DTBE | TB Cohort Review Process 2006 | How to Tailor Cohort Review to Local Program Areas

The purpose of this section is to provide practical guidance on implementing the cohort review method in local program areas. As stated previously, many of the forms and processes highlighted in this document reflect the New York City Department of Health and Mental Hygiene cohort review methodology. Because the New York City program has a high case volume in a small, highly concentrated geographic area, the program has developed methods that work well in that setting. Your program profile may be very different. The keys to successful implementation in your program area include two steps:

1. Establishing Political and Management Commitment

Staff are often reluctant to accept change, such as a new policy or procedure. Change may make them feel uncomfortable. This may be especially true if they perceive that the new policy or procedure means extra work or scrutiny for them. People have to believe something is important to them before they will accept change. Therefore, management staff in the health department must communicate to staff at all levels that they themselves, the management team, believe in the cohort review method. There is no substitute for leading by example. If it is not important to TB program leadership, why will staff want to do it?

In communicating with staff, think of all the people who will need to know about cohort review, what each person’s role is, and what new tasks they will have to do. Staff may be more likely to accept the implementation of the cohort review process if management staff emphasize how the process builds on what they are already doing well. In addition, staff may be more invested and motivated in the process if they are directly involved in tailoring the review process to the particular strengths and needs of the program area. Staff need to hear why it is important and how assistance will be provided to make sure everyone has the knowledge and skills to do the new tasks.

A sample letter follows, showing what the director of TB control may want to communicate to staff when initiating cohort reviews.

Sample Letter from Director of Local Health Department

2. Modifying the Elements of the Cohort Review Process

Adapting the cohort review method to fit the program area is also essential. At first, it is better to start small and allow staff to become accustomed to the process. For each element, be sure that the plan is consistent with the local situation.

Detailed review of each case: This is an element that needs to be specifically tailored to each local situation. There are several approaches to consider for the cohort review session:

A city or county health department may prefer a face-to-face meeting in one large room. Case managers, contact investigators, public health nurses, data analysts, supervisors, and clinicians can be called to a mandatory meeting. Travel within the city, county, or region is a normal part of the job.
In large geographic areas where travel may be a challenge for face-to-face meetings, video and teleconference technology should be considered to facilitate the cohort review session.

The case manager or the presenter should be well prepared to present the details of the cases that he/she is responsible for. The case manager should prepare information on each case, present the information at the cohort review session, and be prepared to follow up on suggestions made by reviewers at the cohort review session.

The reviewer will need practice in learning how to manage time and go over all of the most important points raised in regards to each case. In general, routine cases need less time and attention. It is important to spend more time on the difficult cases, especially those in which the patient is nonadherent, has multidrug-resistant TB, or has numerous contacts in a congregate setting. The reviewer should remember to use “teachable moments” to give feedback to staff and update them on policies, protocols, and guideline revisions.

During the presentation and review of each case, the data analyst must quickly and accurately tally results, update information, and note issues that require follow-up. This can be very exacting work in a fast-paced cohort review session, and it takes some time to get accustomed to the process and how and where to enter results.

Immediate analysis of outcomes: This is the role of the data analyst. If possible, the data analyst should immediately provide a report card of the status of the cohort. The status of patient and contact investigation outcomes should lead to a discussion of programmatic issues, as well as yield direction for follow-up to in order to achieve program objectives.

Timely follow-up of noted problems: No management process is complete until information collected is used to guide improvement. Usually it is the job of the data analyst to compile a summary report of the cohort review outcomes, as well as a list of issues that require follow-up actions. These actions, however, may need follow-up by several different people: program director, medical director, public health nurse, case manager, supervisor, outreach worker—thus, a separate list for each person may be useful.

Also, remember that 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. Case managers and their supervisors have to keep managing these cases and contact investigations until they are “closed.”

Be patient. With time and practice, the skills of the case managers, reviewers, and data analysts will improve.

“For any program that is considering implementing cohort review, there are four main points you have to keep in mind: first you have to have the commitment of your staff to move towards this process; second, recognize that there is a time factor; third, be flexible and look at the models from New York City but adapt them to your regional area; and fourth, you are going to need buy-in from your higher management or others in your state who are providing the direct care…”

Kim Field, RN, MSN, TB Program Manager, Washington State Department of Health TB Program

Case Study: Washington State Department of Health
Cohort Review Process

Process in Washington State

In 2003, the Washington (WA) State Department of Health (DOH) TB Program adapted the New York City cohort review model and implemented this process. Reasons for implementing the cohort review process in WA State included the desire to: 1) increase accountability for patient outcomes, 2) ensuree completion of therapy for TB patients and contacts, 3) evaluate achievement of program objectives, and 4) provide opportunities for staff education.

The cohort includes all patients whose cases were counted by the WA State TB Program during a particular quarter of the year. Quarterly cohort review sessions are scheduled approximately 7–9 months after cases are counted (Table 21).

Table 21: Washington Cohort Review Timeline for 2005

The quarterly cohort review session is conducted with the DOH TB Program Coordinator, DOH Nursing Consultants, DOH medical consultant, DOH epidemiologist, and local health jurisdiction (LHJ) staff. Telephone conference calls are used to conduct these sessions. Nursing Consultants work with LHJ staff to prepare for cohort review presentations using a cohort review form (Appendix C).

Table 22: Washington Cohort Review Data Analyses

Impact of Cohort Review

In 2004, the DOH TB Program conducted an assessment of the impact of implementing cohort review in Washington State. A comparison of the outcome and timeliness measures were analyzed for January–March 2001 patients and their contacts (prior to the introduction of cohort review) and January–March 2003 patients and their contacts (post 1 year of implementing cohort review). The results of the comparison demonstrated that cohort review made a substantial impact on the management of TB cases in Washington State.

Table 23: Outcome measures on TB cases by year, Washington, 2001 and 2003.

Table 24: Timeliness of reporting measures on TB cases by year, Washington, 2001 and 2003

No patients died during treatment or were reported at death among the 2003 cohort as compared to 2001 (0 in 2003 vs. 8% in 2001) (Table 23).

Table 25. Outcome measures on TB contacts by year, Washington, 2001 and 2003

Since implementation in WA State, cohort review has increased knowledge of TB among staff and has increased staff accountability for the management of their cases. Benefits closer scrutiny of patients and contacts, and an increased understanding of TB morbidity due to the cohort review sessions, have improved patient outcomes and the treatment of patients and contacts in Washington State.

Understanding the TB Cohort Review Process: Instruction Guide 2006

How to Tailor Cohort Review to Local Program Areas