TB Cohort Review in Los Angeles County It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity NTCA 2011 April King-Todd, RN, BSN, MPH Nurse Manager LAC TB Control Program Los Angeles County (LAC) at a glance 674 TB cases 2010 8 Service Planning Areas (SPAs) 12 health centers 10 million residents 2 TB Cases by SPA LAC, 2009 (N=701)* Number of Cases % of Total Cases SPA 1 : ANTELOPE VALLEY SPA 2 : SAN FERNANDO SPA 3 : SAN GABRIEL SPA 4 : METRO SPA 5 : WEST SPA 6 : SOUTH SPA 7 : EAST SPA 8 : SOUTH BAY * #5- TBC Admin Data Excludes Long Beach and Pasadena TB Cases LAC DPH/ TB Control Program Epidemiology Unit 1
Community Health Services 12 district health centers PHN Field/Home Suspect, Case & Contact Management (2008) 16,000 suspect/case visits 12,000 contacts family/industrial Clinical TB services (FY 09-10) TB MD 20,000 visits TB ERN 20,000 visits Direct Observed Therapy (FY 09-10) 11,000 clinic visits 52,000 field/home visits TB Cases & Suspects LAC 2003-2010 Number Updated as of 3/3/11 Data Exclude Long Beach and Pasadena TB Cases Public Health / TB Control Program Epidemiology Unit Cohort Review (Core) Objectives & Performance Targets 1 Category Completion of Treatment 3 Contact Investigation Contact Elicitation Contact Evaluation Treatment Initiation Treatment Completion Indicator Percent of patients with newly diagnosed TB for whom 12 months or less of treatment is indicated, who complete treatment within 12 months. Aggregate Reports for Tuberculosis Program Evaluation Contact Investigations Percent of newly diagnosed TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited. Percent of contacts to sputum AFB smearpositive TB patients who are evaluated for infection and disease. Percent of contacts to sputum AFB smearpositive TB patients with newly diagnosed latent TB infection (LTBI) who start treatment. Percent of contacts to sputum AFB smearpositive TB patients who have started treatment for the newly diagnosed LTBI, who complete treatment. 2015 National Objective 93.0% 2004-08 National Average 2004-08 LAC Baseline 71.7% 76.5% 100.0% 92.2%* 92.2% 93.0% 80.4%* 99.5% 88.0% 70.5%* 55.8% 79.0% 63.3%* 51.1% 2
Tuberculosis Cases: Co-morbid conditions Los Angeles County, 2010 (n=674) Co-morbid conditions 24.3% 7.3% 5.2% 0.7% 0.6% Number of TB Cases Updated as of 3/2/11. Statistics may vary due to periodic updates in TB surveillance database. Data Exclude Long Beach and Pasadena TB Cases Public Health TB Control Program/Epidemiology & Research Unit TB Cases who are HIV Co-infected, Homeless, and/or Substance Abuser Los Angeles County, 2006-2010 (N=3,873) HIV (N=271, 7%) n=46 Substance abuser* (N=453, 12%) n=26 n=103 n=23 Homeless (N=234, 6%) *Includes cases reporting injection drug use, non-injection drug use, or alcohol use. **Updated as of 3/2/11 Data exclude Pasadena and Long Beach TB cases Public Health/TB Control Program/Epidemiology & Research Unit Cohort Development in LAC 2007 Lessons learned-initial pilot Monrovia HC 2010 Interested AHO assigned to joint TBC-CHS performance measures from LAC DPH Educational planning meetings using available materials Electronic case presentation form in progress while paper form used 1 st session held-chs Director buy in with caveat 2011 CHS QI Committee presentation- unanimous decision to add 3 more sites. CR proposed as a Quality Initiative for DPH 8 3
Los Angeles County Cohort Review Model Unique Process: 3 ½ hour quarterly meeting face-to-face & teleconference capability ( 18-20 cases) Inclusion of TB suspects & timeliness measures Electronic case presentation form State Liaison & CDC participation Gradual implementation to all 12 health centers Data base for tracking CR quality issues Plan to go almost paperless 9 Los Angeles County Model Timeliness Measures Registration 2 weeks Confirmation/Closure 3 months TB case closure 9 months 11 Cohort Review Instruction Manual 12 4
SPA 6 - South Health Center Approx. 1 million residents 13 TBCP Staff Role & Responsibilities (2) Title Health Center APS, PHN Co-Coordinator and Instructor Cohort review presentation 1. Attends & asks questions of clarification Follow-up after cohort review 1. Tracks education, programmatic & clinical issues needing follow up 2. Ensure that ongoing, follow -up staff education incorporates program strengths & weaknesses 15 5
CHS Staff Role & Responsibilities (1) Title Area Medical Director (AMD)/ Nurse Manager (NM) Has the list of TB cases and calls them to be reviewed May group the cases to allow some essential staff to leave before the end of the session. Preparation: 1. Ensures all staff understand the cohort review process, & has the knowledge and skills to perform this task and ensures the attendance of Health Center CR Team Cohort review presentation 1. Facilitates the introduction of on-site and call-in participants. 2. Reviews the Ground Rules 3. Listen to all case presentations 4. Ask questions of clarification to ensure all aspects of case management adhere to the DPH policies and procedures 5. Use teachable moments to illustrate important lessons in effective TB control. Follow Up after cohort review presentations 1. Ensure medical management & other issues are addressed 2. Address programmatic concerns & modifies staff training or orientation 3. Submits TB cohort summary to CHS Director & TBCP Eval. coordinator. 16 17 TRIMS Auto-populated Case Presentation Form 18 6
Cohort Summary Indicator Completion of tx within 12 months for eligible patients Cohort Review SPA 6 (2010-1 st Qtr) Los Angeles County Performance* (2008) SPA 6 National Average** (NTIP 2008) National Target (2015) 93.8% 79% 82.3% 93% Contacts elicited 62.5% 85% 93.1% 100% Contacts evaluated 99.6% - 83.2% 93% Treatment initiated (LTBI) Treatment completed (LTBI) 70% 78% 74.0% 88% 48% 43% 64.1% 79% *CHS LAC Performance Measures 19 Cohort Review Follow Up Categorized Issue Checklist used during CR Power point presentation: Issues identified Who was assigned Status Database in development for Countywide issues tracking 20 Required Cohort Review Training 1 ½ days 2011-3 additional sites All AMDs, NMs, PHNS, PHNs, PHIs & CWs Request RTMCC assistance with CEU Cohort review process concept & roles, preparation & planning -Mock cohort review onsite at health centers 7
Proposed Cohort Review Implementation 2012 LAC District Public Health Centers Challenges & Opportunities TB Program Infrastructure Re-organization Outreach to Private sector & Building a TB Coalition DHS CHS patient data linkages required Homeless Cluster Analysis -integrated interventions RHAP-QFT-GIT Implementation OVMC TB Isolation Unit School Mandate Revision TB Genotyping/molecular epidemiology Research studies/academic partnerships Feedback from the PHNs The genotyping data is very interesting & an eye opening reality of the potential of missed CI opportunities It helps me to understand case management now I know why we need all that information Our patients are not simply just dealing with TB, most TB cases have complex medical socio or environmental challenges/ high risk factors with multiple co-morbidities 24 8
it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only. Charles Dickens THANK YOU! Acknowledgements Terese Brookins, Epidemiologist Josephine Yumul, Epidemiologist Sharelle Carr, RN Karen Y. Cho, RN South Health Center (SPA 6) staff Frank Alvarez, MD, MPH Zvart Shaverdian, Student Worker 26 9