Perinatal Case Management by pop14118

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									    Perinatal Case Management

              Amy E. Warner, M.P.H.
           Colorado Department of Public
              Health and Environment

Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
   Initial Call to Doc Holiday’s
                Office
 • Test results:
       • Confirmed that Marianna was pregnant
       • Will fax all hepatitis test results to case manager
 • Date of test:
       • January 29th
 • Expected date of delivery:
       • June 15th
 • Expected delivery hospital:
       • not sure

Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
     Initial Call to Doc Holiday’s
             Office (con’t)
• Has Marianna been evaluated for her
  hepatitis infection:
   – Physician told her there’s “no problem”
• Previous births?
   – 1 child born in Texas
   – 1 child born in Colorado
• Any immunization records for the children?
   – Doc thinks they were immunized, but does not know if
     they were tested. Call pediatrician, Dr. Quinn

  Viral Hepatitis Program
  http://www.cdphe.state.co.us/dc/Hepatitis
    Initial Call to Doc Holiday’s
            Office (con’t)
• Does Marianna speak English?
  – A little, but her relative interprets from Spanish
• When is her next appointment
  – March 15th
• Verify contact information
  – Marianna actually lives in Mexico but uses her
    sister’s address in Colorado. She plans on
    moving in with her sister closer to the birth

 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
  Potential Issues with Positive
           HBsAg test
 • Ask for a copy of the lab results
       • Was it confirmed?
       • Were there additional tests done
             •   Anti-HBs or anti-HBc
             •   IgM
             •   Liver enzymes
             •   HBeAg
             •   Anti-Hbe Ag
             •   DNA – Viral load



Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
                  Issue:
       Hepatitis B- “No Problem”
  Hepatitis B infection can lead to liver disease
• Babies need healthy moms
   – Evaluate HBV infection during pregnancy.
         • Mom is more likely to have some insurance
         • Mom may need treatment after the birth
• It’s a good time for the family to learn prevention
         • How not to infect others
         • How to stay healthy


  Viral Hepatitis Program
  http://www.cdphe.state.co.us/dc/Hepatitis
                            More Issues
• Previous births
  – Check your own records on the previous case
        • Immunization registry
        • Perinatal database
  – Call Texas to gather information on previous
    cases
• Language
  – Be prepared with an interpreter
 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                             File History
• Marianna was HBsAg-negative with her first child
  in 2002. Texas does not have a case file
• She was HBsAg-positive with the 2nd pregnancy
  in 2005
• Colorado files indicate that the 1st child received 2
  doses of vaccine and the 2nd child received HBIG
  and 2 doses of vaccine
• The father tested susceptible before the 2nd child
  was born, but there is no record of vaccination
• They were lost to follow-up in 2006
  Viral Hepatitis Program
  http://www.cdphe.state.co.us/dc/Hepatitis
Contacting Marianna-March 11th
• Phone Interview
  –   Use an interpretation service if needed
  –   Explain the program
  –   Conduct the interview
  –   Answer questions and offer to send information
  –   Try to identify alternate contact information.



 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                Caring for Marianna
• Emphasize the need for follow-up testing
  and evaluation
• Ask if she has resources for follow-up care
• Share information about local clinics that
  have a sliding fee or can provide free
  services


 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                    Marianna & Baby
• Explain the baby’s needs for
  prophylaxis
   – Identify birthing hospital
   – Identify pediatrician
• Let her know that you will
  continue to work with her until
  the baby receives post-
  vaccination serologic testing


  Viral Hepatitis Program
  http://www.cdphe.state.co.us/dc/Hepatitis
              Marianna & Contacts
• Emphasize follow-up of children, and
  sexual/household contacts
• Check your immunization registry for
  sibling records
• Speak with both Dr Quinn and Marianna
  about completing the children’s vaccine
  – Refer to local health department or Federally
    Qualified Health Center (FQHC)

 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                                Contacts
• Assess best venue for father and the
  children to get immunization and/or testing
  –   Home
  –   Local laboratory
  –   Provider’s office
  –   Local health department



 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
          Can’t Reach Marianna?




Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
Viral Hepatitis Program
http://www.cdphe.state.co.us/dc/Hepatitis
              Can’t Reach Marianna?
• Ask sister for a forwarding address and send
  a letter explaining that:
     – you have important medical information, and
     – asking her to call you
•   Check registries for WIC or immunization
•   Meet Marianna at her next appointment
•   Consider a home visit
•   Consider an international phone call
    Viral Hepatitis Program
    http://www.cdphe.state.co.us/dc/Hepatitis
                High-risk Behaviors
• Consider Disease Investigation Specialist
  (DIS)
  – Mother may not be able to notify contacts
        • Incarcerated
        • Feels threatened
• Check registries
  – DIS may already be investigating/notifying
    contacts
  – Call parole officers for contact information, but
    do not disclose health information
 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
              Prepare for the Infant
Educate Marianna about prevention
Ensure that Dr. Quinn orders HBIG and
 hepatitis B birth dose
Ask Doc Holiday to send a copy of the
 original lab to the hospital or you send it
Notify the hospital of the impending birth
 and provide guidelines for appropriate
 treatment of the infant
 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
 More Preparation for the Infant
Send an HBIG fax back form to the hospital
Keep in touch with hospital staff
  Keep email lists updated
  Offer in-service training
  Forward new recommendations as they are
   released
  Review hospital protocols regularly

 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                                     Birth
• Follow-up with hospital
  – Did hospital fax the health department
    a completed HBIG form?
• Follow-up with Doc Holiday?
  – Did he perform the birth?
  – Who provided pediatric care? Dr.
    Quinn?
• Call Marianna

 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
             Completing the Series
• How do you keep Marianna engaged long
  enough to complete the infant’s vaccine
  series and post-vaccination testing?




 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                               Strategies
• Contact Dr. Quinn (pediatric provider)
  – What vaccine and what schedule will be used
  – Send a letter describing your program
• Offer free vaccine and waive the
  administration fee
• Reminder/Recall
  – Post-cards
  – Phone calls
  – emails
 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                      More Strategies
• Incentives
  – Given with each service
  – Given once services are completed
• Include Dad or Grandma
• Focus on the need to know a child’s
  infection status


 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
              Even More Strategies
• Offer a variety of free testing choices
  –   In the home
  –   At your office
  –   Private laboratory
  –   Their physician draws blood and sends it to
      your lab
• Don’t delay

 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                            Case Closed
• Fully complete (Gold Standard)
   – The infant receives HBIG and all
     doses of vaccine and is tested for
     HBsAg and anti-HBsAg
   – All contacts are tested
         • Susceptible contacts are immunized
           with 3 doses of vaccine
         • Infected contacts are referred for care




  Viral Hepatitis Program
  http://www.cdphe.state.co.us/dc/Hepatitis
        Patient Information Packets
• Language appropriate
• Program description
• Living with hepatitis B
• Hepatitis B shots are recommended for new
  babies
• Answers to specific questions raised by
  Mom
    Viral Hepatitis Program
    http://www.cdphe.state.co.us/dc/Hepatitis
   Physician Information Packet
• Information given to patient
• Published guidelines
• Website links (IAC, CDC, ACOG,
  AAP,AAFP)
• Names of local specialists



 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                            Case Status
• Marianna was found through the WIC
  registry
• Due to the program’s persistence,
  Marianna’s children are fully immunized
  and immune to hepatitis B
• Marianna saw a specialist who is working
  with her doctor in Mexico

 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis
                  Case Status (con’t)
• Doc Holiday was actually a dentist. He
  decided that this was too much work and
  went back to gambling, drinking, and
  pulling teeth before his lifestyle and
  tuberculosis took his life
• Dr. Quinn became an energetic advocate for
  hepatitis B vaccination and cared for many
  women with hepatitis B
 Viral Hepatitis Program
 http://www.cdphe.state.co.us/dc/Hepatitis

								
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