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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 • • • 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 • – Objectivity/neutrality – Additional evaluation expertise Time frame: March 2003- December 2004 Evaluation Data Sources • • • • • 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 • • 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 • 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.” • • • • 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 • 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 • • • • 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 • • • • • • • 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 • • • • 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 • • 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 • – 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 • • – 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 • – 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 • • • – 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