Tuberculosis (TB) has long been a cause for concern among health authorities worldwide. In 1993, the World Health Organization (WHO) declared the TB situation a state of emergency and now recommends global strategies for its control, sponsoring the Directly Observed Treatment, Short-course (DOTS) program and making Supervised Treatment (ST) one of its pillars. The ST consists of direct administration of medication to the patient by another person. In clinics in Brazil, implementation of ST began in 1998.

The ST may be carried out directly at the clinic, in the work place, in the home, etc.(1) The treatment of the patient is the responsibility of the team in charge of carrying out the TB control program. However, a health professional, usually a clinical nurse, is designated to perform ST in the home or at other locations away from the health clinic.

The administration of ST in the home differs from that practiced under supervision at the health clinic, since it involves inclusion of the family and may be affected by the consequent biopsychosocial interaction, as well as by the cultural background and magicoreligious beliefs of each family member. In this context, the treatment becomes more complex and therefore demands systematization of the attention given to the patient/family.

The operationalization of ST in the home requires, initially, internal assessment of the program, taking into consideration the availability of resources (human and material) and the profile of the patients to be monitored, and, subsequently, the development of an activity plan that is consistent with the objectives of the program or strategy. Therefore, in order to enable the execution of the activity plan in the homes of the patients/families during the ST, the professional responsible for supervising the treatment of the patient in the home is expected to meet certain requirements in terms of knowledge, skills (communication and coordination) and attitude. To that end, it is believed that the teams responsible for the TB control programs should have internal autonomy to choose the health professional with the most appropriate profile to assume this responsibility.

Direct contact of the health professional with the reality of the home environment allows various specific problems to be identified. It is therefore necessary to systematize both the individualized and the overall planning in order to cater to the needs of the patients/families. Such activities must complement each other so as to ensure their continuity and the achievement of the results (adherence and cure) expected by the TB control program. It is important that execution of the activity plan be accompanied by a process of continuous assessment, to intervene and modify this plan whenever necessary.

The planning of supervision activities in the home must include components of assessment, coordination and integration in the activities involving health care, as well as taking available resources and effective intervention into consideration. It is therefore necessary to re-evaluate strategies that subsidize the practice of ST in the home, not only to improve treatment but also to ensure the participation of the patient/family in the treatment process.

A strategy of providing health care that has recently been more widely used is case management (CM), which consists of putting together a health care team (in some organizations a single professional will suffice) that is responsible for giving attention to the patient throughout the treatment process and making decisions regarding the needs and clinical propriety of the services prescribed and received. This team is in charge of coordinating the health care provided by all of the clinics and institutions that compose a system, as well as being responsible for determining the adequacy of the level of services provided and evaluating whether the patient is in compliance with the treatment plan.(2)

A study on ST has shown that TB control programs that incorporate CM may improve adherence and increase the proportion of patients completing the treatment. This model is considered a key factor in achieving adequate TB control. (3)

The use of CM makes it possible to carry out a systematized assessment, using specific instruments (assessment protocols), of the social, economical and emotional state of the patient/family, as well as of the aspects related to material and human resources available in the health institution and in the household context. (4-6)

Finally, incorporation of CM in order to systematize care of the patient/family with TB is important for the control of the disease. This strategy can be adopted not only in the home but in any health care environment since, in either case, a health team or health professional is designated to manage the entire treatment process. It is notable that CM focuses on the institution or program as well as on the needs of the patients/families - the latter being considered the starting point.

References

1. II Diretrizes brasileiras para tuberculose 2004. J Bras Pneumol 2004; 30 (Supl 1): S64.
2. Mendes EV. A organização da saúde no nível local. In: Mendes EV. A reengenharia do sistema de serviços de saúde no nível local. São Paulo (SP): Hucitec; 1998. p.57-86.
3. Mangura B, Napolitano E, Passannante M, Sarrel M, McDonald R, Galanowsky K, et al. Directly observed therapy (DOT) is not the entire answer: an operational cohort analysis. Int J Tuberc Lung Dis 2002; 6(8): 654-61.
4. Cardozo-Gonzales RI. Processo da alta hospitalar do paciente com lesão medular: gerenciamento de caso como estratégia de organização do cuidado.[dissertação]. Ribeirão Preto (SP): Escola de Enfermagem de Ribeirão Preto/USP; 2000.
5. Cardozo-Gonzales RI, Casarin SNA, Caliri MHL, Sassaki CM, Monroe AA, Villa TCS. Gerenciamento de caso: um novo enfoque no cuidado à saúde. Rev Latino-am Enfermagem 2003; 11: 227-31.
6. Cardozo-Gonzales RI, Villa TCS, Casarin SNA, Caliri MHL, Sassaki CM. Gerenciamento de caso de enfermería en el proceso de alta hospitalaria del paciente com lesión medular. Rev Mex Enfermería cardiol 2000; 8: 7-13.

Universidade de São Paulo, Ribeirão Preto, SP