Rajita Bhavaraju, MPH, CHESNJMS Global TB Institute

Rajita Bhavaraju, MPH, CHESNJMS Global TB Institute

Northeastern Regional Training and Medical Consultation Consortium

Training and Medical Consultation Needs Assessment Findings

OutlineOutline

• Needs assessment background and methods

• Results of training needs assessment

• Results of medical consultation needs assessment

• Recommendations

NE RTMCC Needs AssessmentBackground

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

RTMCC RegionRTMCC Region

Needs Assessment Methods TB Programs

Needs Assessment Methods TB 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

• 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

Needs Assessment Methods “End Users”

Needs Assessment Methods “End Users”

TimelineTimeline  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

Needs Assessment ResultsKey Informant Interviews

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

Needs Assessment ResultsTraining

Needs Assessment ResultsTraining

There were 564 end user (providers at service delivery level) training survey respondents

4136

380

107

Physician

Outreach worker/disease investigator

Nurse

Other

Needs Assessment ResultsTraining

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: o Case managemento Tuberculin skin testing,o HIV counseling and testingo Contact investigationo TB in the elderly o TB fundamentals

• End users’ top training needs included:o Legal issues related to TBo MDR-TBo Working with patients from diverse cultural backgrounds

Most needed training topics by profession

Most needed training topics by profession

 

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

Target AudiencesTarget 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

Training Formats Used in the Past 12 Months

Training Formats Used in the Past 12 Months

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 PreferencesTraining 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

Products - 1Products - 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

Products - 2Products - 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

Medical ConsultationMedical Consultation

Needs Assessment ResultsMedical Consultation

Needs Assessment ResultsMedical Consultation

There were 163 end user respondents to the medical consultation survey

61

86

16

Physician

Nurse

Other

Needs Assessment Results Existing System

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

Needs Assessment Results Key Traits for Medical Consultants

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

Needs Assessment Results Tracking Consultation

Needs Assessment Results Tracking 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

Needs Assessment ResultsReason for Seeking Consultation

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

Needs Assessment ResultsNeeds/Gaps

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

Needs Assessment ResultsObstacles and PreferencesNeeds 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

Needs Assessment Results Desired Involvement from RTMCC

Needs Assessment Results Desired 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

RecommendationsRecommendations

RecommendationsTraining

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

RecommendationsMedical ConsultationRecommendations

Medical 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

AcknowledgementsAcknowledgements

• 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

Thanks to all of you!!!