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Case Management Storyboard 1: TB Surveillance Case

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Case Management Storyboard to Illustrate TB Surveillance


The purpose of Tuberculosis (TB) immigration medical surveillance among new immigrants to Canada is to determine if TB treatment and/or ongoing follow-up is necessary. Citizenship and Immigration Canada (CIC) requires that new immigrants identified as having a reportable disease such as TB report to Public Health upon arriving at their destination in Canada. When the client enters the country, CIC sends an [Investigation Request] to the provincial health authorities at the client’s anticipated destination. The CIC request contains a CIC ID number, reason for the surveillance requirement and the client’s anticipated address, or address of a sponsoring organization such as a church or university, where the person can be contacted.

The provincial health authorities, upon receipt of the request from CIC, create a “CIC referral” [Investigation Request] that is directed to the Health Unit (HU) at the client’s expected destination . This informs Health Unit staff that they should be receiving a client for TB medical surveillance. The HU is expected to respond later with a report on the outcome(s) of their investigation, including the possibility that the client was not found if he fails to report to the health unit as instructed.

The provincial authorities may also add the person to their jurisdictional client registry, based upon the information already received from the CIC in the investigation request.


Based on an Immigration Medical Examination (IME) in his country of origin, Neville Nuclear was diagnosed with a latent TB infection. When he arrives in Canada CIC notes this diagnosis in his file and therefore creates an [Investigation Request] which is sent to the Provincial Health Authority (PHA) in his province of destination. After receiving the request, the PHA records Neville’s name and demographic information in the jurisdictional client registry and sends an [Investigation Request] to the appropriate regional health unit.

This request is eventually received by Nurse Nightingale at the Anytown Public Health Unit. Nightingale checks the address information and confirms that Neville is (will be) living within her district. She sends a response message, [Investigation Request Promise Response] saying that she is undertaking a “TB Medical Surveillance” investigation for Neville (in some regions this may be called a “Suspect TB case”).

Nightingale’s next task is to create a reminder to herself to respond to this referral (aka Investigation Request) within 30 days, at which point she will respond in one of two ways. Nightingale will either confirm that the client has made contact with the health unit and medical surveillance has been initiated, or she will respond to the referral by sending a [message –tbd] stating that the referral can not be “acted upon”, because the client can not be located. If Neville does not make contact with the health unit, this “Medical Surveillance” case will be closed, with a discharge classification of “Failure to Report”.

Outcome Scenario 1

Upon his arrival in Anytown, Neville complies with immigration rules by reporting to Nurse Nightingale at the local public health unit. Nightingale records this Encounter and performs a number of administrative tasks: she reviews the information sent from CIC, confirms with Neville that his demographic information in the jurisdictional client registry is correct [Find Candidates Query] + [Get Person Demographics Query] and notes in her records his client identifier, as supplied by the Client registry.

Nightingale provides Neville with information on how to obtain a provincial health insurance card and tells him to contact public health again when his insurance arrives. She sets up a reminder to herself to follow-up later. Nightingale then responds to the original PHA referral (aka Investigation Request), by sending a notification that contact with the client has been made and the client is now under medical surveillance [Case Create Notification].

Three months pass and Neville returns to the health unit. He is referred to the local TB clinic for medical assessment. Dr. Seven at the TB clinic determines that the information that has been provided by CIC is inadequate. He wants to compare Neville’s current chest X-ray with the X-ray that was taken at his country of origin. He requests copies of medical records and radiographs pertaining to the immigration medical examination through CIC and the overseas embassy (from Neville’s country of origin).

Neville is diagnosed with a multi-drug resistant form of TB and is put on an appropriate treatment plan. Nightingale reports these developments to the Provincial Health Authority (PHA) [Case Update Notification]. After a few months, Neville becomes non-compliant. A [Case Update Notification] message is sent to the PHA, informing them that Neville is not following his treatment plan.

Eventually, Neville is provided with additional health education and decides to resume treatment. After completion, a [Case Update Notification] message is sent to PHA, informing them that Neville has met all medical surveillance and treatment requirements. His case is closed and he is discharged from medical surveillance.

Outcome Scenario 2

Upon his arrival in Anytown, Neville complies with immigration rules by reporting to Nurse Nightingale at the local public health unit. Nightingale records this Encounter and performs a number of administrative tasks: she reviews the information sent from CIC, confirms with Neville that his demographic information in the jurisdictional client registry is correct [Find Candidates Query] + [Get Person Demographics Query] and notes in her records his client identifier, as supplied by the Client registry

Nightingale does a TB skin test on Neville, as well as sending him for an X-Ray [Diagnostic Imaging Order Request]. The skin test result later proves to be negative as do the x-ray results when she queries for the report [Diagnostic Imaging Detail Query Response]. Thus, Neville is no longer on medical surveillance. Neville’s test results are recorded, the disposition of the Investigation is changed to “Closed - Medical Surveillance Complete”. A [Case Create Notification] message is sent to the provincial authorities (who in turn will inform CIC).

Outcome Scenario 3

Neville has recently arrived in Anytown, and has not yet reported to the Public Health Unit. Yesterday, he was admitted to hospital with a number of symptoms, including a cough and bloody sputum. The hospital staff suspect TB and send an [Investigation Request] to Public Health requesting that Pubic Health intervene. The hospital orders lab tests and the lab results confirm that Neville is positive for active TB.

Since Neville’s active TB is a notifiable condition, the Laboratory informs Public Health of the test results [Laboratory Result Notification]. Meanwhile, the Anytown Hospital, which is extremely proactive, sends an update message to the health unit, informing them that they have a client with active TB [Revise Investigation Request].

The investigation request from the hospital describes Neville’s current medical condition, medical regime, estimated discharge date (if known) and family physician. The request also references the lab results that confirm Neville’s TB diagnoses. Public Health is expected to initiate contact tracing procedures and to collaborate with the hospital on discharge planning for Neville. (In some circumstances Public Health may request and require that a patient NOT be discharged until follow-up interventions are in place. Public Health also expects to be informed of all cases of “non adherence” to the in-hospital treatment plan.)

Nightingale informs Neville’s family doctor that his patient is being treated by Public Health [Care Plan Notification]. As Neville’s case progresses the doctor may also receive updates on what treatment or care plans are being carried out by Public Health [Care Plan Notification].

Nightingale sends a case notification message to the provincial health authorities [Case Create Notification]. The message identifies the earlier Investigation Request from the provincial authorities to help them in tracking Neville’s case. From time to time Nightingale will follow up with additional notification messages to the provincial authorities to inform them of developments [Case Update Notification].

Nightingale proceeds with her case investigation and identifies Neville’s close contacts. She reviews the health unit records (paper and/or electronic) to assist with the investigation. She also searches for medical record information [Get Care Record Detail Query] from the “Medical Records” department of the hospital and/or sends a request for information to the family doctor.

Since Neville has been travelling recently Nightingale also wants to determine if Neville’s disease is part of an as-yet unreported TB outbreak. The Anytown HU has a number of neighbouring regions with their own public health case management systems. She queries these other systems for a list of all active TB cases [Case Candidate Query/Response] and looks closely at the Exposure information for a number of cases that might be related [Case Detail Query/Response]. However, no link is found between the listed active TB cases and Neville.

Neville remains in hospital and has begun taking the appropriate anti-TB medications. Dr. Admit sends a [Discharge Notification] to Nightingale, informing her that Neville will be discharged from hospital in three days. Based on this information, Nightingale arranges a pre-discharge meeting with Neville. Appointments are arranged through the local TB Clinic for medical follow-up after his discharge from hospital [Care Plan Request]. (Alternatively, Public Health recommendations for his continuing care might have been sent to his family physician [Care Plan Request].)

One day before discharge, Dr. Admit suspects that Neville has a coexisting medical condition. He decides to postpone Neville’s discharge for another three days. This will allow time to conduct additional tests and assessments. The new discharge date is sent to Nurse Nightingale [Discharge Notification] who adjusts Neville’s follow-up appointments accordingly [Revise Care Plan Request].

That same evening, Neville develops a high fever and becomes diaphoretic. A message is sent to Nightingale, indicating that Neville’s discharge plans are cancelled [Discharge Notification]. Currently, no pending discharge date is provided. Pre-scheduled follow-up appointments at the TB clinic are cancelled, until further notice [Abort Care Plan Request]

Neville has been discharged from hospital in Public Health Region East. One week later, he calls Nightingale to state that he has moved to a neighboring region in Public Health Region North. It is public health policy to refer and transfer client records that are in their custodianship to the new jurisdiction. A referral is sent to inform Public Health Region North that Neville is living in their jurisdiction and requires post discharge follow-up [Case Transfer Request]. Public Health Region North responds [Case Transfer Promise], indicating that they will assume responsibility for Neville's case.