Tapologo and the DOH collaborate in the Bojanala District, North West Province

Tapologo ART project has been granted a one year extension on its treatment programme, allowing for improved collaboration with the Department of Health and the provision of quality ART services.  Most patients now receive ART drugs in DOH clinics, but ongoing psychosocial  care and support is provided by Tapologo caregivers and counsellors.  Five hundred patients continue to receive ART drugs at Tapologo itself.  New patients can be initiated when stable patients are transferred out to DOH clinics.  Tapologo hopes to be accredited to provide DOH supplied ART to its patients.  This would enable the programme funded by PEPFAR till now to continue rendering needed services.

 

Rustenburg – Tapologo

Reporting period:    January – March 2013

 1. Current Status and Progress:

  • Patients in our HIV Care (Outreach Programme) are still being traced and monitored during home visits and also during Support Groups that are held in each community.
  • Patients that have been transferred to Government for ART are continuously encouraged to attend our Clinic days whereby they will continue to receive Psycho-social, Opportunistic Infection and clinical care and treatment.
  • Weekly patient support groups continue to be held on each “clinic” day.  During this support group, patients receive a meal and issues pertaining to health and psycho-social issues are discussed in an open forum. Tapologo is also undertaking the I-Act Positive Living Support Group Programme which has vastly increased the number of support groups held and the number of participants.
  • Patients have the opportunity to meet with the Social Worker, upon referral or request.  The Social Worker attends to any psychosocial issues or issues pertaining to obtaining Government Grants, etc.  The Social Worker also sees all new patients admitted to the programme.
  • We have seen a significant reduction in the number of patients in-care and home visits. This is due to the succession plan that is currently in place with the notice of withdrawal of Pepfar for the provision of Anti-retroviral Therapy.
  • We have seen a significant increase in the number of HCT and patient admissions to the Outeach programme in Freedom Park since the transfer of the Tsholofelo owned PHC to the Department of Health.  We have established a good working relationship with the government staff operating this clinic.  So as to avoid a duplication of services, we have agreed to undertake the pre- and post counselling and HCT for patients visiting the clinic.

2. Staff issues:

  • Our staff compliment is sufficient for the provision of quality patient care within the staff: patient ratio’s.
  • A complete Human Resource analysis was undertaken in January to determine current staff levels and systems have been developed to monitor progress towards reaching targets.  We will look at recruiting additional Home Based Caregivers once we have finalised the HR Staffing plan based on targets and actual deliverables achieved.
  • Within this reporting period we have had a number of staff members pass away as well as resignations. We are currently recruiting the following staff members:

-       2 Professional Nurses

-       1 Auxilliary Nurse

-       1 Social Worker

3. HIV testing:

  • HIV testing is still being done on ART Clinic days so that we can collect a blood specimen for the CD4 test at the same time so that patients do not need to incur additional transport costs.
  • We have placed a large emphasis on the importance of having children tested.  Newly diagnosed individuals with children are counseled in this regard.
  • We have seen a large increase in the number of HCT at Freedom Park.  This is attributable to the excellent relationship that we have established with the Government Clinic who has agreed that Tapologo undertake all the HCT on their behalf and therefore they refer patients to our clinic to undertake this activity.
  • Community members have become aware of the possibility of a “one-pill-ARV-treatment” that will be made available, and therefore they are hesitant testing now, as they do not wish to commence triple therapy ARV’s.
  • Most of the patients testing at the moment are reactive due to their living conditions, however, they are reluctant to be admitted to our Programme as we are not initiating ARV’s and they do not wish to receive their treatment from a Government facility.
  • We have seen an increase in HCT since we initiated the community and door-to-door awareness campaigns however even a stronger emphasis will be put on the importance of HCT and health education in terms of STI’s, HIV and AIDS.
  • A HCT Campaign will be held at the Tlaseng Clinic in June 2013.
  • Youth on our programme have been encouraged to reveal their status to their peers and become a “buddy” for those that require HCT and/or those that have been newly diagnosed.

4. HIV Care:

Patients in our HIV Care (Outreach Programme) are still being traced and monitored during home visits and also during Support Groups that are held in each community. Patients that have been transferred to Government for ART are continuously encouraged to attend our ART Clinic days whereby they will continue to receive Psycho-social, Opportunistic Infection and clinical care and treatment.

The referral system to Government facilities is still running well.  We are working on developing an additional external referral system between Tapologo and various mining and corporate organizations in our areas by using the newly established Rustenburg Health Forum as an avenue to address these issues and that of collaboration between the Public – Private – NPO Sector.

 

Tapologo continues to Home Based Care including support groups, and psycho-social interventions in the following community clusters:

  • Boitekong
  • Chaneng which includes Robega, Rasimone and Mafenya
  • Freedom Park
  • Kanana
  • Ledig
  • Mfikdwe which includes Bokomoso and Zakhela
  • Phokeng which includes Lefaragatlhe, Luka and Masosobane
    • Potsaneng
    • Tlaseng

5. Treatment preparation:

We still undertake the 4 pre-treatment preparation sessions with each patient.  We also use this opportunity to explain to the patient and family why they will be receiving their ART from Government and how Tapologo will continue to assist the patient even once the patient is on treatment with Government.

 

We have received special authorization from SACBC to initiate critically ill patients that are admitted in the IPU on ART with immediate effect.

6. ART provision:

Patients ART Adherence is still monitored in the home and the caregivers continue to encourage the families to all be tested.

Due to SACBC extending our contract for another year, we will start planning to initiate patients on ART, however, our succession plan is still in place in that we can maintain 500 patients on ART with the SACBC extension, but we still have not received a number from the DoH.

7. Tuberculosis:

  • We continue to provide INH and TB Prophylaxis and refer patients to the DoH clinics for TB Treatment. Their treatment adherence in monitored by the Home Based Caregivers in the home.
  • In collaboration with the Chaneng PHC (DoH), Tapologo assisted the DoH by undertaking door-to-door TB screening campaign in March.
  • An emphasis was placed on reinforcing the usage and the importance of the N95 mask during a staff TB awareness day and to patients during the support groups held in February.
  • We are experiencing a problem with patients presenting with productive coughs that are refusing to provide sputum for testing.  Tapologo is now insisting on patients providing sputum on the spot, as we have discovered that many patients that are provided with the sputum bottle for collection at home are “cheating” the system and having friends/neighbors provide sputum.
  • TB Negative patients continue to receive INH for 6 months.

8. Cotrimoxazole:

Cotrimoxazole is given to all patients admitted to our HIV Care Programme (Outreach) except those presenting with allergies thereto.

9. Pediatrics:

  • Medical assessments were undertaken on all the OVC registered at our Ledig OVC Centre.
  • Many parents continue to refuse testing and treatment of their children even if the child is on treatment, the parents feel that the child does not need to know their status or why they are on treatment.
  • Specific education regarding the administration of medication to children and the importance of adherence has been reiterated during support groups and individual counseling sessions.

10. Men:

Many of our female patients are still complaining that their partners (men) do not want to be tested and that these men blame the women for infecting them.  We do however find that many of our terminal patients admitted are men due to the fact that they wait for such an extended period before consenting to HCT and finally ART.  We have also found a very low attendance number of males during awareness campaigns.  This obstacle is not one that can be easily resolved however gender issues are discussed during support groups and home visits. Tapologo has embarked on a campaign to encourage “couples” testing.

11. Prevention-Mother-to-Child Transmission:

Pregnant mothers are being referred to Government clinics for ART initiation.

12. South African Government collaboration:

Since the last visit and report (submitted with the previous quarterly report), the Department of Health officials have visited Tapologo again on 2 separate occasions.  The outcomes from these meetings are as follows:

  • Linda Oeloffse (Chief Pharmacist) has inspected the current dispensary and our policies and procedures and has provided the DoH with a letter of recommendation to provide ARV’s to Tapologo prior to Tapologo becoming an Accredited Facility.
  • During their visits, the DoH requested that the following work be undertaken at our Dispensary prior to our accreditation visit:

-        Covering of the existing floor of the wing allocated for this purpose with a vinyl flooring system used in hospitals etc.

-        The construction of a Cool Room inside the building using a Dry Wall system with a PVC ceiling board.  The ART’s will be stored in this room until repacked and sent out to the clinics.

-        An 18000 BTU air conditioner that will keep the temperature in the Cool Room below the required 25 degrees Celsius.

-        Adequate shelving in the Cool Room to pack the ART’s on

  • We are very grateful to SACBC that has approved our quotation to undertake the following work that will commenced in April.
  • Once the above work is complete, Linda Oeloffse will request the District Office to undertake a site visit for accreditation at their earliest convenience.
  • The MOA was developed in December 2012 during a workshop with Dr Tumbo and Mr Tlhowe (DoH) and Meacala van Tonder and Stephen Blakeman.
  • The MOA has been submitted and approved by the Chief Director who in turn has submitted the same to the HOD in Mafikeng.
  • Dr Tumbo has informed us that he is in the process of fast tracking the approval at the Province.  They have submitted the MOA to the District Office and are in the process of finalizing the MOA.

13. Monitoring and Evaluation:

  • The HMIS team is still undertaking periodic site visits to verify the data capturing card to the patient file.  This system is working very well and we have the support of the clinical staff during these audits.
  • Ongoing quality improvement projects are being undertaken to determine the success of multiple dispensing, patient adherence and home visits, etc.
  • On 26 February, the HPCA Palliative Care Development Officer, Dr. Nelia Drenth, undertook an internal Pre-COHSASA survey on 26 February to verify all our documentation in preparation for the COHSASA audit to be held on 11 – 13 March 2013.
  • The HMIS Officers continue to capture the patient interventions on a daily basis and provide feedback to the Nursing Services in terms of patients that have not been visited within 60 days, not collected drugs, are due for blood work, etc.
  • A MER and QI Plan has been developed for 2013.  This programme will guide our MER and QI activities to ensure that quality services are provided in all service elements.
  • A SWOT Analysis and Strategic Planning Workshop was held on 31 January – 01 February 2013 (these documents are available for review upon request).
  • Our internal Financial Audit for 2013 is scheduled for 04 – 08 March 2013.
  • Tapologo received a final Cohsasa accreditation audit on 13 March 2013.  We performed extremely well with an organizational average of 98% and achieved the following scores the service elements as outlined below:

 

SE 1 Governance and Leadership 100%
SE 2 Human Resource Management 99%
SE 3 Administrative Support 100%
SE 4 Risk Management 98%
SE 5 Quality Management 94%
SE 6 Access to Care 97%
SE 7 Interdisciplinary Team 95%
SE 8 Holistic Patient Care 94%
SE 9 Medication Management 96%
SE 10 Support Services 100%
SE 12 Fundraising 100%

 

Due to the above preliminary results, COHSASA will determine our official 5 star accreditation in April 2013.

 

 

14. Training:

  • TB in the context of Palliative Care Training was provided to selected Home Based Caregivers on 28 February to 01 March.

15. Wrap around:

The objective of providing ongoing operations and maintenance activities is to create and maintain conducive and supportive spaces, environments and systems for those working for Tapologo in order that they may effectively render services pursuant to the Tapologo mission.

 

During January the O&M team routinely visited the following sites to determine maintenance needs not identified by site personnel.  A number of O&M requests were received during January and February.   Most of these have been attended to the O&M Team.

 

The new 12m long converted shipping container was delivered to Boitekong on the 15th February which forms part of the Boitekong clinic extension, which is funded by SERVE.  It had since been electrically connected as well as the water supply coupled and the waste water system constructed.  Work has also commenced on the roofing structure for that will extend the waiting area and cover the container.

 

New container at Boitekong to meet patient demands.

 

In January a water shortage was experienced at the Tapologo centre. This was due to both the borehole supply as well as the Phokeng reticulated supply not being available.  The problem with the borehole was eventually traced back to the float control switch in the water storage tanks having been tampered with.  The switch was tested and then replaced back into the tank and the borehole has run normally since then.

 

February saw us spending more time and resources on the Tapologo Centre in light of our COHSASA audit in March.  The team erected scaffolding and scraped off the peeling plaster off the vault roofs in Admin and repainted them.  Paving flagstones were laid at the chapel and Admin to place the existing concrete benches and tables on LM grass runners were planted between the chapel and the IPU garden as part of an ongoing project to complete the landscaping around the chapel area.

 

 

Seating outside Admin                                                          Seating at the chapel

 

An Occupational Safety, Health and Environment committee meeting was held on 24 January 2013 to ensure that all centres are functional and operational within the legal requirements.

16. Significant successes, changes in approach or challenges experienced:

Many of our ART patients that we have transferred to DoH simply do not re-visit our clinics. When our Caregivers visit them at home to find out why, they are informed that it costs them double for transport to visit the DoH clinic to collect their drugs, and then to also visit our clinic and it is more time consuming.  They also feel frustrated and in a way have lost “faith” in Tapologo because we are “throwing” them away and sending them to another institution.

The word of mouth in the communities is that “Tapologo can’t help anymore”.  They understand that ART can save their life, but if we can’t provide it, then why bother being admitted to the programme or staying in the Programme?  Our patients simply do not understand/comprehend what is actually happening and the reasons why we have to send them to the DoH clinic for ART drugs, but we are working very hard in explaining all of this and educating the patient and community about the situation.

Due to all this, we have made a strategic decision (which the DoH has endorsed) that Tapologo would become an “Initiation Site” for ART and provide all the counselling, clinic visits, support groups, nutritional support, home visits, adherence monitoring, etc for a period until the patient is “stable” and has a good adherence rate.

Then the patient will cease to get ART drugs directly from us, and be “transferred” to the DoH Clinic to collect the drugs there. But again, they can still stay in our Outreach / HBC programme and receive our other services.  By doing this, we can “create” an opportunity for another patient to start ART with our support etc. and so the cycle will continue.

 

Our belief is that if we do this, then we will be able to ensure that more people in need of ART can get treatment sooner through our system than at the rate at which Government is able to initiate patients on ART.

NB! 17. Referral systems and follow up!

  • The referral systems with the Trauma Centre, SASA and PHC are still operational.
  • We continue to provide INH and TB Prophylaxis and refer patients to the DoH clinics for TB Treatment. Their treatment adherence in monitored by the Home Based Caregivers in the home. Meetings are held with the Public Health Clinic Sisters to discuss tracing patients that have defaulted on TB Treatment.
  • Patients with MDR TB often have to wait for an extended period before being transferred to the relevant institution.  Tapologo has broached this subject with the Department of Health officials in an attempt to ensure that patients with MDR TB are transferred to the TB Wards as soon as possible so as to avoid further infection in the communities.