Needs Assessment results by wuyunyi

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									Northeastern Regional Training and
 Medical Consultation Consortium
 Training and Medical Consultation
    Needs Assessment Findings

  Rajita Bhavaraju, MPH, CHES
    NJMS Global TB Institute
                    Outline

• Needs assessment background and methods
• Results of training needs assessment
• Results of medical consultation needs assessment
• Recommendations
      NE RTMCC Needs Assessment
                              Background
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 Region
    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
          Needs Assessment Methods
                          “End Users”
• 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
                          Timeline
 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 Results
     Key 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 Results
                  Training

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

           41
  107            36

                       Physician

                       Outreach worker/disease investigator

                       Nurse

                       Other




           380
         Needs Assessment Results
                            Training
•   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 management
    o   Tuberculin skin testing,
    o   HIV counseling and testing
    o   Contact investigation
    o   TB in the elderly
    o   TB fundamentals

•   End users’ top training needs included:
    o Legal issues related to TB
    o MDR-TB
    o Working with patients from diverse cultural backgrounds
         Most needed training topics by
                  profession
Topic           Physician (%)   Nurse (%)   Outreach           Other (%)
                                            Worker-Disease
                                            Investigator (%)


Diagnosis       23.6            23.4        51.8               21.3

Screening/TST   34.2            18.2        30.0               37.0


Treatment       36.9            43.7        48.4               21.4
regimens

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/   26.3            44.8        48.4               21.2
reporting

Laboratory      30.6            50.5        51.5               46.2
issues
                 Target 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 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 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 - 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 - 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 Consultation
     Needs Assessment Results
          Medical Consultation

There were 163 end user respondents to the medical
consultation survey
               16




                           61
                                   Physician
                                   Nurse
                                   Other



          86
      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
• 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
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 Results
 Reason 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 Results
                      Needs/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 Results
      Obstacles 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

• 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
Recommendations
               Recommendations
                   Training
• 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
            Recommendations
           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
          Acknowledgements

• Nisha Ahamed           • Anita Khilall
• Bill Bower             • Lauren Moschetta
• Julie Franks           • DJ McCabe
• Valerie Gunn           • Eileen Napolitano
• Chris Hayden           • Marian Passannante
• Yael Hirsch-Moverman   • Arlene Robinson
• Erin Howe              • Bernie Rodriguez
Thanks to all of you!!!

								
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