TB Notes Newsletter

No. 4, 2010

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Rotary International Projects

Tuberculosis is a major public health problem in Texas.  In 2009, a total of 1,501 TB cases were reported to the Texas Department of State Health Services. The Texas-Mexico border region is significantly affected by TB.  The frequent crossing of citizens from both Texas and Mexico to visit family, to shop, and to work opens the door for the cross-border transmission of TB.

Rotary International districts in Texas and Mexico recognize the significance of preventing and controlling TB, especially in the border region. Taking a page out of the Rotary International’s successful campaign against polio, Rotary districts in Texas and Mexico have been working together to increase public awareness about TB, and to create infrastructure and capacity to prevent and control TB in the border region. 

For some time now, border-area Rotarians have been bringing equipment and supplies into the binational TB projects and health departments in Reynosa, Matamoras, and Nuevo Laredo, Mexico, to support TB clinical services in the area. This support has been critical in the management of patients with complicated drug-resistant TB in the border region.

In another project, Rotary International District 5870 in Texas has collaborated very successfully with Mexican Rotary District 4130 in building TB prevention and control infrastructure and capacity in the Texas-Mexico Rio Grande Valley border region. The Rotary Foundation granted these Rotary districts $300,000 to develop a TB laboratory in Reynosa, Mexico, that will facilitate TB diagnostic services in the area. The laboratory building is nearing completion, and the equipment and supplies are being purchased to outfit this new facility.

The Rotary International districts have also been working to increase awareness in Texas that TB continues to be a major public health problem.  The Texas Department of Transportation has approved the development of a special license plate for Rotary (see image).  The license plate is focused on increasing TB awareness. The funding from this project will be used for TB prevention and control.

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Rotary continues to be a valuable partner to the Texas Department of State Health Services in efforts against TB in the Texas-Mexico border area.

—Reported by Charles Wallace, PhD, MPH
Texas Dept of State Health Services

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Life after the CDC Cooperative Agreement: Implementation of Newly Proposed CoAg Activities

Background
In August 2009, the Los Angeles County TB Control Program (LAC TBCP) submitted its CDC Cooperative Agreement (CoAg) proposal. The CoAg proposal outlines ongoing and proposed activities needed to achieve the national TB objectives over the next 5-year grant cycle (2010–2014). The CDC CoAg was written as a collaborative effort between the various TB program managers and the new TB Program Director during July and August 2009. In addition to listing the ongoing prevention and control activities, the CDC CoAg identified several new initiatives that would strengthen key components of the program. This year’s grant highlighted three areas: 1) provide greater analysis and dissemination of TB surveillance and epidemiologic information; 2) increase partnerships across all TB activities, and 3) build on existing program evaluation efforts.

This year’s CDC grant highlighted the importance of working toward the goals in the National TB Indicators Project (NTIP) and establishing realistic program evaluation methods. As a result, the TB managers identified evaluation measures for each of the following seven grant components:
1. Treatment and case management of persons with active disease;
2. Evaluation of immigrants and refugees;
3. Contact investigation;
4. Public health labs;
5. Human resources development;
6. TB surveillance and reporting; and
7. Program evaluation.

In the past, LAC TBCP has not had total success in systematically integrating evaluation into all of its activities. In order to improve the chances of successfully establishing these new activities, the new Program Director wanted to reorganize the TB program to align program resources.

For these reasons, the program held a series of meetings between late September and December 2009 with the goal of integrating ongoing and proposed activities outlined in the CDC CoAg with the LAC TBCP strategic plan, local LAC TBCP Performance Measures, and the NTIP/CAL TIP measurements.  This report will focus on activities, tools, and outcomes of these meetings.

Description of Activity

Shortly after submitting the CDC CoAg in August 2009, the LAC TBCP initiated a series of weekly meetings to establish a method for strengthening current strategic priorities and implement newly outlined program activities outlined in the CDC CoAg. These meetings included the TB program managers. The goals of these meetings were to:

• Outline the “big picture” of how we plan to implement program activities;
• Brainstorm regarding resources and stakeholders to accomplish our goals;
• Prioritize activities, so as not to spread our resources too thin, and increase collaboration;
• Assign responsibility for developing program plans; and
• Develop detailed program plans to document actions and steps moving forward.

Working closely with the TB Program Director, we developed several key tools to assist in the process.

• A grid was created to better align the seven CDC CoAg components with the TBCP strategic plan, internal Los Angeles County department-wide Performance Measures, and current / proposed program activities. This served as a reference for the program facilitators and as a visual tool to help tie major program directional documents together.
• The program evaluation objectives and performance targets grid was submitted with the CDC CoAg application. This was created to establish annual incremental milestones for each of the NTIP indicators.
• CoAg implementation grids were created for each of the NTIP indicators that outlined the major strategies and activities needed to reach the NTIP indicator. This grid was used as our major tool to identify resources needed to achieve the NTIP activities.

Result of Activity

During this process, our managers came to consensus on key priority strategies for implementation during the first year. With all key managers providing input, we were able to list all ongoing program functions, suggest improvements to ongoing activities, and list all proposed new initiatives. Through this process, our new TB Program Director was able to identify gaps within the program and outline a plan to realign program functions. Program plans are also being developed to describe in greater detail the individual steps that are needed to ensure success of each focus strategy.

Lessons Learned

The following lessons emerged from this process:

• Evaluating a program can be easier if you align the various program measurements/ indicators.  Strategic plans, internal department-wide performance measures, monthly indicators, and other measurements that track the effectiveness and efficiency of a program over time should be similar across a program’s local, state, and national reporting.  Tracking and reporting on the same key indicators enables a program to collect better data over time. In addition, these indicators should be reviewed at set intervals for appropriateness and effectiveness.
• The importance of developing various tools that help program managers document ongoing processes cannot be understated. Tools should be easy to understand and should be completed during the planning meetings. Like all TB program managers, our staff had very little time outside of our planning sessions to collect additional information or complete “homework assignments.” The tools we developed were completed with all managers’ input during the meetings and analyzed by a smaller group of core facilitators later. If you conduct this process over months as we did, you’ll also need to develop summary tables to aid in restarting discussions at the beginning of each meeting and in documenting group actions/decisions.
• Developing a 5-year program plan has to begin with simple steps, by first looking at the big picture. The process should not be done in a vacuum, but rather should be done with key persons sitting at a table together to contribute to the process. The discussion between managers may get heated, but the output of these discussions will be more meaningful and rich. From these discussions, facilitators will be able to identify program gaps and priorities.

Future Plans for this Activity

With the completion of the initial phase, a small group of these managers will continue to work from these action plans as the evaluation team. The evaluation team will review the status of key focus strategies on an ongoing basis to ensure that progress continues.

—Reported by Shameer Poonja
DTBE PHA, Los Angeles, California

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New York City Bureau of TB Control Restructures Clinic Services

In 2009, the New York City Department of Health and Mental Hygiene Bureau of TB Control (BTBC) restructured its clinic functions to improve efficiency and to address severe overcrowding, which was negatively affecting patient satisfaction and staff morale at BTBC’s nine chest centers. It was hoped that the streamlined operations achieved through the restructuring would then allow staff to focus their efforts on activities such as HIV testing, evaluation of high-risk latent TB infection (LTBI) patients such as contacts, and increasing treatment completion for both active TB and LTBI.

An external review conducted by a team of health care delivery consultants in 2008 identified numerous deficiencies in clinic operations. Potential solutions to operational inefficiencies and clinic organizational deficiencies were proposed, and these proposed solutions guided the restructuring plan. In addition, BTBC undertook an assessment of the burden and impact of testing for TB infection (TTBI) at BTBC clinics. This assessment revealed that most of the individuals who sought TB tests did so for employment or school admissions purposes, and yet these people had the lowest risk for TB infection.

The BTBC director convened a workgroup to formulate a restructuring plan and create a monitoring and evaluation plan for the restructuring. The workgroup was made up of staff from various areas of BTBC and from other areas of the Department of Health and Mental Hygiene, including the Commissioner’s Office, the Division of Disease Control (which houses all infectious disease programs) and the Division of Finance and Planning. The workgroup met weekly for 3 months and made recommendations for the restructuring. These recommendations were presented to the Commissioner of Health for approval. The restructuring plan focused on targeted screening and testing of high-risk individuals, TB services for patients with active disease or high-risk LTBI, and clinic cycle-time (the amount of time patients spend in the clinics). The group also developed training/reference materials and conducted training for staff on the new procedures.

To address the lack of targeted testing, BTBC changed its TB testing policies to eliminate “administrative” testing for TB infection except where such testing is required by local public health law.

To address patient flow issues, employees were re-trained on clinic policies and procedures with emphasis on enforcement of appointment protocols. They were trained to remind patients about their next appointment, in person and by telephone. Staff also started making follow-up calls for missed appointments for all patients. Revamping of the appointment system also required that the electronic medical record system be adjusted to prevent unsupervised overbooking of patient appointments, while at the same time allowing walk-ins for priority patients.

To redirect patient flow from the most severely congested clinic, the three clinics in Brooklyn were organized into a “hub and satellite” model: one clinic was designated as the hub, where patients with suspected or confirmed TB would be followed; patients with LTBI would be followed up at either one of the two satellite clinics. The roles of Physician-in-Charge and Center Administrative Manager were re-defined so that they would have administrative oversight not only of one clinic, but of the entire hub-and-satellite structure.

The planned changes were communicated to stakeholders through clinic signage, the Internet, and mass e-mails. Information about the changes was also disseminated through the city’s general information portal (telephone number 311) and at events such as the annual World TB Day conference for health care providers.

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Upon evaluation, it was found that benchmarks were met for almost all of the indicators. From 2008 to 2009, the number of clinic visits at all clinics decreased by 36%, from 124,579 to 80,113, mostly as the result of a drop in administrative TB testing. (Figure 1) This relieved some of the crowding and helped staff focus their efforts on priority activities. Among patients with active TB diagnosed during January–March 2009, treatment completion was 92%, an increase from 88% in the same cohort the previous year. The proportion of contacts who completed LTBI treatment also increased. In addition, the proportion of patients with known HIV status increased from 71% to 76%. The number of tests for TB infection (TTBI) decreased by 60%, from 31,412 to 12,595. At the same time, the TTBI positivity rate increased from 7.7% to 11.5%, indicating that targeted testing was being achieved through removal of low-risk individuals from the testing pool.

Outcomes from the appointment protocol changes and hub-satellite model were also positive: for January–December 2009, the proportion of patients seen without appointments decreased from 33% to 20%. The average patient cycle time for an initial comprehensive visit (consisting of obtaining a chest x-ray, conducting a physician and a nursing evaluation, and collecting specimens for testing) was reduced by about 11%. By December 2009, all (100%) of Brooklyn clinic patients with suspected and active TB were seen at the hub, up from 70% in January 2009.

Although not all of the restructuring indicators reached their targets, they all showed progress. Improvements in long-term outcomes such as treatment completion for active TB and LTBI suggest that clinic restructuring has positively affected the BTBC’s overall performance. The project’s success can be attributed to the high level of buy-in by staff and to the high level of support provided by the Commissioner of Health. Finally, the project was aided by thorough training of staff at all levels; well-executed internal and external communication plans; and a comprehensive, iterative monitoring and evaluation plan.

—Reported by Michelle Macaraig, MPH, and Martha Alexander, MHS
New York City Department of Health and Mental Hygiene

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