Transcript Slide 1

Initiating the
Cohort Review Process
in Los Angeles County
April King-Todd, R.N., B.S.N, M.P.H
Nurse Manager
Los Angeles County Tuberculosis Control Program
Critical Stakeholders
• Internal
– SPA Medical Staff (AHO, AMD, Chest MDs, etc.)
– SPA Nursing Staff (Nurse Managers, PHNSs, PHNs,
Clinic staff and CWs, etc.)
– SPA Administrative Staff (Assist. S.A., F.A, Clerical,
etc.)
– TB Control Staff (APS, STC, PS)
– CHS and Program Administration
– Dr. Jonathan Fielding-Director, LAC DPH
• External:
– CA State TB Branch
– CDC
– Patients
2
Reasons for Implementation
• 2010-2014 CDC Cooperative Agreement
requirement
• Evidence-based methodology to improve
case management
• Quality assurance tool to conduct
program evaluation
• Improve documentation
Description
Cohort Review vs. TB Case Review
• Integrated (TBCP & CHS)
team approach
• Retrospective review of All TB
cases and their contacts
initiated during a quarter
• Monitors group of patients’
progress toward treatment
outcomes
• Identifies system (process),
patient care and programmatic
issues
• PHN, PHNS, or MD
• Real time ongoing review of
specific patient management
• Monitors individual patient
progress and treatment
• Identifies patient clinical
care issues as part of the
case management process
•
• Outcome data
4
Los Angeles County (LAC)
Cohort Review Model
“Face-to-Face”
• The LAC cohort review process is unique:
– Inclusion of TB suspects pending
confirmation/closure
– Planned use of electronic TRIMS auto-populated
case presentation/Contact Inv. forms
5
LAC TB Cohort Review Team
Community Health Services
Director
Team Manager
(Area Med. Dir./
Nurse Mgr.)
TB
Controller
or TBCP
MD
Data Analyst
(TBCP
Epidemiologist)
Medical
Reviewer
(Chest MD)
Public Health
Nurse Supervisor
Case Manager
(Public Health Nurse)
TBCP
Health Center APS,
NM, PS
SCN/Designee, SPHI/Designee,
Community Worker
&
Business Office Staff
TBCP staff
CHS staff
TBCP Staff Role & Responsibilities
(1)
Title
TBCP
Physician
Cohort Review Presentation
1.Attend in person or via teleconference
2.Ask questions of clarification, makes suggestions
3.Review clinical practice based on current/updated policies,
standardized practice
Preparation
1. Provide technical assistance/guidance to CHS staff
TB Health
2. Provide preliminary Cohort Review line lists (open TB Suspects &
Center APS,
TB Cases) four weeks prior to cohort review session
PHN
3. Provide Final Cohort Review line lists to TB Chest MD, PHNS,
business office manager two weeks prior to review date
Co-Coordinator 4. Coordinate cohort review preparation, presentation and follow-up
and instructor
with the assigned CHS PHNS (coordinator/documentation of issues
identified during cohort review session)
5. Assist and coordinate with TBCP NM and PS on ‘Cohort Review
Process’ and ‘Case management’ trainings
Continued on next page
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TBCP Staff Role & Responsibilities (2)
Title
Cont’d
TB Health
Center APS,
PHN
Cohort review presentation
1. Attends and Asks questions of clarification
Follow-up after cohort review
1. Tracks education, programmatic and clinical issues
Coneeding follow up
Coordinator 2. Ensure that ongoing, follow -up staff education
incorporates program strengths and weaknesses
and instructor
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TBCP Staff Role & Responsibilities (3)
Title
Preparation:
1. Reviews the final Cohort Line List for the quarter
2. Prepare spreadsheet for cohort data collection
Epidemiologist/ 3. Provide SPA/Health Center NTIP performance data
Data Analyst 4. Prepares Cohort overall statistics (e.g. demographic
information, site of disease, bacteriology, radiology, drugs,
DOT, status of treatment completion, contact investigation
results, etc.)
Cohort review Presentation
1. Presents preliminary Cohort overall statistics and the data
summaries for the previous cohort quarter reviewed, if
indicated
Continued on next page
TBCP Staff Role & Responsibilities (4)
Title
2.
Epidemiologist/
Data Analyst
3.
Updates and analyzes cohort data and provides
immediate feedback to SPAs on how they ‘re doing in
relation to program objectives
Provides (3) Summary Reports
• Variables
• Indices/Rate for Treatment of TB Cases
• Contact Investigation Data from Cohort Review
Follow up after the cohort review
1. Compiles summary report with CR outcomes and
provides the report to designated health center staff
2. Provides a list of data issues that require follow-up
actions to designated health center staff
TBCP Staff Role & Responsibilities (5)
Title
TBCP Nurse
Manager
(NM) and
Program
Specialist,
PHN
1. Develop LAC TB Cohort Review Instructional Guide with CR
tools, for Cohort Review team.
2. Develop curriculum for ‘TB Cohort Review Process’ and
‘Case Management’ and provide training for entire Cohort
Review team
3. Provide technical support to TBCP H.C. APSs and data
analyst
4. Assist H.C. APSs in coordinating cohort review preparation,
presentation, and follow-up with CHS staff
CHS Staff Role & Responsibilities (1)
Title
Area Medical Director Preparation:
1. Ensures staff at all levels understand the cohort review process, has
(AMD)-/Nurse
the knowledge and skills to perform this task and ensures the
Manager (NM)
attendance of Health Center TB Team
Has the list of TB cases Cohort review presentation
1. Facilitates the introduction of on-site participants and any call-in
and calls them to be
participants.
reviewed
2. States the “Ground Rules” before Cohort Review begins.
3. Listen to all case presentations
 May group the cases to 4. Ask questions of clarification to ensure all aspects of case
management adhere to the department of public health policies and
allow some essential staff
procedures
to leave before the end of 5. Use teachable moments to illustrate important lessons in effective TB
the session.
control.
Follow Up after cohort review presentations
1. Ensure medical management and other issues are addressed
2. Address programmatic concerns and concerns about modifying staff
training or orientation to better meet the needs for staff to learn what
they need to do the job
3. Submits TB case summary to Director of CHS and TBCP evaluation
coordinator.
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CHS Staff Role & Responsibilities (2)
Title
Chest MD/
(Medical
reviewer)
Preparation
1. Ensures the attendance of Health Center TB Team
2. Review the Cohort Review line list /medical records prior to
cohort review presentation date.
Cohort review presentation
1. Listens to all case presentations and review support
documentation (e.g., medical records, TRIMS), and ask questions
for clarification about each case, prompt for details of staff
efforts: likelihood of completing treatment in 12 months (e.g.,
status of pursuit of patients lost)
2. Provide feedback and suggestions on how to follow up
patients and their contacts. Ensures all aspects of case
management adhere to DPH policies and procedures are
followed including but not limited to the following:
Continued on next page
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CHS Staff Role & Responsibilities (3)
Title
a. Drug regimen is appropriate per drug susceptibility
results
b. Sputum conversion documented
c. Contact investigation outcomes are assessed
d. Adherence issues, home isolation issues addressed
3. Use teachable moments to illustrate important lessons in
effective TB case management.
Follow Up after cohort review presentations
1. Address any medical management issues identified
2. Ensure ongoing staff education
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CHS Staff Role & Responsibilities (4)
Title
Public Health
Nurse
Supervisor
(PHNS)/
Coordinator &
Documents
issues
identified
during cohort
review session
Preparation:
1. Supervise and assist PHN staff in following case management
protocols.
2. Hold one-on-one case review meetings with PHNs per LAC PHN
practice manual.
3. Conduct periodic conference meetings with entire team if
necessary.
4. Review the final Cohort Review line list
5. Ensure PHN case presentation will be concise and according to
standardized format.
6. Review the case presentation /contact investigation forms that
each DPHN have prepared to ensure that all information is complete
7. Coordinate cohort review preparation, presentation, and follow-up
with the assigned H.C. APS
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CHS Staff Role & Responsibilities (5)
Title
(Cont’d)
8. PHNS (assigned CHS coordinator) receives 6 copies of the
forms on each case and sorts them by the order on the final
cohort review lists. Each set of the copies will be provided to
AMD, Chest MD, NM(s), PHNS, and TBCP Controller/MD, TBCP
Epidemiologist on the day of the cohort review presentation.
Cohort review presentation
1. Attend with staff
2. Allow PHN to present
3. Determine any training issues, needs for PHN staff and
communicate this to TBC APS
Follow up after cohort review
1. Ensure PHN follows up on case management suggestions
(making sure that patients and contacts finish their treatment),
and complete any missing information and clarifies details and
information as identified during the cohort review
2. Meet with PHNs and provide feedback for future presentations
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CHS Staff Role & Responsibilities (6)
Title
Case
Manager
Preparation:
1. Participates in case review meetings with PHNS and case
conferences with clinic TB team.
2. Follow all protocols for PHN case management and contact
(District
Public Health investigation.
3. Communicates periodically with community workers and clinic
Nurse)
staff for issues affecting patient adherence .
4. Prints case presentation form from TRIMS for cases to be
presented
5. Updates any missing info prior to cohort review presentation
and provides updates at the meeting.
6. Prepares self for cohort review presentation(s)
7. At least 2 days prior to scheduled cohort review presentation
date, makes 6 copies of the completed case presentation forms
and gives them to his/her supervisor to provide them to assigned
PHNS (coordinator).
Continued on next page
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CHS Staff Role & Responsibilities (7)
Title
(Cont’d)
Cohort Review Presentation
1. Delivers concise presentation using case presentation form,
answer any questions from the team members, and ask questions
related to patient care contact investigation issues to brainstorm
with fellow collaborative team.
Follow up after the cohort review
1. Follow up on case management suggestions (making sure that
patients and contacts finish their treatment .
2. Obtain any missing information identified during the cohort
review.
3. Meet with supervisor for feedback to enhance preparation for
the next cohort review, continue case management. Report to
PHNS and/or TB Chest MD, updates case/contact information in
TRIMS .
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CHS Staff Role & Responsibilities (8)
Title
Supervising
Clinic Nurse I
or designee
Preparation
1. Participates in case conferences with clinic TB team
2. Communicates periodically with DPHN, and clinic staff for
issues affecting patient adherence.
Cohort Review Presentation
1. Attend and provide additional information as requested
2. Follow up on clinic issues
Preparation
Community
Workers (CWs) 1. Participates in case conferences with clinic TB team
2. Communicates periodically with DPHN, and clinic staff for
issues affecting patient adherence.
Cohort review Presentation
1. Attend for assigned cases and provide additional information as
needed
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CHS Staff Role & Responsibilities (9)
Title
Supervising
Public Health
Investigators
(SPHI) or
designee
Preparation
1. Participates in case conferences with clinic TB team
Cohort review Presentation
1. Attend and provide additional information as needed
Business Office Preparation
staff
1. Pull patient charts from Cohort Review line list and delivers them
to TB Chest MD a week prior to the review date
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Core Elements for Cohort Review
Cohort Review Process
Preparation Presentation
Follow-Up
21
Preparation
• Comprehensive case management
• Reliable TB registry
• TB Indicators
• Collecting/entering info in TRIMS on
cases for presentation
•
Standardized format
22
Selected TB Indicators and
Performance Targets
Category
1
Completion of
Treatment
3 Contact Investigation
Indicator
Percent of patients with newly diagnosed TB
for whom 12 months or less of treatment is
indicated, who complete treatment within 12
months.
2015 National
Objective
2004-08
National
Average
2004-08
LAC Baseline
93.0%
71.7%
76.5%
Aggregate Reports for Tuberculosis Program
Evaluation – Contact Investigations
Contact Elicitation
Percent of newly diagnosed TB patients with
positive acid-fast bacillus (AFB) sputum-smear
results who have contacts elicited.
100.0%
92.2%*
92.2%
Contact Evaluation
Percent of contacts to sputum AFB smearpositive TB patients who are evaluated for
infection and disease.
93.0%
80.4%*
99.5%
Treatment Initiation
Percent of contacts to sputum AFB smearpositive TB patients with newly diagnosed
latent TB infection (LTBI) who start treatment.
88.0%
70.5%*
55.8%
79.0%
63.3%*
51.1%
Percent of contacts to sputum AFB smearpositive TB patients who have started
Treatment Completion
treatment for the newly diagnosed LTBI, who
complete treatment.
Sample Preliminary Cohort List for TB Cases
(______Quarter)
D_
D_
DO Prim
Smea
Initiate Confirm Rx_Star
Closure Censu
DP # Ln Fn D_Birth Chart Supt HIV T Disease Cavitary r
Cult.
d
ed
t
Rx_ Comp Rsn
Tract
X/XX/ X/XX/ X/XX/
XX/X/ comp.
1
1
Y
PO PO
tx
2393.
7XXXXX L
X/XX/XXXX XXXX PMD
XXXX
XXXX
XXXX
XXXX
X/XX/ XX/X/
X/X/ XX/XX/XX comp.
1
1
Y
NE
PO
tx 5402.0
7XXXXX S
X/XX/XXXX XXXX Public
XXXX
XXXX
XXXX
XX
7XXXXX J
X/XX/XXXX XXXX Public
1
1
7XXXXX G
X/XX/XXXX XXXX
PMD
0
1
Y
PO
PO
PO
PO
X/X/
XXXX
X/XX/
XXXX
X/XX/
XXXX
X/XX/
XXXX
X/X/
XXXX
X/XX/
XXXX
2374
died
2402
Sample Final Cohort List for TB Cases
(______Quarter)
Fn
D_Birth
Chart
Supt
HIV
DOT Prim Disease Cavitary Smear Culture D_Initiated
D_Confirmed
Rx_Start Rx_ Comp Closure Rsn
PHN
A.
#########
xxxxxxx
PH
NE
No
Pul
N
neg
neg
1/20/2010
Not TB
Ma M
N.
5/18/19XX
xxxxxxx
PMD
PO
No
Pul
N
neg
neg
2/10/2010
Moved
Na R
K.
2/10/19XX
xxxxxxx
PH
NE
No
Pul /LN
N
neg
neg
2/10/2010
Sti l l open
Ka C
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DP #:
Patient Name:
Medical Record #:
PHN:
Date of Birth:
Gender:
Race:[If Asian Shows Country] Ethnicity: [Hispanic or Non-Hispanic]
Country of Origin: [Country of Birth] Date Arrived in U.S.: [Date of Arrival or Date of Birth if US Born]
Primary Occupation Within the Past Year: [Shows Answer]
Health Care Worker; Correctional Facility Employee; Migrant Seasonal Worker; Other Occupation; Retired;
Unemployed; Not Seeking Employment
Resident of Correctional Facility at Time of Diagnosis: [Federal Prison; State Prison; Local Jail; Juvenile
Correction Facility; If Other Correctional Facility:, ?Under Custody of Immigration & Customs Enforcement?
Resident of Long-Term Care Facility at Time of Diagnosis: [Nursing Home; Residential Facility; Alcohol or
Drug Treatment Facility; Hospital-Based Facility; Mental Health Residential Facility; Other Long Term Care
Facility]
RISK FACTORS [Will list only those Risk Factors which were answered ‘Yes’]
Homeless
Injecting Drug Use Within Past Year
Non-Injecting Drug Use Within Past Year
Excess Alcohol Use within Past Year
HIV status [Shows answer] Date HIV test [Will show answer if done]
If HIV status ‘Positive’, HIV drugs _____________________________________________________________________________ ,
HIV Provider ______________________________(not available in TRIMS)
Additional TB Risk Factors: [Will list only those Risk Factors which were answered ‘Yes’]
Contact of MDR-TB Patient
Post Organ Transplantation
Contact of Infectious TB Patient
Diabetes Mellitus
Missed Contact
End-Stage Renal Disease
Incomplete LTBI Therapy
Immunosuppression (Not HIV/AIDS)
TNF-α Antagonist Therapy
Other: Specify
Current smoker
DIAGNOSTICS
Primary Reason Evaluated for TB: [TB Symptoms; Abnormal Chest Radiograph; Contact Investigation;
Targeted Testing; Health Care Worker; Employment/Administrative Testing; Immigration Medical Exam (BNotification); or Incidental Lab Result]
Patient Status at Diagnosis: [Alive or Dead]
Patient is diagnosed with: [Pulmonary TB; Both Pulmonary & Extra-Pulmonary TB; Extra-Pulmonary TB]
Primary Site of Disease: [List All in Field]
Confirmation is based on: [Use VerCrit Field: Positive Culture; Positive NAA; Positive Smear/Tissue; Clinical
Case Definition; or Verified by Physician Diagnosis]
IGRA Test Results: [Positive; Negative; Indeterminate] result from [IGRA Type – QFT G iT] specimen collected
on [Date Collected]
Mantoux Tuberculin Skin Test Results: [mm] mm, read on [Date Read]
Chest X-Ray Result: [Normal; Abnormal (Cavitary); Abnormal (Non-Cavitary); Abnormal Not TB]
Sputum Smear Results: [Positive or Negative]
Sputum Culture Results: [Positive or Negative]
Other Source [Specimen Type] Smear Results: [Positive or Negative]
Other Source [Specimen Type] Culture Results: [Positive or Negative]
LAC Case
Presentation
Form
26
Part I: Contact Evaluation
Sputum Results: Smear:
Culture:
Other Pulmonary (clinical improvement/clinical evidence) :
Genotyping [Show result]
[This section not available in TRIMS]
History of Cough: Yes or No (Circle One)
Onset Date:___________________
Infectious Period: Begin Date:_________________ End Date:__________________
Were Contacts Identified: Yes (generate information below); No (no info to
generate below)
Part I: CONTACT ELICITATIONEVALUATION
Number of Contacts Elicited
Number of Contacts Evaluated
Number of Contacts with TB
Disease
Number of Contacts with Latent TB
Infection
Number of Contacts Initiating
Treatment
Number of Contacts Completing
Treatment
Reasons LTBI Treatment Not
Completed
Contacts Died
NUMBER
Contact
Evaluation
Summary
Reference
a
b
c
d
e
f
27
Prior to Cohort Review Presentation
• The PHN Supervisor reviews the forms that each
DPHN has prepared to ensure that all of the
information provided is complete
• 2 days prior to scheduled cohort review
presentation date, DPHN makes 6 copies of the
completed forms on each case
• DPHN gives 5 copies to assigned PHNS coordinator
who sorts them by the order on the final cohort
review list
28
Presentation
• TBCP Epidemiologist presents preliminary
summaries for the cohort being reviewed
during the session, and the data
summaries for the previous cohort quarter
reviewed, if indicated.
• Detailed Review of Each Case
29
Presentation
• The AMD/NM chairs the cohort review meeting.
• The PHN presents the patient case data and contact
information using a standardized form to the Cohort
Review team.
• The AMD and/or chest MD asks questions for
clarification, prompts for details of staff efforts to
solve problems (e.g. trace patients who are lost), and
provides feedback and suggestions on how to follow
up on the cases and their contacts.
30
Presentation
• Clinical staff involved in managing the cases can
provide additional information as needed.
• As each PHN describes the case details,
the TBCP epidemiologist tallies the data elements
needed to evaluate the objectives.
• PHNS(designated documentation coordinator) will
document issues, feedback, suggestions on how to
follow up on the patients and their contacts in a
standardized manner.
31
December 14, 2010
Review of TB suspects/cases initiated between Jan.- March 2010 and their contacts
AGENDA
TIME
1:00 PM –
1:15 PM
1:15 PM –
1:30 PM
1:30 PM –
2:30 PM
TOPIC
Introductions, Review Ground rules,
Confidentiality Statement
Preliminary report on current cohort
Who
Facilitator
TBCP Epidemiologist,
 Presentation of Ist Quarter cases by
PHNs
- Open TB Suspects
- Confirmed TB Cases
 Questions, clarification, identification
of issues from chest MD, AMD on
each case
 Decisions about disposition of each
case
2:30 PM – Break
2:45 PM
2:45 PM – (Continued)
3:30 PM
 Presentation of Ist Quarter cases by
PHNs
- Confirmed TB Cases
 Questions, clarification, identification
of issues from chest MD, AMD on
each case
 Decisions about disposition of each
case
Facilitator
Case Managers
3:30 PM –  Updated report on current cohort
3:50 PM
 Action items and follow-up issues for
next cohort review session
3:50 PM –  Wrap up
4:00 PM
 Determine next Cohort Review
session date
TBCP Epidemiologist
Documentation
coordinator
Facilitator
Medical Reviewer
Facilitator
LAC Cohort
Review
Meeting
Agenda
Case Managers
Medical Reviewer
Next cohort review session: Feb.____, 2011 (Review of all suspects/cases initiated
32
LAC Cohort Review Meeting
Participant Ground Rules
• Begin and end on time
• Remain quiet during the
case presentation
• Turn cell phones on
vibrate -if you need to
answer please go out of
the room
• Listen to and Respect
Others
• Provide positive and
constructive feedback
• Right to disagree but not
offensively
33
34
35
• Measurable
improvement on LAC
TB performance
through countywide
implementation of
the cohort process
Treatment Outcomes LAC 2009
38
COT by Provider Type LAC 2009
39
Summary of Cohort
2010
1st quarter Cohort
40
TALLY SHEET
Date
Quarter Cases Counted
TB Information
Ln
Dp_No Sm+ Cult+
DOT
Dot_
Pulm CavCXR
a b
'
DISPOSITION
c
d
January 1 to March 31, 2010
CONTACT
e f g h
i
j k #ID App Test
#Eval
#Inf
#Tx LTBI
#Comp #Curr
Comments
BA
BE
BR
CA
CL
DE
GA
HE
HO
JA
LE
LI
LO
OX
RI
SA
SP
ZA
TOTAL
DISPOSITION
CONTACTS
a
Patient completing recommended therapy
#ID
b
Likely to complete treatment within 365 days
App test # of contacts appropriate for testing
c
d
Noncount
Reported at death
#Eval
#Inf
e
Counted by "other"
#trtLTBI # contact start on Tx for LTBI
f
g
h
MDR and still on treatment
RIF resistant/intolerant and still on treatment
Died during treatment
Moved
Cohort failure
Lost
#Comp
#Curr
i
j
k
# of contact identified
# contacts evacuated
# contacts infected
# contact compl tx LTBI
# Contacts who are still on Tx LTBI
41
Follow Up
Essential on any
Issues Identified:
•Treatment
•Data
•Contact Investigation
•Case Management
•Education & Training
•NTIP Issues
•Clinical
•Medical Records
42
Follow-Up
Each participant has follow-up tasks to perform.
• PHN Supervisors & PHN case managers
• Follow up on case management suggestions made during
the cohort review
• Ensure that patients and contacts still on treatment finish
treatment. The outcomes of persons with TB disease who
were “likely to complete” treatment and the contacts who
are still on treatment for LTBI will be reported and
reviewed in 6 months, as part of a future cohort review.
• Keep managing the cases and contact investigations until
they are “closed”.
43
Follow-Up
• The AMD and/or NM will address programmatic
concerns and consider modifying staff training to
address staff learning needs.
• The medical reviewer (Chest MD) will address
clinical and programmatic problems that were noted
and provide medical consultation.
• TBCP APS, PS, NM will track education,
programmatic and clinical issues needing follow up
and ensure ongoing, follow -up staff education
44
SAMPLE
a
b
c
d
e
f
g
h
i
j
k
COHORT REPORT CARD
COMPLETION OF TREATMENT
Quarter: 1/1/10 to 3/31/10
SPA: ________
SUMMARY OF VARIABLES
TB Cases Counted 1/1/10-3/31/10
Total case counted
Complete treatment
Likely to complete treatment
Noncount
Reported at death
Counted by "other"
MDR TB
Count
43
26
8
1
2
0
1
RIF resistant/intolerant and still on treatment
Died during treatment
Moved
Cohort failure
Lost
TB Cases Counted 1/1/10-3/31/10
0
2
0
1
1
Rate
Index of treatment completion at time of cohort review
Index of possible treatment completion
Index of likely to complete treatment
Death rate
Default rate
Total cohort failure rate
65.0%
70.3%
91.9%
9.5%
2.4%
4.8%
REPORT CARD
COMPLETION OF
TREATMENT
COHORT REVIEW
Integration of National TB Indicators and
Los Angeles County Performance Measures
Inputs/ Resources
Activities
14,15
Capacity &
infrastructure
Provide TB education
and training to
community providers
4,5,10,12
B,C,D,E
Reduced TB
transmission
Coordinate and
communicate
effectively with
providers outside HD
Find and treat active TB
§ Identify early
§ Use effective drugs
§ Reduce treatment barriers
Reduced LTBI
prevalence
Investigate Contacts
7-2,7-3
8
7-1
3
§ Identify contacts quickly
§ Locate and evaluate in a
timely manner
Provide
patient education
and treatment
2-1, 2-2
11
Prevent TB in high-risk
populations
A
6
1
Ensure:
§ Patient on
appropriate
treatment
§ Patient
adheres to
treatment
§ Timely
completion of
appropriate
treatment
§ Engage community partners
§ Detect LTBI & TB
Monitor & evaluate
§ Data driven interventions to
improve program activities
defined & disseminated
OS 9: Evaluate and improve programs and
interventions
LAC Performance
Measures
Outcomes
7,9
§ Adequate funding
§ Strong and well-staffed
programs
§ Functional data systems,
including case
management data system
§ Adequate physical,
diagnostic and treatment
resources
§ Policies, procedures and
guidelines
§ Clinical, epidemiological,
and operational research
CDC National
TB Indicators
13
COHORT
REVIEW
OS 9
Enhanced
accountability
Reduced TB
incidence
Reduced TB
morbidity and
mortality
Improved quality
of patient life
2
Goal
Elimination of
TB in LAC
Staffing/Training required
• 2011-Cohort review training
– All AMDs, NMs, PHNS, PHNs, PHIs & CWs
2 days training (divided over three sessions)
• RTMCC assistance with CEU
§ Cohort review process concept and roles (1 day)
§ Cohort preparation/planning (½ day) onsite at health center
§ Mock cohort review (½ day) onsite at one health center in
each mega spa
• 2012 Cohort Review sessions
– Continue Cohort review training
– All Health centers begin Cohort Review sessions
Cohort Review Implementation by
December 2011
SPA
1&2
Pacoima
Jan.
Feb.
March
April
May
June
July
August
September October
November December
DPHNs are located at North Hollywood H.C.
3&4
Hollywood
-Wilshire
5&6
Simms M
Patients are seen at
Hollywood-Wilshire H.C.
South
7&8
Whittier
1 center in each Mega-SPA, selected based on CHS needs, and resources; but driven by epi.
48
LAC Program Evaluation Process
(Cohort Review)
Inputs/ Resources
Activities
Monitor
progress
toward
objectives
Outcomes
Met target
Did not meet target
Identify and share
“Best Practices”
Provide justifications,
develop action plan to
evaluate
(CHS & TBCP Evaluation
Team)
Implement Improvements
(CHS )
Refine/develop
activities based on findings
(CHS & TBCP Evaluation Team)
Complete evaluation
(CHS & TBCP Evaluation
Team)
= Data and programs undergo
continuous improvement
with ongoing monitoring and
evaluation feedback
49
References
“Understanding the TB Cohort Review Process: Instruction Guide 2006”
http://www.cdc.gov/tb/pubs/cohort/default.htm
National Tuberculosis Indicators Project (NTIP)
http://www.cdc.gov/tb/pubs/tbfactsheets/NTIP.htm
Fujiwara PI and Frieden TR. TB Control in New York City; A Recent History.
Atlanta, GA: CDC, Division of Tuberculosis Elimination. TB Notes 2000(1): 9-12.
MacMaken M. The Cohort Review Process in New York City. Atlanta, GA: CDC,
Divisions of Tuberculosis Elimination. TB Notes 1997 (1).
Francis J. Curry National Tuberculosis Center; Quality Improvement for TB Case
Management: An Online Course for Systematic Quality Improvement Program
for TB Case Management. (2002).
Acknowledgements:
Karen Y. Cho, RN
Terese Brookins, EPI
Sharelle Carr, RN
Frank Alvarez, MD
Jan King, MD AHO- SPA 6
South Health Center (SPA 6) staff
Thank You!
Questions