The Managerial Role In TB Interviewing and Large Scale Contact Investigations Eileen Napolitano for Mark Wolman NJ Medical School Global Tuberculosis Institute December 8, 2009

Managing Program Activities Is the activity being carried out? How well is it done? What are the outcomes? How do they compare with national, state and local TB Program objectives?

Background - 1 Year Cases reported Sputum smear positive Contacts identified Evaluation Indices Objective Contacts per case Cases w/ no contacts 9%8% 7%8% Contacts evaluated % Contacts not evaluated Contacts w/ disease 1% Contacts w/ LTBI 24%22%26% 25%24% Started treatment for LTBI 69%70%72%73%71%69% Completed treatment 56%60%59% 61%63%85%

Background - 2 CDC estimates on average 15 contacts identified for every verified pulmonary/laryngeal TB case in the U.S. –25-30% are infected with TB –1% of identified contacts are diagnosed with disease –10% of newly infected (immunocompetent) contacts will develop TB disease Incidence of TB disease among close contacts is 700/100,000 –For every 1000 contacts identified and evaluated approximately 7 cases are diagnosed with TB CDC, 2000

In a recent CDC national study of 1080 smear positive pulmonary TB patients interviewers failed to identify –contacts for 8% of TB patients –non-household contacts for 33% of patients –work contacts for 89% of employed patients Marks, et al, 2000 Background - 3

Background - 4 CDC findings indicate the need for improved skills among interviewers for the purpose of identifying all high, medium and low priority contacts to reported TB suspects and cases.

All TB cases began as TB contacts

Just Two Examples Why Quality Contact Investigations Are Important….. 43% of infants aged 0-1 develop TB disease within 1 year of exposure and infection –25% of these pediatric cases are extra-pulmonary 66% are diagnosed with lymph node TB 6% are diagnosed with miliary TB Of those infants who are identified as a contact to a known infectious or potentially infectious TB case 10% who are TST negative develop TB disease

Core Activity Contact Investigation is a core activity in a TB Control Program: –TB interview is critical to the contact investigation –Quality of interview skills have a direct impact on contact investigation outcomes –Essential that all designated TB staff are trained in the skills of interviewing

Interviewer Knows what questions to ask patient? Knows how to ask questions to patient? Potential Number contacts Identified? Poorly trained with little experience Not really….Moot point/ doesn’t even know what to ask None… maybe 1? Partially trained with some experience Kind of….Sort of….Probably 1-3 Properly trained with experience Yes Maximum

Role Of Program Manager - 1 Program Managers should implement quality assurance practices for contact and source case investigations for the purpose of: –Monitoring the overall effectiveness of the interview process –Identifying staff training needs on the methods of effective interviewing –Developing, evaluating and improving the skills of both the experienced and inexperienced interviewers

Role Of Program Manager - 2 Program Managers should provide appropriate training and on-going evaluation for all program staff conducting TB interviews –Education CDC Self-Study Modules on Tuberculosis Familiarity with local health department program policies –patients to be interviewed –time frames for interview initiation and completion –documentation Effective TB interviewing training course

–Training Shadowing –Observing Modeling –Simulating Role-Playing –Practicing –Offer environments and opportunities for: Demonstration of various patient scenarios and techniques of interviewing Time for questions and discussion Role Of Program Manager - 3

–Bridging the Gap between novice and competent interviewer TB Control staff member conducts actual interview with Program Manager present Program Manager should intervene only if interviewer: –loses train of thought or becomes distracted –loses focus –becomes intimidated –omits important tasks –exhibits poor interpersonal skills –provides inaccurate information Role Of Program Manager - 4

Quality Assurance Quality assurance is accomplished through the development and proper use of an assessment instrument which will ideally –Help improve interview skills –Assist in the process of staff development –Ensure a thorough evaluation Assessment is conducted through observation of the interview and review of contact investigation activities –Should be completed periodically for all TB interviewers regardless of experience

Assessment Process Elements –Specific tasks the interviewer is expected to complete during the interview Skills Elements –Communication techniques, problem solving and analytical skills the interviewer demonstrates during the interview

Observation and Assessment - 1 Process elements Medical record review Developing infectious period Planning interview strategies Providing TB education Identifying contacts Collecting contact information

Observation and Assessment - 2 Skills –Basics of Effective Communication Promoting dialogue with index patient Providing encouragement Awareness of body language –Problem Solving Ability Identify verbal and non-verbal problem indicators Addressing potential barriers to adherence

Observation and Assessment - 3 –Analytical Skills Revise infectious period (If necessary) Distinguish between high, medium and low priority contacts –Developing investigation plan and strategies based on information collected Expanding investigation

Components Of The TB Interview The five components of the TB interview include –Pre-interview –Introduction –Information and Education exchange –Contact identification –Conclusion

Pre-interview Activities –Review medical record –Establish preliminary infectious period –Develop an interview strategy –Arrange interview time and place Introduction –Introduce self –Explain purpose of the interview –Ensure confidentiality TB Interview Structure – 1

TB Interview Structure - 2 Information and Education Exchange –Observe patient physical and mental behavior and evaluate communication skills –Collect and verify personal and medical information –Assess disease comprehension and provide education –Discuss basis of patient’s current diagnosis –Discuss disease intervention behaviors –If needed refine infectious period and review with patient

TB Interview Structure - 3 Contact Identification –Focus on infectious period –Explain high-priority (close) and low-priority (casual) contact –Stress importance of identification of all high priority contacts –Collect information on contacts in the household and all congregate settings during the infectious period –Discuss site visits and sharing of information on a need-to-know basis reinforce confidentiality –Discuss referral process

TB Interview Structure - 4 Conclusion –Answer questions –Review and reinforce adherence plan –Restate next appointment (if known) –Arrange re-interview and home visit –Leave name and phone number –Thank patient and close interview

Interview Process And Skills Evaluation Form

Program Manager Recommendations Facilitates discussion and provides an environment for –Encouraging the interviewer’s comments –Reviewing the evaluation form noting both strengths and areas needing improvement –Offering specific techniques of interviewing –Establishing a mutually agreed upon plan for improvement (if needed) –Providing a copy of the evaluation form to the staff member

Contact Investigation Outcomes – Your Data Year Cases reported Sputum smear positive Contacts identified Evaluation Indices Objective Contacts per case Cases w/ no contacts 7%8% Contacts evaluated % Contacts not evaluated Contacts w/ disease 1% Contacts w/ LTBI 26%25%24% Started treatment for LTBI 73%71%69% Completed treatment 59%61%63%85%

Congregate Setting Investigations Require more sophisticated skills –Technical expertise in infectiousness and transmission –Skill and professionalism in dealing with site management TB Program Managers should periodically review and assess the quality of congregate setting investigations within their program area for: –Appropriateness –Effectiveness –Professionalism

Some of the more common congregate setting investigation sites… Childcare and pre-school centers Correctional facilities Houses of worship Hospitals and other health care facilities Schools Shelters Workplaces

An evaluation of congregate setting investigations will enable you to: –Assess performance of both new and existing staff –Identify and address problems associated with congregate setting investigations –Identify training needs –Review and analyze outcomes Evaluation

Need for On-site Assessment If sufficient program resources are available, the Program Manager should ensure the on-site assessment of the congregate setting be initiated if the index case is diagnosed with suspected or confirmed respiratory TB and presents with –Smear positive respiratory specimen and/or –Cavitary disease with cough or laryngitis Current CDC guidelines recommend that all potential settings for transmission should be visited within 5 business days of initiating the contact investigation or upon identification of setting

Communication is Essential Patient – the need to conduct congregate setting investigation Management – TB exposure and provision of TB education –Should be done in person –Importance of confidentiality Individuals exposed –Inform about TB exposure, transmission and treatment –Educate about the need for testing and evaluation –To reduce anxiety for those identified as contacts

On-Site Assessment of Congregate Setting Determine potential for exposure and transmission –Assessment ideally should include accurate and detailed drawings and or photographs with emphasis on: Room design(s) Room size(s) in sq. feet Ceiling height Type of ventilation Proximity of individuals in relation to index case

Restaurant Kitchen Area – Hand Drawing

Coat Manufacturer - Camera

Daycare Center - Diagram

Determining When To Expand A Contact Investigation Program Manager needs to consider the following factors for consideration of expansion: Extent of recent transmission in identified contacts –Unexpected high rate of (+)TST results or –Evidence of secondary cases or –Transmission to contacts <5 years of age or –Documented TST conversions or –Change in TST status from negative to positive In absence of recent transmission investigations should not be expanded

Problems and Challenges Depending on the setting the following can be associated with large-scale contact investigations –Potential for a large number of identified contacts –Potential for vague information for determining contact priorities –Potential for incomplete identity and locating information –Challenges in maintaining patient confidentiality –Collaboration with officials and administrators who are unfamiliar with TB –Media coverage

Skills & Performance Evaluation

Skills & Performance Evaluation Cont’d

Outcomes Evaluation Form

Sample Summary Form

Sample Summary Form Cont’d

Resources Performance Guidelines for Contact Investigation: The TB Interview Tuberculosis Contact Investigation in Congregate Settings: A Resource for Evaluation CDC Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis