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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!!!