Initiating the Cohort Review Process in Los Angeles County Los Angeles County Tuberculosis Control Program April King-Todd, R.N., B.S.N, M.P.H Nurse Manager Los Angeles County Tuberculosis Control Program

Critical Stakeholders Internal –SPA Medical Staff (AHO, AMD, Chest MDs, etc.) –SPA Nursing Staff (Nurse Managers, PHNSs, PHNs, Clinic staff and CWs, etc.) –SPA Administrative Staff (Assist. S.A., F.A, Clerical, etc.) –TB Control Staff (APS, STC, PS) –CHS and Program Administration –Dr. Jonathan Fielding-Director, LAC DPH External: –CA State TB Branch –CDC –Patients 2

Reasons for Implementation CDC Cooperative Agreement requirement Evidence-based methodology to improve case management Quality assurance tool to conduct program evaluation Improve documentation

4 Description Cohort Review vs. TB Case Review Integrated (TBCP & CHS) team approach Retrospective review of All TB cases and their contacts initiated during a quarter Monitors group of patients’ progress toward treatment outcomes Identifies system (process), patient care and programmatic issues Outcome data PHN, PHNS, or MD Real time ongoing review of specific patient management Monitors individual patient progress and treatment Identifies patient clinical care issues as part of the case management process

Los Angeles County (LAC) Cohort Review Model “Face-to-Face” The LAC cohort review process is unique: – Inclusion of TB suspects pending confirmation/closure – Planned use of electronic TRIMS auto-populated case presentation/Contact Inv. forms 5

TBCP Staff Role & Responsibilities (1) Title TBCP Physician Cohort Review Presentation 1.Attend in person or via teleconference 2.Ask questions of clarification, makes suggestions 3.Review clinical practice based on current/updated policies, standardized practice TB Health Center APS, PHN Co-Coordinator and instructor Preparation 1.Provide technical assistance/guidance to CHS staff 2.Provide preliminary Cohort Review line lists (open TB Suspects & TB Cases) four weeks prior to cohort review session 3.Provide Final Cohort Review line lists to TB Chest MD, PHNS, business office manager two weeks prior to review date 4.Coordinate cohort review preparation, presentation and follow-up with the assigned CHS PHNS (coordinator/documentation of issues identified during cohort review session) 5.Assist and coordinate with TBCP NM and PS on ‘Cohort Review Process’ and ‘Case management’ trainings Continued on next page 7

TBCP Staff Role & Responsibilities (2) 8 Title Cont’d TB Health Center APS, PHN Co- Coordinator and instructor Cohort review presentation 1.Attends and Asks questions of clarification Follow-up after cohort review 1.Tracks education, programmatic and clinical issues needing follow up 2.Ensure that ongoing, follow -up staff education incorporates program strengths and weaknesses

TBCP Staff Role & Responsibilities (3) Title Epidemiologist/ Data Analyst Preparation: 1. Reviews the final Cohort Line List for the quarter 2. Prepare spreadsheet for cohort data collection 3. Provide SPA/Health Center NTIP performance data 4. Prepares Cohort overall statistics (e.g. demographic information, site of disease, bacteriology, radiology, drugs, DOT, status of treatment completion, contact investigation results, etc.) Cohort review Presentation 1. Presents preliminary Cohort overall statistics and the data summaries for the previous cohort quarter reviewed, if indicated Continued on next page

TBCP Staff Role & Responsibilities (4) Title Epidemiologist/ Data Analyst 2.Updates and analyzes cohort data and provides immediate feedback to SPAs on how they ‘re doing in relation to program objectives 3. Provides (3) Summary Reports Variables Indices/Rate for Treatment of TB Cases Contact Investigation Data from Cohort Review Follow up after the cohort review 1.Compiles summary report with CR outcomes and provides the report to designated health center staff 2.Provides a list of data issues that require follow-up actions to designated health center staff

TBCP Staff Role & Responsibilities (5) Title TBCP Nurse Manager (NM) and Program Specialist, PHN 1.Develop LAC TB Cohort Review Instructional Guide with CR tools, for Cohort Review team. 2.Develop curriculum for ‘TB Cohort Review Process’ and ‘Case Management’ and provide training for entire Cohort Review team 3.Provide technical support to TBCP H.C. APSs and data analyst 4.Assist H.C. APSs in coordinating cohort review preparation, presentation, and follow-up with CHS staff

CHS Staff Role & Responsibilities (1) Title Area Medical Director (AMD)-/Nurse Manager (NM) Has the list of TB cases and calls them to be reviewed May group the cases to allow some essential staff to leave before the end of the session. Preparation: 1. Ensures staff at all levels understand the cohort review process, has the knowledge and skills to perform this task and ensures the attendance of Health Center TB Team Cohort review presentation 1. Facilitates the introduction of on-site participants and any call-in participants. 2. States the “Ground Rules” before Cohort Review begins. 3. Listen to all case presentations 4. Ask questions of clarification to ensure all aspects of case management adhere to the department of public health policies and procedures 5. Use teachable moments to illustrate important lessons in effective TB control. Follow Up after cohort review presentations 1. Ensure medical management and other issues are addressed 2. Address programmatic concerns and concerns about modifying staff training or orientation to better meet the needs for staff to learn what they need to do the job 3. Submits TB case summary to Director of CHS and TBCP evaluation coordinator. 12

CHS Staff Role & Responsibilities (2) Title Chest MD/ (Medical reviewer) Preparation 1. Ensures the attendance of Health Center TB Team 2. Review the Cohort Review line list /medical records prior to cohort review presentation date. Cohort review presentation 1. Listens to all case presentations and review support documentation (e.g., medical records, TRIMS), and ask questions for clarification about each case, prompt for details of staff efforts: likelihood of completing treatment in 12 months (e.g., status of pursuit of patients lost) 2. Provide feedback and suggestions on how to follow up patients and their contacts. Ensures all aspects of case management adhere to DPH policies and procedures are followed including but not limited to the following: Continued on next page 13

CHS Staff Role & Responsibilities (3) Title a.Drug regimen is appropriate per drug susceptibility results b.Sputum conversion documented c.Contact investigation outcomes are assessed d.Adherence issues, home isolation issues addressed 3.Use teachable moments to illustrate important lessons in effective TB case management. Follow Up after cohort review presentations 1.Address any medical management issues identified 2.Ensure ongoing staff education 14

CHS Staff Role & Responsibilities (4) 15 Title Public Health Nurse Supervisor (PHNS)/ Coordinator & Documents issues identified during cohort review session Preparation: 1. Supervise and assist PHN staff in following case management protocols. 2. Hold one-on-one case review meetings with PHNs per LAC PHN practice manual. 3. Conduct periodic conference meetings with entire team if necessary. 4. Review the final Cohort Review line list 5. Ensure PHN case presentation will be concise and according to standardized format. 6. Review the case presentation /contact investigation forms that each DPHN have prepared to ensure that all information is complete 7. Coordinate cohort review preparation, presentation, and follow-up with the assigned H.C. APS

CHS Staff Role & Responsibilities (5) 16 Title (Cont’d) 8. PHNS ( assigned CHS coordinator) receives 6 copies of the forms on each case and sorts them by the order on the final cohort review lists. Each set of the copies will be provided to AMD, Chest MD, NM(s), PHNS, and TBCP Controller/MD, TBCP Epidemiologist on the day of the cohort review presentation. Cohort review presentation 1.Attend with staff 2.Allow PHN to present 3.Determine any training issues, needs for PHN staff and communicate this to TBC APS Follow up after cohort review 1.Ensure PHN follows up on case management suggestions (making sure that patients and contacts finish their treatment), and complete any missing information and clarifies details and information as identified during the cohort review 2.Meet with PHNs and provide feedback for future presentations

CHS Staff Role & Responsibilities (6) 17 Title Case Manager (District Public Health Nurse) Preparation: 1. Participates in case review meetings with PHNS and case conferences with clinic TB team. 2. Follow all protocols for PHN case management and contact investigation. 3. Communicates periodically with community workers and clinic staff for issues affecting patient adherence. 4. Prints case presentation form from TRIMS for cases to be presented 5. Updates any missing info prior to cohort review presentation and provides updates at the meeting. 6. Prepares self for cohort review presentation(s) 7. At least 2 days prior to scheduled cohort review presentation date, makes 6 copies of the completed case presentation forms and gives them to his/her supervisor to provide them to assigned PHNS (coordinator). Continued on next page

CHS Staff Role & Responsibilities (7) 18 Title (Cont’d) Cohort Review Presentation 1. Delivers concise presentation using case presentation form, answer any questions from the team members, and ask questions related to patient care contact investigation issues to brainstorm with fellow collaborative team. Follow up after the cohort review 1. Follow up on case management suggestions (making sure that patients and contacts finish their treatment. 2. Obtain any missing information identified during the cohort review. 3. Meet with supervisor for feedback to enhance preparation for the next cohort review, continue case management. Report to PHNS and/or TB Chest MD, updates case/contact information in TRIMS.

CHS Staff Role & Responsibilities (8) 19 Title Supervising Clinic Nurse I or designee Preparation 1. Participates in case conferences with clinic TB team 2. Communicates periodically with DPHN, and clinic staff for issues affecting patient adherence. Cohort Review Presentation 1. Attend and provide additional information as requested 2. Follow up on clinic issues Community Workers (CWs) Preparation 1. Participates in case conferences with clinic TB team 2. Communicates periodically with DPHN, and clinic staff for issues affecting patient adherence. Cohort review Presentation 1. Attend for assigned cases and provide additional information as needed

CHS Staff Role & Responsibilities (9) 20 Title Supervising Public Health Investigators (SPHI) or designee Preparation 1. Participates in case conferences with clinic TB team Cohort review Presentation 1. Attend and provide additional information as needed Business Office staff Preparation 1. Pull patient charts from Cohort Review line list and delivers them to TB Chest MD a week prior to the review date

Core Elements for Cohort Review Cohort Review Process 21 Preparation Presentation Follow-Up

Preparation Comprehensive case management Reliable TB registry TB Indicators Collecting/entering info in TRIMS on cases for presentation Standardized format 22

CategoryIndicator 2015 National Objective National Average LAC Baseline 1 Completion of Treatment Percent of patients with newly diagnosed TB for whom 12 months or less of treatment is indicated, who complete treatment within 12 months. 93.0% 71.7%76.5% 3 Contact Investigation Aggregate Reports for Tuberculosis Program Evaluation – Contact Investigations Contact Elicitation Percent of newly diagnosed TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited %92.2%*92.2% Contact Evaluation Percent of contacts to sputum AFB smear- positive TB patients who are evaluated for infection and disease. 93.0%80.4%*99.5% Treatment Initiation Percent of contacts to sputum AFB smear- positive TB patients with newly diagnosed latent TB infection (LTBI) who start treatment. 88.0%70.5%*55.8% Treatment Completion Percent of contacts to sputum AFB smear- positive TB patients who have started treatment for the newly diagnosed LTBI, who complete treatment. 79.0%63.3%*51.1% Selected TB Indicators and Performance Targets

Sample Preliminary Cohort List for TB Cases (______Quarter) DP #LnFnD_BirthChartSuptHIV DO T Prim DiseaseCavitary Smea rCult. D_ Initiate d D_ Confirm ed Rx_Star tRx_ Comp Closure Rsn Census Tract 7XXXXX L X/XX/XXXXXXXX PMD 11YPO X/XX/ XXXX X/XX/ XXXX X/XX/ XXXX XX/X/ XXXX comp. tx XXXXX S X/XX/XXXXXXXX Public 11YNEPO X/XX/ XXXX XX/X/ XXXX X/X/ XXXX XX/XX/XX XX comp. tx XXXXX J X/XX/XXXXXXXX Public 11YPO X/X/ XXXX X/XX/ XXXX X/X/ XXXX XXXXX G X/XX/XXXXXXXX PMD 01 PO X/XX/ XXXX X/XX/ XXXX X/XX/ XXXX died2402

Sample Final Cohort List for TB Cases (______Quarter) 25

LAC Case Presentation Form 26

Contact Evaluation Summary 27

Prior to Cohort Review Presentation The PHN Supervisor reviews the forms that each DPHN has prepared to ensure that all of the information provided is complete 2 days prior to scheduled cohort review presentation date, DPHN makes 6 copies of the completed forms on each case DPHN gives 5 copies to assigned PHNS coordinator who sorts them by the order on the final cohort review list 28

Presentation TBCP Epidemiologist presents preliminary summaries for the cohort being reviewed during the session, and the data summaries for the previous cohort quarter reviewed, if indicated. Detailed Review of Each Case 29

Presentation The AMD/NM chairs the cohort review meeting. The PHN presents the patient case data and contact information using a standardized form to the Cohort Review team. The AMD and/or chest MD asks questions for clarification, prompts for details of staff efforts to solve problems (e.g. trace patients who are lost), and provides feedback and suggestions on how to follow up on the cases and their contacts. 30

Presentation Clinical staff involved in managing the cases can provide additional information as needed. As each PHN describes the case details, the TBCP epidemiologist tallies the data elements needed to evaluate the objectives. PHNS(designated documentation coordinator) will document issues, feedback, suggestions on how to follow up on the patients and their contacts in a standardized manner. 31

LAC Cohort Review Meeting Agenda 32

LAC Cohort Review Meeting Participant Ground Rules Begin and end on time Remain quiet during the case presentation Turn cell phones on vibrate -if you need to answer please go out of the room Listen to and Respect Others Provide positive and constructive feedback Right to disagree but not offensively 33

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Measurable improvement on LAC TB performance through countywide implementation of the cohort process

Treatment Outcomes LAC

COT by Provider Type LAC

st quarter Cohort Summary of Cohort

41 TALLY SHEET Date Quarter Cases CountedJanuary 1 to March 31, 2010 TB InformationDOTDISPOSITIONCONTACT Comments LnDp_NoSm+Cult+PulmCavCXR Dot_ ' abcdefgh i jk#IDApp Test#Eval#Inf#Tx LTBI#Comp#Curr BA BE BR CA CL DE GA HE HO JA LE LI LO OX RI SA SP ZA TOTAL DISPOSITION CONTACTS aPatient completing recommended therapy #ID# of contact identified bLikely to complete treatment within 365 daysApp test# of contacts appropriate for testing cNoncount#Eval# contacts evacuated dReported at death#Inf# contacts infected eCounted by "other"#trtLTBI# contact start on Tx for LTBI fMDR and still on treatment#Comp# contact compl tx LTBI gRIF resistant/intolerant and still on treatment#Curr# Contacts who are still on Tx LTBI hDied during treatment i Moved jCohort failure kLost

42 Follow Up Essential on any Issues Identified: Treatment Data Contact Investigation Case Management Education & Training NTIP Issues Clinical Medical Records

Follow-Up Each participant has follow-up tasks to perform. PHN Supervisors & PHN case managers Follow up on case management suggestions made during the cohort review Ensure that patients and contacts still on treatment finish treatment. The outcomes of persons with TB disease who were “likely to complete” treatment and the contacts who are still on treatment for LTBI will be reported and reviewed in 6 months, as part of a future cohort review. Keep managing the cases and contact investigations until they are “closed”. 43

Follow-Up The AMD and/or NM will address programmatic concerns and consider modifying staff training to address staff learning needs. The medical reviewer (Chest MD) will address clinical and programmatic problems that were noted and provide medical consultation. TBCP APS, PS, NM will track education, programmatic and clinical issues needing follow up and ensure ongoing, follow -up staff education 44

SAMPLE COHORT REPORT CARD Quarter: 1/1/10 to 3/31/10 COMPLETION OF TREATMENT SPA: ________ SUMMARY OF VARIABLES TB Cases Counted 1/1/10-3/31/10Count Total case counted43 aComplete treatment26 bLikely to complete treatment8 cNoncount1 dReported at death2 eCounted by "other"0 fMDR TB1 gRIF resistant/intolerant and still on treatment0 hDied during treatment2 iMoved0 jCohort failure1 kLost1 TB Cases Counted 1/1/10-3/31/10Rate Index of treatment completion at time of cohort review65.0% Index of possible treatment completion70.3% Index of likely to complete treatment91.9% Death rate9.5% Default rate2.4% Total cohort failure rate4.8% REPORT CARD COMPLETION OF TREATMENT

, ,5,10,12 14,15 LAC Performance Measures CDC National TB Indicators COHORT REVIEW Integration of National TB Indicators and Los Angeles County Performance Measures

Staffing/Training required 2011-Cohort review training – All AMDs, NMs, PHNS, PHNs, PHIs & CWs 2 days training (divided over three sessions) RTMCC assistance with CEU  Cohort review process concept and roles (1 day)  Cohort preparation/planning (½ day) onsite at health center  Mock cohort review (½ day) onsite at one health center in each mega spa 2012 Cohort Review sessions –Continue Cohort review training –All Health centers begin Cohort Review sessions

Cohort Review Implementation by December

LAC Program Evaluation Process (Cohort Review) 49

“Understanding the TB Cohort Review Process: Instruction Guide 2006” National Tuberculosis Indicators Project (NTIP) Fujiwara PI and Frieden TR. TB Control in New York City; A Recent History. Atlanta, GA: CDC, Division of Tuberculosis Elimination. TB Notes 2000(1): MacMaken M. The Cohort Review Process in New York City. Atlanta, GA: CDC, Divisions of Tuberculosis Elimination. TB Notes 1997 (1). Francis J. Curry National Tuberculosis Center; Quality Improvement for TB Case Management: An Online Course for Systematic Quality Improvement Program for TB Case Management. (2002). References

Acknowledgements: Acknowledgements: Karen Y. Cho, RN Terese Brookins, EPI Sharelle Carr, RN Frank Alvarez, MD Jan King, MD AHO- SPA 6 South Health Center (SPA 6) staff Thank You! Questions