Perinatal Case Management by pop14118


									    Perinatal Case Management

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

Viral Hepatitis Program
Viral Hepatitis Program
   Initial Call to Doc Holiday’s
 • 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
     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
    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
Viral Hepatitis Program
  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
       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
                            More Issues
• Previous births
  – Check your own records on the previous case
        • Immunization registry
        • Perinatal database
  – Call Texas to gather information on previous
• Language
  – Be prepared with an interpreter
 Viral Hepatitis Program
                             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
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
                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

 Viral Hepatitis Program
                    Marianna & Baby
• Explain the baby’s needs for
   – 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
              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
• 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
          Can’t Reach Marianna?

Viral Hepatitis Program
Viral Hepatitis Program
              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
                High-risk Behaviors
• Consider Disease Investigation Specialist
  – Mother may not be able to notify contacts
        • Incarcerated
        • Feels threatened
• Check registries
  – DIS may already be investigating/notifying
  – Call parole officers for contact information, but
    do not disclose health information
 Viral Hepatitis Program
              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
 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
  Review hospital protocols regularly

 Viral Hepatitis Program
• 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.
• Call Marianna

 Viral Hepatitis Program
             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
• 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
                      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
              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
                            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
        Patient Information Packets
• Language appropriate
• Program description
• Living with hepatitis B
• Hepatitis B shots are recommended for new
• Answers to specific questions raised by
    Viral Hepatitis Program
   Physician Information Packet
• Information given to patient
• Published guidelines
• Website links (IAC, CDC, ACOG,
• Names of local specialists

 Viral Hepatitis Program
                            Case Status
• Marianna was found through the WIC
• 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
                  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

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