does what at the clinic?
NurseNurse Offer HIV testing and provide pre-Offer HIV testing and provide pre-
test counsellingtest counselling ANC and PMTCTANC and PMTCT Clinical review of symptoms and Clinical review of symptoms and
signssigns Determine HIV clinical stage and Determine HIV clinical stage and
functional statusfunctional status Assess adherence to medicationsAssess adherence to medications Drawing and processing of blood Drawing and processing of blood
samplessamples Manage symptoms according to Manage symptoms according to
Acute Care guidelinesAcute Care guidelines Pre-screen for ART eligibility; refer Pre-screen for ART eligibility; refer
for ART initiationfor ART initiation Completion of HIV Care/ART Completion of HIV Care/ART
Follow-up FormFollow-up Form
Community CounsellorCommunity Counsellor HIV testing and post-test HIV testing and post-test
counsellingcounselling Register new patients in the Pre-Register new patients in the Pre-
ART registerART register Discuss disclosureDiscuss disclosure Explain treatment, follow-up careExplain treatment, follow-up care Support chronic HIV careSupport chronic HIV care Assess and support adherence to Assess and support adherence to
prophylaxis and ARTprophylaxis and ART Prevention education (safer sex, Prevention education (safer sex,
condoms)condoms) Link with community servicesLink with community services Update Pre-ART and ART Update Pre-ART and ART
registersregisters
Sequence of Care—11 stepsSequence of Care—11 steps
1.1. TriageTriage
2.2. Education and Education and supportsupport
3.3. AssessAssess
4.4. Review pregnancy Review pregnancy statusstatus
5.5. Review TB statusReview TB status
6.6. Provide clinical careProvide clinical care
7.7. Give prophylaxisGive prophylaxis
8.8. ARTART
9.9. Manage chronic Manage chronic problemsproblems
10.10. ArrangeArrange
11.11. PreventionPrevention
Sequence of care Sequence of care Non-clinicians Clinicians
Members of the Care TeamMembers of the Care Team
CliniciansClinicians DoctorDoctor Health OfficerHealth Officer NurseNurse
Non-clinicians Non-clinicians (potentially filled by (potentially filled by PLHA)PLHA) ART AidART Aid Triage/receptionistTriage/receptionist Data clerkData clerk
Triage/Data ClerkTriage/Data Clerk
When patients come to the clinic, When patients come to the clinic, someone greets them, locates their HIV someone greets them, locates their HIV Care/ART card, finds out why they have Care/ART card, finds out why they have come, and weighs them. After the come, and weighs them. After the evaluation, this person can transfer the evaluation, this person can transfer the relevant data from the HIV Care/ART Card relevant data from the HIV Care/ART Card to the register. to the register.
Sequence of care Sequence of care Triage/Receptionist
ART AidART Aid
Given the importance of patient education Given the importance of patient education and the time required for effective and the time required for effective adherence support, it is advisable to have adherence support, it is advisable to have one or more additional team members one or more additional team members who can work as ART Aids. A specialized who can work as ART Aids. A specialized counsellor is counsellor is notnot necessary; an ART Aid necessary; an ART Aid can be a nursing assistant or PLHA or can be a nursing assistant or PLHA or other lay provider who has gone through other lay provider who has gone through the IMAI ART Aid course. the IMAI ART Aid course.
Sequence of care Sequence of care ART Aid
Nurse/midwifeNurse/midwife
In the IMAI approach, these cadres do In the IMAI approach, these cadres do clinical staging, monitor adherence, clinical staging, monitor adherence, provide patient education, and recommend provide patient education, and recommend or initiate first-line treatment in or initiate first-line treatment in uncomplicated patients under the uncomplicated patients under the supervision of a health officer/clinical supervision of a health officer/clinical officer or a doctor.officer or a doctor.
Sequence of care Sequence of care Nurse/midwife
Doctor Doctor
Even if not stationed at the facility, a Even if not stationed at the facility, a doctor needs to take responsibility for the doctor needs to take responsibility for the care, make frequent visits to supervise, be care, make frequent visits to supervise, be a clinical mentor (reviewing cases, a clinical mentor (reviewing cases, answering questions, etc), be available for answering questions, etc), be available for consultation on cases, and be responsible consultation on cases, and be responsible for substitutions and for switches to for substitutions and for switches to second-line treatment. second-line treatment.
Health Officer/Clinical OfficerHealth Officer/Clinical Officer
Provides supervision to the rest of the care Provides supervision to the rest of the care team, initiate first-line treatment and team, initiate first-line treatment and manage adverse effects under the manage adverse effects under the supervision of the doctor.supervision of the doctor.
Sequence of care Sequence of care
Doctor or Health Officer/Clinical Officer
DispenserDispenser
In a small health centre, dispensing may In a small health centre, dispensing may be done by a clinician. In a larger health be done by a clinician. In a larger health centre or a district hospital, dispensing is centre or a district hospital, dispensing is often done by a pharmacist technician, often done by a pharmacist technician, supervised by a pharmacist. supervised by a pharmacist.
Sequence of care Sequence of care
Dispenser
ART AidART Aid
Increased need of HR in the context of scale up Increased need of HR in the context of scale up ART Aids (counsellors, health educators, PLWA) ART Aids (counsellors, health educators, PLWA)
are often more effective than doctors and health are often more effective than doctors and health officers/clinical officers at patient education and officers/clinical officers at patient education and adherence support. adherence support.
Basic ART Aid Course is designed for people Basic ART Aid Course is designed for people with little or NO clinical background—LAY with little or NO clinical background—LAY PROVIDERS can become ART Aid PROVIDERS can become ART Aid
Can provide important insights during team Can provide important insights during team meetings about "difficult" patients.meetings about "difficult" patients.
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
Roles of the Basic ART AidRoles of the Basic ART Aid
Adherence preparation (includes ART Adherence preparation (includes ART preparation and initiation)preparation and initiation)
Monitoring and supporting patients on ARTMonitoring and supporting patients on ART Post-test and on-going psychosocial supportPost-test and on-going psychosocial support Patient education on HIV/AIDS, disclosure, Patient education on HIV/AIDS, disclosure,
prevention, and positive living in the context of prevention, and positive living in the context of clinical careclinical care
TriageTriage Peer supportPeer support Community supportCommunity support
What is needed to integrate community What is needed to integrate community members more effectively?members more effectively?
Lay provider needs to Lay provider needs to "formally" integrated in "formally" integrated in the health system with the health system with regular jobs as trainers regular jobs as trainers and ART Aid. and ART Aid.
"Emergency" policy "Emergency" policy decisions to create new decisions to create new posts for LP in the posts for LP in the context of the clinical context of the clinical team and for community team and for community support and education support and education
Task ShiftingTask Shifting
Improves team efficiency, which:Improves team efficiency, which: Is more convenient for the patientIs more convenient for the patient Increases the number of patients that can be Increases the number of patients that can be
cared for by one teamcared for by one teamDecreases costsDecreases costs
For optimal team efficiency:For optimal team efficiency:
# of non-clinicians > # of clinicians# of non-clinicians > # of clinicians
TriageTriage
Acute Care Acute Care
vs. vs.
Chronic HIV CareChronic HIV Care
Quick circuit Quick circuit
vs. vs.
Regular circuitRegular circuit
Regular CircuitRegular Circuit
For:For:Patients with OI'sPatients with OI'sPatients starting or recently starting ARTPatients starting or recently starting ARTPatients with ART toxicityPatients with ART toxicity
Triage → ART Aid → Nurse → [HO/CO if Triage → ART Aid → Nurse → [HO/CO if necessary] → Dispensernecessary] → Dispenser
40-60 minutes40-60 minutes
Sequence of care Sequence of care Regular Circuit
Quick CircuitQuick Circuit
For: For: Stable patients in Chronic HIV Care needing Stable patients in Chronic HIV Care needing
refills of cotrimoxazole refills of cotrimoxazole Stable patients with > 3 months of ART Stable patients with > 3 months of ART
without toxicity or OI'swithout toxicity or OI's
Triage → ART Aid → Dispenser Triage → ART Aid → Dispenser 10-15 minutes10-15 minutes
Sequence of care Sequence of care Quick Circuit
Community-based Refills and Community-based Refills and MonitoringMonitoring
For: For: Stable patients in Chronic HIV Care or ART who live Stable patients in Chronic HIV Care or ART who live
far away from the health facility.far away from the health facility.
Refill and counselling provided by a community Refill and counselling provided by a community health worker or community volunteerhealth worker or community volunteer
Coordinated by someone at the health facilityCoordinated by someone at the health facility Decrease patient load within health facility, but Decrease patient load within health facility, but
requires time and resources to train and requires time and resources to train and coordinate community volunteerscoordinate community volunteers
Sequence of care Sequence of care
Community-based refills and monitoring
Which cadre will be:Which cadre will be:
Providing first-level facility HIV care/ART- Providing first-level facility HIV care/ART- nurses, clinical officers, medical nurses, clinical officers, medical assistants, other…? Will they be initiating assistants, other…? Will they be initiating first-line ART or only recommending?first-line ART or only recommending?
Providing patient education and support, Providing patient education and support, adherence preparation and support (ART adherence preparation and support (ART counselling)—lay providers on clinical counselling)—lay providers on clinical team, nursing assistants, nurses, other…team, nursing assistants, nurses, other…
District MD/MO on clinical teamDistrict MD/MO on clinical team