ࡱ>  ;bjbjVV 4<<t381%18 &1(1(1(1(1(1(12]5(1'''(1=1...'&1.'&1...Va)͵(.1S101.6+6.6.x . <#(1(1:.1''''6 : Slide 1 Bill Bower: Good afternoon and welcome to our second web-based seminar on key activities and roles in the TB Cohort Review Process. My name is Bill Bower and Im the Director of Education and Training at the Charles P. Felton National TB Center, a component of the New Jersey Medical School Global Tuberculosis Institute. I will be moderating todays program. Slide 2 This is the second in the series of best practices webinars that will highlight the TB Cohort Review Process. Slide 3 The specific objectives are these: describe the activities that key personnel do in preparing, conducting, and following up a TB cohort review; outline steps for implementing cohort reviews with available staff and resources; and discuss strategies for identifying or training appropriate staff for these key activities. Slide 4 Our faculty members today are: myself; Kim Field, Section Manager, Tuberculosis Services, Washington State Department of Health; Shu-Hua Wang, Medical Director of the Ben Franking TB Clinic, TB Consultant for the Ohio Department of Health, and Assistant Professor of Infectious Diseases at Ohio State University; Slide 5 Christina Dogbey, Epidemiologist at the Philadelphia Department of Public Health Tuberculosis Control Program; and Mary Sisk, Supervisory Nurse Coordinator at the District of Columbia Department of Health Tuberculosis Control Program. Slide 6 After this introduction, Ill provide an overview of cohort reviews and some background definitions. Ill highlight the key activities and roles people play and then well get right to our panel of speakers who will share exactly what they do in preparing, conducting and following up cohort reviews. After that, I have got a bit to add about getting started, the steps of planning and staffing cohort reviews. And finally, well have time for questions and discussion. Slide 7 Participating in the webinar, I know we have a mixed audience. Some of you may be program managers, medical directors or consultants, epidemiologists, public health nurses, supervisors, case managers, outreach workers, or any of a number of health occupations that contribute to the effort to eliminate TB. I want to get us all on the same page by going over some basic definitions that were mentioned in our first Webinar, Introduction to the Cohort Review Process. Slide 8 Now, here you see two definitions from the recent CDC guidance regarding the TB cohort review process. And they state that a cohort review is a systematic review of the management of patients with TB disease and their contacts, and they define a cohort as a group of TB patients encountered over a specific period of time. So, thats usually a three month period but it can be six months in some cases. The review occurs after all the cases are counted, and this review is used as a tool to look at patient outcomes and monitor and evaluate program performance. In contrast, case review is a regular systematic part of case management in which individual patient progress is presented by the person who is primarily responsible for managing that case. And its purpose is to address any treatment and patient management concerns that are identified. So, its more for the ongoing frequent monitoring of a patient. Slide 9 So, heres a way to contrast both of them. The point is made that case reviews are not cohort reviews. While case reviews are real-time, ongoing and provide an opportunity to review individual patient care, they also allow for immediate analysis of a patients progress and plans to address needed changes in treatment and management right then. In contrast, cohort reviews provide an opportunity to sort of step back and review case data to address systemic concerns of your program as a whole regarding the overall management of TB patients in order to improve patient care and program performance, and become more efficient as a team. So, that contrasts both. You shouldn't be thinking that one will substitute for the other. Slide 10 I also want to remind you that the basic sources for the information are both entitled Understanding the TB Cohort Review Process. This guide is undergoing revision and an updated version will be available soon. Slide 11 Now, in the CDC instruction guide, youll see this sort of a constellation of TB control staff who are involved in the cohort review process. The activities that each person does are detailed on pages four through nine of that guide, and theyre actually modeled by amateur actors in the DVD. These can be very good training tools for preparing your staff to participate in cohort reviews, but we have to be realistic. Not every program has these personnel resources. In fact, you probably have these staff that run right down the middle here as a part of your program. I figure you probably have a program manager, a supervisor and people who are doing case management. But on the left, there is a medical reviewers role and on the right theres the data analyst in here. You may have to think creatively to find who can do the activities that these people are described as doing here. And I ask you not to focus on the job title, but on the activities themselves. For example, to do the tasks that are listed in the guide for the data analyst, maybe you can find another departments data person or someone whos familiar with your TB registry or maybe you can find a volunteer epidemiologist whos working on a public health degree or just someone whos good with a spreadsheet and wouldn't be afraid of handling data. Well talk more about this later when we talk about who does things because it can be any of a number of resources that you have in your program. Slide 12 So, what do people do during the cohort review process? Were going to hear right now from experts who practice it regularly in their TB control programs. Theyll lead us through what's involved in the preparation, presentation and follow-up. So, I am going to turn the program over to Kim Field. Kim studied to be a nurse at San Diego State University, Nurse Practitioner at University of California in San Diego, and advanced Practice Community Clinical Nurse specialty at Seattle University. As the section manager of TB services at the Washington State Department of Health, she has become a pioneer in adapting the cohort review process from its U.S. origins in a big city to the unique approach that her state now uses. Shes been a passionate advocate for what cohort review can do for you, and theres nobody better to explain the activities of a program manager and getting started in doing this. Kim Slide 13 Kim Field: Thank you, Bill. Welcome to all of you that are the audience and thank you to all the New Jersey Global Center staff. I appreciate all your support. I am very much honored to be able to start here with our discussion about the activities that are really, you know, necessary for the cohort review process. I am very passionate about it and I very much want all of you that are really in your planning stages to understand that its a process that you can do, that when Washington State initiated this in 2003, we didnt ask for new resources, we didnt request them. We took the tools, youre all very fortunate right now because theres many areas now with tools to share. We took the tools that were working within New York. It really hand-in-hand helped us in what Im going to explain on what are the activities to really get going and setting up your program. And I want you to realize through all of todays discussion that were giving you examples of individuals that are working with the process. But feel free that as you move on, as an expectation as Bill Bower mentioned from CDC in our cooperative agreements, that you can individualize all of the tools, materials and knowledge to fit your needs. Slide 14 I need to start out with demonstrating commitment and then looking at the reasons for undertaking cohort reviews. Dr. Tom Frieden, who was the New York City Commissioner of Health prior to becoming the director of CDC, look at your program and ask, no matter what size of the program, if youre a state or youre a large city or a county. The fundamental question he stated is What percentage of your patients do you cure? And too many programs cant answer that question. I will add on to that. Prior to 2003 in Washington State, I can honestly say to you we didnt look, we didnt know. If youre not looking, youre really not being either proactive in a retrospect or even in a current way, to know are you really curing and what is the status of case management in your state? The second statement I think was very important by Dr. Friedman and was true and is true for my experience, that cohort reviews arent fancy. Theyre not expensive. In fact, at heart they are incredibly simple; do not make them complicated. You get a list of patients; youve got the people with firsthand knowledge of these patients, thats direct care staff and some of you in the audience or those individuals; youve got someone supervising, reviewing the work and that is what cohort review is. It doesnt take a lot of money, it doesnt take high tech. It just takes the knowledge of the patients and the systematic tracking of how each one is doing. And as Im working with a brand new staff, Ive had turnover in my tenure within my state, new staff, I have a new epi, two new nurses. Even at the state level, its very hard to have them understand that were not looking at the surveillance data. We are looking at the journey of a patient through their course of TB, how do we interact in our case management, in our interventions, and were looking at the outcomes that we want to measure so that we are assuring that we are providing the care that is needed, that were identifying barriers to that care, so a higher management can understand what resources that we need to our work. And to explain the reasons for undertaking the cohort review, once you separate out that it takes the direct care, it takes ongoing chart review, it takes ongoing case review. You retrospectively are going to then look to cohort review. How did all that work? How did that all fit together and then measure, at a level of Gee, did we meet this objective? Right now were looking in Seattle in the last year where they incorporated the National TB Indicators Project. So, when theyre presenting their case theyre actually relating it to national objectives as well as their local objectives. I will say that another reason, and in Washington State we really had poor outcomes in contact investigations. So, its also that way to list the contact investigation up as high priority, which we all know is a difficult thing based on resources, the amount of training and knowledge of contact investigation and the amount of time. But the cohort brings that review so that the focus needs to be there. Another issue in Washington State at the time was I can honestly tell you whether it was large city or county, we did not truly practice or have TB case management. And that has changed, you really have to have case management in your areas to really be able to focus on reviewing your outcomes. I mean, that may seem very simplistic, but thats why my passion with cohort is that it changes behavior over time even if you dont have all the pieces in place. So, in the beginning, you really want to look at that you have to have that commitment from management managers. We need to explain it teach ourselves. Certainly, the reasons Ive underscored here for undertaking cohort, who wouldn't want to have better documentation, better outcomes and a measurement. And then the developing of tools and training your staff to me, today, at this time for CDC requirement is a lot easier than it was in 2003. I feel we had a really close relationship with New York in doing this and that is where we gained all of our knowledge. But today, as I say, there are many tools, so I encourage you, and I understand CDCs attempting to put all these tools in one library, if you will, to access and take those tools and as a group, whoever is going to implement from your level and look at them, look at how you can revise them, and anyone thats developed those tools is on hand to assist you. We all want to assist each other and not have you reinvent the wheel. Slide 15 So, conducting the cohort review. I think most important as the activity of a program manager, and we prepare each time. In my state, we do it quarterly at a state level where we have a face-to-face in our large city of Seattle but our counties call in on a phone conference. And this has been very successful. And I want to advocate that when we, as a group trained ourselves, developed our tools, got consensus from founding input about our tools, our definitions of our work related to the cohort form and process, we went out and trained each county and I felt that was to the success because not one county, even in all the resources and the terrible resource cuts today, has stopped doing cohort review. I want to underscore that because I think if folks feel that this is going to require resources that they dont have or people are going to refuse to do it. They dont. And they dont stop because it documents really their work and right now with resources being cut, you can document. This is the level, the bar I was needing, the resources went away. This is where, you know, were lacking. So, as the program manager, you want a safe atmosphere with individuals if they have their training and education and lets say that we went down to a county level. They understand the purpose. They understand theyre not being challenged. But this is a presentation of their work, a discussion opportunity for them to present and for others really to review and identify the strengths but also identify barriers. And this requires really listening in a very thoughtful, careful way. We changed midway between 2003 and 2010. We added a mock cohort review that just means that we work with our counties over the phone two months prior to our quarterly review. And at this time, I think it takes away any kind of pressures. We had several new nurses this time for our cohort coming up that are new, it allows them to feel comfortable, allows them to know that this is a training, education, and a team process. The ability for individuals to be able to ask a panel of experts, questions if theyre not with an ongoing expert in TB, they have the opportunity to talk to these people and to hear what advice they may give. We dont have that at a local direct care level everyday as were doing our work most often other than in a large clinic setting. And for me, what is the tantamount part of cohort is the training and education. Its training and education ongoing whether youre going to set up quarterly or twice a year, whatever fits your program, its training and education you wouldn't have otherwise. We dont have the luxury to bring people together on an ongoing basis and we do have our wonderful regional training centers. But this is on the ground, education and training, working with those that are providing the direct care. Slide 16 For the follow-up, what we have found and I know many programs do this, many states listen in or areas listen in to our cohort by phone as were all doing today. But we keep an ongoing list within the cohort, we identify someone as a list-taker and Ill give you a great example. This came up in the cohort at the end of 2010 where we were hearing delays and reporting within TB specimen results. That was very serious. I mean, although it be retrospect, just keep in mind if you werent looking at this you may not notice or see it especially at a state-wide level. When we addressed it, went right back with our state lab after the cohort. We looked through the whole cohort, through all the cases and we unfortunately, in our state, have decentralized laboratory so that it can be any state lab, it can be any state hospital lab out-of-state rather than our public health lab. And there were issues there. So, it allows you to identify issues raised in cohort and then we bring that back to the next cohort, the person thats doing the follow-up and reports to the entire group as to was it resolved or what improvements we can make. The staff, I believe, through the whole process youre continuously identifying training and education opportunity. So, it may be that as staff turnover where people cutting their staff that have seniority and people are going to be replaced that dont have the knowledge. I can think of no better way that if your cohort form that you decide on is implemented, has definitions with it, its a way of orientation and training into how to understand at least the whole TB treatment course and implementation of case management to a good end. Slide 17 So, many programs have certainly adapted the principles of cohort review. I was able to be invited across the nation last year to speak mainly on cohort review. I was in one state but I didnt obviously do my homework. As it came to be end of the part of the day of cohort, the questions were raised, I dont even do TB, so how do I even know why cohort would approve of what Im doing? I think the issue is, if youre very low morbidity, and Ill use my dear state next me, Denise Ingman in Montana, who has less than 10 cases a year. She would even challenge me and say, How can I do cohort review?, Why would I do that quarterly? You may take and implement and improvise with the forms, with the system. The idea is just like we see in commercials, just do it. There are political realities where you will have to overcome the issue that people arent going to see the benefit of the ongoing training and education, they are not going to see that behavior is going to change. You have to bring that reality from the experiences that you hear today to really get your support to get it going. And then, when youre initiating the cohort process, there are really steps that I believe that would assist you in your planning. Obtain those examples, obtain those tools, obtain the training and that is now out there through the regional training centers. Decide on how often youre going to do this based on your morbidity or your geographic location and your staffing size. So, youre going to look at your tools, youre going to personalize them, decide how often youre going to do it, and then decide is this going to be face-to-face? You know, its wonderful how New York City and their first modeling that face-to-face. We knew that we couldn't bring the counties throughout a whole state together, so as I said, we used the phone or you could use webinar. And then emphasize that your staff, and I cant emphasize this enough, you are doing this work already. You are doing it. Its just pulling it to a systematic way that you understand that the cohort itself is one piece of paper, its utilizing your surveillance data. And by the way, your surveillance data its almost a QA/QI when youre doing cohort for that surveillance data to be more complete. It forces accurate documentation in order to perform cohort review. That youre utilizing laboratory reports, and as I gave the example, we have time limit measures for laboratory in our cohort because of our system of being decentralized. That youre utilizing the patient charts. So, Ive had nurses really say to me that it changed the way they documented in the chart when they were preparing for cohort. And then, the completion is that then, you have the ability at the end of cohort to certainly review, to analyze, and get summary thats going to document your work. Slide 18 Think outside of the box and by that, I mean, as Bill Bower says, look at what your staff are and look at what people have done with their models and personalize it for you. And as far as no surprises, make it clear what the performance measures. My advice to you in the very beginning of setting this up is that you have to have not only obviously buy in, so you have to have knowledge of cohort youve brought to your management, like in my state the epidemiologist at the state level that you have buy-in from their management. Then you go to the county level, we took everything back to the counties, made sure that they had buy-in. The laboratories, they were part of the definitions for the time limit measures. And at the end, youre bringing together the team, arent you? Youre bringing together the medical director, youre bringing together the program manager, the direct care, the outreach. It is truly a concept really focused on the efforts of all that makes our activities of making TB prevention and control a great success. And it allows us to continue to improve upon that. Thank you very much. Bill Bower: Thanks very much, Kim. Thanks for sharing your states experience with us. Actually, I think the way that you got started with just about no additional resources, and that you creatively made the process fit the needs of your program. It always inspires me. Thanks. Slide 19 Our next speaker is Dr. Shu Wang. She Studied biology at the University of California Davis, got a Doctorate in Pharmacy at the University of San Francisco, and then degrees in Medicine at the Medical College of Wisconsin and Public Health and Tropical Medicine at Tulane University. She is the Medical Director of the Ben Franklin TB Clinic in Columbus, Ohio where she participates in cohort reviews herself. She is also a TB consultant for the Ohio State Department of Health and Assistant Professor of Infectious Diseases at Ohio State University. Shu? Shu Wang: Thank you so much. Today, Im going to talk about the activities of the medical reviewer, the activities prior to starting cohort review, during the cohort review process, as well as following the process. But first I want to emphasize what Bill and Kim Field had mentioned, that the program does not necessarily need a medical reviewer on staff in order to develop and adopt a cohort review process. You do have to be creative and you may have to think outside the box. You may have a part-time physician who can be the medical reviewer or even a very experienced TB nurse can do the job. Slide 20 In preparation to develop the cohort review process, the mission may seem impossible for the medical reviewer. And perhaps the task may seem impossible even for the captain and his trusted number one. But working as a team, you can do this. And in fact, you may be more ready than you think. Slide 21 Are you currently performing case management review sessions or conducting contact investigations? Then you have a double impact for the one two punch that you need to get started. For our program, we started with really concentrating on case reviews initially and then now focusing on contact investigations. So, it is true, cohort review does not equal case review and cohort review is not the same as contact investigation. However, if you are currently performing administrative reviews of cases and contacts, then cohort review is the next step. Cohort review can turn what you are already doing into a quantitative difference for your program review and your treatment outcome. Slide 22 As Kim Field has mentioned, you need to demonstrate commitment to the cohort review process. When preparing to do cohort review, this may also give you an opportunity in engage and educate not only your staff but also your community partners, physicians and healthcare workers who are caring for the TB patients that you are following. You may need to communicate with them prior to cohort review to obtain some of the data that you need. For example, follow-up of contacts, what were their skin tests, what were their chest x-ray results? You can in fact invite them to come. They may state that theyre busy with clinics or rounds but then you can update them on the outcome. If you a series of pediatric patients, you may invite the TB infectious disease specialist to join in. But lastly, you want to ensure that all staff goes in your department as well as the community know and understand the reason why youre undertaking cohort review. Slide 23 I think were going to be quoting from Dr. Thomas Frieden, the Director of CDC, a lot today for he had the foresight to see this. And for me, I think this really simplifies the reason for cohort review. When you say that the fundamental concept of cohort review is accountability, staff are accountable to supervisors and to the program for how well they are caring for the patients and the program is accountable to the patients and to the public for controlling TB. Slide 24 Now, for the medical reviewer, you need to know the programs objectives so you can assist them in attaining their goals, and making them accountable. The medical reviewer, as stated, may be a part of a large program where hes doing the review for the entire state or a wide geographic region. That may not be the actual person caring for that patient, and may not know the programs objectives. But you need to find out. So, the local objectives may not be the same as the state or the national objectives. But the best thing about cohort is that you make these objectives what you want. For example, our program wanted to document how many clients were receiving extra incentive for social work so that we can document it. We added that to the cohort review process. We also wanted to know many clients were receiving incentives because we needed to document that. So, we added it to the cohort review process. You can truly tailor this program to what your programs needs are. Slide 25 Going on to the actual process of cohort review, you need to listen to the cases carefully as they are being presented. The format of the case presentation may vary depending on the program. Some programs do it like a grand rounds where a case presentation includes x-ray, CT scans, labs. Other programs use only the TB registry or case management forms and no other medical records. I use my trusty binder where all of the patients in the county are alphabetically kept in a folder with their case management form that I can flip back to. Some programs are an all-day affair, others can take a few hours depending on the case load. We do our programs every six months and we had about 66 cases last year. So, it takes a couple of hours for us to get this done, but we have it scheduled and we do it routinely. Once again, it is what you need and what you want from the program. The important thing is to ensure that all aspects of case management adhere to the department and health policies and procedures. Slide 26 So, for case reviews, you want to make sure that all of the activities are completed in a timely manner and all dates are complete. For example, were tracking the time between case notification and when the patient was first interviewed. Your team has learned to optimize and prioritize their time because they have a time clock or an objective that they need to perform this task by. Whether its three days or seven days, they are going to be accountable when they present the case if they did not get this done and they will need to know the reason why. Next to this is a copy of our Columbus Public Health Cohort Review form. And as Kim stated, we also borrowed the form originally from other programs that were out there. So, you can do the same and after a while, you can modify it to what you need. So, at the bottom you could see weve added the social worker and the incentives. Most of the data on this form is things that you have routinely collected, either for case management or contact investigation, or your surveillance reports that you did for the state and national. So, its just a matter of organizing this data so that you can present and analyze the data in a certain format. Slide 27 Now, we come to the meat of the cohort process for the medical reviewer. Its really reviewing the case, the diagnosis and the treatment. This is really a simplified version. Youre looking at each case but youre looking at your program as a whole. So, it kind of condenses everything and makes the analysis. So, were the cases pulmonary or extra pulmonary? Was it culture confirmed or a clinical case? What about tests that led up to the diagnosis, the tuberculosis skin tests, are you now using one of the new blood tests, interferon gamma release assays? What about nucleic acid amplification tests? Were very lucky that our health department and Ohio they have these tests available for us, and we perform the interferon gamma release assay Quanti-FERON in our own lab here. What about the acid fast smear and culture results? With these results, was the initial drug regimen appropriate? And then when you did get the drug susceptibility test results back, was the drug regimen adjusted if necessary? What about sputum conversion? Did they convert their sputum for the culture-positive cases? If not, do we need to extend their therapy? What about treatment completion? Because cohort review sessions may take place before the treatment completion of some patients, the medical reviewer and the team may need to take this opportunity to decide whether the patient is likely to finish their therapy within a certain time frames such as less than 365 days. Slide 28 The next big part of the cohort review process is, as been stated, the contact investigation. Youre documenting the number of contact identified for a certain case, the number of contacts that were evaluated, the number of active TB disease or latent TB infection that may have been identified through the contact investigation, and how many people were started on latent TB therapy, the ones that you had made the initial diagnosis, and how many completed the therapy? These are all number-crunching essentially, and youre looking at the program as a whole. But for me, one of the most important reasons for doing this is as a whole, I can look at the program and say, What were the reasons why contacts did not get evaluated or clients with latent TB infection did not complete their treatment? Did they move out of the area? Did they get deported? Is their work schedule or class schedule preventing from coming into the clinic? Did we make an effort to go out and reach them at their homes to do the contact investigation? What about adverse drug reactions? If they had initial reaction to the first drug, were they attempted to try on a second medication? So, as a program, you can look at it and then perhaps you might even be able to identify trends in your program where we are not achieving the contact investigation numbers that we want to and hope for. And then somehow, develop a program to improve those stats. Slide 29 So, this leads to my next slide which is really to ask questions or clarifications to make sure that things are being followed and the outcome is satisfactory to you. If its not, try to come up with ways to improve that outcome. And during the session, you can determine if there were any lapses in following the protocol. Where there missing or incorrect information? Do all the numbers add up correctly? And was an action taken to prevent further occurrences in the future? Slide 30 And now, the best part of this, I think is really assessing the outcome. Because this is, to me, is really like a report card. You get to see your grade, and you get to compare your grade to other people such as the national objective or other programs. So, we are very lucky in our program that we have our captain, our program director, we have a contact investigation specialist, as well as an epidemiologist and a nurse supervisor. But once again, you dont need any specific number of people or any specialized person in order to get this task done. There are also programs out there that you can use, and if the data are entered correctly it will automatically crunch out some of these numbers for you. For the medical reviewer, you can take this opportunity to teach and illustrate important points about your programs and the lessons learned for TB control. For example, we noticed that we recently had several contacts who were not identified initially or who did not complete their initial treatment and now a couple of years later, they are our active cases. So, this has really made us focus on our contact investigations. We have now formed a special contact investigation team to really try to improve these numbers. So, this has shown our program the importance of following up on these contacts. Slide 31 What to do in terms of after the cohort review. So, you may have identified certain issues, whether its medical or programmatic that you want to follow up on. This may also be an important opportunity for the medical reviewer to get feedback or contact your medical colleagues in the community, especially if they are not doing the management of the patients in the manner which you would like them to be doing. So, this is really a good opportunity for you to connect with the community as well as your team. It allows you to ensure that all ongoing follow-up staff gets educated as well and you want to be able to not only pulling out your strengths but also your weaknesses during these program reviews. Slide 32 For a successful cohort review, the medical reviewer is assisting in improving patient care, improving TB control program and improving public health and after all, these are the foundation or the first steps towards TB elimination and that elusive double rainbow. And I actually asked my staff for some testimonials on just how they think that the cohort review process that weve been doing these last couple of years have improved their own jobs or changed the outcome. And to quote one of my nurses, Overall I feel that cohort has improved the contact investigation portion of the program, it has made us more accountable as well as keep up with vital information that has prevented from scrambling in the end of the year reports such as for our aggregate report. And I truly believe that this has made us more accountable. It forces you to present your data and calculate them and analyze them so that you can improve your program. And that scrambling at the end is truly not occurring - its still occurring but not as frantic as before. Slide 33 So, I want to just take this opportunity to thank the Ben Franklin TB Control staff for their hard work and commitment to our review and remember the medical review is not alone, you can do this as a team. Thanks. Bill Bower: Shu, thanks for sharing your activities as a medical reviewer with us. I find it really interesting to see how you combine your medical review activities with a very broad public health perspective. I can see that you see your main responsibility as looking at the clinical aspects of the case, but you really keep a strong focus on adhering to program protocols and doing thorough contact investigations. So, I think thats got to really be paying off and making things strong there. Slide 34 Our next presenter is Christina Dogbey. She studied Economics at Cornell and then Public Health at Drexel University. And now, shes with the City of Philadelphia Department of Public Health TB Control Program as their epidemiologist. More than anyone, shes proved to me that someone who is not afraid of a spreadsheet can jump in and take over the activities of data analysts or epidemiologists in the cohort review process. She has also helped to teach this process to others using some very creative and hands-on computer exercises. So, Christina? Christina Dogbey: Thanks for that great introduction Bill. Im going to talk a bit about my role as the epidemiologist and what I do to kind of get this off the ground and running. As Kim said, the cohort review actually is a really great training tool for new people, because from personal experience, I actually sat in on my first cohort review two weeks after I was hired with the TB program. And then I ran the first my first cohort review three months later. And it was a very seamless process. So, it was really great for me to learn more about the natural history of TB and what I was actually going to be doing as the epidemiologist and then it was just lots of fun to really get my hands into helping the program prepare for this every single quarter. Slide 35 So, the Philadelphia experience, we have been doing cohort review since 2005. We, in that time period, we counted between 100 to 140 cases each year which translates into about 25 to 40 cases being reviewed each quarter. It is an anticipated and expected part of our program. Our staff looks forward to it, they always get ready for me to generate the list of patients who are going to be reviewed. And even people started getting me their information early, so I can start prepopulating our spreadsheet which I will talk about a little bit more later. From my standpoint as the epidemiologist, it makes the filling data requests a lot easier. The data has already been cleaned and verified by me because of the process of cohort review. So, when somebody actually calls and asks for asks the question or asks for some data, its kind of given me my answers already. I dont have to scramble or do too much to try and find the answers for people. And it also has generated study questions that we have used to actually write papers and conduct research just for our own personal input or curiosity especially with our medical director. We have been able to modify pieces of cohort review to fit our program objectives. There are things that we are interested in looking at with our own in-house lab, our own clinic because we do manage every single case of TB that is reported in the city of Philadelphia. So, how are we actually doing with serving the population? So, we have a lot of things that weve added to the process. We did use as plug and play approach from the New York City model. We went there, we trained, we took their model and we came in to Philadelphia and just made a couple of tweaks and started using it. And its working very, very well for us. And I am not afraid of a spreadsheet. I do spreadsheets all day long, so it was a lot of fun for me. Slide 36 So, Im just going to break this up into three very simple pieces, the before, during and after. There are things that Im resourceful for doing before to make sure were ready for cohort as a team. The things I do during the actual cohort review, and the things I do to follow up to make sure that we clear out the issues from the cohort review we just finished and we prepare for the next one thats coming. So, before cohort, I am responsible for and I do prepare and distribute the list of cases for review, collecting the demographic information about each patient that is going to be reviewed that quarter, and prepopulating the spreadsheet with the data. And all of this is fairly easily accomplished by using our TB registry. We have PA NEDS which is the Pennsylvania version of the National Electronic Disease Surveillance System. And so, I simply go in and start pulling down information on each of the cases to start prepping for cohort. I also sit down with my staff during this time and we have practice sessions so that they can get comfortable with presenting their cases for the quarter, and also so that if there is any missing information that I dont know or that hasnt made it into the registry or into the chart yet that we can fill in that information and update everything so our systems are flowing nicely. Slide 37 OK. So, this right here is actually a screen shot of a line list and I have taken out actual patient names and put in some more familiar names for you. This is the spreadsheet that I generate when cohort review is coming and we go by our case ID. The patient names and all of the demographic information that I need to prep a presentation for the staff on basic characteristics, both demographic and medical of the cohort that were going to review. Slide 38 During cohort, this is kind of where the magic happens. At least thats how I feel about it. So, during cohort, we present information on the demographic and clinical characteristics of the cohort as a whole. The staff is responsible for each individual patient but I will present kind of summary data. While the staff is presenting, Im listening to each presentation and updating any information in the spreadsheet which I will show you momentarily that either has changed or maybe was incorrect before I actually got to cohort. At the same time, Im recording issues that arise. Issues like, you know, how a patient has not completed, why are they not complete yet, contacts that may not have been identified and the reasons why. Also, any policy programs, things that arise regarding treatment of patients, patients who leave out of jurisdiction or the country, what are we going to do to make sure that we know that they have completed therapy, things like that. I also calculate the rates for completion of therapy, contacts identified and their outcomes as well. Actually, the spreadsheet really does it for me because its been set up that way. And at the end, I report the results of the cohort. So, everything that everybody has told me has been entered into the spreadsheet, it has been calculated and then I give the staff the final report of how they did that cohort based on the information they have told me. So, I am the grader. Somebody mentioned that this is the report card and I am the grader. Im the one who takes all the information in and does other calculations and tells the staff weve done as a whole. And its very good because we have people who come in to our meetings such as our - the Director of the Division of Disease Control. Sometimes the Assistant Health Commissioner will come and other outside people who dont really get a day-to-day sense of what we do or would like to know how is TB being managed in the City of Philadelphia and by coming to cohort review they can walk away from the meeting knowing exactly what were doing as a program. Slide 39 So, here is a screen shot of the spreadsheet. This is my master task list. Everything that I need to know about each patient is entered into this spreadsheet. I tried to do as much before cohort as possible because when youre listening to the presentations and try and update it at the same time, you either have to have really fast fingers or have two brains. So, I try to get as much of this done as possible ahead of time by meeting with my staff, and thats why we have practice sessions, also so that our staff is comfortable with presenting. So, in the first couple of columns, you see where we will put in the patients name and their registry number. The middle columns are the clinical data and time measurements which is the blue area. We look at their DOT. Slide 40 And then the next part of the spreadsheet we give them a disposition. So, each person gets one X in one box. So, whether or not they completed, if theyre a cohort failure, if they are likely to complete, if theyre multi-drug resistant, if they were lost, if they died, moved were reported at death or if there are a non-count. And then the next set of boxes is regarding their contacts. So, how many were identified, how many were appropriate for evaluation, how many were actually evaluated and their outcomes if they were infected, if they had disease, if they were a suspect, if they started treatment, if they have completed, refused to start, or if theyre still on treatment or if they have died in the process. So, at the end of this you know exactly what has happened with each and every contact that has been identified and reported on. Slide 41 The third part of the spreadsheet is where we actually get all the data from those first two pages I showed you and the computer automatically calculates these numbers. So we get the number of cases that were counted and started and completed therapy and all of their outcomes with and rates. Slide 42 And this last part of the spreadsheet is where we actually report on the contacts. So, well take out the number of pulmonary cases. For Philadelphia, we dont report on contacts of extrapulmonary cases. It just saves us from time because our cohort runs for about three hours. So, we look at the number of pulmonary cases that had contacts identified, we calculate indices so a mean number of contacts per case. And then we go through all of the outcomes I talked about before if they were appropriate for evaluation, if they were evaluated, how many started treatment, how many were have completed treatment and how many have refused to complete treatment or refused to start. Slide 43 Alright, so the last piece is after cohort. So, after all of that work has been done in cohort and Ive reported to the staff, I also go back to my desk and I summarize the results of the cohort and I disseminate them to the team, so that everybody has an idea of how they did. I also begin the process of following up on the issues. I submit the issues list to our medical director, our program director, our CDC assignee and our disease surveillance supervisor. And then I say these are the issues we need to work on and we start meeting to make sure we are following up on making sure that things that we identified as problems in the previous cohort are followed up on and closed and that we avoid any major issues for the next cohort and at the same time Im preparing the list of cases that will be reviewed in the upcoming cohort. Slide 44 So, this works really well for Philadelphia because it is simple and straightforward. We have a lot on our plates here in general running a fairly large program. And so, doing this does not interrupt our daily program functions. Its actually kind of become part of what we do. The process is very easy to master. Like I said, I ran my first cohort review three months after I was hired. And it is buildable. Once you start you can build on your previous cohorts the processes running in place, and its just a matter of changing names, repopulating the spreadsheet and getting things ready for the next cohort review. Calculations can be done by hand if youre not Excel-savvy because in the guide for the cohort review, there are the equations for calculating all of these indices. I put it into Excel so I dont have to do it by hand. But if you need to if youre not really familiar with Excel, if youre not if it doesnt seem very friendly to you, it can be done by hand. Its adaptable to different program models. Weve taught it to different programs whose models are different from us, and they have, you know, implemented it in the way that is comfortable for them and they are still doing it. I actually speak with Florida from time to time and Baltimore and Washington, D.C. about their cohort review processes and they ask me questions and sometimes Ill provide technical support. And they have changed it on me but I still theyre still doing it and theyre sticking with the process. And I think the best part about cohort is that everybody leaves the meeting knowing exactly how we performed for that quarter. There are no questions. And it lets us know where we are and where we need to go. And that is all I have for you and I thank you guys for listening. Bill Bower: So thanks. Christina, thanks for sharing your experience with cohort reviews in Philadelphia. The way that youre there in the background of the cohort review, putting out the first line list of cases, helping people get ready and then capturing all that information on the spreadsheet to give people feedback on how to do it and how the program is doing is really important. And I have to say, the spirit of your team is infectious. Christina Dogbey: Thanks. Slide 45 Bill Bower: Our next presenter is Katie Sisk. She studied Nursing at Washington Hospital Center School of Nursing in D.C. and took advanced courses and certificates from the Association of Professionals in Infection Control and Epidemiology. Shes now a supervisory nurse coordinator at the District of Columbia Bureau of TB Control. And theres nobody who better exemplifies the activities of a public health nurse supervisor and case manager in cohort reviews. Katie? Katie Sisk: Thank you so much for the introduction, Bill. Im going to tying case management into the cohort review process. Slide 46 What I hope you get to take a way from my talk is how easily your daily work activities translate to the cohort review process. The four basic steps that will prepare you, that have been actually outlined by others and ways to achieve staff buy-in. Slide 47 The first things for us were to develop a cohort sheets and actually make them work for us. We borrowed from New York, Philadelphia, Washington we looked at those sheets and then adapted them towards us. You want to have clear, defined definition, so that no matter who is filling out the sheet, they understand exactly what youre looking for, this validity of your data and also since we do cohort by quarter, sometimes you need to just actually look back to refresh yourself as to what exactly are we looking for in this section of the cohort review form. And just to reinforce that, we dont find the cohort review process burdensome and that the information since I work with it daily, fill out the forms, help the nurses, it is readily available in everything that you have. Slide 48 We have four steps here in D.C. that we follow for cohort review preparation, the practice and review, the actual review and then our follow-up. Slide 49 For our preparation again is the collection of the patients, the notification which is very important that you give your staff adequate notification as to what quarter patients youre doing, when the practices will take place and what's expected of them at the practice and when the actual review time and location for the review will occur and then the preparation of the sheets. Slide 50 For the selection of the patients again, many of the other speakers talked, its really a program based on the programs needs. You can do number of patients, you can do months, you can incorporate any process that for selecting the patient that works for your program. Here in D.C., were currently doing cohort review four times a year. And then defining who is actually going to be responsible at the time of cohort to report on the patient. Because as you know, sometimes cases are moved based on maybe a staff members case load at that time, people go in and out for possibly medical reasons, so its important that everybody understands who will be responsible when cohort happens. Slide 51 For notification, I do it by email and currently we send out the next cohort review list two weeks after weve just had cohort. This gives a little over two months for the staff to prepare which is adequate time. And I find that doing by email everybody sees the list, understands, theres no misunderstanding as to whos responsible. Slide 52 This is an example of the email, its very basic. I just include when that cohort will be, what's to be expected, theyre to be in their chair, cellphones on mute and come prepared, when the practice will occur and I deleted the patients names for confidentiality for today but you can see we use case managers and TB investigators. Both will report during cohort on the work that theyve done. And then ask that if there is any discrepancy in this list that they notify me within 48 hours, without that we can review that and ensure that when cohort comes, everyone understands what theyre going to be doing. And then the date for the final review that I need the final sheets a week before cohort to pass on to the data entry person so as the speaker before me clarifies, they need time to prepopulate and to do as little changing of the data as possible during the cohort review. Slide 53 Since we all collect the same basic information, our processes might be different, but were all looking to gather the same basic information thats on the E-RVCT. So, we have that information at hand. What we try to do is begin completing the forms as the case comes in and Ill show you in a few minutes how thats easily done so that when the list comes out, your sheets are halfway complete already. And remember that most of the case information by the time cohort comes about has already been completed. The case may even be closed by then. And it does allow preparing the sheets for a final review, was something important missing. Is it important enough for us to go back and try to gather that information, find that person. Its a last review of the case. And I can tell by practical experience that it should take you no more than 10 minutes on a pulmonary case to complete the sheet, five minutes on an extrapulmonary. Slide 54 This is a snapshot of our definitions. The numbers will coordinate to the numbers that youll find on the cohort review sheet. To be honest, this is probably what we spent the most time on making those definitions clear to what we understood them to be, and so that all the staff understood them. So, most of the reluctance here was not to begin cohort just deciding on terms that we all understood and agreed upon. Slide 55 This is the top part of our cohort review sheet. You can see in Section one all of that information comes in basically on the case report form or during your interview. The second part again, you find much of this on the case report form or the only thing is the culture conversion, youll probably have a month out. The drug sensitivities, the chest x-ray information is found on our case report form. And then the final section of that is treatment start date. If they are coming from the hospital, most likely theyve already been started on treatment. The completion date, a case manager or whoever is managing the patient has that information readily at hand and since I know most programs do a monthly count, youre well aware of what DOT month the patients on and their percentage of completion. Slide 56 Our final section of our form concerns the contact. And remember, this is six to nine months after youve got the case. Your contact investigation has been complete. These are numbers that you would readily have available. And the final portion is the treatment of the contacts. Ill be honest, for us this generates the most work. Some patients have had issues dropped on treatment, dropped back off, come back on, weve lost them, weve found them, and also getting information that was sent out through jurisdictional. So, gathering that information, this is probably the most time-consuming portion for us. As you can see, we added a date and a signature line because now this document is entered into the patients medical record. It can be done because no confidentiality has been broken, there are no contact names and if ever I need a quick snapshot of what went on, this is readily available. We added the signature line because this is work that people have done and they are responsible for the work thats occurred. Slide 57 Our extrapulmonary sheet, again, you can see that this information you would have from your patient interview or the case report form and then this section, is again, easily found in the medical records either on the case report form or from the treatment thats occurred in your clinic. And again, just a signature and some notes on the form. Slide 58 Our cohort practice, you have to determine what practice sessions work for you. You want to conduct the practice sessions as you would in actual cohort review. We ask that we get copies of the sheet shortly before the practice, the two supervisors who will act as the medical reviewers so that we can begin to look over them to see any missing information, something that just doesnt look right. And we schedule our first practice three weeks before the actual cohort review occurs. Slide 59 The cohort practice, I normally call them and we ask that during the review this happens in the order of the notification. And the only reason that we ask this, it does decrease some of the anxiety because the staff know the order that the patients are going to be called on, they know when theyll be called to speak, they have their forms in order. So, it just actually helps with lessening any anxiety that is occurring. So we follow that practice in the cohort practice. Anything thats found missing during the first practice, the staff are given one week to make the changes and return the corrected sheets to us. Whether you actually have a second practice will be based on your need. If your case load is fairly straightforward and there werent a lot of issues you may determine that one practice is enough. If you have some cases that were quite complicated and had large contact investigations involved, you may decide that you need a second practice. We actually left it up to the staff at the end of the practice, do they feel they want another practice? After the second practice, the final sheets are given to me to forward to the data entry person to enter into the system. Again, none of this has to be done by a supervisor, it can be done by designated person. Slide 60 The actual review for us as youve seen on some of the other slides is a formal process. We dont allow food, drinks, cellphones are on mute. No paperwork other than the actual cohort review form. I do allow people to put notes on their forms since I have the final version thats going to go in the medical record, and they know from what's come up in the practice session, what is going to generate questions. And youll probably find this is less and less needed as you get past your second, third, and fourth cohort review. The thing to remember, once youve sat through one or two, you will readily see the difference that its not case management. It is actually a snapshot, a summation of the care thats been provided for this patient. We invite all our staff to the cohort review and all staff are allowed to participate in the discussion of the data. And that goes from our registration clerks to the registry to the investigators anyone thats been involved and then anyone from outside thats been invited. Slide 61 For the aftermath, what we do is we post our data in our main hall so that we can all see it. You want to definitely post your success and this also lets people know where we need to go. You want to clear up any missing information. Did we were we missing a death certificate when they asked for it? Was there a certain piece of information concerning a patient that the medical reviewer asked that we didnt have? And then based on the outcome of your data from the cohort review, you can select the indicators that your program needs to improve upon, select the actions, come to an agreement as to what actions are going to be taken and then how are you going to evaluate these actions. And then, after you get your evaluation maybe three to six months later, are we improving, then you can select new indicators. But basically after this, we begin the prep, as I said, I send out the notification two weeks after the preceding cohort review. So, we begin again. Slide 42 As far as selling cohort review, Ive sat through many nurse meetings and in Atlanta and New Jersey where people werent necessarily too positive, maybe fearful about moving to cohort review, Ive always felt that this was the way to go, that its going to give you documented evidence of how youre doing. It could actually be a positive force within your program, it does help organize charting, it does make people more responsible. So, you need to select those people in your program that can be your cohort champions that understand this is the direction you want to move in and then for lack of a better word, help drag everybody else along. You want to involve all of your staff in the training. We did. Everybody in the building was involved. That way, everybody understood how they fit into the cohort process, how that translated to improving care for our patients. And again, its always better to hear about the highlights and the benefits rather than to think this is more added work. And I think Ive demonstrated that it really is not more added work. Just remember that there are a few people that dont like change and change is what's coming, we have to move with it and I think after theyve moved through the process through one or two cohorts, youll see that it is really what's in the future for us. Thank you. Slide 63 Bill Bower: And thats the end. Katie, thanks you very much for sharing your perspective as a supervisor and case manager in this process. You actually made it seem sort of pretty natural and easy to build cohort reviews into the routine of TB care and case management. Even though you did point out that theres challenges. Slide 64 I want to move on a little bit forward, because now, youve heard from all sorts of people just like you who are already doing cohort reviews and I imagine that youre building up questions especially about how youre going to get started. Slide 65 So, in fact, what should be your first steps in planning? And I want you to know that there really are a lot of tools that help you along the way. For one thing, there is this section, pages 53 to 57 in the instruction guide. And I think that its important because it helps give points as youve heard from other speakers, like Katie and Christina and Kim and Dr. Wang about how to get people on board, how to help them realize that this doesnt have to be overwhelming because in fact, the presentations using those forms can be pretty short. And in fact, theyre just summarizing the work that youve already done. When it comes to modifying the elements of the cohort review process, right now youve got samples of the forms that you can get from any of the programs that are doing it already. And I believe that the TB program PEN, the Program Evaluators Network is also keeping a list of all the tools that are available. You may want to make the forms shorter or add different fields, different areas that your program wants to concentrate on. In fact, some programs will kind of take a glimpse at their NTIP indicators or how theyve done in the past and say, these are areas we are weak, so lets really make sure we collect information on those areas. Slide 66 There are also some specific exercises that are inside the instruction guide. One of them is this self-assessment exercise. It can help you to identify aspects of your program that may be going just fine or that may need to be enhanced in order to conduct a cohort review. So, you may see that youve got good case management, youve got clear objectives and a functioning registry, so you can just check those off. Those are OK. But then you might find errors like, Hmmm, how are we going to plan to give feedback? Who will do that function? How will we get that done? Or how are we going to plan systematic follow-up afterwards? So maybe those are areas that youll have to give a little bit more thought to. And this exercise kind of helps you see where you stand and where youll need to work on most. Slide 67 In fact, there are seven different exercises that are in that guide. Theres one about making sure youve got clear objectives for your program, making sure your case management protocols are clear, and then the forms and using those forms to practice review of cases. There are a couple of exercises for that. And points six and seven here are exercises in which you use youll see what the formulas are, and youll learn about the calculations of the rates for treatment of completion or the indices for the contacts that have been identified, that have been evaluated, started and completed treatment. So, there are exercises in planning how youll calculate that and especially the person doing the activities of a data analyst or epidemiologist would find those useful. Slide 68 Ive also provided an implementation handout. This is the second page of it. and you see there are a sort of a series of actions or decisions that you need to do, and you can plan who will do it, when and track it. And this, I think, can be useful in kind of giving you a road map to get started doing cohort review. Slide 69 Lastly, we do have to think of people. Who are the people who are going to be involved? What skills do they have? You will actually have to delegate different tasks to different people. What activities do you need help with? You may need to find support or substitute resources from one part of your program or another part of your health department. Then, as leaders in your programs, youve got to figure out how are you going to get everybody on board, oriented, and motivated to do cohort reviews. I think that youve heard a lot of examples from all of the speakers about doing that. The thing is that people who are doing it routinely sometimes just think, Well OK, this is how we do it. And I think we sometimes forget that at some point we hadnt done it yet, and we may have thought that there were more obstacles. But in fact, this really is doable. Call us, email us, well be glad to give advice and help on that. Now, in addition there is a wider group of case managers, probably across your area, who at a minimum, will need some basic training and what's expected of them, whats in it for them and why its good for TB control, and in a practical way, theyll need to know how to use the form that you have chosen for a case presentation. So, for that you really will probably have to tailor some specific training for your programs cohort review approach in order to get those people up to speed and contributing in the way that you wish. Slide 70 By now, I know you probably have more than a few questions. And Id like to invite you to ask questions so please call in. I guess Ill sort of jump ahead and answer a question that some people have asked me before. Should they start full speed doing everything, or should they start small? And in fact, Ive seen many different ways in which programs start small just to figure out, you know, how they want to do things and how they can get it done. I know some states have sort of started in the rural areas and then they have moved to the big cities or the higher incidence areas later. But I do know some programs that decided to start in a few key cities or counties with more cases and then later roll out a state level effort. Sometimes, Ive seen programs that just started out looking only a treatment completion, and once they got a handle on that, then looking more at contacts and other aspects. Another way to do it would be to look at your national indicators from last year and just pick some areas that you think you may not be as strong in. And get started looking at those based upon the information that you collect case by case. Kim Field: Bill, this is Kim Field. Just to add on to what youre saying, Im preparing on working with the regional center in San Francisco and I have some assignments to follow up how different people are doing in the Western region, and I know Dr. Alvarez from Los Angeles County wouldn't mind me sharing that you can think of Los Angeles County as almost likely a country for some of us. And I think he thoughtfully went to your courses back east and brought it back to his staff. And theyre just taking one pilot in one health department in Los Angeles County working with that group implementing it there. And then if you will, that will be a core group that can sell it and do the training and education of others, and I think thats a great example of, you know, not tackling it all at once and maybe not being able to have control or resources. And again, another example of San Diego County, Dr. Kathy Moser there, the medical director, they do exactly as youre saying. She said, Oh, we dont do cohort. And I said, Well, what do you do? And they choose certain elements of whether its contacts, outcomes or theyre now looking at their screening, the impact of their screening across the B1/B2 to preventable cases in relation to a cohort time. So, I said, Well, thats cohort. You know, you start where you want to start and then build upon that. I think its very important for people to realize that. Bill Bower: OK, thanks. We have a couple of questions that have come in via the Web. One of them is Is the cohort a review of all TB cases within a certain timeframe? And I guess Ill jump and answer this one first. The answer is yes it is, usually, its within a three month period, the case is identified then and you let six months go by so that theyve got time to complete treatment and then you do the review. The recent guidance from CDC now allows programs to have a smaller number of cases to do this every six months instead of every quarter. So, let me jump to the second question and this one can go to any of our panel here. Can you comment on how long it took to develop or implement cohort review in your area? Any of the panelists? Kim Field: Well, Ill just start again, Kim. It took us a year but it only took us a year because I think we didnt have the wonderful, you know, panel of people that we just heard from here today that were already engaged in and had worked through the processes and we have a small program of 7.7 employees are at state level. But I contend as some of the other panel as you train, it doesnt take that long. And you heard the wonderful experience of Philadelphia and the epi. You can learn from therapy processes that are there and implement it much sooner than that. Bill Bower: OK. Other panelists? How long did it take you to actually do this? Katie Sisk: Bill, this is Katie in D.C. Our program manager and our outreach supervisor traveled to two locations that were doing cohort review. We came back, we had a formal training and three months later we were running cohort review. During that three month period, we refined the sheets, made them the way we wanted to and then from the time we held the training to our first review was three months. Shu Wang: This is Dr. Wang. I just wanted to say we started the program with really focusing on case review and management initially, so it took us maybe about two years. We did send our nurse supervisor for both the DOT and the clinic to New Jersey for the cohort review program. And then maybe about a year after that, we began formal cohort review, but we had to build the foundation initially. And I think we did it step by step. So, I would say maybe two to three year total to get it to where we are now. Bill Bower: Thank you. Christina? Christina Dogbey: It took Philadelphia about four years to really get it started but by around the end of 2004 beginning 2005, it was really starting to take off and I think it was because of staffing changes. They wrote a couple of grants, hired and epidemiologist, hi, and got it going. I actually came in while Philadelphia was already doing cohort review. So, for me, as I guess, personally speaking, it only took me a couple of months to really get my head around it. Bill Bower: Sure, I do remember six months after you came to course in New York, Philadelphia was doing it. So, I put you down in the six month category. Ive got another question that came in over the Web here. Are there any additional guidelines suggested for setting up cohort review process that includes HIV status? Bill Bower: I would like to say, all of you saw that spreadsheet that Christina showed. Its easy to put a column in that spreadsheet that is HIV status. And I know thats one way in which its just included as a routine part of things. Do any of the other panelists have any comments on how thats included in their cohort reviews? Kim Field: I just want to say in Washington that that was one of the single most things that improved statewide after cohort was the number of individuals being screened and having results. Bill Bower: So, you included in the basic form that people need for presentations, so therefore they know its expected and then its just it folds right in. OK. Shu Wang: Yes, and this is Dr. Wang. I agree with Kim. I think we do account for HIV status, but because we invite people from all sectors to our meetings we have actually and we use only the initials, we dont usually say the name of the client. We do have a list for the main people reviewing that matches the names. But then during the presentation process, we simply say special therapy yes or no and that indicates HIV yes or now. So, were not saying it but we are documenting and accounting for the HIV status of the client. Katie Sisk: And this is Katie in D.C. We account for the HIV status on the form and the dates and the result is in the section one of our form. And we too use an initial and ending case number for our actual cohort review. Bill Bower: Thank you very much. Another question came in one the Web here. Wouldn't it be easier to do the review after the clients contact completed their LTBI treatment? What do you guys think of that? Kim Field: Again, raising the review of contacts and putting them at the highest priority of your case, improves upon the timeline. Were looking at standards with timelines that the individual yes has received the case report, you begin working with the case, you begin the interviewing, you begin the contact investigation. You could individualize this and this has been a discussion between Seattle who has half of our cases in our state at any one time. We had 237 last year. About extending the period of time of reporting contacts for completion, but you know, my philosophy on this is that if were truly looking to improve upon standards that we keep it within whatever recommended measurements that is agreed upon within your location. Bill Bower: This is Bill. Im going to jump in on this one. Lets say your cohort is the first three months of the year, the first quarter. So, if you let six months go by after that, then youre looking at maybe September or October to do your cohort review and I think at that point, all of the cases would have had six months or more in which they could have completed their treatment but still have say, three to six months before you hit that one year period in which the goal is to complete treatment within less than 365 days. And I really think that if the focus of this has to be on cases with TB disease because you still have time to interrupt the cycle of transmission if youve done your treatment correctly. And I think that if you were to wait until a nine month period of latent TB infection treatment was completed, that would really, really mean youre doing your cohort review sometimes even more than a year after cases were identified. Its too far removed. I really would argue that we keep the primary group as being the cases with TB disease and most of the programs I work with will follow up those patients on LTBI treatment six months after the last cohort review, they will kind of do a summary of how many of them completed. So, its not like you forget them. You do follow-up and six months after cohort review you check on the patients who are on LTBI treatment. But you cant make them be your time-limiting group. The last question that we have here is Who does the contact investigation? Support staff, clerk, or medical staff, or nurses? So, let me throw that out to our panel. Katie Sisk: I can speak to it in D.C. W have case managers and investigators. They actually work together. But the primary function of going out and finding the contacts, testing them, getting them into the clinic are the investigators, but again, the case manager is going to be ultimately responsible for what happens to the contacts. And by having them both present at cohort review, it does directly share that responsibility so that everybody knows that the work must be done and they will be held accountable. But thats what works for us. There are times when the case is solely managed by the case manager. It just depends. Bill Bower: Anyone else? Kim Field: I would just underscore what was just stated there in that and Seattle was a great example. They did a pilot a year ago with CDC on looking at their format. And where they moved and changed within a year as was just stated here is that yes, the case managers presenting the case but the disease investigator, the person thats really working out in the field on the contact investigation is sitting at the table reporting too, and just an emotional thing that occurred who was their medical director here in the last couple of years where they were out on a long-term medical leave. And the very first cohort that they attended, the M.D. was so proud to look at his staff and said even in his absence the work went on and they worked as a team to accomplish it. So, I think it does underscore that you can have within your resources various staff doing it, but you will certainly strengthen it by having all people reporting on what their actual work was. Bill Bower: Thats a very good point. Regardless of what level of staff are doing the action, you need to be working as team and reporting and analyzing it together. That sounds good. I want to really give my sincere thanks to the faculty for sharing their knowledge and experience with all of us. I think its really been a thrill. Thank you very much for your participation. This concludes the conference. 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