Cohort Review Process

1
Cohort Review Process

• Yvonne Luster-Harvey, MPH
• Bureau of TB and Refugee Health
• Statewide Meeting
• Tampa, Florida, 2007

2
Objectives

• Define the Cohort Review Process
• Enumerate the benefits of the cohort review
• Define the three key elements in the process
• Identify the roles of key TB control staff
  involved in a cohort review
• Explain the integration of cohort review as an
  integral part of future TB case management
  strategies for controlling TB in Florida

3
Cohort Review Defined

• The cohort review process is a systematic
  review of the management of patients with TB
  disease and their contacts.

4
Cohort Review Concept

• The fundamental concept of a cohort review is
  accountability. Staff are accountable to
  supervisors and to the program for how well they
  are caring for patientsand the program is
  accountable to patients and to the public for
  controlling tuberculosis
• Thomas Frieden, MD, MPH
• NYC Commissioner of Health

5
Benefits of Cohort Review

• Increasing staff accountability for patient
  outcomes
• Improving TB case management and the
  identification of contacts
• Motivating staff
• Revealing program strengths and weaknesses
• Indicating staff training and education needs

6
Sample Organizational Chart
TB Program Manager
Medical Reviewer
Data Analyst
Supervisor
Review Team
TB Control Staff
Case Manager
Outreach Staff
DOT Staff
7
Key Elements in Process

• Preparation for a cohort review
• Cohort review presentation
• Follow-up after cohort review

8
Preparation

• Encompasses developing program objectives,
  ensuring that sound case management protocols are
  in place, using a reliable TB registry and
  carefully preparing the case.

9
Presentation

• Includes using a standardized format for cohort
  reviews, providing TB case and contact
  information to the TB control team and presenting
  immediate feedback on goal accomplishment.

10
Follow-up

• Involves acting on the recommendations of the TB
  control team from the cohort review session,
  ensuring that those patients, and contacts
  started on treatment complete treatment and
  following up on programmatic issues (e.g.
  training) that were noted at the the cohort
  review session. Using this process allows TB
  programs to improve outcomes through a continual
  cycle of learning.

11
TB Manager Role

• Preparation
• Demonstrate commitment
• Ensure staff at all levels understand the reasons
  for undertaking cohort reviews
• Ensure staff at all levels have the knowledge and
  skills needed to perform the tasks required.

12
TB Managers Role, cont.

• Review
• Listen to all case presentations.
• Ask questions of clarification to ensure that all
  aspects of case management adhere to Department
  of Health policies and procedures.
• Use teachable moments to illustrate important
  lessons in effective TB control.

13
TB Manager Role, cont.

• Follow-up
• Ensure that medical management and other issues
  are addressed.
• Ensure that ongoing, follow-up staff education
  incorporates program strengths and weaknesses.
• Update TB registry information as needed.

14
Medical Reviewer Role

• Preparation
• Demonstrate commitment to the cohort review
  process.
• Ensure staff at all levels understand the reasons
  for undertaking cohort reviews.

15
Medical Reviewer, cont.

• Review
• Listen carefully to all case presentations and
  review available support documents (e.g.,
  printouts from TB registry, charts and medical
  records).
• Ensure that all aspects of case management adhere
  to Department of Health policies and procedures

16
Medical Reviewer, cont.

• Activities are completed in a timely manner
• Data are complete
• Drug regimen is appropriate
• Susceptibility results are obtained drug
  regimen is adjusted if necessary
• Sputum conversion and completion of treatment are
  documented
• Contact investigation activities and outcomes are
  assessed

17
Medical Reviewer, cont.

• Review - continued
• Ask questions of clarification to make sure
  policies and procedures were followed and the
  outcome is satisfactory.
• Use teachable moments to illustrate important
  lessons in effective TB control.

18
Medical Reviewer, cont.

• Follow-up
• Ensure that medical management and other issues
  are addressed.
• Ensure that ongoing, follow-up staff education
  incorporates program strengths and weaknesses.

19
Data Analyst Role

• Preparation
• Prepare lists of cases to be reviewed ahead of
  time preliminary cohort list 5 months before
  cohort review, final cohort list 2 months prior.
• Distribute lists to case managers supervisors
• Enter relevant data for each case contact on a
  cohort summary sheet.
• Prepare summary of current cohort to present.
• Calculate outcomes of previous cohort patients
  who were likely to complete contacts still on
  RX.

20
Data Analyst, cont.

• Review
• Present summary of the current cohort of cases.
• Record data on treatment outcomes and other
  missing information, while the case managers
  present each case. Note any issues for
  clarification.
• Tabulate or calculate the treatment outcomes for
  cases and contact present this at end of the
  cohort review session.

21
Data Analyst, cont.

• Follow-up
• Write a report of the cohort review outcomes and
  distribute it to everyone who has a need to know.

22
Case Manager Role

• Preparation
• Follow all protocols for case management to
  ensure patients adhere to treatment, comply with
  medical visits and complete treatment.
• Follow all protocols for contact investigation to
  ensure that contacts are identified and evaluated
  and that they complete treatment for LTBI, if
  appropriate.
• Participate in case review meetings with your
  supervisor and case conference meetings with your
  TB control team as these are scheduled.

23
Case Manager, cont.

• Preparation
• Ensure a complete job had been done (e.g., all
  loose ends are tied up, all details are
  considered and you have information to answer any
  questions).
• Prepare a concise presentation of the case
  according to a standard format.
• Participate in mock cohort review sessions to
  practice your presentation become accustomed to
  handling questions that might arise (optional).

24
Case Manager, cont.

• Review
• Speak clearly and audibly as you deliver a
  concise presentation.
• Answer questions from your TB team members and
  other cohort review members.
• Ask fellow caseworkers and supervisor to provide
  any information relevant to your case
  presentation if necessary.
• Ask any questions you might have about patient
  care issues.

25
Case Manager, cont.

• Follow-up
• Follow-up to obtain any missing information and
  clarify details that were noted during the
  review.
• Update TB registry information as needed.
• Meet with your supervisor to discuss what went
  well and how to improve the process.
• Continue case management if patient has not
  completed treatment continue contact
  investigation activities until contacts who
  should start or complete LTBI treatment have done
  so.

26
Supervisor Role

• Preparation
• Supervise and assist your case management and
  contact investigation staff in following
  protocols.
• Hold case review meetings with each staff member.
• Hold periodic case conferences with team.
• Troubleshoot problems with staff.
• Ensure staff prepare concise presentations
  according to standard format.
• Hold mock cohort review sessions.

27
Supervisor, cont.

• Follow-up
• Follow-up to ensure staff obtain missing
  information, clarify details and update TB
  registry information, as noted during the cohort
  review.
• Meet with staff as soon as possible to discuss
  what went well and what could be improved for the
  next cohort review in 3 months.

28
Timeline
29
Timeline continued
30
Proposed Cohort Review Schedule, Florida, 2008
31
Getting Started

• Organize cohort review workgroup
• Determine local team members
• Discuss information to be presented
• Discuss format for presentations
• Discuss format for distributed reports
• Communicate desired outcomes for respective
  programs

32
To some it means.
I see the cohort review as an educational
experience. I learn what it is that staff are
doing, it tells me what are the issues that are
there for every patient, what are the barriers
that staff face and all of the things that they
accomplish Sonal Munsiff, MD, Dir., Bureau of
TB ControlNew York City Department of Health and
Mental Hygiene
33
What will it mean to you??
34
(No Transcript)