Transcript Managerial Role In The TB Interviewing Process

The Managerial Role In TB
Interviewing and Large Scale
Contact Investigations
Eileen Napolitano
for Mark Wolman
NJ Medical School Global Tuberculosis Institute
December 8, 2009
Managing Program Activities
• Is the activity being carried out?
• How well is it done?
• What are the outcomes?
• How do they compare with national, state and local
TB Program objectives?
Background - 1
Year
2000
2001
2002
2003
2004
2005
Cases reported
16309
15946
15056
14840
14515
14097
Sputum smear positive
5275
4771
5080
5233
4798
4821
Contacts identified
80239
85238
77424
73319
71489
73281
Objective
Evaluation Indices
Contacts per case
15.2
17.9
15.2
14.0
14.9
15.2
Cases w/ no contacts
9%
8%
8%
7%
8%
8%
Contacts evaluated
65795
68190
63487
58655
58620
58624
Contacts not evaluated
14444
17048
13937
14664
12869
14656
Contacts w/ disease
1%
1%
1%
1%
1%
1%
Contacts w/ LTBI
24%
22%
26%
26%
25%
24%
Started treatment for
LTBI
69%
70%
72%
73%
71%
69%
Completed treatment
56%
60%
59%
59%
61%
63%
95%
85%
Background - 2
• CDC estimates on average 15 contacts identified
for every verified pulmonary/laryngeal TB case in
the U.S.
– 25-30% are infected with TB
– 1% of identified contacts are diagnosed with disease
– 10% of newly infected (immunocompetent) contacts
will develop TB disease
• Incidence of TB disease among close contacts is
700/100,000
– For every 1000 contacts identified and evaluated
approximately 7 cases are diagnosed with TB
CDC, 2000
Background - 3
• In a recent CDC national study of 1080 smear
positive pulmonary TB patients interviewers
failed to identify
– contacts for 8% of TB patients
– non-household contacts for 33% of patients
– work contacts for 89% of employed patients
Marks, et al, 2000
Background - 4
CDC findings indicate the need for improved
skills among interviewers for the purpose of
identifying all high, medium and low priority
contacts to reported TB suspects and cases.
All TB cases began as TB contacts
Just Two Examples Why Quality
Contact Investigations Are
Important…..
• 43% of infants aged 0-1 develop TB disease within
1 year of exposure and infection
– 25% of these pediatric cases are extra-pulmonary
• 66% are diagnosed with lymph node TB
• 6% are diagnosed with miliary TB
• Of those infants who are identified as a contact to
a known infectious or potentially infectious TB
case 10% who are TST negative develop TB
disease
Core Activity
• Contact Investigation is a core activity in a TB
Control Program:
– TB interview is critical to the contact investigation
– Quality of interview skills have a direct impact on
contact investigation outcomes
– Essential that all designated TB staff are trained in the
skills of interviewing
Interviewer
Knows what
questions to
ask patient?
Knows how to
ask questions
to patient?
Potential
Number
contacts
Identified?
Poorly trained
with little
experience
Not really….
Moot point/
doesn’t even
know what to
ask
None… maybe
1?
Partially trained
with some
experience
Kind of….
Sort of….
Probably 1-3
Properly
trained with
experience
Yes
Yes
Maximum
Role Of Program Manager - 1
• Program Managers should implement quality
assurance practices for contact and source case
investigations for the purpose of:
– Monitoring the overall effectiveness of the interview
process
– Identifying staff training needs on the methods of effective
interviewing
– Developing, evaluating and improving the skills of both
the experienced and inexperienced interviewers
Role Of Program Manager - 2
• Program Managers should provide appropriate
training and on-going evaluation for all
program staff conducting TB interviews
– Education
• CDC Self-Study Modules on Tuberculosis
• Familiarity with local health department program
policies
– patients to be interviewed
– time frames for interview initiation and completion
– documentation
• Effective TB interviewing training course
Role Of Program Manager - 3
– Training
• Shadowing
– Observing
• Modeling
– Simulating
• Role-Playing
– Practicing
– Offer environments and opportunities for:
• Demonstration of various patient scenarios and
techniques of interviewing
• Time for questions and discussion
Role Of Program Manager - 4
– Bridging the Gap between novice and competent
interviewer
• TB Control staff member conducts actual interview with
Program Manager present
• Program Manager should intervene only if interviewer:
– loses train of thought or becomes distracted
– loses focus
– becomes intimidated
– omits important tasks
– exhibits poor interpersonal skills
– provides inaccurate information
Quality Assurance
• Quality assurance is accomplished through the
development and proper use of an assessment
instrument which will ideally
– Help improve interview skills
– Assist in the process of staff development
– Ensure a thorough evaluation
• Assessment is conducted through observation of
the interview and review of contact investigation
activities
– Should be completed periodically for all TB interviewers
regardless of experience
Assessment
• Process Elements
– Specific tasks the interviewer is expected to complete
during the interview
• Skills Elements
– Communication techniques, problem solving and
analytical skills the interviewer demonstrates during the
interview
Observation and Assessment - 1
• Process elements
• Medical record review
• Developing infectious period
• Planning interview strategies
• Providing TB education
• Identifying contacts
• Collecting contact information
Observation and Assessment - 2
• Skills
– Basics of Effective Communication
• Promoting dialogue with index patient
• Providing encouragement
• Awareness of body language
– Problem Solving Ability
• Identify verbal and non-verbal problem indicators
• Addressing potential barriers to adherence
Observation and Assessment - 3
– Analytical Skills
• Revise infectious period (If necessary)
• Distinguish between high, medium and low priority
contacts
– Developing investigation plan and strategies based on
information collected
• Expanding investigation
Components Of The TB Interview
• The five components of the TB interview include
–
–
–
–
–
Pre-interview
Introduction
Information and Education exchange
Contact identification
Conclusion
TB Interview Structure – 1
• Pre-interview Activities
–
–
–
–
Review medical record
Establish preliminary infectious period
Develop an interview strategy
Arrange interview time and place
• Introduction
– Introduce self
– Explain purpose of the interview
– Ensure confidentiality
TB Interview Structure - 2
• Information and Education Exchange
– Observe patient physical and mental behavior
and evaluate communication skills
– Collect and verify personal and medical
information
– Assess disease comprehension and provide
education
– Discuss basis of patient’s current diagnosis
– Discuss disease intervention behaviors
– If needed refine infectious period and review with
patient
TB Interview Structure - 3
• Contact Identification
– Focus on infectious period
– Explain high-priority (close) and low-priority
(casual) contact
– Stress importance of identification of all high
priority contacts
– Collect information on contacts in the household
and all congregate settings during the infectious
period
– Discuss site visits and sharing of information on a
need-to-know basis
• reinforce confidentiality
– Discuss referral process
TB Interview Structure - 4
• Conclusion
–
–
–
–
–
–
Answer questions
Review and reinforce adherence plan
Restate next appointment (if known)
Arrange re-interview and home visit
Leave name and phone number
Thank patient and close interview
Interview Process And Skills
Evaluation Form
Program Manager
Recommendations
• Facilitates discussion and provides an
environment for
– Encouraging the interviewer’s comments
– Reviewing the evaluation form noting both
strengths and areas needing improvement
– Offering specific techniques of interviewing
– Establishing a mutually agreed upon plan for
improvement (if needed)
– Providing a copy of the evaluation form to the staff
member
Contact Investigation Outcomes –
Your Data
Year
2003
2004
2005
Cases reported
14840
14515
14097
Sputum smear positive
5233
4798
4821
Contacts identified
73319
71489
73281
2006
2007
2008
Objective
Evaluation Indices
Contacts per case
14.0
14.9
15.2
Cases w/ no contacts
7%
8%
8%
Contacts evaluated
58655
58620
58624
Contacts not evaluated
14664
12869
14656
Contacts w/ disease
1%
1%
1%
Contacts w/ LTBI
26%
25%
24%
Started treatment for
LTBI
73%
71%
69%
Completed treatment
59%
61%
63%
95%
85%
Congregate Setting Investigations
• Require more sophisticated skills
– Technical expertise in infectiousness and transmission
– Skill and professionalism in dealing with site
management
• TB Program Managers should periodically review
and assess the quality of congregate setting
investigations within their program area for:
– Appropriateness
– Effectiveness
– Professionalism
Some of the more common
congregate setting investigation
sites…
• Childcare and pre-school centers
• Correctional facilities
• Houses of worship
• Hospitals and other health care facilities
• Schools
• Shelters
• Workplaces
Evaluation
• An evaluation of congregate setting investigations
will enable you to:
– Assess performance of both new and existing staff
– Identify and address problems associated with
congregate setting investigations
– Identify training needs
– Review and analyze outcomes
Need for On-site Assessment
• If sufficient program resources are available, the
Program Manager should ensure the on-site
assessment of the congregate setting be initiated if
the index case is diagnosed with suspected or
confirmed respiratory TB and presents with
– Smear positive respiratory specimen and/or
– Cavitary disease with cough or laryngitis
• Current CDC guidelines recommend that all
potential settings for transmission should be
visited within 5 business days of initiating the
contact investigation or upon identification of
setting
Communication is Essential
• Patient – the need to conduct congregate
setting investigation
• Management – TB exposure and provision of
TB education
– Should be done in person
– Importance of confidentiality
• Individuals exposed
– Inform about TB exposure, transmission and treatment
– Educate about the need for testing and evaluation
– To reduce anxiety for those identified as contacts
On-Site Assessment of Congregate
Setting
• Determine potential for exposure and transmission
– Assessment ideally should include accurate and
detailed drawings and or photographs with emphasis
on:
• Room design(s)
• Room size(s) in sq. feet
• Ceiling height
• Type of ventilation
• Proximity of individuals in relation to index case
Restaurant Kitchen Area – Hand
Drawing
Coat Manufacturer - Camera
Daycare Center - Diagram
Determining When To Expand A
Contact Investigation
Program Manager needs to consider the
following factors for consideration of expansion:
• Extent of recent transmission in identified contacts
– Unexpected high rate of (+)TST results or
– Evidence of secondary cases or
– Transmission to contacts <5 years of age or
– Documented TST conversions or
– Change in TST status from negative to positive
• In absence of recent transmission investigations
should not be expanded
Problems and Challenges
• Depending on the setting the following can be
associated with large-scale contact investigations
– Potential for a large number of identified contacts
– Potential for vague information for determining contact
priorities
– Potential for incomplete identity and locating
information
– Challenges in maintaining patient confidentiality
– Collaboration with officials and administrators who are
unfamiliar with TB
– Media coverage
Skills & Performance Evaluation
Skills & Performance Evaluation
Cont’d
Outcomes Evaluation Form
Sample Summary Form
Sample Summary Form Cont’d
Resources
• Performance Guidelines for Contact Investigation:
The TB Interview
www.umdnj.edu/globaltb/products/tbinterview.htm
• Tuberculosis Contact Investigation in Congregate
Settings: A Resource for Evaluation
www.umdnj.edu/globaltb/products/tbcontactinvestigation.htm
• CDC Guidelines for the Investigation of Contacts of
Persons with Infectious Tuberculosis
www.cdc.gov/tb/publications/guidelines/default.htm