ࡱ>  xUbjbjVV =<<xM@@3oooooJJJ֐ؐؐؐؐؐؐ^ؐJJؐooqqqoo֐q֐qq~ &oO^N03:=&&TzHJL6q,JJJؐؐJJJ3JJJJJJJJJ@ I: Slide 1: Best Practices in TB Control #2: Key Roles and Activities in the TB Cohort Review Process January 20, 2011 Slide 2: TB Cohort Review Webinar Series This is the second in a series of three best practices webinars that will highlight the TB Cohort Review Process: #1: Introduction #2: Key Activities and Roles #3: TB Cohort Review in Action Putting it all Together Slide 3: Objectives Upon completion of this seminar, participants will be able to: Describe the activities that key personnel do in preparing, conducting and following up a TB cohort review webinar Outline steps for implementing cohort reviews with available staff and resources Discuss strategies for implementing cohort reviews or training appropriate staff for these key activities Slide 4: Faculty (1) (List of faculty members with a picture of each person.) Bill L. Bower, MPH Director of Education and Training, Charles P. Felton National TB Center; Assistant Clinical Professor, Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University Kim Field, RN, MSN Section Manager, Tuberculosis Services, Washington State Department of Health Shu-Hua Wang, MD, MPH & TM Medical Director, Ben Franklin TB Clinic TB Consultant, Ohio Department of Health Assistant Professor, Infectious Diseases, Ohio State University Slide 5: Faculty (2) (List of faculty members with a picture of each person.) Christina Dogbey, MPH Epidemiologist, Tuberculosis Control Program, Philadelphia Department of Public Health Mary Katie Sisk, RN, CIC Supervisory Nurse Coordinator, Bureau of Tuberculosis Control, District of Columbia Department of Health Slide 6: Agenda Introduction, housekeeping Bill Bower Key Activities and Roles Bill Bower Program Manager Kim Field Medical Reviewer Shu-Hua Wang Epidemiologist Christina Dogbey Nurse Case Manager/Supervisor Katie Sisk Planning and Staffing Bill Bower Questions and Answers Wrap up Slide 7: Key Activities and Roles Presented by Bill Bower, MPH Slide 8: Definitions (Screen capture from the CDC Guidance Regarding the TB Cohort Review Process, 8/9/2010) Cohort Review A cohort review is a systematic review of the management of patients with TB disease and their contacts. A cohort is a group of TB cases counted over a specified period of time and the review occurs after the cases are counted. Cohort review if used as a tool to review patient outcomes and to monitor and evaluate program performance. At a cohort review, cases presented by case managers are examined for the patients clinical status, the adequacy of the medication regimen, treatment adherence or completion, and the results of contact investigation. Cohort review is currently used in countries around the world and in several U.S. cities and county jurisdictions. Case Review A case review is a systematic review of individual patient progress presented by the health department employee who is primarily responsible for managing that case. Case review is a fundamental component of case management and thus is an ongoing process for each patient. Plans are made to immediately address any treatment and patient management concerns identified through a case review. Slide 9: Cohort versus Case Reviews (Screen capture from the CDC Guidance Regarding the TB Cohort Review Process, 8/9/2010) The Difference between Cohort Reviews and Case Reviews Case reviews are not cohort reviews. Case reviews are real-time, ongoing, and provide an opportunity to review individual patient specific care. They allow for immediate analysis of a patients progress and plans to address any needed changes to treatment and management Cohort reviews provide an opportunity to review case data to address systemic programmatic concerns regarding the overall management of TB patients in order to improve patient care and programmatic performance and to promote efficiency. A cohort is a group of TB cases counted over a specific period of time, usually 3 months. The cohort cases are reviewed approximately 6-9 months after they are counted. Therefore, many of the cohort cases have completed or are near completion of treatment. Slide 10: Background Resources (Picture of instruction guide and video on the TB Cohort Review Process with URL for ordering or accessing the resources on the website for the Centers for Disease Control and Prevention) www.cdc.gov/tb/education/cohort.htm www.cdc.gov/tb/publications/guidestoolkits/cohort/Cohort.pdf Slide 11: Activities and Roles (Diagram showing levels of roles in TB Program) TB Program Manager Medical Reviewer and Data Analyst Supervisor Case Manager Outreach Staff, DOT Staff, and Community Providers Activities of staff are detailed in 4-9 of the CDC Instruction Guide Slide 12: What do people do during the Cohort Review Process (Diagram showing steps in the cohort review process) Preparation Presentation Follow up Slide 13: Cohort Review Process: Activities of the Program Manager Presented by Kim Field, RN, MSN Section Manager, Tuberculosis Services Washington State Department of Health Slide 14: Preparing for a Cohort Review Demonstrate commitment Explain reasons for undertaking cohort reviews Develop tools and train staff Slide 15: Conducting the Cohort Review Presentation Foster safe and productive atmosphere Listen to all case presentations to identify strengths and weaknesses Ask questions to clarify Use case experience to teach knowledge and skills for effective TB control Slide 16: Following up After Cohort Review Address issues raised Continue staff education Slide 17: Tips for Getting Started (1) Many programs have adapted the principles of cohort review to their staffing, resources and political realities learn from them Break the implementation into steps so it is not too overwhelming Emphasize that staff are already doing most of the work anyway this will just add a systematic way of summarizing and learning Slide 18: Tips for Getting Started (2) You may have to think outside the box to identify people who can do the needed activities, given scarce resources No surprises make it very clear what performance measures you will be looking at and where the program stands on these Slide 19: Activities of the Medical Reviewer in the TB Cohort Review Process Presented by Shu-Hua Wang, MD, MPH & TM Medical Director, Ben Franklin TB Control Program Medical TB Consultant, Ohio Department of Health Assistant Professor of Medicine, The Ohio State University Slide 20: Preparation to Develop a Cohort Review Process (1) Picture of two mean with palm of hands covering their face. Caption reads: double facepalm when one facepalm doesnt cut it. Slide 21: Preparation to Develop a Cohort Review Process (2) Cohort review is not equal to case review Cohort review is not review is not equal to contact investigation Administrative reviews of cases and contacts Quantitative difference of program review and treatment outcome! (Picture of two men shown on movie poster for Double Impact) Slide 22: Preparation Prior to Cohort Review (1) Demonstrate commitment to the cohort review process Ensure staff at all levels understand the reasons for undertaking cohort reviews Slide 23: Preparation Prior to Cohort Review (2) (Picture of Dr. Thomas Frieden, Director of CDC and former New York City Commissioner of Health) The fundamental concept of a cohort review is accountability. Staff are accountable to supervisors and to the program for how well they are caring for patientsand the program is accountable to the patients and to the public for controlling TB. Slide 24: Preparation Prior to Cohort Review (3) (Table showing selected CDC National TB Program Objectives with blank spaces for state level and local level objectives for TB control) Know the programs objectives CDC National TB Program Objectives At least 90% of confirmed TB patients will complete treatment withib 365 days At least 90% of TB patients with positive AFB sputum-smear results will have contacts identified At least 95% of contacts to TB patients with positive AFB sputum-smear results will be evaluated At least 85% of infected contacts who are started on treatment for LTBI will complete treatment within 365 days State level objectives for TB control Local level objectives for TB control Slide 25: During Cohort Review Presentations (1) (Picture of people sitting at a table with arrows pointing to presenter and medical reviewer) Listen carefully to all case presentations Review available support documents TB registry, case management forms, medical records Ensure that all aspects of case management adhere to department of health policies and procedures Slide 26: During Cohort Review Presentations (2) (Image of form for Cohort Presentation I: Pulmonary of Extrapulmonary TB) Review of cases: Activities are complete in a timely manner Date case was assigned Date case was interviewed Data are complete Date of birth Entry to US HIV status Slide 27: During Cohort Review Presentations (3) Review case, diagnosis and treatment: Pulmonary or extrapulmonary Culture confirmed or clinical case Tuberculin skin test, interferon gamma release assays Nucleic acid amplification tests AFB smear/culture result Drug regimen is appropriate Drug susceptibility results are obtained Drug regimens are adjusted if necessary Sputum conversions are documented Treatment completions are documented Slide 28: During Cohort Review Presentations (4) Review contact investigations Number of contacts identified Number of contacts evaluated Number diagnosed with active TB disease or latent TB infection (LTBI) Number started on LTBI treatment Number completing LTBI treatment Reasons why contacts not evaluated or LTBI treatment not completed Slide 29: During Cohort Review Presentations (5) Ask questions of clarifications to make sure policies and procedures were followed and the outcome is satisfactory. Clarify: Lapses in following protocols Missing or incorrect information Action taken to prevent their occurrence in future reviews Slide 30: During Cohort Review Presentations (6) (Picture of staff watching presentation on screen) Assess outcomes Use teachable moments to illustrate important lessons in effective TB control Use specific areas as examples of how certain problems should be handled Give feedback to staff Update staff on policies, protocols, and scientific changes Slide 31: Follow-up After Cohort Review (1) Ensure that medical management issues and programmatic problems are addressed Provide medical consultation for any problems identified Ensure that ongoing follow-up staff education includes Program strengths and weaknesses identified during cohort review Slide 32: Successful Cohort Review (Picture of double rainbow) The medical reviewer assists in: Improving patient care Improving TB control Improving public health First steps toward TB elimination Slide 33: Thank you! (Picture of people standing on staircase) Slide 34: Activities of the Epidemiologist in the Cohort Review Process Presented by Christina Dogbey, MPH Philadelphia Department of Public Health Tuberculosis Control Program Slide 35: The Philadelphia Experience (Picture of Philadelphia) Conducting cohort reviews since 2005 Expected and anticipated part of our program Staff looks forward to it From an epi/data analyst perspective, makes writing annual reports and fulfilling data requests easier We have been able to modify pieces of cohort to fit out program objectives and what we want to measure Slide 36: Epidemiologist or Data Analyst is Responsible for: Before cohort Preparing and distributing the list of cases for review Collecting demographic information about the cohort for presentation Preparing and pre-populating the spreadsheet with data Slide 37: Line List of Patients for Cohort (Image of spreadsheet showing patient data) Slide 38: Epidemiologist or Data Analyst is Responsible for: During cohort Presenting information on the demographic and clinical characteristics of the cohort as a whole Listening to each case presentation and updating information on the spreadsheet for each patient Recording issues that arise regarding individual patients and overall program policies Calculating rates for completion of therapy, contacts, etc. Reporting the results of the cohort back to the team and comparing them to goals and objectives Slide 39: Cohort Spreadsheet 1 (Image of spreadsheet showing patient data including name, registry number, clinical data, time measurements, and DOT information) Slide 40: Cohort Spreadsheet 2: Disposition and Contacts (Image of spreadsheet showing patient data related to disposition and contacts.) Disposition: completed treatment, cohort failure, likely to complete, MDR, lost, died, reported at death, non count. Contacts: how many identified, how many appropriate for evaluation, how many evaluated, and outcomes (infected, TB disease, suspect, started treatment, completed treatment, refused to start treatment, still on treatment, or died Slide 41: Cohort Spreadsheet 3: Calculations Page, Pt. 1 (Image of spreadsheet showing calculations, including the number of cases counted, number of cases that started and completed therapy and all outcomes and rates) Slide 42: Cohort Spreadsheet 3: Calculations Page, Pt. 2 (Image of spreadsheet showing report on contacts of pulmonary cases, including mean number of contacts per case and outcomes, e.g., appropriate for evaluation, evaluated, how many started treatment, how many completed treatment, how many refused to start, and how many refused to complete treatment) Slide 43: Epidemiologist or Data Analyst is responsible for: After cohort Summarizing results and disseminating them to the team Beginning the process of following up on issues Preparing the list of cases for the next cohort review Slide 44: Why it Works Simple and straightforward Process is easy to master Buildable once you start, build on previous cohorts Calculations can be done by hand or in Excel Adaptable to different program models Everyone leaves the meeting knowing exactly how the program performed Slide 45: Case Management and Cohort Review Presented by Mary Katie Sisk, RN, CIC Nursing Supervisor Bureau of TB Control, Washington DC Slide 46: Objectives Identify means of translating daily work activities to the cohort review process Define pre-cohort review preparation steps for case managers and supervisor Identify means to facilitate staff buy in Slide 47: First Things First Development of cohort sheets make them work for you Have clear documented definitions for terms used on cohort sheets Cohort review should not be burdensome it is not additional work but a summation of all work done on a case; information should be easily obtained from your case report and clinic records Slide 48: Steps to Cohort Review Step One: Preparation Step Two: Practice and Review Step Three: Cohort Review Step Four: Aftermath or Follow-up Cohort Review Slide 49: Step One: Preparation Selection of patient group to be reviewed Notification of staff: Staff/patient selection Cohort practice time and location Cohort review time and location Preparation of cohort sheets Slide 50: Selection of Patients Define patient cohort group as determined by program case numbers and/or needs (number of patients/months/quarters) Define staff who were responsible for case work, this will vary program to program Slide 51: Notification of Staff Adequate notification currently the DC program sends out next cohort notice within 2 weeks of preceding cohort Notification is via email using a line listing; designates which staff member will be responsible for reporting during the cohort review Slide 52: Sample Email Notification (Image showing example of email) Slide 53: Preparation of Cohort Sheets TB programs basically collect the same information; our process might be different but the information needed should be available Begin completing the form as you begin working the case, it saves time Most of the case information will be complete or near completion at time of the review It allows for a final review of case It should take approximately 10 minutes to complete the review sheet Slide 54: Note, Definitions and Special Cases (Image showing sample of definitions with numbers that coordinate with numbers on the spreadsheet) Slide 55: Cohort Presentation I: Pulmonary or Laryngeal TB (Image showing the cohort review sheet sections 1, 2, 3 and 4) Slide 56: Cohort Presentation I: Pulmonary or Laryngeal TB (Image showing section 5 of the cohort review sheet) Slide 57: Cohort Presentation I: Clinically Confirmed or Extrapulmonary TB Case (Image showing cohort review sheet for clinical confirmed or extrapulmonary TB cases) Slide 58: Step Two: Cohort Practice Determine number of practice sessions Conduct practice as you would an actual cohort review Case managers provide copies of sheets to supervisors prior to 1st practice Supervisors review sheets prior to practice for missing or conflicting information Practice is conducted 3 weeks prior to actual review Slide 59: Cohort Practice Cases are called in the order listed in notification Supervisors act as medical reviewers Staff are given 1 week to make changes and return corrected sheets to supervisors A 2nd practice session is held 2 weeks prior to actual cohort (if needed) 1 week prior to cohort review the sheets are forwarded for data entry Slide 60: Step Three: Cohort Review A formal process No drinks, cell phones on mute No paperwork other than cohort sheets Remember this is not case management! It is not the daily management of the patient but a summation of the care provided to index and contacts Allow all of staff to participate in discussing data results Slide 61: Step Four: Aftermath of Cohort Post your data Obtain or clarify missing information Select indicators that need improvement Select actions to initiate/implement these actions What process will you use? How will you evaluate results? Document results of implementation did you get the desired results? Begin prep for next cohort review Slide 62: Selling Cohort Pick several cohort review champions Enlist all of staff (interns, clerks, nurses, investigators, registry, etc.) Include all staff in training, everyone will then understand where they fit in Highlight the benefits to program and staff Remember not everyone likes change, but change we must! Slide 63: Contact Information Mary Katie Sisk Email: mary.sisk@dc.gov Office: 202-698-4024 Main: 202-698-4040 Fax: 202-724-2363 Slide 64: Planning and Staffing Presented by Bill Bower, MPH Slide 65: Planning How to Tailor Cohort Review to Local Program Areas (p 53-57) Establishing Political and Management Commitment Modifying the Elements of the Cohort Review Process Slide 66: Exercises for Planning and Training (1) (Image showing worksheet for TB Program Self Assessment Exercise) TB Program Self Assessment Exercise can help you identify aspects of your program that may need to be enhanced in order to conduct a cohort review (p.13) Slide 67: Exercised for Planning and Training (2) TB Program Self Assessment Developing TB Program Objectives Reviewing Case Management Protocols Completing Forms for Cohort Review Practice Presentation and Review of Cases Calculation of Indices/Rates for Treatment of TB Disease Calculation of Indices for Contact Investigation Slide 68: Implementation Handout (Image showing steps for implementation with list of action, who, when and status) Slide 69: People Staffing Identifying the right people Orienting them to the process Training as needed Slide 74: Questions and Discussion Slide 75: Thank you for your participation!! 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