Nursing Case Management: Impact on Adherence and · PDF fileMichigan HIV Clinical Nursing Conference Nursing Case Management: Impact on Adherence and Care Kathy Forrest ... medical

MichiganHIVClinicalNursingConference

NursingCaseManagement:ImpactonAdherenceandCare

KathyForrest,MSN,MA,RNMay19,2017

1

Acknowledgements:GailDenkins,RN,BS;HIVHealthCoordinator,MDHHSandJenniferLangholz,BSN,RN;NurseCaseManager,MercyHealthPhysicianPartners-InfectiousDisease

Disclosure

Noconflictofinterestisdisclosedbytheauthorforthispresentation

2

LearningGoals

Attheconclusionofthispresentation,nurseswillbeableto:

• DescribethefoundationalprinciplesofnursecasemanagementanditsvalueinthecareofpatientswithHIVandSTDs

• Determineappropriateinterventionsforselectedclinicalexamplesusingconceptmappingwithcolleagues

• EvaluateconceptsandstrategiesforapplicationtopatientsinpracticewithHIVandSTDs

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Foundational Principles of Nurse Case Management

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Nurses’Role

• Centralroleinhealthcaredelivery• Uniquelypositionedtoassistpatientsandfamilieswithchroniccaremanagement

• Healthsystemshiftingtoemphasisonprimarycarewithcaredeliveredbyhighlyfunctioningteams

• RNleadingateam-based,patientcenteredapproachtocare

5MacyFoundation.2016.JosiahMacyAnnualReport.http://macyfoundation.org/docs/annual_reports/2016_Josiah_Macy_Annual_Report_Final.pdf

Whatiscasemanagement?

• Acollaborativeprocessofassessment,planning,facilitation,carecoordination,evaluation,andadvocacy foroptionsandservicestomeetanindividual’sandfamily’scomprehensivehealthneedsthroughcommunicationandavailableresourcestopromotequality,cost-effectiveoutcomes.

CaseManagementSocietyofAmerica(CMSA),2016:http://www.cmsa.org6

CommissionforCaseManagementCertification(CCMC)

• “Casemanagementisacollaborativeprocessthatassesses,plans,implements,coordinates,monitorsandevaluatestheoptionsandservicesrequiredtomeettheclient’shealthandhumanservicesneeds.Itischaracterizedbyadvocacy,communication,andresourcemanagementandpromotesqualityandcost-effectiveinterventionsandoutcomes.”(CommissiononCaseManagerCertification[CCMC],2010,p.3)

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PhilosophyofCaseManagement

UnderlyingPremise:“Whenanindividualreachestheoptimumlevelofwellnessandfunctionalcapability,everyonebenefits:theindividual,theirsupportsystems,thehealthcaredeliverysystemandreimbursementsources”(cmsa.org).

Thecasemanageristhefacilitatoroftheprocess!

CaseManagementSocietyofAmerica(CMSA),2016:http://www.cmsa.org 8

CaseManagementBodyofKnowledge

• KnowledgeDomainsofCMSpecialtyPractice– Casemanagementconcepts– Principlesofpractice– Healthcaremanagementanddelivery– Healthcarereimbursement– Psychosocialaspectsofcare– Rehabilitation– Professionaldevelopmentandadvancement

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CommissiononCaseManagerCertification[CCMC],(2017).Retrievedfromhttps://www.cmbodyofknowledge.com/content/case-management-knowledge-2

ACAandCaseManagementACA:intendedtobroadencoverageforallregardlessofpre-existingcondition;reduceMCRandMCAspending;reducehospitalcosts;reducereadmissionratestohospitals;improvepatientoutcomes;improvedqualityofcareandserviceCaseManagement:CoordinationandCollaborationofhealthcareservicesusingthecasemanagementprocess• Advocacyandeducation:insurancecasemanagervpatientcarecase

manager(CaseManagementAdvisor,2015)• Bridgingthegapbetweeneffectivecareandreimbursementchallenges• Educationtoincreaseawarenessofhealthplans,navigatehealthcare

system• Diagnosisrelatedstrategicplanningtoreducereadmissions• Guidingcaretopromoteself-management,smoothtransitions,and

coordinationofcare• Focusonhomecareservicestoreducehealthcarecosts• Valuedrivencaretransformation:CMsimproveclinicalcareoutcomes

andimprovepatients’experiences

Phillips&Fitzsimons(2015).TheAffordableCareAct:ImpactonCaseManagers10

HealthCareReform:CaseManager

• ExpandstheroleofCaseManagerUsingdata:

– Improvesclientconditionandoutcomes– Improvesfinancialpositionoforganization–Providesreturnoninvestment(ROI)

11CMSA,2015

CaseManagementModelTheContinuumofHealthCareandProfessionalCaseManagement

CaseManagementProcess

§ Assess§ Plan§ Collaborate§ Implement§ Monitor§ Evaluate

12CaseManagementSocietyofAmerica(2016).StandardsofPracticeforCaseManagement.Cmsa.org

WithintheWalls BeyondtheWalls• Acutecare

– Utilizationofservices– Dischargeplanning– Transitionplanning– Episodicvsintegrated– Unitspecific:(throughput)

• Emergencydepartment• Admittingdepartment• Peri-operativeareas(pre-

anesthesia,intra-operative,andpostsurgical)

– Diseasespecific– PhysicianGroup– Combinationofabovecomponents

– Outpatientservices– Ambulatorycare

• Physicianpractices– Community

• Faithbasedorganizations• Publichealthorganizations• ElderDaycare

– Payor-based:HMO,privateinsurance

– Longtermcare/Rehabilitation– AssistedLivingCenters– HomeCare– Telehealth&TelephonicCM

ModelsofCaseManagement

13Powell&Tahan,2010

TheChronicCareModel

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Improvingchroniccare.org

OutcomesofOptimalCMPractice• ThreeTargetGoals

– 1.Qualitycare/WellnessPromotion– 2.Accesstoappropriatehealthcareservices– 3.Costefficiency/financialresourceuse

• OutcomesoftheCaseManagementProcess– Qualityofcare– Collaborationamonghealthcareteammembers– Fiscalresponsibilities– Patientandfamilyadvocacy– Outpatient/community-basedcare– Professionalpractice

Source:Powell,S.andTahan,H.(2010).Essentialcasemanagementjobresponsibilitiesandskills.CaseManagement:APracticalGuideforEducationandPractice.(3rd ed.,p.35-68). 15

AdvantagesofCMPractice• AcrossalllevelsofcareCaseManagementhasseveraladvantages:– Focusonwellness, optimizingQOL,function,independenceandautonomy

– Preventivepracticestodetourorpreventproblems– Fewerhospitalreadmissions/preventadmissions– Lessacuityuponadmission– Resources tonavigatehealthcaresystem– FewerEDvisitsand911calls– Maximizereimbursement– Lowercostsofprovidingcare

Source:Powell,S.andTahan,H.(2010).OverviewofCasemanagement.CaseManagement:APracticalGuideforEducationandPractice.(3rd ed.,p.10). 16

RegardlessofCareorPracticeSetting

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• CaseManagementincludes:– Outcomesorientedcaredelivery– Appropriateresourceallocation/utilization– Comprehensivecareplanning:assessment,interventionsand

linkingtoneededresources– Integrationandcoordinationofcaretoeliminatefragmentation– Collaborationacrosscareprovidersandsettings– Advocacy toensureneededservicesareobtained/outcomes

met– Useoflicensedprofessionalascasemanager– Compliancewithstandardsofaccreditationandregulatory

agencies– Effectivecommunicationacrossproviders,caresettingand

includingthepatient/family– Consumerandstaffsatisfaction

CategoriesandDomainsRoles,ResponsibilitiesandFunctions

• 5BroadCategories oftheCMRoles/Responsibilities– 1.ClinicalCareManagement– 2.ManagementandLeadership– 3.FinancialandResourceManagement– 4.InformationManagement– 5.ProfessionalResponsibilities

• 6Domains ofCMRolesandFunctions– 1.Casefindingandintake– 2.ProvidingCMservices– 3.OutcomesEvaluation/ClosingCase– 4.UtilizationManagement– 5.PsychosocialandEconomicIssues– 6.Vocationalconceptsandstrategies

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CMCertification-CCM

• Nationalcertification• Demonstratesadherencetostandardsofcasemanagementpractice

• Validatesknowledge,educationandskillsinspecialtypractice

• Demonstratesprofessionalcompetence• Boostyourprofessionalcareer

19CommissionforCaseManagerCertification(CCMC):www.ccmcertification.org

TitleProtection

• CaseManagertitle- - advocacyworkunderway• PA499of2016

– RecognizesClinicalNurseSpecialistsinthePublicHealthCode,specialtycertification

– “Clinicalnursespecialist-certified”meansanindividualwhoislicensedasaregisteredprofessionalnurseandwhohasbeengrantedaspecialtycertificationasaclinicalnursespecialistbytheMichiganboardofnursing

– AllowsspecificAPRNactivities(prescribing;rounds;orders)

• Nurse(RN)versusmedicalassistant- -thinkofitintheseterms

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PA0499:http://www.legislature.mi.gov/documents/2015-2016/publicact/pdf/2016-PA-0499.pdf

CASEMANAGEMENTVALUEINCAREOFPATIENTSWITHHIVANDSTDS

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ContinuumofHIVCare

Not inHIVCareEngagedinHIVCare

NotawareAwareofHIV ReceivingsomeEnteredHIVCyclical,FullyengagedofHIVinfectioninfectionmedicalcare;care; losttointermittentinHIVcare

(notincare)notHIVcarefollow upcareforHIV

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AdaptedfromEldred&Malitz(2007),HealthResourcesandServicesAdministration(HRSA)continuumofHIVcareascitedinGardner,McLees,Steiner,delRio,&Burman(2011).ThespectrumofengagementinHIVcareanditsrelevancetotest-and-treatstrategiesforpreventionofHIVinfection.ClinicalInfectiousDisease,52(6),793-800.

Known• Asof2015,1.2millionpeopleinUSwerelivingwithHIV:1in

8wereunaware(CDC,2017)• Duringtheperiodof2005-2014,theannualnumberofnew

HIVdiagnosesdeclined19%(CDC,2017)• Availabilityofpotentantiretroviraltherapy(ART)resultsin

remarkabledecreasesinHIV-relatedmorbidityandmortality(CDC,HIVSurveillance,2016);UNAIDS,2016)

• EntryintoHIVmedicalcareandretentioniscriticaltoprovisionofART

• AdherencetoARTisakeycomponenttodeterminesuccessfulHIVoutcomes

• IdentifyingpotentialgapsintheHIVcontinuumofcareandpreventingthemisimportanttoimprovedoutcomes

Thompsonetal,2012;CentersforDiseaseControlandPrevention[CDC],2017;CDC,2016;Gardneretal.,2011;UNAIDS,2016) 23

Statistics• 38%personswithHIVinU.S.achievedviralsuppression(UNAIDS,2016)

• OfthosewhoknewtheyhadHIV,69%linkedtocare;only59%retainedincare(ascitedinThompsonetal.,2012)

• Highlevelsofadherencerequiredtopreventresistantmutationsandvirologicfailure.Only62%ofpersonsachievedadherenceto90%ofdoses(ascitedinThompsonetal.,2012)

• Challenge:explorebestpracticestoimproveentryintocareandretainincare.

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CoordinatedCare:PersonsLivingwithHIV• Accessto:

– Comprehensiveandholistichealthcare inamedicalhome

– Healthpromotionservicesandchronicdiseasemanagement

– Navigation assistance(healthcareandsocialservicesnetwork)

– Coordinatedlogistics (transportationorchildcare)– Governmentfundedbenefitsandprograms– Coordinatedhealthinformation(primarycare,specialistandotherteammembers)

– Strategiestoovercomebarriersofadherencetoantiretroviraltreatment(ART)

25HIVCareSectionCareCoordinationRFP2014

CareCoordination• PatientcareactivitiesareintentionallyorganizedwithallparticipantstobenefittheindividualwithHIVacrossthecontinuumofcare

• MostimportantaspectofHIVcare• Experts:knowledge,skills,experience• Usingcareguidelines- evidence-basedpractice• Sharedplanofcare- - clinicalinformationsharedinatransparentwaybyallcareproviders

• Patientsengagedandretainedincare=improvedhealthoutcomes,suppressedviralload

26HIVCareSectionCareCoordinationRFP2014

WhyisCareCoordinationsoDifficult?1.Accountability fortheprocessisshared,whichcontributestoambiguity astowhoisresponsibleformakingitworkwell.2.ManyPCPsnolongerhavethepersonalrelationshipswithconsultantsandhospitalsthatmakecommunicationeasier.3.Theaddedtimeandeffortrequiredtoachieveaneffectivereferral/consultationortransitionisgenerallynotreimbursed.4.Mostprimarycarepracticesdonot havethededicatedpersonnelorinformationinfrastructuretocoordinatecareeffective

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CaliforniaHealthCareFoundation.(2008).ReducingCareFragmentation:AToolkitforCoordinatingCare.Retrievedfromhttp://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf

Recommendations:EntryIntoandRetentioninCare

#1Systematicallymonitorentry intocare- sharedresponsibility

#2Systematicallymonitorretention- biomarkers,visitadherence,gapsincare,visitsperinterval

#3Strengthbasedcasemanagement- newlydiagnosed(upto5visitsin90days)[motivationalinterviewing]

#4Intensiveoutreach toindividualsnotengagedinmedicalcarewithin6monthsofdiagnosis

#5Peer orparaprofessionalpatientnavigators-facilitateinteractionwithhealthcare;keepvisitsThompsonetal,2012 28

Recommendations:MonitoringARTAdherence

#6Selfreportedadherence- useshortinterval(oneweekvmonth)#7Pharmacyrefilldata-whenrefillsnotautosenttopatients#8Drugconcentrationsinbiologicalsamples- notrecommended.Toomuchvariation

#9Pillcountsbystafforpatientsnotrecommended(susceptibletopilldumping)

#10Electronic drugmonitors- impractical,burdensome(not recommended)

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Recommendations:InterventionstoImproveARTAdherence

#11Oncedailyregimensarerecommended,iftoleratedfortreatmentnaïvepatients

#12Switchcomplexorpoorlytoleratedregimenstooncedailywithequivalentefficacy(experiencedpatients)

#13Fixeddosecombinationstodecreasepillburden

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RecommendationsAdherenceToolsforPatients

#14Reminderdevices,communication(phonealarms,textmessages

#15Education/counseling onadherencetools#16Individualone-oneoneARTeducation#17Individualizedadherencesupport(one-on-one)#18Groupeducation/counseling#19Multidisciplinary education/counseling(recommended)

#20Peersupport-helpfulforsomepatients

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RecommendationsHealthSystem&ServiceDelivery

#21Usingnurses andcommunitycounselor-basedcareapproachesimprovesadherence#22Casemanagementservicestoaddressfoodinsecurities,housing,andtransportation(recommended)#23Integratingmedication/pharmacymanagementsystems#24DirectlyadministeredARTisnotrecommendedforroutineclinicalcaresettings

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Recommendations:SpecialPopulations

PregnantWomenSubstanceAbuseDisordersMentalHealthIncarcerationHomeless/MarginallyHousedChildrenandAdolescents

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OtherConsiderations:MotivationalInterviewing

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• Evidence-basedstrategytoassistpatientstofollowtreatmentrecommendations

• Usesdirective,client-centeredcounselingstyletoelicitbehaviorchangebyhelpingpatientexploreandresolveambivalence

• Acollaborativegoal-orientedstyleofcommunicatingwithparticularattentiontothelanguageofchange.Itisdesignedtostrengthenmotivationforancommitmenttoaspecificgoalbyelicitingandexploringtheperson’sownreasonsforchange inanatmosphereofacceptanceandcompassion

Levensky,Forcehimes,O’Donohue,Beitz,2007.;MillerandRollnick,2013

Motivationis• Fundamentaltochange

• Adynamicandfluctuatingstate

• Particularlysensitivetointerpersonalinteractionswithinfluentialothers

• Stronglyinfluencedbytheinterpersonalstyleofhelpingprofessionals—likenursesorotherhealthcareproviders(HCP)

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TheproperquestionisnotWhyisn’tthispersonmotivated?

butrather,Forwhatisthispersonmotivated?

Source:MillerandRollnic

TheMotivationalPart

ChangeTalk

Desire

Ability

Reasons

Need

Commitment

TakingSteps

BehaviorChange

(Rollnick,Miller&Butler,2008) 37

OtherConsiderations:HumanTrafficking?

• HumanTraffickingOverview(sexandlabor)• 88%oftraffickedvictimsseekhealthcareserviceswhile

enslaved• HIVprophylaxis• Traumainformedcare• STDsasriskfactor/redflag• APP– downloadSexTraff apptoday!• MSUHumanTrafficking:CNEoffering:

http://nursing.msu.edu/Continuing%20Education/Online%20Offerings/default.htm

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CapitalAreaHumanTrafficking2016ResourceGuide

Localresourcesbycategorywithcontactphonenumbers– LawEnforcement– LegalAid– Shelters– TransitionalHousing– ChildProtectiveServices– HealthCare– OutpatientandInpatientMentalHealthServices– FamilySupportResources– Transportation– EmploymentServices– FoodServices

http://wrc.msu.edu/_files/pdf/2016-resource-guide-CAATA.pdf39

AdditionalHelpinMichigan• MichiganHumanTraffickingTask

Force• CapitalAreaAnti-traffickingAlliance

(517)-574-5643• GeneseeCountyHumanTrafficking

TaskForce• KalamazooAnti-HumanTrafficking

Coalition(269)303-0725• KentCo.HumanTraffickingTask

ForceHotline:(616)726-7777Contact:616-426-3730

• Midland– (989)835-6771orK.Ade(989)-832-6818 [email protected] orNickiSmith [email protected]

• Mid-MichiganUndergroundRailroad,Inc.(989)399-0007x109or(989)996-0423

• NorthernMichiganCoalitiontoEndHumanTrafficking(231)846-8485

• Ottawa-AlleganCountyHumanTraffickingTaskForce

• SaginawCountyHumanTraffickingToolkit:https://www.saginawcountyms.com/human-trafficking-toolkit.html

• SoutheastMichiganHumanTraffickingTaskForce313-269-5490

• SouthernMichigan(517)266-8880or(517)918-8082

SouthwestMichiganTraffickingTaskForce:http://swmihumantrafficking.org/additional-help-in-michigan/ 40

PositiveSelf-ManagementProgramforHIV(PSMP)

• 2½hours,onceweekly,for6weeks• Facilitatedbytrainedleaders• LivingaHealthyLifewithHIV,4th ed.• Subjectscovered:

1. Howtointegratemedicationregimenintodailylife2. Dealingwithproblems(fear,frustration,fatigue,pain,isolation,etc)3. Appropriateexercisetomaintainandimprovestrength,flexibilityandendurance4. Communicatingwithfamily,friends,healthcareprofessionals5. Nutrition6. Evaluatingsymptoms7. Advanceddirectives8. Decisionmaking9. Sex,intimacyanddisclosure

• ProgramOutcomes– Improvedsymptommanagement– Significantlybettermedicationadherence(ofthoseusingART)– ImprovedHIVsuppressioninbloodafter6months– NoincreasedsideeffectsthannonPSMPparticipants

StanfordMedicine.(2017) 41

LearningRetention—Repetition

https://www.phase-6.com/en/vocabulary-tool/scientific-background/scientific-background.html

INTERVENTIONS:CAREMAPPING

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CaseManagementModel

CaseManagementProcess

§ Assess§ Plan§ Collaborate§ Implement§ Monitor§ Evaluate

44

CaseManagementSocietyofAmerica(2016).StandardsofPracticeforCaseManagement.cmsa.org

CareMapping

• Meanstolearn/sortcomplexconcepts,sub-conceptsandtheirinterrelationship

• Central concept/issueisinthecenterofthepage(patient/family)

• Relatedconcepts/issuessurroundthemainissue• Facilitatesteamengagementtoidentifyissuesandformulatecollaborateplansofcareandfollowup

Billings&Halstead(2012).TeachinginNursing:AGuideforFaculty45

www.durgastoolbox.com

46

CareMapping

Patient

Family/supports

HealthCareProviders:

47

CareMap

Patient

Considerations:Healthcareproviders;Socio-economicandpsychologicalfactors;Nutrition;Education;Legal/financial;Functionalstatus;Cultural/spiritual;Medication/pharmacy;Work;School;Housing;Transportation;CaregiverSupport/respite;Therapy;Recreation;Supplies

CMProcess:Assess;Plan;Collaborate;Implement;Monitor;Evaluate

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CaseStudy:Mrs.P.3monthfollowupvisittochecklabs/progress

• 42yoAfricanAmericanfemale

• HIV+for10years• Medicationadherent;samescripts2years• CD4countnormal;undetectableviralload

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CaseStudy:Mrs.P.continued• “justdon’tfeelright”• Reportsincreasingfatiguesincelastvisit“alltuckeredout”

• Activitiesofdailylivingaffected:unabletogroceryshop“tootired”,admittedgettingfooditemsfromconveniencestore1blockaway,“that’sthebestIcoulddo”

• Unabletowalkstairsto2nd floorapartment;usestheelevator

50

CaseStudy:Mrs.P.continuedAssessmentfindings:Temp:97.2degreesF(oral)Pulse:60bpmRR:16bpmBP:116/78Ht:5feet,5inchesWt:115lbs (5lb weightlossinlast3months)Skin:pale,cooltotouchSaO2:96%(pulse-ox)(usually99%)

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CareMap

Patient:Mrs.P.



AssessmentT97.2;P60;RR16;B/P116/78Ht 5ft 5”;Wt 115 (5lb wt.loss)SaO296%(downfrom99%)Skinpale;cooltotouchADL:diminishedexercisetolerance,tiredMedications:?Zidovudine?Nutrition:conveniencestorefoodHousekeeping?Financial?Insurance?Education?CaregiverSupport?Husband?Transportation?Work?Confidentiality/Okdisclosure?

Plan:CollaborateRequestlabs:CBC,Hgb/Hct;Retic CountDeterminecauseofanemia;monitorfatiguelevel;medicationadherence;determinepatientgoalsPCP- - Lab- - Pharmacy- -Transfusion?- -Pulse-ox- - HomeHealth/Help- -Transportation- -NutritionCounseling/Assist- -Referralsneeded- -Infusion/Injection?

- -Patienteducation

Implement/InterventionsLabs;transfusion;injections?epoetin alfa (Epogen,Procrit);Referralsforsupportservices;self-managementeducation

MonitorSaO2;labs;targetHgb level;activitylevel;medicationadherence;referralfollowup;patientunderstanding(telephonic;inperson;whatinterval?Anythingelse?)

Evaluate• Effectivenessoftreatmentplan• Improvementofbloodcounts• Improvementofexercise

tolerance,ADLs• Adherencetotreatmentand

medicationplan• Appetite,securingfood• Self-managementknowledge• Needforfollowup;interval

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YourTurn:CareMapActivity

Patient:Larry



53

CaseStudy:Larry• 45yogayman;HIVdiagnosisin1987• Collegedegree;hasbeenemployedasCommunityCollegeinstructor

• Noopportunisticinfection• Experiencingwasting,depletionofCD4count,highviralload;failedallHAARTregimens

• Angry;despondentaboutfuture(verballyabusivetoclinicstaffandproviders)

• Malepartner(same)forover10years;couplestherapytoaddressangerissues

54

CaseStudy:LarrycontinuedRecentIssues:• Unabletoengageinenjoyableactivities(creativewriting,hiking,swimming,andreading)

• Reportsnoappetite,cannotsleep,feelsdepressedandsad;occasionallythinksofsuicide;withdrawnfromusualcircleoffriends;admittedhesometimesthinksofsuicide

• Watchestelevisionseatedinrecliner,dayandnight

55

CaseStudy:LarrycontinuedMoreInformation:

• Psychiatristinvolvedincareforafewyears;seesmentalhealthCNSregularlyinclinic

• Treatedwithbuproprion (Wellbutrin),sequentialtrialsofdifferentSSRIsandzolpidem (Ambien)totreatdepressionandsleepdisorder

• Patientreportssomerelieffromsymptoms(heattributestomedications)

• Patientiscoherent,insightfulabouthisfeelings,andabletoengageinplanningcare

56


Patient:Larry



Assessment Plan/Collaborate Implement/Interventions

Monitor Evaluate

57


Patient:Larry



Assessment Plan/Collaborate Implement/Interventions

Monitor Evaluate

58

EVALUATIONOFSTRATEGIES

59

QUESTIONS

• WhatisgoingonwiththisPatient?• WhatspecificconsiderationsdoyouhaveforLarry?

60

MOREQUESTIONS

• Canweassumeconfidentialitydisclosureisestablished?

• WhatareLarry’sgoals?Havetheybeenexplored?

• Whataboutendoflife?

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KathyForrest:[email protected]

63

ReferencesBillings&Halstead(2012).Teachinginnursing:Aguideforfaculty(4th ed.).StLouis,MO:Elsevier

CaliforniaHealthCareFoundation.(2008).ReducingCareFragmentation:AToolkitforCoordinatingCare.Retrievedfromhttp://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf

CaseManagementSocietyofAmerica.(2012).AdherenceGuidelines.Retrievedfromhttp://www.cmsa.org/Individual/Education/CaseManagementAdherenceGuidelines/tabid/253/Default.aspx

CaseManagementSocietyofAmerica.(2016).StandardsofPractice.Retrievedfromhttp://solutions.cmsa.org/acton/media/10442/standards-of-practice-for-case-management

CaseManagementSocietyofAmerica.(2016).[Website]Retrievedfromhttp://www.cmsa.org/

CentersforDiseaseControlandPrevention[CDC],(2017).HIVintheUnitedStates:AtaGlance.Retrievedfromhttps://www.cdc.gov/hiv/statistics/overview/ataglance.html

CentersforDiseaseControlandPrevention(2017).HIVGuidelines.Retrievedfromhttps://www.cdc.gov/hiv/guidelines/

CommissiononCaseManagementCertification[CCMC],(2017).Casemanagementknowledge.Retrievedfromhttps://www.cmbodyofknowledge.com/content/case-management-knowledge-2

Gardner,E.M.,McLees,M.P.Steiner,J.F.delRio,C.&Burman,W.J.(2011).ThespectrumofengagementinHIVcareanditsrelevancetotest-and-treatstrategiesforpreventionofHIVinfection.ClinicalInfectiousDisease,52(6),793-800.

Levensky,E.,Forcehimes,A.,O’Donohue,W.,&Beitz,K.(2007).Motivational interviewing:Anevidence-basedapproachtocounselinghelpspatientsfollowtreatmentrecommendations.AmericanJournalofNursing,107(10),50-58.

MacyFoundation.(2016).JosiahMacyAnnualReport.http://macyfoundation.org/docs/annual_reports/2016_Josiah_Macy_Annual_Report_Final.pdf

MichiganPublicHealthCode:Act368of1978http://www.legislature.mi.gov/(S(upi1k0w4n1kd1jxr5bjir1of))/mileg.aspx?page=getobject&objectname=mcl-act-368-of-1978

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change, (3rd ed.). New York, NY: Guilford Press. 64

ReferencesNationalInstituteofAllergyandInfectiousDiseases,HIV/AIDStreatment.Retrievedfromhttps://www.niaid.nih.gov/diseases-conditions/hiv-treatment

NationalInstituteofHealth(2017).GuidelinesfortheuseofantiretroviralagentsinHIV-1Infectedadultsandadolescents.Retrievedfromhttps://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

PA0499:http://www.legislature.mi.gov/documents/2015-2016/publicact/pdf/2016-PA-0499.pdf

Phillips&Fitzsimons(2015).TheAffordableCareAct:Impactoncasemanagers.ProfessionalCaseManagement,20(6),323-327.

Powell,S.K.&Tahan,H.A.(2010).Casemanagement:Apracticalguideforeducationandpractice(3rd ed.).Philadelphia,PA:WoltersKluwerHealth.

Rollnick, S., Miller, W.R., Butler, C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York, NY: Guilford Press.

StanfordMedicine.(2017).Positiveself-managementprogramforHIV(PSMP).Retrievedfromhttp://patienteducation.stanford.edu/programs/psmp.html

Tahan,H.M.&Treiger,T.M.(2017).CMSACorecurriculumforcasemanagement( 3rd ed.).Philadelphia,PA:WoltersKluwer.

Thompson,M.A.,Mugavero,M.J.,Amico,R.,Cargill,V.A.,Chang,L.W.,Gross,R.,…Nachega,J.B.(2012).GuidelinesforimprovingentryintoandretentionincareandantiretroviraladherenceforpersonswithHIV:Evidence-basedrecommendationsfromaninternationalassociationofphysiciansinAIDScarepanel.AnnalsofInternalMedicine,156(11),817-833.Retrievedfromhttp://annals.org/aim/article/1170890/guidelines-improving-entry-retention-care-antiretroviral-adherence-persons-hiv-evidence

UNAIDS.(2016).GlobalAIDSUpdate2016.Retrievedfromhttp://www.unaids.org/en/resources/documents/2016/Global-AIDS-update-2016

UNAIDS.(2016).PreventionGapReport.Retrievedfromhttp://www.unaids.org/en/resources/documents/2016/prevention-gap

U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention[CDC].(2016).HIVCaseReportingandSurveillance.Retrievedfromhttps://www.cdc.gov/hiv/guidelines/reporting.html

U.S.PublicHealthServiceGuidelinesfortheManagementofOccupationalExposurestoHumanImmunodeficiencyVirusandRecommendationsforPostexposure Prophylaxis.Retrievedfromhttp://nccc.ucsf.edu/wp-content/uploads/2014/03/Updated_USPHS_Guidelines_Mgmt_Occupational_Exposures_HIV_Recommendations_PEP.pdf 65

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Nursing Case Management: Impact on Adherence and · PDF fileMichigan HIV Clinical Nursing Conference Nursing Case Management: Impact on Adherence and Care Kathy Forrest ... medical