1. US-Mexico Binational TB Referral and Case Management Project: Preliminary Evaluation Findings Kayla Laserson, ScD Elizabeth Ferreira, MD July 19, 2005

2. Goals of the US-Mexico Binational TB Referral and Case Management Project Ensure continuity of care and completion of therapy Reduce TB incidence and prevent drug resistance Coordinate referral of patients between health systems Provide model for other diseases

3. Pilot Sites US-Mexico border sister cities/states –San Diego, CA – Tijuana, BC –El Paso, TX/Las Cruces, NM - Ciudad Juarez, CHIH –Webb/Cameron Counties, TX – Matamoros, TAMPS –Arizona – Nogales - Caborca, SON –Anáhuac, NL –Piedras Negras – Cd. Acuña, COAH INS / ICE Detention Centers –Texas, California, Arizona, Washington US States –Tennessee, Washington, Illinois

4. Evaluation Design Joint US/Mexico endeavor Two phases Evaluation Design Workgroup Assistance of an external evaluation firm –Objectivity/neutrality –Additional evaluation expertise Time frame: March 2003- December 2004

5. Evaluation Data Sources 2 Project databases and 2 national surveillance systems CureTB and Mexican NTP referral records Site visits Focus groups –6 with health center staff –4 with patients Interviews –36 with TB program and referral agency staff –13 with key stakeholders –7 by telephone with patients who moved to locations other than pilot sites

6. Card Distribution and Movement 793 TB patients received a Card in Mexico –2% (n=17) moved to the US –Destination 33% (5/15) TX 53% (8/15) CA 7% (1/15) Minnesota 1 US destination not specified 488 TB patients received a Card in the US –30% (n=147) moved to Mexico –61% (90/147) of movers in ICE custody at move –Destination Patients went to 19 Mexican states Top 3: BC, CHIH, SON 71% (100/141) went to Mexican Pilot site states

7. Added Value of Project to Outcome Determination Comparison with the outcome reported to the US National TB Surveillance System –32% (11/34) of Card patients who were listed as moved or lost in the NTSS had outcomes ascertained from the Pilot that could update national data

8. Health Care Workers’ Perspective: A Worthy Idea The Project can benefit patients directly (tangible service) “it is like a security blanket, because if these guys are gone, they have all the information to get care.” “The patient has something to show, and a number to call.” Sites (especially away from the border) appreciate having a conduit for referrals Sites are eager to know what happened to referred patients The Project is “one more tool at the Program’s disposal” Some tangible evidence of success –Patients have been successfully referred –Providers made contact because patient showed the Card

9. Health Care Workers’ Perspective The Project has also had some “side-benefits” –Learning about Mexico and its health care system –Reaching out to Hispanic patients –Reinforcing connection with local providers –Reiterating the importance of case reporting –Redeploying resources –Domestic referral tool

10. Health Care Workers’ Perspective: An Increased Workload Additional forms to fill out Eligibility criteria too broad Additional responsibilities, but no additional staff or resources Tracking referred patients is difficult, time consuming, and detracts from routine activities –Inaccurate, imprecise contact information –No relationship with patient –Some patients are not confirmed TB cases

11. Patients’ Perspective Patients accept Card (only 1 refusal reported) Very few patients report having had questions at the time they were given the Card –Too much information to absorb at one time? –Not relevant until needed? Patients generally seem to understand the overall purpose, limitations, and how to use it Some misunderstandings noted: –800# directly reaches the provider in country of origin –Card helpful only to carry medication across the border

12. Patients’ Perspective: Perceived Benefits Guarantee that they will obtain medications Expression of moral support, concern for well-being Ability of provider at destination to obtain their treatment record from their place of origin Not having to answer so many questions at destination Not having to be retested/to start treatment over Explain why they are carrying medications when crossing the border *Show that they have TB and be released by the Border Patrol

13. Patient Education Patients able to summarize the key points “A lot to take in” –Needs to be repeated/reinforced periodically Some sites have to rely on translators –Help CureTB/TBNet Reported need for additional educational materials for patients –Brochure patients can take with them, or videos that patients can watch –Must be appropriate for low-literacy levels –“Flipchart” now available –Continuous education

14. Coordination with Immigration Authorities Project embraced by participating facilities NEW standard procedures and protocols used at all ICE facilities –Now include the Card –“Medical hold” facilitates the process Perceived benefits of the Card –Helps comply with requirements to arrange for follow-up of active cases Coordination with ICE is an important achievement of the Pilot Project

15. Political Will Officials on both sides committed to the Project –Recognition that TB problem extends into the interior of both countries Effective collaboration across the border is an important outcome for many “The Pilot Project is a model for collaboration. Project staff in Texas and California are more open-minded than previously thought and they are mostly Latinos. There is excellent communication between the two sides... It’s a chance of telling the world US-Mexico collaboration can happen.” “The program is a success and it shows the rest of the world that collaboration can exist and work successfully between the two countries.”

16. Stakeholders Recommendations April 2005 Progress Meeting Continue the Pilot Project –Find additional resources Expand the Pilot Project to new sites in the interior Utilize evaluation to change the program –Modify eligibility criteria (site-specific) –Improve data systems, data flow, and data management both in-country and across countries

17. Evaluation Follow-Up Weekly conference calls since Progress meeting –Eligibility criteria narrowed in both US and Mexico –Referrals for TB suspects from ICE facilities held by CureTB until case verified –Referral forms redesigned To limit amount of data collected To avoid duplication To standardize data elements across countries –Data flow streamlined CureTB can send referrals directly to local Mexican site, with copy to the NTP Ways to improve transmission of referrals from the NTP to CureTB are being discussed New system to be implemented by end of July

18. Next Steps The project is continuing at the current sites It is expanding to other sites –ICE facilities –Other states in Mexico –Other US states beginning implementation (Utah, Ohio) Additional resources are being identified –USAID (Mexico only) –CDC COAGs –Border Health Commission –Others?

19. Summary The Project has merit and worth –Treatment outcomes –Health care workers –Patients –Key stakeholders Intangible positive results –Communication and collaboration –Truly binational Challenges exist –Evaluation has helped stakeholders identify them to seek solutions The Project can serve as a model for managing migrating patients