Follow-up after training and Follow-up after training and supportive supervisionsupportive supervision

The IMAI District Coordinator The IMAI District Coordinator CourseCourse

Strengthening Health SystemsStrengthening Health Systems

District focus: Fills gaps and complements District focus: Fills gaps and complements existing training/modules for specialized doctors, existing training/modules for specialized doctors, higher resource settings; for home-communityhigher resource settings; for home-community

Builds on and strengthens routine health Builds on and strengthens routine health servicesservices

Focus on building a district system withFocus on building a district system with Clinical teamsClinical teams Referral, backReferral, back--referral; improved communication referral; improved communication

Regional Referral Hospital

District Hospital

District Hospital

District Hospital

Health Centre

Health Centre

Health Centre

Health Centre

Health Centre

Health Centre

Health Centre

Health Centre

Health Centre

First-level health workers

Clinical team may include nurse and ART Aid at first-level and doctor at second-level

Second-level health workers

DISTRICT HOSPITAL

Doctors/medical officers/inpatient RN

HEALTH CENTRE Clinical care—nurses, medical assistants;

ART counsellors (ART Aids)

COMMUNITY Treatment supporters, community health workers, peer support

groups, CBOs, advocates

CENTRAL / PROVINCIAL Specialised referral (physicians,

pediatricians, subspecialists)

Referral, back-referral, clinical mentoring

Patient monitoring

Drugs, diagnostics,

commodities, logistics support

National, Regional and District ART Management

Individualised care for patients

A Public Health approach facilitates broad coverage and enables the majority to access care and ART

Some patients will develop complex problems and need specialist input to their clinical or psychosocial management

Mentoring: Specialists in apex or tertiary centres linked with district generalist clinicians

Referral: complex cases referred upwards for specialist care and management

It is not either specialist services or a public health approach – it is both together

Planning for scale up Planning for scale up Preparing the community Preparing the community Establishing collaboration with partnersEstablishing collaboration with partners Planning capacity buildingPlanning capacity building Establishing distance communication for clinical team Establishing distance communication for clinical team

supportsupport Follow-up support and supervision after trainingFollow-up support and supervision after training Medicines, diagnostics and health suppliesMedicines, diagnostics and health supplies Patient monitoring Patient monitoring Orienting and optimizing entry pointsOrienting and optimizing entry points Prevention accelerationPrevention acceleration

The IMAI district coordinator course:The IMAI district coordinator course:

Administrative and managerial tasksAdministrative and managerial tasks

Preparation before training

Training

Follow-up after training:•District/regional management-

supportive supervision to sites: clinical, drug supply managementpatient monitoring

•Clinical supervision •Facility accreditation•Health worker certification•Team to team exchange•Other QA methods

Community/PLHA/stakeholder/other programme involvement

Setting targets and choice of sites for

HIV Care/ART

Preparation IMAI training

Choose clinical teams, plan training by cadres

Logistics: maintaining the supply of drugs, diagnostics, equipment

Establish good communication for clinical team support

Patient monitoring system: registers, reports, data use

IMAI Training by cadre

and team

On-site visits after trainingMentorship

Team to team support

Prevention acceleration

Orient and optimize entry points

Evaluation

Patient MonitoringPatient Monitoring

Supportive supervisionSupportive supervisionCollection/aggregation of reportsCollection/aggregation of reports

Regional Office

District Coordinator

Hospital

HC HC HC

Monthly report, cohort analysis

Aggregate data

Aggregate data

National Office

Aim of Clinical MentorshipAim of Clinical Mentorship

As part of emergency HIV care/ART scale-up, As part of emergency HIV care/ART scale-up, mentorship is aimed tomentorship is aimed to:: Support decentralized delivery of HIV care, ART and Support decentralized delivery of HIV care, ART and

prevention with quality of care at all levelsprevention with quality of care at all levels Build capacity of primary-care providers to manage Build capacity of primary-care providers to manage

unfamiliar or complicated cases by consultation and unfamiliar or complicated cases by consultation and on-site management where appropriateon-site management where appropriate

Promote and facilitate ongoing learning, skill Promote and facilitate ongoing learning, skill development and quality promotiondevelopment and quality promotion

Health Centre

Health Centre

Health Centre

Regular mentoring visits provided by experienced clinicians at the regional level

Regional Referral Hospital

Regular supportive supervision provided by the existing district management team (e.g. district medical officer, district matron)

Basic administrative subunit: the district

External mentors (e.g. expatriate) paired with local mentors on initial visits if sufficient expertise does not exist at regional level

District Hospital

Observe case management and reinforce skills

Observe case management and reinforce skills

Clinical case review

Clinical case review

Clinical team meeting

Clinical team meeting

Review patient monitoring system

Review patient monitoring system

Document the visit Document the visit

Sequence of steps in the clinical mentoring visitSequence of steps in the clinical mentoring visit

Agreed minimum essentialdata elements

What happens to the data

Indicators or other aggregated data

1.Entry point 2.Why eligible for ART 3.Reasons for:Substitution within first-lineSwitch/Substitution to or within second-line STOP ART1.Number and weeks of each ART treatment interruption2.Pregnancy status 3.Start/stop dates of prophylaxis: •Cotrimoxazole•Fluconazole•INH•TB treatment •Adherence on ARTSource: II. HIV Care, III. ART Summary, IV. Patient Encounter and Family Status

Transferred to pre-ART or ART register but used only by clinical team /district ART coordinator—not transferred to quarterly report or cohort analysis

Indicators for patient and programme management at the facility/district level:Distribution of entry points in patients enrolled in HIV careWhy eligible for ART: clinical only, CD4 or TLCDistribution of patients not yet on ART by clinical stage•Distribution of reasons for substitute, switch, stop to investigate problems; whether substitutions and switches are appropriate (use in context reviewing medical officer log)•ART treatment interruptions:

Number/Percentage of patientsNumber weeks

Percentage of pregnant patients linked with PMTCT interventions (or simply use to generate lists to assure linkage)Number on cotrimoxazole, fluconazole, INH prophylaxis at end of quarter (for ordering prophylaxis drugs)Number/Percentage of patients on both TB treatment and ART3b. % patients with good adherence to ART