Rajita Bhavaraju, MPH, CHES NJMS Global TB Institute

1. Rajita Bhavaraju, MPH, CHESNJMS Global TB Institute Northeastern Regional Training and Medical Consultation Consortium Training and Medical Consultation Needs Assessment Findings

2. Outline • Needs assessment background and methods • Results of training needs assessment • Results of medical consultation needs assessment • Recommendations

3. NE RTMCC Needs AssessmentBackground 1995 – 2004 CDC funded the NJMS National Tuberculosis Center • State-of-the-art clinical care • Education and training • Research 2005 – 2009 CDC funded the NE RTMCC to support, strengthen, and supplement training and medical consultation in the 20 TB Project areas in the NE Region • Training and medical consultation needs assessment conducted in 2005 from 2 perspectives: • TB program staff • Local HD staff and other providers at service delivery level

4. RTMCC Region

5. Needs Assessment MethodsTB Programs • Review of surveillance data for each area, cooperative agreement reports, and other information • Key Informant Questionnaire – TB program staff provided information about: • TB problem • Program’s structure • Training and medical consultation needs • Onsite Key Informant Interview • With key staff • Provided additional qualitative information

6. Needs Assessment Methods“End Users” • On-line or fax/mail/in-person survey • Separate surveys for training and medical consultation • TB programs sent survey to HD and other providers at service delivery level • Limitations: • Recipients of survey varied by project area • Lack of response rate • Convenience sample • Mixed methods • Time • Potentially efficient way to survey providers in future providing: • Entire target audience identified • Survey sent to entire audience or representative sample • Tracking mechanism established

7. Timeline ·Jan-Feb 2005: Sent letter of introduction to project areas ·Mar-Apr 2005: Discussed needs assessment process with project areas; collected surveillance and programmatic information ·May-Jun 2005: Developed draft needs assessment instruments and procedures and discussed plans at the NTCA Meeting ·Jul-Aug 2005: Refined and field tested needs assessment instruments and submitted instruments for Human Subjects Review ·Oct-Nov 2005: After IRB approval, carried out needs assessment process in each project area ·Dec 2005: Analyzed available data; a preliminary aggregate report was sent to CDC ·Jan 2006: A 2nd download of end user survey data was completed for data collected through December 31 ·Feb 2006: Individual project area data was analyzed and incorporated into the individual area reports

8. Needs Assessment ResultsKey Informant Interviews ·Key staff in all project areas participated in face-to-face interviews and completed questionnaires. ·Programs varied greatly within the region regarding size and organizational structure of program, number of staff, morbidity, responsibilities, and services and partnerships with outside organizations

9. Needs Assessment ResultsTraining There were 564 end user (providers at service delivery level) training survey respondents

10. Needs Assessment ResultsTraining • Each program provides basic TB training for new staff and non-TB program staff who work with at-risk persons • Training topics identified by key informants varied based on the morbidity of the area, specific staff responsibilities, and status of meeting national program objectives and included: • Case management • Tuberculin skin testing, • HIV counseling and testing • Contact investigation • TB in the elderly • TB fundamentals • End users’ top training needs included: • Legal issues related to TB • MDR-TB • Working with patients from diverse cultural backgrounds

11. Topic Physician (%) Nurse (%) Outreach Worker-Disease Investigator (%) Other (%) Diagnosis 23.6 23.4 51.8 21.3 Screening/TST 34.2 18.2 30.0 37.0 Treatment regimens 36.9 43.7 48.4 21.4 MDR-TB 56.7 62.6 47.0 48.8 Pediatric TB 36.0 57.6 51.5 37.9 Legal issues 47.4 68.1 42.4 59.6 Surveillance/ reporting 26.3 44.8 48.4 21.2 Laboratory issues 30.6 50.5 51.5 46.2 Most needed training topics by profession

12. Target Audiences • Key informants were asked about primary target audiences for training and identified: • Private sector physicians • Correctional facility providers • Local public health staff,mainly nurses • Other audiences were other community providers, medical consultants, private sector nurses, training focal points, outreach workers, immigration health authorities, respiratory therapists, and hospital emergency department staff • Special populations mentioned included foreign-born patients, patients at risk for HIV infection, patients with substance abuse issues, Somali and Hmong refugees, and homeless patients

13. Training format # of responses In person 376 In service meetings 229 Written/self-study 187 Computer-based (archived or live) 150 Teleconference 118 Satellite broadcast 107 Video/DVD 85 Videoconference 83 CD-ROM 62 Other 14 Training Formats Used in the Past 12 Months

14. Training Preferences • Formats • In-person ranked highest • Length of training • 1-3 days preferred • Dependent upon type of training and target audience • Barriers to training • Relate mostly to staff availability • Frontline public health nurses and outreach staff have the most difficulty finding the time to attend training events

15. Products - 1 • Prefer quick reference materials, videos and brief, user-friendly versions of any new guidelines. Topics needed: • Cultural competency • Improving adherence and treatment completion • Tuberculin skin testing and dealing with BCG vaccine history • New employee orientation • Tracking system for private physicians • QuantiFERON-TB Gold® • Infection control • Contact investigation • Interpretation of chest radiographs • MDR-TB • Pediatric tuberculin skin testing • Sputum induction and collection

16. Products - 2 • Audiences: • Emphasis on patient-centered materials • State and local health department staff • Private providers including homeless shelter staff, emergency department personnel, and infection control staff • Printing budgets vary based on how HRD funding is used

17. Medical Consultation

18. Needs Assessment ResultsMedical Consultation There were 163 end user respondents to the medical consultation survey

19. Needs Assessment Results Existing System • Nearly all programs felt they had an adequate MC system in place • Wide variation in structure, availability, and expertise • Types of access included: • Open access – providers call consultants of choice directly • Referrals initiated through PHNs, senior staff, or program managers • Stratified system of local consultants who can call state MC as needed • More common in high incidence areas • State MC may access external experts • State MC includes local MC in all communication with provider

20. Needs Assessment Results Key Traits for Medical Consultants • Critical components for MC systems include: • Availability • Expert knowledge about TB • Knowledge about state and local TB: • Programs • Resources • Policies and regulations • End users • Most often sought MC from a HD TB specialist • Consider previous interaction and health department affiliation in seeking medical consultation

21. Needs Assessment ResultsTracking Consultation Programs record information in a variety of ways: • Log books • Referral forms with written recommendations • Most TB programs have no systematic procedure in place to track or review requests for medical consultation • One area recently instituted a formal tracking system and QA measures • State nurse consultant triages calls and schedules difficult cases for review by state MC. • Local HD or corrections staff submit a form and lab/x-ray information • Cases reviewed weekly with written recommendations provided • Another program maintains a log which can be reviewed to identify training needs and plan topics for Grand Rounds

22. Needs Assessment ResultsReason for Seeking Consultation • Programs indicated need for access to experts for patients with complex medical and management issues, e.g., • MDR-TB • Contacts to MDR-TB • TB/HIV • Treatment failures • Pediatric TB • TB in elderly • Concurrent illnesses • Drug toxicity • Drug levels and absorption • Surgical management of TB • End users said they most often sought consultation for: • Drug resistance • Adverse drug reaction • TB/HIV co-infection • Concurrent medical conditions

23. Needs Assessment ResultsNeeds/Gaps TB programs identified other MC-related needs/issues: • Providers most likely to require consultation often unaware that they need assistance in diagnosing and managing TB • Not sure what questions to ask • Feel they have all the training & experience they need • Limited access to TB specific training opportunities • Lack of concise educational material related to newly published (lengthy and complex) TB guidelines

24. Needs Assessment ResultsObstacles and Preferences • Obstacles to Accessing Medical Consultation • Technological: Difficulty in electronically delivering x-rays or files to consultants • Legal: Only mentioned by one TB program as a potential problem • Preferred mode of delivering consultation services • Telephone - current preferred mode by all programs • Email - second choice • Some programs open to web-based delivery in future

25. Needs Assessment ResultsDesired Involvement from RTMCC • Degree of TB program involvement with RTMCC consultations • Nearly all programs wanted to maintain own MC systems • Most programs wanted RTMCC to provide callers with TB Program contact information for future MC requests • Programs valued RTMCC as a back up MC service, especially for complex cases • Degree of feedback TB programs want from RTMCC • All programs wanted periodic aggregate reports for their area • Several programs wanted timely reports if cluster of calls received from same geographic area • All programs wanted immediate report of calls with public health implications

26. Recommendations

27. RecommendationsTraining • Increase accessibility by marketing trainings in advance to allow time to plan for travel and staff coverage and provide more onsite and distance-based learning • Work with programs to conduct program specific needs assessments and develop collaborations • Build capacity through assisting and bringing together focal points, expanding successful training initiatives, and adapting existing materials • Promote training by developing trainer-of-trainer programs, more seminars for private providers, mini-fellowship for program staff, and TB fundamentals materials

28. RecommendationsMedical Consultation Develop and enhance existing medical consultation through: • Identifying and building a network of consultants within the region • Providing continuing medical education to consultants • Develop a system of tracking consultations for project area use • Expand and enhance training opportunities for community providers serving patients at high risk for TB

29. Nisha Ahamed Bill Bower Julie Franks Valerie Gunn Chris Hayden Yael Hirsch-Moverman Erin Howe Anita Khilall Lauren Moschetta DJ McCabe Eileen Napolitano Marian Passannante Arlene Robinson Bernie Rodriguez Acknowledgements

30. Thanks to all of you!!!