Transcript July 19, 2005 - United States - Mexico Border Health Commission

US-Mexico Binational TB Referral
and Case Management Project:
Preliminary Evaluation Findings
Kayla Laserson, ScD
Elizabeth Ferreira, MD
July 19, 2005
Tu b e rc u lo sis
Goals of the US-Mexico Binational TB
Referral and Case Management
Project
• Ensure continuity of care and completion of
therapy
• Reduce TB incidence and prevent drug resistance
• Coordinate referral of patients between health
systems
• Provide model for other diseases
Pilot Sites
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US-Mexico border sister cities/states
– San Diego, CA – Tijuana, BC
– El Paso, TX/Las Cruces, NM - Ciudad Juarez, CHIH
– Webb/Cameron Counties, TX – Matamoros, TAMPS
– Arizona – Nogales - Caborca, SON
– Anáhuac, NL
– Piedras Negras – Cd. Acuña, COAH
INS / ICE Detention Centers
– Texas, California, Arizona, Washington
US States
– Tennessee, Washington, Illinois
Evaluation Design
• Joint US/Mexico endeavor
• Two phases
• Evaluation Design Workgroup
• Assistance of an external evaluation firm
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– Objectivity/neutrality
– Additional evaluation expertise
Time frame: March 2003- December 2004
Evaluation Data Sources
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2 Project databases and 2 national surveillance systems
CureTB and Mexican NTP referral records
Site visits
Focus groups
– 6 with health center staff
– 4 with patients
Interviews
– 36 with TB program and referral agency staff
– 13 with key stakeholders
– 7 by telephone with patients who moved to locations
other than pilot sites
Card Distribution and Movement
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793 TB patients received a Card in Mexico
– 2% (n=17) moved to the US
– Destination
• 33% (5/15) TX
• 53% (8/15) CA
• 7% (1/15) Minnesota
• 1 US destination not specified
488 TB patients received a Card in the US
– 30% (n=147) moved to Mexico
– 61% (90/147) of movers in ICE custody at move
– Destination
• Patients went to 19 Mexican states
• Top 3: BC, CHIH, SON
• 71% (100/141) went to Mexican Pilot site states
Added Value of Project to
Outcome Determination
• Comparison with the outcome reported to the
US National TB Surveillance System
– 32% (11/34) of Card patients who were listed
as moved or lost in the NTSS had outcomes
ascertained from the Pilot that could update
national data
Health Care Workers’ Perspective:
A Worthy Idea
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The Project can benefit patients directly (tangible service)
“it is like a security blanket, because if these guys are gone,
they have all the information to get care.”
“The patient has something to show, and a number to call.”
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Sites (especially away from the border) appreciate having a
conduit for referrals
Sites are eager to know what happened to referred patients
The Project is “one more tool at the Program’s disposal”
Some tangible evidence of success
– Patients have been successfully referred
– Providers made contact because patient showed the Card
Health Care Workers’ Perspective
• The Project has also had some “side-benefits”
– Learning about Mexico and its health care
system
– Reaching out to Hispanic patients
– Reinforcing connection with local providers
– Reiterating the importance of case reporting
– Redeploying resources
– Domestic referral tool
Health Care Workers’ Perspective:
An Increased Workload
• Additional forms to fill out
• Eligibility criteria too broad
• Additional responsibilities, but no additional
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staff or resources
Tracking referred patients is difficult, time
consuming, and detracts from routine
activities
– Inaccurate, imprecise contact information
– No relationship with patient
– Some patients are not confirmed TB cases
Patients’ Perspective
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Patients accept Card (only 1 refusal reported)
Very few patients report having had questions at the
time they were given the Card
– Too much information to absorb at one time?
– Not relevant until needed?
Patients generally seem to understand the overall
purpose, limitations, and how to use it
Some misunderstandings noted:
– 800# directly reaches the provider in country of origin
– Card helpful only to carry medication across the
border
Patients’ Perspective: Perceived
Benefits
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Guarantee that they will obtain medications
Expression of moral support, concern for well-being
Ability of provider at destination to obtain their
treatment record from their place of origin
Not having to answer so many questions at destination
Not having to be retested/to start treatment over
Explain why they are carrying medications when
crossing the border
*Show that they have TB and be released by the
Border Patrol
Patient Education
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Patients able to summarize the key points
“A lot to take in”
– Needs to be repeated/reinforced periodically
Some sites have to rely on translators
– Help CureTB/TBNet
Reported need for additional educational materials for
patients
– Brochure patients can take with them, or videos that
patients can watch
– Must be appropriate for low-literacy levels
– “Flipchart” now available
– Continuous education
Coordination with Immigration
Authorities
• Project embraced by participating facilities
• NEW standard procedures and protocols used
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at all ICE facilities
– Now include the Card
– “Medical hold” facilitates the process
Perceived benefits of the Card
– Helps comply with requirements to arrange
for follow-up of active cases
Coordination with ICE is an important
achievement of the Pilot Project
Political Will
• Officials on both sides committed to the Project
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– Recognition that TB problem extends into the
interior of both countries
Effective collaboration across the border is an
important outcome for many
“The Pilot Project is a model for collaboration. Project staff in
Texas and California are more open-minded than
previously thought and they are mostly Latinos. There is
excellent communication between the two sides . . . It’s a
chance of telling the world US-Mexico collaboration can
happen.”
“The program is a success and it shows the rest of the world
that collaboration can exist and work successfully between
the two countries.”
Stakeholders Recommendations
April 2005 Progress Meeting
• Continue the Pilot Project
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– Find additional resources
Expand the Pilot Project to new sites in the
interior
Utilize evaluation to change the program
– Modify eligibility criteria (site-specific)
– Improve data systems, data flow, and data
management both in-country and across
countries
Evaluation Follow-Up
• Weekly conference calls since Progress meeting
– Eligibility criteria narrowed in both US and Mexico
– Referrals for TB suspects from ICE facilities held by
CureTB until case verified
– Referral forms redesigned
• To limit amount of data collected
• To avoid duplication
• To standardize data elements across countries
– Data flow streamlined
• CureTB can send referrals directly to local Mexican
site, with copy to the NTP
• Ways to improve transmission of referrals from the
NTP to CureTB are being discussed
• New system to be implemented by end of July
Next Steps
• The project is continuing at the current sites
• It is expanding to other sites
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– ICE facilities
– Other states in Mexico
– Other US states beginning implementation
(Utah, Ohio)
Additional resources are being identified
– USAID (Mexico only)
– CDC COAGs
– Border Health Commission
– Others?
Summary
• The Project has merit and worth
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– Treatment outcomes
– Health care workers
– Patients
– Key stakeholders
Intangible positive results
– Communication and collaboration
– Truly binational
Challenges exist
– Evaluation has helped stakeholders identify
them to seek solutions
The Project can serve as a model for managing
migrating patients