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