US-Mexico Binational TB Referral and Case Management Project: Preliminary Evaluation Findings

Kayla Laserson, ScDElizabeth Ferreira, MD

July 19, 2005

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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