Dr Shabir Moosa, MMed, MBA, PhD

Chronic Care

The Chronic Care Medicine Dispensing and Delivery (CCMDD) Programme, now rebranded as “Dablameds” has been running for a few years. It is now mostly involving stable chronic patients collecting their meds at a local pharmacy. See the CCMDD Training Slides and Standard Operating Procedures to understand the programme better. There are a letter and formulary guiding its implementation.

With COVID-19 many districts have had to close the community and facility-based chronic care clubs where patients collected medicines and resorted to Community Health Workers (CHWs) delivering medicines to patients. Johannesburg Health District wanted to implement this and used the experience at Chiawelo Community Practice. Prof S. Moosa, family physician leading clinical governance in Soweto, led the development of a Standard Operating Procedure in August 2020 not only for CHW deliveries but for case management in the community. This is being piloted in five facilities in Soweto: Zola CHC, Mofolo CHC, Chiawelo CHC, Green Village Clinic, and Zondi Clinic.

CHWs develop a profile of their Chronic Patients in these facilities local communities as a CHW Client List. These patient’s files are then pulled out and marked with the CHWs name. Team leaders of CHWs are also mapping the catchment communities, with a list of streets covered by CHWs (both from that facility and neighbouring facilities) and those not covered by CHWs.

Clinicians use a Chronic Care Record to use on all chronic patients. Nurses in the vitals stations fill in the vitals in black blocks and ask patients their choices about visits by CHWs and Team Leaders, and delivery options (CCMDD and CHW). They then attach and fill the forms needed. Clinicians review the clinical condition of the chronic patient using our Protocol and Clinician Explanation. Once suitable patients are identified the clinician should use the Case Mgmt Plan to prescribe care in the community. The clinicians need to ask whether the patient is happy with CHW/Team Leader visits, if yes then whether they prefer CHW deliveries or delivery via the CCMDD system (i.e. local pharmacy). They also have the option of prescribing 3-6-9 month visits by the Team Leaders (two-year trained enrolled nurses) to do various monitoring checks as per protocol. The clinicians are aware of the  Protocol Poster that Team Leaders are guided by. They then dispense two months’ medication and then prescribe medication for the next 4-10 months for the patient. They can use either the CCMDD form or the orange TPH prescription card to write the prescription. They need to ensure patient details (including file reference) and CHW visit dates are recorded on the orange card. These forms are then passed to the Clubs Coordinators and/or Team Leaders.

Club Coordinators separate the prescriptions and send them to the CCMDD system or the Central Dispensing Unit (for CHW delivery). Team Leaders take the Case Mgmt Plan and sit with the CHWs, allocate the patients, and diarise the visits by CHWs and Team Leaders. The Case Mgmt Plan is then returned to the patient’s file. As each patient visit comes up on the diary the Team Leader takes the file out in preparation. When meds arrive for CHW deliveries of medicines, the CHW pulls out the Individual Care Form, writes out that medicines are to be delivered, takes the medicines parcel for delivery, gets the patient to sign off on receipt (after checking), and then returns with the signed Individual Care Form. The Team Leader needs to check the signature against the signature on the Case Mgmt Plan for audit purposes and sign off that it was checked.

Team Leaders need to plan their own visits, do the examinations and blood tests, and check on the CHWs visits. Barcodes for NHLS blood tests stick to be stuck on the last column on the Case Mgmt Plan. They should check on the results and ensure it is as aimed for in the Protocol Poster. The focus on these patients should be education and medication adherence. CHWs  use the CHW Education Material. Should patients be out of control the patient should be referred back. There are many resource materials for CHWs

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