Self-Study Modules on 

Tuberculosis, 6-9

Module 6

Managing Tuberculosis Patients 

and Improving Adherence

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

Division of Tuberculosis Elimination 

Atlanta, Georgia 

2014

 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Contents 

 Background

 Objectives

 New Terms

 Goals of TB Prevention and Control 

 Identifying TB Cases

 Case Management

 Working Effectively with TB Patients

 Developing a Treatment and Monitoring Plan 

 Adherence to Treatment

 Providing Directly Observed Therapy (DOT)

 Addressing Barriers to Adherence 

 Legal Remedies to Nonadherence

 Quality Assurance in Case Management 

 Other TB Control Practices to Complete

 Inter-Jurisdictional and International Referrals

 Considerations for TB Case Management in Special Settings

 Additional Resources

 Answers to Study Questions

 Case Study Answers
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Background 

In this module, you will learn about managing TB patients and improving adherence to 

TB treatment. Patients with TB disease must follow their recommended course of 

treatment and complete treatment in a timely manner in order to cure TB and prevent 

drug resistance. Ensuring patient adherence to treatment can be difficult because TB 

disease treatment requires many drugs given for at least 6 months. It is important that 

health care workers help patients adhere to treatment, because nonadherence can have 

serious consequences. 

This module describes case management activities and methods health care workers 

can use to improve patient adherence. Case management is a strategy to provide 

patient-centered care and ensure all public health activities related to TB care are 

completed. This module also describes several methods for promoting adherence, 

including directly observed therapy (DOT), the use of incentives and enablers, 

education, and legal remedies. 

Note: This module does not cover all topics relevant to nursing case management. For in-depth 

information on nursing case management for TB, please refer to Tuberculosis Case 

Management: A Guide for Nurses, from the Global Tuberculosis Institute at Rutgers, the State 

University of New Jersey and the Tuberculosis Nursing: A Comprehensive Guide to Patient Care, 

2nd edition from the National Tuberculosis Nurse Coalition. 

Objectives 

After working through this module, you will be able to

1. List the four priority activities of TB prevention and control.

2. Describe the activities associated with TB case management.

3. Describe directly observed therapy (DOT). 

4. Discuss TB treatment adherence strategies.

5. Explain considerations for TB case management in special settings.

define explain list describe
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New Terms 

New terms introduced in this module are included below. Please refer to the Self-Study 

Modules 1-5 Glossary if you encounter unfamiliar terms related to TB that are not 

defined in the glossary below.

active case finding— identifying 

unreported cases of TB disease by 

actively searching for them through, for 

example, laboratory and pharmacy 

audits

adherence agreement— a written 

document that describes understanding 

between a health care worker and a 

patient regarding TB treatment 

adherence and completion

adherence plan— a written plan that is 

based on the patient’s understanding 

and acceptance of the TB diagnosis and 

recommended treatment. It addresses 

barriers to adherence and details the 

method chosen to deliver treatment and 

monitor adherence for that specific 

patient. 

adherence to treatment— following the 

recommended course of treatment by 

taking all of the prescribed medications 

for the entire recommended time

barriers— anything that may prevent a 

patient from being able to adhere to a 

TB treatment regimen

 

 

 

case management— a strategy health 

departments can use to manage patient 

care and help ensure patients 

successfully complete treatment

case manager— a specific health care 

worker who is assigned primary 

responsibility for the patient

case review— the systematic, regular 

review of a patient’s progress by the 

case management team. Case reviews 

should be weekly and real-time. 

clinic-based directly observed therapy 

(DOT)— DOT that is delivered in a TB 

clinic or comparable healthcare facility

cohort review— the systematic review of 

the management of a specific cohort of 

TB patients and their contacts. A 

“cohort” is a group of TB cases counted 

over a specific period of time, usually 3 

months. 

court-ordered directly observed therapy 

(DOT)— DOT that is administered to a 

patient by order of a public health 

official or a court with the appropriate 

authority 
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cultural competence— having the 

capacity to function effectively as an 

individual and an organization within 

the context of the cultural beliefs, 

behaviors, and needs presented by 

patients and their communities 

discharge planning— the preparation 

for continued and comprehensive care 

of a patient after that patient’s 

discharge from a hospital or institution 

electronic directly observed therapy 

(eDOT)— DOT that is delivered remotely 

(e.g., over a smartphone, tablet, or 

computer). eDOT can either be realtime or recorded. 

enablers— things that make it possible 

or easier for patients to receive 

treatment by overcoming barriers 

field-based directly observed therapy 

(DOT)— DOT that is delivered in a 

setting outside of the TB clinic or 

healthcare facility 

genotype— distinct genetic pattern of 

an organism 

genotyping— a laboratory-based 

method that can determine the genetic 

pattern of the strain of M. tuberculosis

that caused TB disease in a person 

incentives— small rewards given to 

patients to encourage them to either 

take their medicine or keep their clinic 

or field DOT appointments 

nonadherence— a patient’s inability or 

refusal to take TB drugs as prescribed 

open-ended questions— a question 

that cannot be answered with a simple 

“yes” or “no.” Open-ended questions 

are designed to elicit the patient’s 

knowledge, feelings, and beliefs. 

 

passive case reporting— required 

reporting of suspected or confirmed TB 

cases to a public health authority 

 

patient assessment— talking to a 

patient about his or her medical history, 

knowledge about TB, and beliefs about 

TB treatment 

 

quality assurance— the review and 

evaluation of the quality of care and 

effectiveness of the TB program 

 

TB Genotyping Information 

Management System (TB GIMS)— a 

secure CDC-sponsored online national 

database of genotyping and case 

information
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Goals of TB Prevention and Control 

In the United States, state and local health departments have legal responsibility for 

the prevention and control of TB in their communities. As such, each TB program 

should focus on four fundamental priority prevention and control activities. The 

priority activities, in order, include 

1. Identifying and treating persons who have TB disease; 

2. Finding and assessing persons who have been in contact with TB patients to 

determine whether they have latent TB infection (LTBI) or TB disease and 

providing them with appropriate treatment; 

3. Using targeted testing strategies to identify and treat persons with LTBI at risk 

for developing TB disease; and 

4. Identifying settings in which there is a high risk for transmission of M. 

tuberculosis and applying effective infection control measures 

The identification and treatment of TB disease is aimed at both helping the individual 

patient sick with TB disease and protecting the public by reducing the further 

transmission of M. tuberculosis. To identify TB patients effectively, health departments 

should collaborate with other providers, partners, and organizations including private 

physicians, laboratories, community health centers, migrant health centers, 

correctional facilities, hospitals, hospices, long-term care facilities, and homeless 

shelters. 

Once TB patients are identified, the health department needs to ensure that a plan is in 

place for patients to receive appropriate follow-up and treatment. Case management is 

a strategy health departments can use to manage patient care and help ensure patients 

successfully complete treatment. 

Case management is a strategy health departments can use to 

manage patient care and help ensure patients successfully complete 

treatment. 
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Identifying TB Cases 

The two basic methods health departments should use for identifying suspected or 

confirmed TB cases are:

 Passive case reporting

 Active case finding

Passive Case Reporting 

Passive case reporting is the required reporting of suspected or confirmed TB cases to 

a public health authority. TB programs should receive a case report when a suspected 

or confirmed TB case has been identified by any health care provider or institution. 

This is the most common way health departments identify TB patients. Laboratories 

should report positive results on smears and cultures within 24 hours by telephone or 

fax to the state or local TB control program, as required by law.

Passive case reporting is the required reporting of suspected or confirmed 

TB cases to a public health authority. 

Active Case Finding 

Health departments may also identify cases by active case finding. 

In active case finding, the TB program identifies unreported cases of TB disease by 

actively searching for TB cases. Active case finding can be implemented in several 

ways, depending on local needs and practices. Examples of active case finding 

activities include

 Contact investigations

 Laboratory and pharmacy audits

 Facility and organization inquiries

Active case finding is identifying unreported cases of TB disease by actively 

searching for them. 

Contact Investigations 

Public health workers actively find TB cases through the assessment of contacts to 

patients with infectious TB. A TB contact investigation is a systematic process to:

 Identify persons (contacts) exposed to someone with infectious TB disease 
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 Assess contacts for infection with M. tuberculosis and TB disease 

 Provide appropriate treatment for contacts with LTBI or TB disease 

Contact investigation is discussed in more detail in Module 8, Contact Investigations 

for Tuberculosis. 

Laboratory and Pharmacy Audits 

Some TB control programs may collaborate with pharmacies and mycobacteriology 

laboratories to identify unreported TB cases by conducting laboratory or pharmacy 

audits. Active case finding with laboratories or pharmacies require special agreements 

regarding the sharing of information. The ability to perform this activity depends on 

local confidentiality laws and regulations. In many areas, active case finding will be 

most effective when targeted to specific laboratories or pharmacies with the goal of 

reviewing specific data. Because it can be difficult to gain access to laboratory 

databases to search for unreported cases, public health workers may need to request 

reports from laboratories. Acid-fast bacilli (AFB) smear, culture, and nucleic acid 

amplification test (NAAT) results should be reviewed periodically to identify unreported 

suspected or confirmed TB cases.

Acid-fast bacilli (AFB) smear, culture, and nucleic acid amplification 

test (NAAT) results should be reviewed periodically to identify 

unreported suspected or confirmed TB cases. 

Pharmacy surveillance can also help to identify unreported cases of TB disease. When 

patients are being treated for TB based on a clinical diagnosis, pharmacy records can 

be an important active case finding tool. If possible, the pharmacy may be able to 

provide information regarding patients who are taking TB treatment drugs. Local 

confidentiality laws and regulations must be considered. 

Facility and Organization Inquiries 

TB program staff should be familiar with facilities or organizations that provide 

services to persons considered to be at high risk for TB infection and TB disease. 

Relationships with staff from these facilities (e.g., homeless shelters, correctional 

facilities, community health centers) should be developed and sustained. The TB 

program should educate these staff about TB public health reporting regulations. In 

addition, educating healthcare providers and staff about TB infection and disease may 

help prevent delayed diagnosis or misdiagnosis.
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TB program staff should be familiar with facilities or organizations 

that provide services to persons considered to be at high risk for TB 

infection and TB disease. 

Study Questions 6.1 – 6.2 

 

6.1 What are the four priority TB prevention and control activities? 

 

 

 

 

 

6.2 Name two methods health departments use to identify TB cases. 

Answers to study questions are on pages 80-87
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Case Management 

Once persons with TB infection or TB disease are identified, successful TB treatment is 

primarily the responsibility of medical providers and health care workers, not the 

patient. Public health workers in TB programs and other facilities play an integral role 

in helping patients complete TB treatment through the use of a strategy referred to as 

case management. The strategy’s goal is to provide patient-centered care for 

completion of treatment and to ensure all public health activities related to stopping 

TB transmission are completed. Patient-centered care can help ensure successful 

treatment outcomes because it emphasizes tailoring treatment to address both the 

patient’s clinical and social concerns. For example, to help some patients through the 

lengthy TB treatment process, it may be necessary to provide treatment incentives and 

enablers, housing assistance, or a referral for substance abuse treatment. 

Successful TB treatment is primarily the responsibility of medical 

providers and health care workers, not the patient. 

In the case management approach, a specific health care worker (i.e., a case manager) 

is assigned primary responsibility for ensuring that all treatment and public health 

activities affiliated with the TB patient are completed. Although one person is assigned 

primary responsibility, case management usually involves a team of persons who work 

together to provide continuity of care. These team members may include clinic 

supervisors, outreach workers, health educators, nurses, nurse practitioners, physician 

assistants, pharmacists, physicians, and social workers. Some specific responsibilities 

may be assigned to other team members; however, the case manager is ultimately 

responsible for ensuring that needed activities are performed. Although some patients 

may undergo their evaluation and treatment in settings other than the health 

department, such as hospitals or correctional facilities, it is still the health 

department’s duty to monitor and ensure the quality of all TB-related activities in their 

jurisdiction. Thus, all TB patients should be assigned a case manager, whether they 

receive TB care in a health department clinic or from a private provider. For more 

information about TB case management in special settings, refer to page 73 of this

module.
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A case manager is assigned primary responsibility for ensuring that 

all treatment and public health activities affiliated with the TB patient 

are completed. 

The case manager is responsible for ensuring the following activities are completed for 

all TB patients to whom they are assigned:

 Establishing a trusting relationship with the patient

 Educating the patient about TB and its treatment

 Developing a treatment and monitoring plan

 Ensuring the patient adheres to and completes treatment

 Conducting quality assurance through systematic regular review of patient 

progress

This module covers the basic case management strategies; it does not cover all topics 

relevant to nursing case management. For in-depth information on nursing case 

management for TB, please refer to Tuberculosis Case Management: A Guide for 

Nurses from the Global Tuberculosis Institute at Rutgers, the State University of New 

Jersey and the Tuberculosis Nursing: A Comprehensive Guide to Patient Care, 2nd 

Edition from the National Tuberculosis Nurse Coalition. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Study Question 6.3 

 

6.3 What is the goal of TB case management? 

 

 

 

 

Answers to study questions are on pages 80-87
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Working Effectively with TB Patients 

In order for case management to be successful, it is very important that the TB case 

manager is able to effectively work with patients. Working effectively with patients 

includes 

 Getting to know the patient

 Developing a good relationship with the patient that is built on trust and rapport

 Educating the patient about TB disease

 Addressing language barriers

 Discussing health beliefs and misconceptions

Getting to Know the Patient 

Once a patient has been reported to the health department and a case manager has 

been assigned, the case manager or another health care worker on the case 

management team will need to visit the patient as soon as possible. During this visit, 

the case manager should try to learn as much as possible about the patient. To do so, 

the case manager should conduct a patient assessment. Specific topics that the health 

care worker should discuss with the patient during the assessment include 

 Medical history 

 Knowledge, attitudes, and beliefs about TB 

 Ability to follow the TB treatment plan 

 Resources (e.g., family, other social support, finances) 

 Anticipated barriers (e.g., lack of transportation) and perceived barriers (e.g., TB 

medications will be very expensive) to treatment

 History of adherence to previous TB regimens or other medication

The case manager should conduct a patient assessment to discuss 

with the patient his or her medical history, knowledge about TB, and 

beliefs about TB treatment. 

How is the Patient Assessment Conducted? 

One way that health care workers can conduct an assessment is to ask several openended questions. An open-ended question is one that cannot be answered with a 

simple “yes” or “no.” Open-ended questions are designed to elicit the patient’s 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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knowledge, feelings, and beliefs by beginning with words that require an explanation, 

such as

 What?

 Why? 

 Who? 

 When?

 How?

In addition, phrases that begin with “Tell me about” or “Explain to me” may be helpful 

in eliciting information from the patient. 

The questions in Table 6.1 are examples of questions that can be used to assess TB 

patients’ knowledge, attitudes, and beliefs regarding TB. These questions are a starting 

point; the health care worker should adapt such questions according to the patient’s 

age, family situation, education level, and cultural background. These questions are 

useful during the initial patient assessment and later on during other interactions with 

the patient. Throughout treatment, the health care worker should ask the patient about 

his or her concerns about TB and adherence to the TB regimen. 

Table 6.1 

Examples of Open-Ended Questions for Patient Assessment 

 What are some difficulties you have taking medicine?

 How do your family members or close friends feel about your TB?

 How do you feel about taking your TB medication?

 How severe do you think your illness is?

 What problems has your illness caused for you?

 What are the most important results you hope to get from this treatment?

 What do you know about TB?

 What causes TB?

 What do you think TB does to your body?

 What treatment do you think you should receive for TB?

 What caused you to go to the doctor who diagnosed your TB?

 What did you think when you were told you had TB?

 How do you think you got TB?
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Establishing Rapport and Building Trust 

Establishing rapport, trust, and good communication with the patient is critical. If the 

patient and the health care worker have a good relationship with each other, the 

patient is more likely to adhere to treatment, name contacts, and follow the health care 

worker’s instructions and advice. 

Establishing rapport, trust, and good communication with the patient 

is critical. 

The relationship with the patient will develop over time; however, the foundation from 

which a trusting relationship is established begins immediately. Therefore, health care 

workers should begin to establish rapport with the patient at the initial visit. Ways to 

develop rapport include

 Using effective communication skills

 Finding common ground

 Displaying respect and empathy 

Examples of effective communication skills include active listening, using appropriate 

nonverbal communication, and communicating at the patient’s level of understanding 

(for more information regarding effective communication skills, refer to page 17 of this

module). Additionally, it is important that the health care worker is objective and 

nonjudgmental. The health care worker should keep in mind that judgments about the 

patient’s lifestyle, beliefs, and behaviors may be conveyed through nonverbal body 

language. This can negatively affect the health care worker’s relationship with the 

patient. 

Examples of effective communication skills include active listening, 

using appropriate nonverbal communication, and communicating at 

the patient’s level of understanding. 

To build a good relationship, the health care worker should

 Treat the patient with dignity and respect

 Listen carefully to the patient 

 Communicate clearly 

 Speak openly, honestly, and politely about differences in ideas; correct 

misconceptions about TB tactfully, and allow time for questions 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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 Involve the patient in the development of the treatment plan and be flexible in 

meeting the patient’s needs

 Listen and try to understand the patient’s knowledge, beliefs, and feelings about 

TB disease and treatment

 Be open minded about the patient’s cultural beliefs 

 Recognize and address the patient’s fears about the illness

 Understand and fulfill the patient’s expectations about treatment, when possible

 Avoid criticizing the patient’s adherence behavior; suggest behavior changes 

respectfully

 Be consistent in what is done and told to the patient 

Educating the Patient About TB 

TB education should begin at the initial patient visit and continue with each encounter. 

This includes information regarding 

 TB transmission and pathogenesis

 Expected outcomes of treatment

 Benefits and possible adverse effects of the treatment regimen

 Methods of supervision, such as directly observed therapy (DOT)

 Assessment of treatment response

 Infectiousness and infection control 

TB education should begin at the initial patient visit and continue 

with each encounter. 

Information obtained from the patient assessment should guide education efforts. As 

soon as the health care worker begins to work with a patient, it is important to ask 

what the patient understands and believes about TB disease and treatment. If the 

patient does not understand the rationale for a lengthy treatment regimen and the 

need for finishing treatment, adherence will be very difficult. If a patient has some 

understanding of the disease and its treatment, the health care worker should confirm 

the accurate information and correct any misconceptions the patient may have. To be 

sure a patient has an accurate understanding of their TB disease and treatment, the 

health care worker should ask the patient to repeat back and explain what they 

understood. This should be done with concern and care so the patient does not feel 

threatened. The health care worker may have to spend extra time reviewing important 

information.
Module 6—Managing Tuberculosis Patients and Improving Adherence

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As soon as the health care worker begins to work with a patient, it is 

important to ask what the patient understands and believes about TB 

disease and treatment. 

Health care workers should take the time to clearly explain to patients what medication 

should be taken, how much, how often, and when. Patients need to be informed about 

possible adverse reactions to the medications and when to seek necessary medical 

attention. Providing patients with information regarding the consequences of not 

taking TB medicine correctly is very important.

Effective Communication and Education Techniques 

When educating a patient, health care workers should use effective communication and 

education techniques such as the following

 Use simple, nonmedical terms

 Use the appropriate language level

 Limit the amount of information 

 Discuss the most important topics first and last

 Repeat important information

 Listen to feedback and questions 

 Use concrete examples

 Make interactions with the patient as positive as possible

 Provide patient education materials

Use Simple, Nonmedical Terms 

Do not use medical jargon and be specific about the behaviors that are expected by 

the patient. For example, it is usually more helpful to say, “This pill will help kill the TB 

germs in your body so you get better,” than to say, “This drug, isoniazid, is a 

bactericidal agent that is highly active against Mycobacterium tuberculosis.” Using 

words that are familiar to patients can make the information relevant to them.

Use the Appropriate Language Level 

Written information should match the patient’s reading level. Persons with a limited 

education may only be able to understand basic materials. Highly educated patients 

may prefer more detailed information. If a patient does not read or write, health care 

workers should give instructions verbally and leave visual cues or reminders, such as a 

picture of each medication, with the time the patient should take it written in large 

numbers.
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Limit the Amount of Information 

If too much information is given at one time, the patient may not remember all of it. To 

avoid overwhelming the patient, the topics discussed should be organized in the order 

of importance. In the first session, the most essential topics (such as the names of 

exposed contacts) should be discussed, in case the patient does not return for followup care.

Discuss the Most Important Topics First and Last 

People remember information presented at the beginning and at the end of a session 

more easily than they do the information presented in the middle. Health care workers 

should tell the patient what is expected of him or her before they explain test results, 

the expected outcome of a procedure, or treatment. For example, early in the first 

session the health care worker might say, “To get well, you must take four of these 

pills every day.” This information should be reviewed before leaving the patient.

Repeat Important Information 

People need to hear new information several times before they will remember it. Health 

care workers should repeat key messages throughout the session; have the patient 

repeat back the information; then in later sessions review previously presented 

material first. The topic can be introduced by saying, “As we discussed last time...”

Listen to Feedback and Questions 

Communication with the patient should always be a two-way interaction. The health 

care worker should listen to feedback and questions from the patient to ensure the 

patient understood the message.

Use Concrete Examples 

Use examples to make information easy to remember. This is especially important for 

patients who are not on DOT. For example, visual descriptions of pills can be helpful. 

The health care worker could say, “Take two Rifamate capsules in the morning when 

you get out of bed. These are the big red pills in the little brown bottle.” If there is 

something the patient does every morning, such as brushing teeth, a picture or note 

placed on the mirror near the toothbrush can serve as a reminder.

Make the Interaction with the Patient a Positive Experience 

It is not only what is said and done, but how it is said and done, that will help the 

patient adhere to treatment. The health care worker should be encouraging and 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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supportive. A warm, concerned, and respectful attitude toward the patient will make 

the experience more pleasant and successful.

Provide Patient Education Materials 

When educating patients, it may be helpful to give them written educational materials 

on TB that they can keep. Culturally and linguistically appropriate patient education 

materials can be found on the CDC website (www.cdc.gov/tb) and the Find TB 

Resources website (https://findtbresources.cdc.gov). 

Addressing Language Barriers 

If the patient and health care worker do not speak the same language, it can be a 

barrier to successful care and treatment. TB programs should provide language 

assistance services, such as bilingual staff and interpreter services, at no cost to 

patients with limited English proficiency.

Using Interpreters 

Using an interpreter can help the health care worker and patient communicate. It is 

best to use trained medical interpreters whenever possible (Figure 6.1). Language lines 

can also be used to do over-the-phone interpretation. If a trained interpreter is not 

available, other persons who could be used as interpreters include other health care 

workers who speak the patient’s language, or people from the patient’s community 

(with the patient’s prior permission). Using family members as interpreters is strongly 

discouraged, but do not exclude them if the patient wants them to be part of the clinic 

visit. If family members must be used to interpret, children should not be used.

It is best to use trained medical interpreters whenever possible. 

 

If family members must be used to interpret, children should not be 

used. 

 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Guidelines for Interpreters 

After the health care worker has identified an interpreter, he or she should follow these 

guidelines to make the best use of the interview:

 Ask for the patient’s permission to use an interpreter.

 Plan the interview and decide what key points to talk about with the patient.

 Meet with the interpreter before the interview to talk about the goals for the 

interview, to give instructions and guidance, and to make sure the interpreter is 

comfortable with the questions and topics that will be discussed.

 Remind the interpreter that all information in the interview is confidential.

 Ask the interpreter to refrain from adding his or her own comments.

 Address the patient directly, not the interpreter.

 Ask the interpreter to explain questions or answers that are not clear.

 Keep the messages simple and factual; use short phrases and focus on one 

topic at a time.

 Give the interpreter time to translate each phrase before continuing; do not 

interrupt the interpreter.

 Ask the interpreter to translate the patient’s and the health care worker’s own 

words exactly.

 Give the patient time to answer questions.
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Figure 6.1 Health care worker interviewing a patient with the assistance of an 

interpreter.

Discussing Health Beliefs with Patients 

Sometimes cultural, religious, or other personal beliefs affect a patient’s TB care and 

treatment. This may include beliefs about how TB is transmitted, how TB is treated, 

and the significance the disease has for the affected person. The long history of TB has 

led to various theories about its cause, including beliefs that certain factors, such as 

poor hygiene, pollution, or hard labor, may cause TB and contribute to its progression. 

Furthermore, remedies for symptom relief and cure of the disease can vary. Patient 

beliefs about TB may differ from the medical model of TB treatment.

Sometimes cultural, religious, or other personal beliefs affect a 

patient’s TB care and treatment. 

It is important to respect patient health beliefs while providing information about the 

rationale for medical TB treatment in a non-judgmental fashion. Health care workers 

and their organizations should strive to be culturally competent. Cultural competence

means having the capacity to function effectively as an individual and an organization 

within the context of the cultural beliefs, behaviors, and needs presented by patients 

and their communities.
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Cultural competence means having the capacity to function 

effectively as an individual and an organization within the context of 

the cultural beliefs, behaviors, and needs presented by patients and 

their communities. 

While it is important to respect the patient’s beliefs, it is just as important for the 

health care worker to clearly present the rationale for taking prescribed TB medication 

for a full course of treatment. In order for treatment to be successful, the patient must 

agree to take TB medicines. The health care worker can do a great deal to help the 

patient adhere and incorporate his or her beliefs into the treatment, but it is crucial 

that both come to an agreement about taking TB medication. For example, traditional 

or folk medicine can complement Western medicine, but should be overseen by the 

treating clinician.

While it is important to respect the patient’s beliefs, it is just as 

important for the health care worker to clearly present the rationale 

for taking prescribed TB medication for a full course of treatment. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Study Questions 6.4 – 6.6 

 

6.4 During a patient assessment, what specific topics should the health care 

worker discuss with the patient? 

 

 

 

 

6.5 In the list below, there are closed-ended and open-ended questions. Mark 

an X next to the open-ended questions. 

 What is TB? 

 Do you think TB can be cured? 

 How is TB spread? 

 Do you have difficulty taking medicine? 

 What are some of the difficulties you have taking medicine? 

 Why do you think you need to take medicine? 

 Is TB curable? 

 How is TB cured? 

 

6.6 Explain the importance of building rapport and establishing a trusting 

relationship with the patient. 

 

 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Study Questions 6.7 – 6.8 

 

6.7 List at least four effective communication and education techniques that 

health care workers should use when educating a patient. 

 

 

 

 

 

 

6.8 List at least six guidelines for working with an interpreter that can help 

the health care worker make the best of the interview. 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

25

Case Study 6.1 

 

Thanh is a cook at a local restaurant. He went to see his physician because he 

was feeling extremely tired, had lost his appetite, and had been coughing for 

several weeks. His physician suspected TB and admitted Thanh to the hospital 

for further tests.

His sputum smears were positive and he was started on appropriate therapy. 

The physician called the local health department to report the diagnosis. A case 

manager was assigned and visited Thanh in the hospital.

 How should the case manager assess Thanh's knowledge, beliefs, and 

feelings about TB disease and treatment? 

 Why is it important to assess Thanh's knowledge, beliefs, and feelings 

about TB disease and treatment? 

Answers to case studies are on pages 88-93
Module 6—Managing Tuberculosis Patients and Improving Adherence

26

Developing a Treatment and 

Monitoring Plan 

A specific treatment and monitoring plan should be developed for each TB patient. 

This should be done within one week of the suspected diagnosis. This plan should 

include

 A description of the treatment regimen 

 Methods of monitoring for adverse reactions 

 Methods of assessing and ensuring adherence to the treatment 

 Methods for evaluating treatment response 

A specific treatment and monitoring plan should be developed for 

each TB patient. 

For more information about developing a treatment and monitoring plan, refer to 

Module 4, Treatment of Latent Tuberculosis Infection and Tuberculosis Disease. For 

detailed information on treating TB, refer to the ATS, CDC, and IDSA Treatment of 

Drug-Susceptible Tuberculosis Guidelines. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

27

Adherence to Treatment 

Helping patients adhere to and complete TB treatment is a key component of case 

management. Adherence to treatment means following the recommended course of 

treatment by taking all medications as prescribed, for the entire recommended time. 

Nonadherence is a patient’s inability or refusal to take TB drugs as prescribed. 

Examples of nonadherent behavior include

 Taking medications inconsistently

 Missing clinic appointments

 Missing DOT appointments

 Refusing medications 

Nonadherence to treatment for TB disease can lead to serious consequences such as 

acquired drug resistance, an increase in the severity of illness, ongoing TB 

transmission, and even death. (For more information on drug resistance and treatment,

refer to Module 4, Treatment of Latent Tuberculosis Infection and Tuberculosis 

Disease.)

It is also important that persons with LTBI adhere to the prescribed treatment regimen. 

Completion of LTBI treatment can prevent the development of TB disease.

Adherence to treatment means following the recommended course of 

treatment by taking all medications as prescribed, for the entire 

recommended time. 

Explaining the Importance of Adherence 

As part of patient education, health care workers should explain the importance of why 

people with TB disease need to take their medicine. Health care workers should explain 

how adhering to TB treatment is good for the patient and for others. For example, 

adhering to treatment can help a patient feel better sooner, cure their TB, and help 

them return to normal activities. Likewise, a patient’s adherence to treatment can 

prevent the further spread of TB to others.
Module 6—Managing Tuberculosis Patients and Improving Adherence

28

Health care workers should explain to the patient that some people have trouble 

staying on the medication schedule. The health care worker should help patients 

identify and address potential adherence problems. Patients are more likely to be 

adherent if they help make the decisions and choose solutions rather than being told 

what to do. For example, the health care worker can ask the patient to provide 

feedback on the site and time for DOT. Patients are more inclined to pay attention to 

information that is relevant to their needs and does not require abrupt changes in their 

behavior.

The health care worker should help patients identify and address 

potential adherence problems. 

Parents of children and adolescents with TB disease should be educated about TB and 

the importance of adherence. Additionally, parents should be educated about the 

problems their children might have during TB treatment and possible solutions. 

Children may resist taking medications, have adverse reactions to the medications, or 

have problems swallowing pills. When parents can anticipate possible problems that 

may come up during their child’s treatment, they can cope with and help solve 

problems as they arise.

Why Are Some Patients Nonadherent? 

Each patient is unique, and there are many reasons why a patient might be unable or 

unwilling to complete TB treatment. Some patients may face barriers, which can 

prevent them from adhering to TB treatment. Many health care workers think they 

know which patients will be adherent; however, there is no way to predict who will take 

their medicine correctly or not. 

Below are some reasons why patients may be nonadherent to TB treatment.

Improved or No Symptoms 

TB symptoms can improve dramatically during the first 2 months of treatment. When 

patients no longer feel sick, they sometimes stop taking their TB drugs. However, 

unless patients continue treatment for at least 6 months, some tubercle bacilli may 

survive, putting patients at risk for a relapse of TB disease and the development of 

drug resistance.
Module 6—Managing Tuberculosis Patients and Improving Adherence

29

In addition, people with LTBI do not have symptoms; therefore, they may not see 

treatment for LTBI as a priority since they are not sick.

Lack of Knowledge 

Patients sometimes do not fully understand the treatment regimen, how to take their 

drugs, or the reasons for the long duration of TB treatment. This lack of knowledge 

can lead to an inability or lack of motivation to complete treatment.

 

Cultural Beliefs 

Some patients have strong personal or cultural beliefs about TB disease (including 

what causes the disease, how it is transmitted, and who is affected), how it should be 

treated, and who they should go to for help. When TB is diagnosed or TB treatment 

conflicts with these beliefs, patients may display a variety of behaviors, such as 

becoming fearful, anxious, or alienated from their health care workers.

Language Barriers 

When a patient and the health care worker do not speak the same language, it can lead 

to problems with adherence. Health care workers should try to accommodate this 

language barrier through various means, including the use of an interpreter.

Lack of Access to Healthcare 

Lack of access to healthcare can also be a barrier to successfully completing TB 

treatment. For example, patients may have work schedules that conflict with clinic 

hours or lack transportation to the clinic. 

Poor Relationship between the Patient and the Health Care Worker 

When patients and health care workers fail to establish a trusting relationship, this can 

negatively affect patient adherence. If a patient develops trust with the health care 

worker, he or she may be more likely to follow instructions and to cooperate. Patients 

may also be more likely to bring questions and concerns to the health care worker’s 

attention.

Competing Priorities 

Some patients have many competing priorities in their lives such as familial 

obligations, legal issues, substance abuse, homelessness, or other diseases (e.g., HIV). 

Because of these competing priorities, taking TB medication may not be considered a 

priority to them.
Module 6—Managing Tuberculosis Patients and Improving Adherence

30

Stigma 

Patients may fear job loss, stigmatization, or being ostracized by their family, spouse, 

or community. As a result, they may deny their diagnosis and refuse treatment. 

Mental Health 

Patients’ mental health issues, including addiction, can adversely impact TB treatment 

adherence and completion, as well as successful contact investigation.

Above are some of the reasons why patients may be nonadherent. It is important to 

keep in mind that any patient can have problems with adherence. The more the health 

care worker knows about the patient, the better he or she will be able to understand 

and address the patient’s potential adherence problems. Each patient is different and 

may require different approaches to ensure adherence. 

It is important to keep in mind that any patient can have problems 

with adherence. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

31

Study Questions 6.9 – 6.11 

 

6.9 What is adherence to treatment? 

 

 

 

 

 

 

 

6.10 What are four serious consequences that can result when a patient with TB 

disease is nonadherent? 

 

 

 

 

 

 

 

6.11 Give eight reasons why a patient might be nonadherent. 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

32

Providing Directly Observed 

Therapy (DOT) 

What is DOT? 

DOT is the most effective strategy for ensuring patients take their medicine correctly. It 

is recommended as a standard of care worldwide. DOT means that a health care 

worker or other designated individual watches the patient swallow every dose of the 

prescribed drugs. DOT can reduce the development of drug resistance, treatment 

failure, or relapse after the end of treatment. Good patient-centered case 

management, which includes establishing a relationship with the patient and 

addressing barriers to adherence, facilitates successful DOT. 

DOT is the most effective strategy for ensuring patients take their 

medicine correctly. 

DOT visits can also be an opportunity to include a number of other case management 

functions, such as

 Helping patients keep appointments

 Monitoring for adverse side effects of the medication 

 Providing effective education 

 Offering incentives and enablers to encourage adherence

 Providing social services 

For example, some health departments provide an array of services, such as help in 

finding housing for homeless patients; or providing specially trained community 

service aides, transportation to clinics, and delivery of drugs to the patient’s home, 

workplace, or other convenient site. 

Who Should Receive DOT? 

DOT is the preferred treatment strategy and should be considered for all patients 

because it is impossible to predict which patients will be adherent. Even patients who 

intend to take their medicine might have trouble remembering to take their pills every 

time. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

33

DOT is the preferred treatment strategy and should be considered for 

all patients because it is impossible to predict which patients will be 

adherent. 

DOT should be used for all children and adolescents with TB disease. Even when drugs 

are given by DOT, adherence to and tolerability of the regimen must be monitored 

closely. Parents should not be relied on to supervise DOT. 

DOT is highly recommended for patients on intermittent regimens (e.g., patients 

receiving treatment three times a week). 

Other persons who should be considered a high priority for receiving DOT include

 Patients with drug-resistant TB

 Patients with positive sputum smears

 Patients with delayed culture conversion

 Patients with treatment failure or relapse

 Patients with HIV infection 

 Persons at high risk for nonadherence, such as

o Persons experiencing homelessness or persons with unstable housing 

o Persons who abuse alcohol or use illicit drugs

o Persons who are unable to take pills on their own due to mental, 

emotional, or physical disabilities

o Children and adolescents

o Persons with a history of nonadherence 

 Residents at correctional or long-term care facilities

 Patients who have been previously treated for TB disease or LTBI

DOT for Latent TB Infection Treatment 

DOT for LTBI treatment should be considered for persons who are at especially high 

risk for TB disease and are either taking an intermittent regimen or are suspected of 

nonadherence. Persons who are at high risk for TB disease include young children, 

persons living with HIV/AIDS, and other immunosuppressed persons.

DOT for LTBI treatment should be considered for persons who are at 

especially high risk for TB disease and are either taking an 

intermittent regimen or are suspected of nonadherence. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

34

DOT is especially appropriate if the person in need of LTBI treatment lives with a 

household member who is on DOT for TB disease, or lives in an institution or facility 

where treatment for LTBI can be observed by a staff member. Because persons with 

LTBI have no symptoms, it is very important that they understand the need for 

medication so that they are motivated to start and finish LTBI treatment.

The use of DOT for LTBI is one strategy that can improve patients’ adherence to 

treatment for LTBI. However, if resources are limited, DOT for TB disease should be 

prioritized over DOT for LTBI. 

Tasks Involved in Delivering DOT 

DOT for TB disease and DOT for LTBI involve more than watching the patient swallow 

each pill. At each DOT encounter, the health care worker should perform the following 

tasks:

 Check for side effects

 Verify medication

 Watch patient take pills

 Document the visit 

Check for Side Effects 

Health care workers should ask if the patient is having any adverse side effects at each 

visit, before the drugs are given. Examples of side effects include fever, rash, vomiting, 

upset stomach, changes in eyesight or hearing, yellow skin or eyes, aching joints (see 

Module 4, Treatment of Latent Tuberculosis Infection and Tuberculosis Disease for 

more information on potential side effects of treatment). If the patient has symptoms 

of serious adverse reactions, a new drug supply should not be given; the patient 

should stop taking medication immediately. The health care worker should tell their 

supervisor that the drugs were not given and notify the prescribing clinician about the 

adverse reaction. The health care worker should arrange for the patient to see the 

clinician as soon as possible.

Verify Medication 

Each time DOT is delivered, the health care worker should verify that the right drugs 

are delivered to the right patient, and that he or she has the correct amount of 

medication. If this cannot be confirmed, the drugs should not be given to the patient. 

The supervisor should be contacted for clarification.
Module 6—Managing Tuberculosis Patients and Improving Adherence

35

Watch Patient Take Pills 

Health care workers should watch for techniques some patients may use to avoid 

swallowing medication. Some patients may hide pills in their mouth and spit them out 

later, hide medicine in clothing, or vomit the pills after the DOT visit. The health care 

worker or the patient should get a glass of water or other beverage before the patient 

is given the pills. The health care worker should watch the patient continuously from 

the time each pill is given to the time he or she swallows it. If it is necessary to make 

sure that the patient swallows the pills, the health care worker may have to check the 

patient’s mouth, or ask the patient to wait for a half hour before leaving so the 

medication can dissolve in the patient’s stomach. Medication should not be left for the 

patient to take on his or her own unless self-administered therapy has been prescribed 

for non-DOT days, such as weekends. 

Document the Visit 

The health care worker should document each visit with the patient and indicate 

whether or not the medication was given. If the medicine was not given, the reason 

and follow-up plans should be included. Instances of nonadherence should be 

documented. It is important to correct any interruption in treatment as soon as 

possible. Figure 6.2 is a sample form used to monitor and document a patient’s DOT. 

At each DOT encounter, the health care worker should check for side 

effects, verify medication, watch the patient take pills, and document 

the visit. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

36

Figure 6.2 Sample DOT form.

CLIENT NAME: 

SSN#: 

DIAGNOSIS: 

ADDRESS: 

OTHER LOCATION INFO: 

DOT START: 

DOT DISCONTINUED: 

CLINICIAN: 

Drug 

Dosage 

Date 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

MEDS TAKEN (NUMBER OF DAYS):_________/ AVAILABLE DAYS:________ = ________% ADHERENCE 

INH Signature of 

person observing 

or giving medicine 

Time 

medicine 

observed Comments 

HEALTH CARE WORKER: 

DOT SITE: 

DOT INCENTIVE: 

TELEPHONE: 

SPECIAL ATTENTION REQUIRED: 

(EXPLAIN) 

STATE CASE#: CITY/COUNTY CASE#: 

DATE OF BIRTH: / / AGE: 
Module 6—Managing Tuberculosis Patients and Improving Adherence

37

Delivering DOT in the Clinic and the Field 

DOT can be given anywhere the patient and health care worker agree upon, provided 

the time and location are convenient and safe. It is important that the location is 

convenient for the patient. Clinic-based DOT is delivered in a TB clinic or comparable 

healthcare facility (Figure 6.3). When a patient cannot easily get to the TB clinic, the 

health care worker must go to the patient. DOT delivered in a setting outside of the TB 

clinic or healthcare facility is called field-based DOT (Figure 6.4 and Figure 6.5). Field 

DOT can be given at almost any site:

 Patient’s home

 Patient’s workplace

 Public park or other agreed-upon public location

 School

 Restaurant

 Church 

DOT can be given anywhere the patient and health care worker agree 

upon, provided the time and location are convenient and safe. 

Figure 6.3 Clinic-based DOT.
Module 6—Managing Tuberculosis Patients and Improving Adherence

38

Figure 6.4 Field-based DOT in the patient’s home.

Figure 6.5 Field-based DOT at an agreed-upon public location.

DOT is usually given by TB clinic personnel such as an outreach worker, nurse, or other 

health care worker. Sometimes staff at other healthcare settings, such as outpatient 

treatment centers, can be asked to give DOT to a patient who can travel to an 

alternative healthcare setting more easily than to the TB clinic.

Likewise, staff may choose a person other than a health care worker to watch the 

patient take medicine. Family members should NOT be responsible for watching the 

patient take medicines. Because of strong emotional ties, the family may be unwilling 
Module 6—Managing Tuberculosis Patients and Improving Adherence

39

to ensure the patient takes treatment if he or she refuses treatment. However, other 

persons—such as school or employee health nurses, clergy, or other responsible 

persons who do not have strong emotional ties with the patient—can provide DOT, if 

the patient agrees to this arrangement. These arrangements must be approved in 

advance by supervisory clinical and management staff and should be monitored closely 

to ensure there are no problems.

Family members should NOT be responsible for watching the patient 

take medicines.

Regardless of the arrangement, it is always important to protect the patient’s 

confidentiality. For example, the patient may not want the health care worker to tell 

neighbors why he or she is visiting. If home visits create confidentiality problems, the 

health care worker and the patient should work together to identify another location. 

(For more information on confidentiality, refer to Module 7, Patient Rights and 

Confidentiality in Tuberculosis Control.)

Another critical consideration for conducting field DOT is the health care worker’s own 

safety. Health care workers should become familiar with policies and recommendations 

of local law enforcement agencies and health department administration regarding 

personal security. Current information on local high-risk areas for crime can be very 

valuable in planning and conducting safe field visits. (For more information on safety in 

the field, refer to Module 8, Contact Investigations for Tuberculosis.)

Electronic DOT (eDOT) 

Electronic DOT (eDOT) is an alternative method to in-person DOT in which a patient is 

remotely observed (e.g., over a smartphone, tablet, or computer) taking his or her TB 

medication. eDOT can be either real-time or recorded. During a real-time eDOT visit, 

the health care worker and the patient schedule a specific day and time to meet 

virtually, and the health care worker watches the patient take his or her medication. In 

contrast, recorded eDOT is when the health care worker and the patient do not set a 

specific time to meet, and the patient records himself or herself taking the 

medications. The patient then saves the recording and sends it to the health 

department for review. This option may be useful when patient schedules do not align 

with the health department, and the health care worker is unable to watch the patient 

live. For more information on eDOT, please refer to Implementing an Electronic Directly 
Module 6—Managing Tuberculosis Patients and Improving Adherence

40

Observed Therapy (eDOT) Program: A Toolkit for Tuberculosis (TB) Programs, available 

on the CDC website (www.cdc.gov/tb).

Advantages and Challenges to DOT 

DOT has many advantages, but it also has a few challenges (Table 6.2). When used as a 

collaborative effort with the patient, the advantages of DOT over self-administered 

therapy include

 Ensuring that the patient completes an adequate regimen

 Enabling the health care worker to monitor the patient regularly for side effects 

and response to treatment

 Helping the health care worker solve problems that might interrupt treatment

 Ensuring the patient takes every dose of medicine, which helps the patient 

become noninfectious sooner

DOT does have a few challenges because it

 Is time consuming*

 Is labor intensive*

 Can be perceived as insulting to some patients

 Can imply that the patient is incapable or irresponsible

 Can be perceived as demeaning or punitive

It is important to explain the benefits of DOT to each patient and stress the fact that 

DOT is not a punishment; rather, DOT is a highly effective way for the patient and 

health care worker to collaborate so that the patient will successfully complete an 

adequate regimen. Health care workers can also inform the patient that DOT is the 

national standard of practice for the treatment of TB disease. 

 
Module 6—Managing Tuberculosis Patients and Improving Adherence

41

Table 6.2 

Advantages and Challenges to DOT 

Advantages Challenges 

 Ensures that the patient completes an 

adequate regimen

 Allows the health care worker monitor 

the patient regularly for side effects 

and response to therapy

 Helps the health care worker solve 

problems that might interrupt 

treatment

 Helps the patient become 

noninfectious sooner by ensuring the 

patient takes every dose of medicine

 Time consuming*

 Labor intensive*

 Can be insulting to some patients

 Can imply that the patient is 

incapable or irresponsible

 Can be perceived as demeaning or 

punitive

*eDOT may not be as time consuming or labor intensive as clinic-based or field-based 

DOT. For more information on the advantages and challenges of eDOT, please refer to 

Implementing an Electronic Directly Observed Therapy (eDOT) Program: A Toolkit for 

Tuberculosis (TB) Programs.
Module 6—Managing Tuberculosis Patients and Improving Adherence

42

 

 

Study Questions 6.12 – 6.14 

 

6.12 What is DOT? 

 

 

 

 

 

 

 

 

6.13 List and explain four tasks that are part of the DOT encounter. 

 

 

 

 

 

 

 

 

6.14 What are four advantages of DOT? 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

43

 

Case Study 6.2 

 

You are an outreach worker at a TB clinic and have been assigned to deliver DOT 

to Mrs. Wilson, a 76-year-old woman who lives alone in the house that she and 

her husband bought many years ago. Mrs. Wilson was recently released from the 

hospital. Upon discharge from the hospital, she received education about TB and 

about the need to take medications until she completes treatment. She was told 

that she would be started on DOT and a health care worker would visit her at 

home to help her take her medication. Mrs. Wilson is excited to have some 

company. She happily offers you cookies and wants to “talk awhile” before she 

takes her medication.

 

 How should you respond to Mrs. Wilson’s request to “talk awhile”? How 

could your reaction affect her adherence? 

Answers to case studies are on pages 88-93
Module 6—Managing Tuberculosis Patients and Improving Adherence

44

Addressing Barriers to Adherence 

Even with education and DOT, some patients may still face barriers to adhering to their 

treatment. The health care worker should identify the specific reasons why a patient is 

not being adherent. Different patients will have different reasons. Once a patient’s 

specific set of adherence problems are known, the health care worker can develop an 

individualized plan of action to overcome the difficulties and promote adherence. 

There are several additional strategies health care workers can use to address barriers 

to adherence: 

1. Create an adherence agreement

2. Help patients keep appointments

3. Use incentives and enablers to improve adherence

4. Encourage the patient to seek support

5. Give TB drugs in easy-to-take preparations

6. Coordinate other services

1. Create an Adherence Agreement 

For some patients, a formal adherence agreement—a written understanding 

between the health care worker and a patient—may be useful. If many barriers are 

identified, it may be appropriate to have an adherence agreement at the very 

beginning of treatment. A sample adherence agreement is presented in Figure 6.6. 

A patient should write down the activities he or she agrees to carry out (such as 

taking medicine as prescribed), in return for specific services, activities, or 

incentives from the health care worker. For some patients, this written commitment 

increases the likelihood of adherence. The patient should be asked to sign the 

agreement and be given a copy. The health care worker should review the 

agreement with his or her patient periodically to assess how well both are doing 

and make changes as needed.
Module 6—Managing Tuberculosis Patients and Improving Adherence

45

Figure 6.6 Sample adherence agreement.

 
Module 6—Managing Tuberculosis Patients and Improving Adherence

46

2. Help Patients Keep Appointments 

Throughout the course of treatment, TB patients will have many appointments they 

need to keep, such as DOT encounters and clinic visits. For a variety of reasons, 

some patients may have difficulty keeping all of these appointments. 

To help patients remember scheduled visits, health care workers can give patients 

an appointment card or calendar. If the patient has a home address, the health care 

worker can send a reminder postcard. If the patient has a telephone, the health care 

worker should call the patient to remind them of the scheduled appointment. Using 

telephone reminders gives the health care worker an opportunity to counsel the 

patient and help the patient solve scheduling and transportation problems or other 

barriers to adherence. Health care workers should be aware of confidentiality issues 

when leaving telephone messages for TB patients. (For more information, refer to 

Module 7, Patient Rights and Confidentiality in Tuberculosis Control.)

If a patient fails to keep an appointment, the health care worker should immediately 

call or text the patient to find out why he or she missed the appointment. If the 

health care worker is unable to reach the patient, he or she should visit the patient 

at home. Once the health care worker reaches the patient, he or she should counsel 

the patient and attempt to identify and solve problems that interfere with 

appointment keeping. If the patient repeatedly misses appointments, the health 

care worker may need to try several different strategies, such as discussing the 

matter with the other health care team or providing incentives or enablers.

If a patient fails to keep an appointment, the health care worker 

should immediately call or text the patient to find out why he or she 

missed the appointment. 

3. Use Incentives and Enablers 

Incentives are small rewards given to patients to encourage them to either take 

their own medicine or keep their DOT appointments. Incentives should be chosen 

according to the patients’ special needs and interests. Incentives are usually used 

on an ongoing basis- weekly, monthly, or when key milestones are reached. 

When offering incentives, health care workers should make a verbal or written 

agreement with the patient. For example, be clear that if the patient keeps all DOT 
Module 6—Managing Tuberculosis Patients and Improving Adherence

47

appointments, they will receive the agreed-upon incentive. If the patient does not 

keep their end of the agreement, health care workers should withhold the incentive 

and kindly but firmly explain why the incentive was not given and what the patient 

needs to do to receive it.

Enablers are things that make it possible or easier for patients to receive treatment 

by overcoming barriers, such as a lack of transportation to get to the clinic. Health 

care workers should identify barriers that interfere with the patient’s ability to 

adhere to treatment and provide an enabler that will help overcome that specific 

barrier. For example, if the health care worker knows that transportation is a 

problem, he or she could offer bus tokens, bus fare, or taxi fare as an enabler. 

Figure 6.7 shows examples of incentives and enablers.

Incentives and enablers are not “bribes.” Incentives should be used to motivate and 

must not be used as coercion. Furthermore, using incentives and enablers should 

not necessarily be routine or “automatic” for all TB patients. Not everyone needs 

this type of help to finish treatment. 

Sources of Incentives and Enablers 

Programs can obtain incentives and enablers from many different sources. Possible 

sources for obtaining incentives and enablers include

 The state or local American Lung Association chapter

 Community organizations, such as church groups

 Businesses that can donate items such as food or food coupons or gift 

vouchers

 Volunteers who can contribute goods and services, such as baked goods or 

childcare

 TB program staff who are willing to devote extra time and attention 

Table 6.3 is a list of examples of incentives and enablers.
Module 6—Managing Tuberculosis Patients and Improving Adherence

48

Table 6.3 

Examples of Incentives and Enablers 

Money 

• Gift cards

Food

• Nutritional 

supplements

• Fast food

• Sandwiches

• Canned food

• Food vouchers

• Fruit 

• Ice cream

Beverages

• Juices

• Milk

• Coffee

• Tea

Clothing

• Socks

• Gloves

• Stockings

• Sweaters

• Coats/Scarves

• Shoes

Automotive

• Battery

• Gasoline

• Motor oil

Fishing supplies

• Fishing pole

• Crickets 

Services

• Social service 

referrals

• Help in obtaining 

housing, social 

security, food 

stamps

• Help in obtaining 

drug treatment

• Help in paying rent

• Help in obtaining 

other medicines

• Child care

• Legal services

• Help in obtaining 

birth certificate

• Help in obtaining 

driver’s license

• Repairing bicycle

Household

• Paying rent or 

mortgage

• Cooking utensils

• Furniture

• Pre-paid cell 

phone

• Cell phone 

minutes or data

Transportation

• Bus and subway 

fare

• Taxi fare

• Bicycle

• Transportation 

provided by staff

Seasonal

• Special seasonal 

treats

• Homemade 

holiday cookies

• Food baskets

• Birthday cakes and 

cards

Personal care

• Toiletries

• Contraceptives 

(e.g., condoms)

• Razors

• Shaving cream

• Face cream

• Makeup

• Nail polish

Garden

• Flowers

• Flower bulbs

For children

• Toys

• Books

• Painting child’s 

nails

• Tea party

• Playing games

• Stuffed animals

• Grab bag with 

assorted treats

• Chewing gum

• School supplies

• Crossword puzzle 

books

Source: Adapted from Using Incentives and Enablers in the Tuberculosis Control Program. 

Columbia: American Lung Association of South Carolina and South Carolina Department of 

Health and Environmental Control, Division of Tuberculosis Control, 1989.
Module 6—Managing Tuberculosis Patients and Improving Adherence

49

Figure 6.7 Examples of incentives and enablers.

4. Encourage the Patient to Seek Support 

The support of family, friends, and others can be important to patients trying to 

complete treatment. Some health departments may use former TB patients as peer 

workers to support patients currently going through TB treatment. The health care 

worker should ask his or her patients to identify persons who support their TB 

treatment and can help them remember to take medications or keep their DOT 

appointments. However, the health care worker should remember that they are 

ultimately responsible for ensuring the patient completes treatment. 

The support of family, friends, and others can be important to 

patients trying to complete treatment. 

Persons who may be able to support the patient throughout treatment include

 Family members 

 Friends

 Teachers

 Social workers

 Clergy 

 Neighbors 

 Peer educators
Module 6—Managing Tuberculosis Patients and Improving Adherence

50

With the patient’s permission, family members, friends, or others may be included 

in educational sessions so that they also understand the patient’s diagnosis, and 

what the patient needs to do. Educating a patient’s family and friends also helps to 

reduce TB stigma.

5. Give TB drugs in Easy-to-Take Preparations 

Particularly with children, it can be helpful to give TB drugs in easy-to-take 

preparations. For example, isoniazid (INH) and pyrazinamide (PZA) pills can be 

crushed and given with small amounts of food, such as apple sauce or yogurt. 

Some patients may find it difficult to take multiple pills at once. Health care workers 

should check with the patient’s clinician about the option of using combined 

capsules or liquid medication.

Particularly with children, it can be helpful to give TB drugs in easyto-take preparations. 

6. Coordinate Other Services 

The health care worker may identify problems other than TB that patients are 

struggling to overcome. These problems may include other medical conditions, 

inadequate housing, poverty, mental health issues, family dysfunction, or substance 

abuse. Unless these problems are addressed, patients may have serious barriers 

that prevent them from adhering to the prescribed regimen and keeping clinic 

appointments. 

When patients have other issues, the health care worker has an opportunity to help 

them by providing appropriate referrals for support and assistance. By helping 

patients with these other issues, providers and public health workers are also 

helping patients complete TB treatment successfully. Table 6.4 presents some 

examples of the service providers the public health worker may want to contact for 

eligible patients. Relationships with such providers can often be improved by means 

of formal referral agreements and educational sessions for staff about TB, including 

information on services the TB program has to offer.
Module 6—Managing Tuberculosis Patients and Improving Adherence

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When patients have other issues, the health care worker has an 

opportunity to help them by providing appropriate referrals for 

support and assistance. 

In some cases, the patient and his or her family may already be receiving visits 

from social workers or public health nurses for other conditions or problems. If 

this is the case, the team should coordinate efforts. By helping to coordinate 

care provided to a single patient, the public health worker can often improve 

patient adherence and maximize the use of public health resources. 

Table 6.4 

Service Providers with Benefits for Eligible TB Patients 

Service Provider Examples of Benefits Available 

to Qualified Persons 

Public health nursing services  Integrated home healthcare

 Public health clinic services

 Patient incentives

HIV/AIDS services  HIV testing, counseling, and treatment programs

 Patient support groups

 Meal programs

Housing services  Temporary shelter

 Location of available housing options

Social services  Food stamps

 Medicaid

 Unemployment or disability support

Emergency assistance 

programs

 Shelter for battered women

 Placements for victims of child abuse

Substance abuse treatment 

programs

 Detoxification programs

 Methadone treatment programs and other 

medication-assisted treatment programs

Mental health services  Counseling

 Psychiatric care
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Service Provider Examples of Benefits Available 

to Qualified Persons 

Medical services  Medicaid

 Low income clinics

Table 6.5 provides additional methods for overcoming specific barriers to adherence.

 

Table 6.5 

Methods to Overcome Adherence Barriers 

Barriers to 

Adherence Examples of Methods to Overcome Adherence Barriers 

Lack of knowledge  Assess patient’s knowledge, beliefs, and feelings about TB

 Use health education, provide written materials

Forgetfulness  Get help from family or friends

 Simplify the regimen or use combination pills

 Link pill taking with other activities

 Provide special pill dispensers and memory cues

 Send reminder text message or phone call

 Use DOT

Lack of motivation  Point out the dangers of nonadherence and benefits of therapy

 Increase the frequency of visits

 Provide incentives and set short-term goals

 Use DOT

Fear of side effects  Allow extra time to discuss known side effects

 Provide reassurance

 Make staff available to answer questions

 Use DOT

Lack of skills in pill 

taking

 Demonstrate correct pill taking

 Have the patient practice with guidance

 Use DOT

Lack of support from 

family or friends

 Make home visits

 Encourage family or friends to accompany patient on clinic visits

 Use DOT
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Poor relationship 

with the health care 

worker

 Develop communication skills of staff

 Be accessible throughout care

 Work on staff attitudes about patients and DOT

 Provide cultural competency training for staff

 Change health care workers

 Provide social services

Lack of money to pay 

for healthcare

 Provide free care, facilitate third-party payment

 Refer to social worker

No sick leave 

available

 Provide clinic appointments during off hours

 Use DOT at work site or nearby location

Long clinic waiting 

time

 Keep to scheduled appointment times

 Make efficient use of patient visits

 Have separate appointments for drug refills

Other medical 

conditions or 

physical limitations

 Use a home health nursing service

 Use DOT

Complex regimen  Simplify the regimen

 Associate the regimen with other activities

 Use combined capsules

 Use DOT

Medication side 

effects

 Take medication before or after meals, as indicated

 Evaluate medication options

 Change drugs or dosages
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Study Questions 6.15 – 6.17 

 

6.15 What is a formal adherence agreement? 

 

 

 

 

 

 

6.16 What are incentives and enablers? 

 

 

 

 

 

 

6.17 Describe at least three strategies health care workers can use to address 

barriers to adherence. 

 

 

 

 

 

 

 

 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

55

Case Study 6.3 

 

Mr. Sivaraman is a recent immigrant from India who is working two jobs to 

support his wife and three children. He has been on DOT for two months and his 

TB symptoms have greatly improved. Mr. Sivaraman has kept daily DOT 

appointments with the health care worker, but recently has missed two 

appointments and skipped his last clinic visit.

 

 What do you know about Mr. Sivaraman’s history that might lead to 

nonadherence? 

 

 

 

 

 What steps can the health care worker take to help Mr. Sivaraman keep his 

appointments and adhere to treatment? 

 

 

 

 

Answers to case studies are on pages 88-93
Module 6—Managing Tuberculosis Patients and Improving Adherence

56

Legal Remedies to Nonadherence 

Patients who are unwilling or unable to adhere to treatment may be required to do so 

by law or may be isolated until noninfectious. State governments have legal 

responsibility for TB control activities, including treatment protocols for nonadherent 

patients; the health care worker should refer to the laws in his or her state for those 

procedures as TB control laws vary considerably from state to state. Health care 

workers should notify the appropriate supervisory clinical and management staff when 

patients are repeatedly nonadherent. 

Patients who are unwilling or unable to adhere to treatment may be 

required to do so by law or may be isolated until noninfectious. 

Progressive Interventions 

State and local TB control programs should have a treatment plan that goes step-bystep from voluntary participation to involuntary confinement as a last resort (Figure 

6.8). The plan should begin with learning the possible reasons for nonadherence and 

addressing the identified problems using methods such as DOT, incentives and 

enablers, and an adherence agreement. The patient should be told verbally and in 

writing of the importance of adhering to treatment, the consequences of failing to do 

so, and the legal actions that will have to be taken if the patient refuses to take 

medication. 

If the patient does not adhere to DOT voluntarily, the next step may be court-ordered 

DOT. Court-ordered DOT is DOT that is administered to a patient by order of a public 

health official or a court with the appropriate authority. It is used when patients have 

been nonadherent despite the best efforts of TB program staff. It can be successful in 

convincing a patient that his or her TB treatment is an important public health priority. 

Figure 6.9 is an example of a letter given to patients who demonstrate nonadherent 

behavior and who may be candidates for legal action. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

57

Court-ordered DOT can be successful in convincing a patient that his 

or her TB treatment is an important public health priority. 

TB control programs should not begin procedures for confining patients to a treatment 

facility until after the patient has shown that he or she is unable or unwilling to follow 

a treatment regimen implemented outside such a facility. Involuntary confinement or 

isolation for inpatient treatment should be viewed as the last step. Confinement can be 

either in a hospital or in some other institution with TB isolation facilities. An order to 

confine a patient should require that he or she be isolated until no longer a public 

health threat.

Involuntary confinement or isolation for inpatient treatment should 

be viewed as the last step. 

When deciding whether to legally confine a TB patient to protect the public, local 

health officials must decide whether the person is at real risk of infecting others (now 

or in the future). To determine this risk, these factors need to be considered

 Laboratory results (i.e., sputum smears and cultures)

 Clinical signs and symptoms of infectious TB

 An abnormal chest x-ray, especially if cavities are present

 A history of nonadherence 

 The opportunity to infect others

Throughout the process, there must be detailed documentation of the patient’s 

nonadherence and the steps taken to address it. Although nonadherence laws are 

available in some areas, they may be hard to enforce and should be used only when all 

other measures have failed. When legal steps are taken, the health care worker must 

make sure that the patient’s rights are protected; patients undergoing these 

procedures should have legal counsel.

Throughout the process, there must be detailed documentation of 

the patient’s nonadherence and the steps taken to address it. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Figure 6.8 Example of progressive intervention for nonadherent patients to a TB 

treatment plan.
Module 6—Managing Tuberculosis Patients and Improving Adherence

59

Figure 6.9 A sample letter given to patients who demonstrate nonadherent behavior 

and who may be candidates for legal action.
Module 6—Managing Tuberculosis Patients and Improving Adherence

60

Study Questions 6.18 – 6.19 

 

6.18 Describe the progressive interventions that should be attempted before a 

court orders involuntary confinement. 

 

 

 

 

 

 

 

 

 

 

 

6.19 List the criteria for deciding if a patient should be confined. 

 

 

 

 

 

 

 

 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

61

Case Study 6.4 

 

Walter is a 50-year-old male who was diagnosed with TB one month before he 

was released from prison. The prison doctor called the health department to 

report the case and asked them to take over managing Walter’s TB treatment 

upon his release. The case manager assigned a health care worker to work with 

Walter. The health care worker met with Walter while he was still in prison and 

set up a plan to continue DOT upon Walter’s release. 

For the first two weeks after his release, Walter adhered to treatment. He then 

began missing appointments at the arranged DOT site and at the clinic. The 

health care worker offered to meet Walter in other locations for DOT. He also 

provided incentives and enablers.

When Walter continued to miss appointments, the health care worker called and 

texted Walter to discuss the missed appointments. Unable to reach Walter via 

phone, the health care worker then went to Walter’s house. Walter became 

agitated and stated that he feels “okay” and does not like the health care worker 

“harassing” him in front of his friends. The health care worker documented all of 

his efforts to get Walter to adhere to treatment.

 

 

 What should the health care worker do next? 

Answers to case studies are on pages 88-93

 

 

 

 
Module 6—Managing Tuberculosis Patients and Improving Adherence

62

Quality Assurance in Case 

Management 

To ensure appropriate care and treatment for each patient, a variety of quality 

assurance activities should take place throughout the case management process. 

Quality assurance is the review and evaluation of the quality of care per established 

protocols and the effectiveness of the TB program. In quality assurance, problems are 

identified, prioritized, and addressed. Quality assurance should be continuous and 

ongoing. Case management is never complete without quality assurance. 

Quality assurance should be continuous and ongoing. 

Quality assurance activities include:

 Documentation

 Case review

 Cohort review

Documentation of all steps in the case management process is essential. The case 

manager must ensure that documentation is completed regularly by all members of the 

case management team. All interventions should be documented in a clear and concise 

manner to ensure continuity of care, particularly if different providers are involved. The 

case manager should remember the cardinal rule of documentation “If it isn’t 

documented, it didn’t happen.”

Case review is the systematic, regular review of a patient’s progress by the case 

management team. Case reviews should be weekly and real-time. Case reviews 

conducted in real time assist in identifying and resolving problems early and prevents 

a patient from “slipping through the cracks.” For example, during the first week after a 

pulmonary case is reported, it is important to review the patient’s progress to ensure 

that sputum smear and culture tests have been ordered and results are documented in 

the patient record. 

Cohort review is the systematic review of the management of TB patients and their 

contacts. A “cohort” is a group of TB cases counted over a specific period of time, 

usually 3 months. Cohorts are typically reviewed 6 to 9 months after being reported. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

63

Case managers are expected to prepare information on each case, present the 

information at the cohort review session, and follow-up on suggestions made at the 

cohort review session. Table 6.6 lists some of the differences between case review and 

cohort review. Please refer to CDC’s Understanding the TB Cohort Review Process: An 

Instruction Guide for more information on how to conduct a cohort review.

Table 6.6 

Differences between Case Review and Cohort Review 

Case Review Cohort Review 

Weekly Quarterly; biannually

Real time, ongoing review of single 

patient management and care issues

Retrospective review of ALL counted TB 

patients and contacts during specified 

time period

Monitor individual patient progress and 

treatment outcome

Monitor group progress toward 

treatment outcomes

Identify patient care issues Identify programmatic issues
Module 6—Managing Tuberculosis Patients and Improving Adherence

64

Other TB Control Practices to 

Complete 

It is important that TB programs ensure that appropriate TB control practices are 

completed for the patient, including:

 A contact investigation is performed

 TB genotyping results are obtained

Performing a Contact Investigation 

A contact investigation is required for all confirmed cases that have infectious forms of 

TB disease (e.g., TB disease of the lungs, airway, or larynx). Patients who have 

noninfectious forms of TB disease do not require a contact investigation (e.g., TB 

disease in the brain, the kidneys, or the bones and joint). In most health departments, 

a case manager is responsible for ensuring that a contact investigation is completed 

for the patient, if necessary. A contact investigation is a systematic process to: 

 Identify persons (contacts) exposed to a person with infectious TB disease;

 Assess contacts for infection with M. tuberculosis and TB disease; and

 Provide appropriate treatment for contacts with LTBI or TB disease.

For more information about initiating and performing TB contact investigations, refer 

to Module 8: Contact Investigations for Tuberculosis.

Obtaining TB Genotyping Results 

TB genotyping is a laboratory-based method that can determine the genetic pattern of

the strain of M. tuberculosis that caused TB disease in a person. Each strain has a 

distinct genetic pattern, or genotype. Genotyping is done for culture-positive cases of 

TB disease. TB programs should work with laboratories to ensure that TB genotyping 

results are obtained for all culture-positive cases they are assigned. At the local level, 

this typically requires ensuring that the isolate has been sent to the State Health 

Department or the State Laboratory. For case managers at the state level, this typically 

requires ensuring that the isolate has been sent to the appropriate genotyping 

laboratory. This process may vary by jurisdiction. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

65

TB programs should work with laboratories to ensure that TB 

genotyping results are obtained for all culture-positive cases they are 

assigned. 

In the United States, genotyping information on individual cases is available to state 

and local health departments through the TB Genotyping Information Management 

System (TB GIMS), a secure online national database of genotyping and case 

information. Local health departments obtain access to genotyping data in various 

ways, usually either through TB GIMS directly or from the state TB program.

Applications of Genotyping 

Genotyping has applications at both the population level and the individual patient 

level. At the population level, genotyping is most commonly used for detecting, 

refuting, and monitoring TB outbreaks. For more information about the use of 

genotyping in TB outbreaks, refer to Module 9, Tuberculosis Outbreak Detection and 

Response.

At the patient level, TB genotyping has three uses: 

 Distinguishing relapse from reinfection

 Detecting false-positive culture results

 Conducting contact investigations

Distinguishing Relapse from Reinfection 

Some patients previously treated for TB disease may develop TB disease again. This 

could be due to a relapse or reinfection. Genotyping results can be used to distinguish 

relapse from reinfection. 

Recurrence of TB disease after treatment is generally known as a relapse of TB disease. 

Relapse can occur for several reasons including inappropriate treatment, nonadherence 

to treatment, or unidentified drug resistance. If genotype information from the first 

episode of TB is available, it can be compared with genotype information from the 

second episode. If the genotypes match, it is likely the TB disease was not completely 

cured the first time it was treated.

If the genotypes from the two episodes of TB disease do not match, it is likely the 

second episode occurred because the person became infected with a different strain of 

M. tuberculosis (reinfection).
Module 6—Managing Tuberculosis Patients and Improving Adherence

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Detecting False-Positive Cultures 

Genotype information can alert laboratory and public health staff to situations 

where specimens from different patients, processed within the same facility and 

time period, share genotypes. When this situation occurs, the laboratory can follow 

a process to determine if an error has been made, and one or more of the cultures 

are falsely positive. False-positive TB cultures can be caused by crosscontamination of a specimen in the laboratory, clerical error such as mislabeling of 

specimens, or contaminated equipment such as a bronchoscope used to collect the 

samples. 

Identifying false-positive cultures is important because doing so helps prevent 

unnecessary treatment and contact investigations for persons who would otherwise 

be misdiagnosed with TB disease.

 

Conducting Contact Investigations 

Typically, genotype information will not be available during the early stages of a 

contact investigation; however, when it is available, genotype results can help confirm, 

disprove, or detect connections among patients. If two patients have matching 

genotypes, they might be connected even if the connection is not recent or obvious. 

For example, two persons whose TB strains match by genotype may not know one 

another, but they might have both been exposed to the same infectious TB case 

several years earlier.

At the patient level, TB genotyping can be used for distinguishing 

relapse from new infection, detecting false-positive culture results, 

and conducting contact investigations. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

67

 

Study Questions 6.20 – 6.21 

 

6.20 List three applications of genotyping. 

 

 

 

 

 

 

6.21 Explain the difference between a cohort review and case review. 

 

 

 

 

 

 

 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

68

Inter-Jurisdictional and 

International Referrals 

Inter-Jurisdictional Referrals 

Some patients may move to another jurisdiction at some point during their treatment. 

For example, seasonal migrant farm workers may move between health jurisdictions 

based on the growing seasons. A patient may move to a health jurisdiction within the 

same state, to another state, or another country. The public health worker needs to be 

familiar with the guidelines and case referral processes in their health jurisdiction. This 

will aid in transferring information on TB patients who move, as well as facilitate 

follow-up to ensure continuity of care. The end goal is completion of therapy for all TB 

patients. 

The public health worker needs to be familiar with the guidelines and 

case referral processes in their health jurisdiction in order to transfer 

information on TB patients who move, as well as facilitate follow-up 

to ensure TB patients’ continuity of care. 

When a patient leaves a health jurisdiction before completing TB treatment, patient 

information should be sent to the health jurisdiction at the patient’s destination. The 

following procedures should be followed: 

 Patients who are taking treatment for TB disease should be given (1) a copy of 

records they can take with them to indicate their current treatment and 

diagnostic status, and (2) a supply of medications to self-administer during the 

transition of care. Special care should be taken to instruct these patients on how 

to take their medications and how and where to get additional medication and 

medical care at the destination site. 

 Patients should be asked to provide their new address and phone number, if 

known. Patients can also be asked to provide the name and phone numbers of 

family or friends whom staff in the new jurisdiction could speak with, in order to 

connect with the patient during or after the move. 

 All relevant medical information, including TB laboratory reports, and patient 

contact information should be forwarded to the destination jurisdiction. Some 
Module 6—Managing Tuberculosis Patients and Improving Adherence

69

jurisdictions use a standard form when referring patients between health 

jurisdictions. See Figure 6.10 as an example of a referral form. 

 The state health department TB control officer should be contacted and made 

aware of the need for follow-up and the next possible destination of the patient. 

 Although sharing necessary information between health departments is 

encouraged to ensure continuity of care, as well as protect the public, measures 

should be taken to ensure confidentiality.

International Referrals 

Some patients under treatment for TB disease in the United States move to another 

country before completing treatment. To assist in treatment completion and continuity 

of care, the CDC has developed a process for international notification: 

 Notification of TB control personnel in the patient’s country of destination

 TB control personnel in that country advise patient to complete treatment

 Patient is advised and educated on the importance of completing treatment

To access the International Tuberculosis Notification Form, visit the CDC website: 

www.cdc.gov/tb/programs/international/PDF/internat_proces.pdf.
Module 6—Managing Tuberculosis Patients and Improving Adherence

70

Figure 6.10 Sample Inter-jurisdictional Tuberculosis Notification Form, available from 

the National TB Controllers Association Website: 

http://tbcontrollers.org/docs/IJ_Form_Page1.pdf.
Module 6—Managing Tuberculosis Patients and Improving Adherence

71

Study Question 6.22 

 

6.22 Explain the procedures for sending patient information from one health 

jurisdiction to another. 

 

 

 

 

 

 

 

 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

72

Case Study 6.5 

 

You are a health care worker at a County Health Department. You have been 

working closely with Juan, a 35-year-old Hispanic agricultural worker. Juan was 

diagnosed with TB about 2 months ago. You have been providing DOT to Juan at 

a local farm where he picks oranges. Orange season is coming to an end and you 

realize that Juan will soon be heading North to look for more work. You have 

spoken to him about where he will be going next. He tells you that he is going to 

a farm in the next state over. He is not exactly sure where it is, but he thinks he 

remembers the farm is located near a town called Jasper. 

 

 What steps will you take before Juan leaves to ensure the continuity of 

care? 

Answers to case studies are on pages 88-93 

 

 

 

 

 

 

 
Module 6—Managing Tuberculosis Patients and Improving Adherence

73

Considerations for TB Case 

Management in Special Settings 

Management of TB cases often includes working in various environments and with 

other facilities. These may include hospitals, correctional facilities, homeless shelters, 

workplaces and long term-care facilities. Maintaining confidentiality and building 

partnerships with these facilities are very important. 

A first step in establishing a good working relationship in a facility or institution is for 

a public health worker to visit key staff and explain his or her role as a liaison between 

the facility and the TB program. The health care worker should provide TB education 

and offer resources as needed. It may be helpful for the public health worker to show 

the staff an official letter of introduction from the TB program stating the purpose of 

his or her assignment and the legal authority of the TB program. 

A first step in establishing a good working relationship in a facility or 

institution is for a public health worker to visit key staff and explain 

his or her role as a liaison between the facility and the TB program. 

As liaisons with the TB program, public health workers support facility or institutional 

staff by

 Providing information on a patient’s TB history

 Providing information on services available through the TB program

 Supplying educational materials for patients and hospital or institutional staff

 Helping to plan for follow-up care for TB patients upon discharge

Health departments should assist facilities in developing and updating policies, 

procedures, and record systems for TB control. The health department should also 

provide access to expert TB medical consultation and ensure that facilities have access 

to laboratory services. A specific health department contact person should be 

designated to provide epidemiologic and case management assistance to facilities. 

Health departments should also provide consultation for contact investigations for 

each case within facilities and ensure appropriate examinations of contacts. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

74

Discharge Planning 

When TB patients leave a facility, such as a hospital or correctional facility, it is 

important to ensure continuity of treatment and quality care. Discharge planning is the 

preparation for comprehensive care of a hospitalized or institutionalized patient after 

that patient’s discharge. 

Discharge planning is the preparation for comprehensive care of a 

hospitalized or institutionalized patient after that patient’s discharge. 

It is usually a team effort, led by a nurse or a facility’s discharge planner. In some 

cases, a case manager assigned by the public health department may be in charge of 

planning for a patient’s discharge. Team members often include at least two or more 

of the following: 

 The discharge planner or case manager 

 Nurses or therapists involved in the patient's care 

 A social worker 

 The patient's physician 

 Expert consultants, if required 

 DOT outreach worker 

An institution-based public health worker can also provide input and share 

responsibility for ensuring that the TB patient is appropriately managed after 

discharge. 

The discharge planning team should meet while the patient is in the facility to review 

the patient’s treatment plan and develop an adherence plan. An adherence plan is 

written and based on the patient’s understanding and acceptance of the TB diagnosis. 

It addresses barriers to adherence, and details the method chosen to deliver treatment 

and monitor adherence for that specific patient. This is especially important in 

correctional facilities, as correctional facilities do not always know when a patient will 

be discharged. If possible, the patient should be included in this meeting to aid in 

decision-making. 

The discharge planning team should meet while the patient is in the 

facility to review the patient’s treatment plan and develop an 

adherence plan. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

75

Whenever possible, the person responsible for the patient’s follow-up care should visit 

the hospital or institution to meet the patient and explain the program that will be 

followed. The discharge planner or case worker should notify the provider of the date 

of discharge and of any changes in the treatment or adherence plan.

The public health worker is responsible for conveying relevant information on 

discharged patients to the TB program. This information is very important for other 

team members assigned to the case who will provide follow-up care in the community.

The public health worker is responsible for conveying relevant 

information on discharged patients to the TB program. 
Module 6—Managing Tuberculosis Patients and Improving Adherence

76

Study Question 6.23 – 6.24 

 

6.23 List four ways that public health workers support hospital or institutional 

personnel. 

 

 

 

 

 

 

 

6.24 Explain the purpose of discharge planning and briefly describe the public 

health worker's role. 

 

 

 

Answers to study questions are on pages 80-87
Module 6—Managing Tuberculosis Patients and Improving Adherence

77

Case Study 6.6 

 

You have just been assigned to work in the state prison. The prison has several 

hundred prisoners; typically three to six prisoners are diagnosed with active TB 

disease each year. Currently, two prisoners are taking TB medication and seven 

are on regimens for the treatment of LTBI. 

When prisoners with TB disease are released, the current procedure is to notify 

the health department immediately before the prisoner is released. The health 

department makes a clinic appointment for the patient, the patient is informed of 

the appointment and provided the clinic’s contact information. If the patient 

does not keep the appointment, the health department sends a reminder card to 

the patient’s address (supplied by the prison administration). The treatment 

completion rate for these cases has been very low. 

 

 One of the prisoners with TB disease is near the end of his sentence and is 

scheduled to be released in a week. What can you do to plan for TB care 

upon his release? 

Answers to case studies are on pages 88-93
Additional Resources 

1. CDC. Essential Components of a Tuberculosis Prevention and Control Program: 

Recommendations of the Advisory Council for the Elimination of Tuberculosis. 

MMWR 1995; 44 (No. RR-11). 

www.cdc.gov/mmwr/preview/mmwrhtml/00038823.htm. 

2. CDC. Implementing an Electronic Directly Observed Therapy (eDOT) Program: A 

Toolkit for Tuberculosis (TB) Programs. Atlanta, GA: Department of Health and 

Human Services, CDC; 2017. 

www.cdc.gov/tb/publications/guidestoolkits/tbedottoolkit.htm. 

3. CDC. Menu of Suggested Provisions for State Tuberculosis Prevention and Control 

Laws. Atlanta, GA: Department of Health and Human Services, CDC; 2010. 

www.cdc.gov/tb/programs/Laws/menu/TBLawMenu.pdf

4. CDC. Understanding the TB Cohort Review Process: Instruction Guide. Atlanta, GA: 

Department of Health and Human Services, CDC; 2006. 

www.cdc.gov/tb/education/cohort.htm. 

5. Curry International Tuberculosis Center. Making the Connection: An Introduction to 

Interpretation Skills for TB Control, 2nd edition; 2008. 

www.currytbcenter.ucsf.edu/products/view/making-connection-introductioninterpretation-skills-tb-control-2nd-edition.

6. Global Tuberculosis Institute at Rutgers, The State University of New Jersey. Cultural 

Competency and Tuberculosis Care: A Guide for Self-Study and Self-Assessment.

http://globaltb.njms.rutgers.edu/educationalmaterials/productfolder/culturalcomp

etency.php.

7. Global Tuberculosis Institute at Rutgers, The State University of New Jersey. 

Tuberculosis Case Management: A Guide for Nurses; 2017. 

http://globaltb.njms.rutgers.edu/educationalmaterials/productfolder/tbcasenurse.

php.
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8. Heartland National Tuberculosis Center. Beyond Diversity: A Journey to Cultural 

Proficiency – Facilitator’s Guide; 2008. 

www.heartlandntbc.org/assets/products/hntc_cultural_prof_guide.pdf. 

9. Heartland National Tuberculosis Center. Case Studies in TB – Nurse Case 

Management Training Tools for Patient Success; 2017. 

www.heartlandntbc.org/assets/products/case_studies_tb_ncm_training_tools.pdf. 

10.Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, 

Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, 

Lienhardt C, Menzies R, Merrifield C, Narita M, O’Brien R, Peloquin CA, Raftery A, 

Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official 

American Thoracic Society/Centers for Disease Control and Prevention/Infectious

Diseases Society of America Clinical Practice Guidelines: Treatment of DrugSusceptible Tuberculosis. Clinical Infectious Disease 2016:1–49. 

https://academic.oup.com/cid/article/63/7/853/2197067.

11. National Tuberculosis Nurse Coalition. Tuberculosis Nursing: A Comprehensive 

Guide to Patient Care, 2nd edition; 2011. www.tbcontrollers.org/resources/tbnursing-manual/.

12. Southeastern National Tuberculosis Center. Country Specific Quick Reference 

Guides; 2010. https://sntc.medicine.ufl.edu/home/index#/products. 

 
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Answers to Study Questions 

6.1 What are the four priority TB prevention and control activities? 

The four priority TB prevention and control activities are:

1. Identifying and treating persons who have TB disease;

2. Finding and assessing persons who have been in contact with TB patients 

to determine whether they have LTBI or TB disease and providing them with 

appropriate treatment; 

3. Using targeted testing strategies to identify and treat persons with LTBI at 

risk for developing TB disease; and

4. Identifying settings in which there is a high risk for transmission of M. 

tuberculosis and applying effective infection control measures.

 

6.2 Name two methods health departments use to identify TB cases. 

Health departments typically identify TB cases by either passive case reporting or 

active case finding. Contact investigations, pharmacy and laboratory surveillance, 

and facility and organization inquiries are examples of active case finding 

activities.

 

6.3 What is the goal of case management? 

The goal of case management is to provide patient-centered care for completion 

of treatment and to ensure all public health activities related to stopping TB 

transmission are completed.

 

6.4 During a patient assessment, what specific topics should the health care worker 

discuss with the patient? 

Conducting an assessment involves talking to a patient about his or her medical 

history, knowledge about TB, and beliefs about TB transmission and treatment. 

Specific topics that the health care worker should find out include

 Medical history 

 Knowledge, attitudes, and beliefs about TB 

 Ability to follow the TB treatment plan 

 Resources (e.g., family, other social support, finances) 

 Anticipated barriers to treatment (e.g., lack of transportation)

 Perceived barriers to treatment (e.g., TB medications will be very 

expensive) 
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 History of adherence to previous TB regimens or other medication

 

6.5 In the list below, there are closed-ended and open-ended questions. Mark an X 

next to the open-ended questions. 

X What is TB? 

□ Do you think TB can be cured? 

X How is TB spread? 

□ Do you have difficulty taking medicine? 

X What are some of the difficulties you have taking medicine? 

X Why do you think you need to take medicine? 

□ Is TB curable? 

X How is TB cured? 

 

6.6 Explain the importance of building rapport and establishing a trusting 

relationship with the patient. 

Establishing rapport, trust, and good communication with the patient is critical. 

The quality of the patient-health care worker relationship is especially important 

in TB control, where long-term adherence to treatment is necessary. If the patient 

and the health care worker have a good relationship with each other, the patient 

is more likely to adhere to treatment, name contacts, and follow the health care 

worker’s instructions and advice.

6.7 List at least four effective communication and education techniques that health 

care workers should use when educating a patient. 

There are several effective communication and education techniques that can be 

used when educating patients:

 Use simple, nonmedical terms

 Use the appropriate language level

 Limit the amount of information 

 Discuss the most important topics first and last

 Repeat important information

 Listen to feedback and questions 

 Use concrete examples

 Make interactions with the patient as positive as possible
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6.8 List at least six guidelines for working with an interpreter that can help the health 

care worker make the best of the interview. 

Health care workers should follow these guidelines to make the best use of the 

interview when working with interpreters:

 Ask for the patient’s permission to use an interpreter

 Plan the interview and decide what key points to talk about with the patient

 Meet with the interpreter before the interview to talk about the goals for 

the interview, to give instructions and guidance, and to make sure the 

interpreter is comfortable with the questions and topics that will be 

discussed

 Remind the interpreter that all information in the interview is confidential

 Ask the interpreter to refrain from adding his or her own comments

 Address the patient directly, not the interpreter

 Ask the interpreter to explain questions or answers that are not clear

 Keep the messages simple and factual; use short phrases and focus on one 

topic at a time

 Give the interpreter time to translate each phrase before continuing; do not 

interrupt the interpreter

 Ask the interpreter to translate the patient’s and the health care worker’s 

own words exactly 

 Give the patient time to answer questions

6.9 What is adherence to treatment? 

Adherence to treatment means following the recommended course of treatment 

by taking all medications as prescribed, for the entire recommended time.

 

6.10 What are four serious consequences that can result when a patient with TB 

disease is nonadherent? 

Nonadherence to treatment for TB disease can lead to serious consequences, such 

as acquired drug resistance, an increase in the severity of illness, ongoing TB 

transmission, and even death.

6.11 Give eight reasons why a patient might be nonadherent. 

There are many reasons why a person might have trouble completing a regimen 

of TB drugs. Here are a few examples.

 Improved or no symptoms

 Lack of knowledge

 Cultural beliefs
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 Language barriers

 Lack of access to healthcare 

 Poor relationship between the patient and the health care worker

 Competing priorities

 Stigma

 Mental health

6.12 What is DOT? 

DOT stands for directly observed therapy. DOT means that a health care worker or 

other designated individual watches the patient swallow every dose of the 

prescribed drugs. It is the most effective strategy for ensuring patients take their 

medicine correctly.

 

6.13 List and explain four tasks that are part of the DOT encounter. 

During DOT encounters, health care workers should do the following: 

Check for Side Effects 

Health care workers should ask if the patient is having any adverse side effects at 

each visit, before the drugs are given. If the patient has symptoms of serious 

adverse reactions, a new drug supply should not be given; the patient should stop 

taking medication immediately. The health care worker should tell their 

supervisor that the drugs were not given and notify the prescribing clinician about 

the adverse reaction. The health care worker should arrange for the patient to see 

the clinician as soon as possible.

Verify Medication 

Each time DOT is delivered, the health care worker should verify that the right 

drugs are delivered to the right patient, and that he or she has the correct amount 

of medication. If this cannot be confirmed, the drugs should not be given to the 

patient. The supervisor should be asked for clarification. 

Watch the Patient Take Pills 

Health care workers should watch for techniques some patients may use to avoid 

swallowing medication. Some patients may hide pills in their mouth and spit them 

out later, hide medicine in clothing, or vomit the pills after the DOT visit. The 

health care worker should watch the patient continuously from the time each pill 

is given to the time the patient swallows it. 
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Document the Visit 

The health care worker should document each visit with the patient and indicate 

whether or not the medication was given. If not given, the reason and follow-up 

plans should be included. It is important to correct any interruption in treatment 

as soon as possible.

 

6.14 What are four advantages of DOT? 

 DOT ensures that the patient completes an adequate regimen

 DOT lets the health care worker monitor the patient regularly for side 

effects and response to therapy

 DOT helps the health care worker solve problems that might interrupt 

treatment

 By ensuring the patient takes every dose of medicine, it helps the patient 

become noninfectious sooner

 

6.15 What is a formal adherence agreement? 

A formal adherence agreement is a written understanding between the health care 

worker and a patient. A patient should write down the activities he or she agrees 

to carry out (such as taking medicine as prescribed), in return for specific 

services, activities, or incentives from the health care worker. For some patients, 

this written commitment increases the likelihood of adherence. 

6.16 What are incentives and enablers? 

Incentives are small rewards given to patients to encourage them to either take 

their own medicine or keep their clinic or field DOT appointments. Enablers are 

things that make it possible or easier for patients to receive treatment by 

overcoming barriers, such as a lack of transportation to get to the clinic. 

 

6.17 Describe three strategies health care workers can use to address barriers to 

adherence. 

There are several additional strategies health care workers can use to address 

barriers to adherence:

 Create an adherence agreement

 Use incentives and enablers 

 Encourage the patient to seek support

 Give TB drugs in easy-to-take preparations

 Coordinate other services

 
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6.18 Describe the progressive interventions that should be attempted before a court 

orders involuntary confinement. 

State and local TB control programs should have a treatment plan that goes stepby-step from voluntary participation to involuntary confinement as a last resort. 

The plan should begin with learning the possible reasons for nonadherence and

addressing the identified problems using methods such as DOT, incentives, and 

enablers. The patient should be told verbally and in writing of the importance of 

adhering to treatment, the consequences of failing to do so, and the legal actions 

that will have to be taken if the patient refuses to take medication.

If the patient does not adhere to DOT voluntarily, the next step may be courtordered DOT. Court-ordered DOT is DOT that is administered to a patient by 

order of a public health official or a court with the appropriate authority.

TB control programs should not begin procedures for confining patients to a 

treatment facility until after the patient has shown that he or she is unable or 

unwilling to follow a treatment regimen implemented outside such a facility. 

Involuntary confinement or isolation for inpatient treatment should be viewed as 

the last step. When deciding whether to confine a TB patient legally to protect the 

public, local health officials must decide whether the person is at real risk of 

infecting others. 

Throughout the process, there must be detailed documentation of the patient’s 

nonadherence and the steps taken to address it. 

 

6.19 List the criteria for deciding if a patient should be confined. 

When deciding whether to legally confine a TB patient to protect the public, local 

health officials must decide whether the person is at real risk of infecting others. 

To determine this risk, these factors should be considered

 Laboratory results (i.e., smears and cultures)

 Clinical signs and symptoms of infectious TB

 An abnormal chest x-ray, especially if cavities are present

 A history of nonadherence

 The opportunity to infect others

 

 

 

 
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6.20 List three applications of genotyping. 

At the patient level, TB genotyping has three uses: 

 Distinguishing relapse from reinfection

 Detecting false-positive culture results

 Conducting contact investigations

At the population level, genotyping is most commonly used for detecting, 

refuting, and monitoring TB outbreaks.

6.21 Explain the difference between a cohort review and case review.

Case Review Cohort Review 

Weekly Quarterly; biannually

Real time, ongoing review of single 

patient management and care issues

Retrospective review of ALL counted 

TB patients and contacts during 

specified time period

Monitor individual patient progress 

and treatment outcome

Monitor group progress toward 

treatment outcomes

Identify patient care issues Identify programmatic issues

 

 

6.22 Explain the procedures for sending patient information from one health 

jurisdiction to another. 

When a patient leaves a health jurisdiction before completing TB treatment, 

patient information should be sent to the health jurisdiction at the patient’s 

destination. The following procedures should be followed

 Patients who are taking treatment for TB disease should be given (1) a copy 

of records they can take with them to indicate their current treatment and 

diagnostic status and (2) a supply of medications to self-administer during 

the transition of care. Special care should be taken to instruct such persons 

on how to take their medications and how and where to get additional 

medication and medical care at the destination site. 

 Patients should be asked to provide their new address and phone number, 

if known. Patients can also be asked to provide the name and phone 

numbers of family or friends whom staff in the new jurisdiction could 

speak with, in order to connect with the patient during or after the move.
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 All relevant medical information, including TB laboratory reports, and 

patient contact information should be forwarded to the destination 

jurisdiction. 

 The state health department TB control officer should be contacted and 

made aware of the need for follow-up and the next possible destination of 

the patient.

 Measures should be taken to ensure confidentiality.

 

6.23 List four ways that public health workers support hospital or institutional 

personnel. 

 Providing information on a patient’s TB history

 Providing information on services available through the TB program

 Supplying educational materials for patients and hospital or institutional 

staff

 Helping to plan for follow-up care for TB patients upon discharge

 

6.24 Explain the purpose of discharge planning and briefly describe the public health 

worker's role. 

The purpose of discharge planning is to prepare for comprehensive care of a 

hospitalized or institutionalized patient after that patient’s discharge. The public 

health worker is responsible for conveying relevant information on discharged 

patients to the TB program. This information is very important for other team 

members assigned to the case who will provide follow-up care in the community.
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Answers to Case Studies 

6.1 Thanh is a cook at a local restaurant. He went to see his physician because he was 

feeling extremely tired, had lost his appetite, and had been coughing for several 

weeks. His physician suspected TB and admitted Thanh to the hospital for further 

tests. 

 

His sputum smears were positive and he was started on appropriate therapy. The 

physician called the local health department to report the diagnosis. A case 

manager was assigned and visited Thanh in the hospital. 

 How should the case manager assess Thanh's knowledge, beliefs, and 

feelings about TB disease and treatment? 

One way to learn about Thanh’s knowledge, beliefs, and feelings about TB 

disease is to ask open-ended questions. For example, the health care 

worker could ask Thanh

• What do you know about TB? 

• What causes TB?

• What are the most important results you hope to get from this 

treatment?

 

 Why is it important to assess Thanh's knowledge, beliefs, and feelings 

about TB disease and treatment? 

It is important to assess Thanh’s knowledge, beliefs, and feelings about TB 

disease and its treatment because the more the health care worker is aware 

of Thanh’s ideas and concerns, the better prepared the health care worker 

will be to anticipate and resolve problems that can arise. An assessment 

will help the health care worker better understand Thanh’s views and will 

help determine areas in which he needs education.

An assessment may also give the health care worker some idea of Thanh’s 

ability to adhere to a treatment regimen. For example, asking Thanh what 

problems the illness has caused him can help the health care worker assess 

the strength of his family and social support, and potential job-related 

problems.
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6.2 You are assigned to deliver DOT to Mrs. Wilson, a 76-year-old woman who lives 

alone in the house that she and her husband bought many years ago. Mrs. Wilson 

was recently released from the hospital. Upon discharge from the hospital, she 

received education about TB and about the need to take medications until she 

completes treatment. She was told that she would be started on DOT and a health 

care worker would visit her at home to help her take her medication. Mrs. Wilson 

is excited to have some company. She happily offers you cookies and wants to 

“talk awhile” before she takes her medication. 

 How should you respond to Mrs. Wilson’s request to “talk awhile”? How 

could your reaction affect her adherence? 

Establishing rapport, trust, and good communication with the patient is 

critical. The relationship with the patient will develop over time; however, 

the foundation from which a trusting relationship is established begins 

immediately. To develop rapport with Mrs. Wilson, you should be open, 

friendly, and willing to “talk awhile” at the DOT visit. If you immediately 

refuse to talk with her, it may negatively affect rapport and damage the 

patient-health care worker relationship. If you are uncomfortable eating 

the cookies she has offered, you should respectfully decline to eat them. 

6.3 Mr. Sivaraman is a recent immigrant from India who is working two jobs to 

support his wife and three children. He has been on DOT for 2 months and his TB 

symptoms have greatly improved. Mr. Sivaraman has kept daily DOT 

appointments with the health care worker, but recently has missed two 

appointments and skipped his last clinic visit. 

 What do you know about Mr. Sivaraman’s history that might lead to 

nonadherence? 

Mr. Sivaraman may be having difficulties keeping appointments with his 

busy work schedule. In addition, since his symptoms have improved, he 

may be less motivated to continue treatment. Sometimes the health care 

worker can find out what problems a patient is having by contacting them 

with either a phone call on the same day or with a home visit. 

 

 

 
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 What steps can the health care worker take to help Mr. Sivaraman keep his 

appointments and adhere to treatment? 

The health care worker should call Mr. Sivaraman right away to schedule a 

new clinic appointment and reconfirm the DOT schedule. The health care 

worker should use this discussion to counsel him and to identify and solve 

problems that interfere with appointment keeping. If Mr. Sivaraman 

continues to break appointments, the health care worker may want to hold 

a conference with all members of the healthcare team so that the problem 

can be discussed and resolved with help from the entire staff. Mr. 

Sivaraman could also be included in this conference so he will be able to 

help make adjustments to the treatment plan.

A formal adherence agreement may also be useful. Mr. Sivaraman should 

be asked to sign the agreement and be given a copy to keep. The health 

care worker should review the agreement with him periodically to assess 

how well both are doing and to make changes as needed. If Mr. Sivaraman 

becomes chronically nonadherent, the health care worker may need to try 

several different strategies to help him, and possibly even consider legal 

alternatives. 

6.4 Walter is a 50-year-old male who was diagnosed with TB one month before he 

was released from prison. The prison doctor called the health department to 

report the case and asked them to take over managing Walter’s TB treatment 

upon his release. The case manager assigned a health care worker to work with 

Walter. The health care worker met with Walter while he was still in prison and set 

up a plan to continue DOT upon Walter’s release. 

 

For the first two weeks after his release, Walter adhered to treatment. He then 

began missing appointments at the arranged DOT site and at the clinic. The 

health care worker offered to meet Walter in other locations for DOT. He also 

provided incentives and enablers. 

 

When Walter continued to miss appointments, the health care worker called and 

texted Walter to discuss the missed appointments. Unable to reach Walter via 

phone, the health care worker then went to Walter’s house. Walter became 

agitated and stated that he feels “okay” and does not like the health care worker 

“harassing” him in front of his friends. The health care worker documented all of 

his efforts to get Walter to adhere to treatment. 
Module 6: Managing Tuberculosis Patients and Improving Adherence

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 What should the health care worker do next? 

Since addressing the identified problems using methods such as DOT, 

incentives, and enablers did not work, the next step is to try DOT that is 

ordered by a public health official or a court. Court-ordered DOT may be 

successful in convincing Walter that his TB treatment is an important public 

health priority. Since Walter has recently been released from prison, courtordered DOT may convince him to continue his treatment and come to the 

clinic for follow-up.

The health care worker should not begin procedures for confining Walter to 

a treatment facility until after Walter has shown that he is unable or 

unwilling to follow a treatment regimen implemented outside such a 

facility. Involuntary confinement or isolation for inpatient treatment should 

be viewed as the last step. When legal steps are taken, the health care 

worker must make sure that Walter’s rights are protected and he should 

have legal counsel. 

 

6.5 You are a health care worker at a County Health Department. You have been 

working closely with Juan, a 35-year-old Hispanic agricultural worker. Juan was 

diagnosed with TB about 2 months ago. You have been providing DOT to Juan at 

a local farm where he picks oranges. Orange season is coming to an end and you 

realize that Juan will soon be heading North to look for more work. You have 

spoken to him about where he will be going next. He tells you that he is going to 

a farm in the next state over. He is not exactly sure where it is, but he thinks he 

remembers the farm is located near a town called Jasper. 

 What steps will you take before Juan leaves to ensure the continuity of 

care? 

You need to find out Juan’s destination and have locating/contact 

information for him (e.g., phone number) before he leaves. You should 

follow these procedures to help him continue his TB care

• Juan should be given (1) records he can take with him to indicate his 

current treatment and diagnostic status and (2) a supply of 

medications to self-administer during the transition of care. Special 

care should be taken to instruct Juan on how to take his medications 
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and how and where to get additional medication and medical care at 

the destination site. 

• All relevant medical information, including TB laboratory reports, 

and patient contact information should be forwarded to the 

destination jurisdiction. 

• The state health department TB control officer should be contacted 

and made aware of the need for follow-up and the next possible 

destination of the patient.

• Although sharing information about Juan is encouraged to maintain 

continuity of care, measures should be taken to ensure 

confidentiality. 

6.6 You have just been assigned to work in the state prison. The prison has several 

hundred prisoners; typically three to six prisoners are diagnosed with active TB 

disease each year. Currently, two prisoners are taking TB medication and seven 

are on regimens for the treatment of LTBI. 

When prisoners with TB disease are released, the current procedure is to notify 

the health department immediately before the prisoner is released. The health 

department makes a clinic appointment for the patient, the patient is informed of 

the appointment and provided the clinic’s contact information. If the patient does 

not keep the appointment, the health department sends a reminder card to the 

patient’s address (supplied by the prison administration). The treatment 

completion rate for these cases has been very low. 

 One of the prisoners with TB disease is near the end of his sentence and is 

scheduled to be released in a week. What can you do to plan for TB care 

upon his release? 

For TB patients who leave a correctional facility, discharge planning is 

necessary to ensure continuity of treatment and quality care.

If possible, the patient should be included in discharge planning to aid in 

decision making. You should review both the treatment plan and the 

adherence plan. For this patient, specific incentives may be necessary to 

ensure that he keeps a follow-up appointment. The follow-up appointment 

for DOT or for continued monitoring should be made at a location that is 

convenient (and preferably, familiar) to the patient. As a representative of 

the TB program, you should discuss follow-up care with the patient and 
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93

explain the program that will be followed. You should notify the TB 

program of the date of discharge when it becomes known and of any 

changes in the treatment plan or adherence plan. This information is very 

important for coworkers assigned to the case who will provide follow-up 

care in the community.