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

1. US-Mexico Binational TB Referral and Case Management Project: Preliminary Evaluation Findings Kayla Laserson, ScD Elizabeth Ferreira, MD July 19, 2005

2. 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

3. 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

4. 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

5. 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 • 4with 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.”

16. 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

17. 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

18. 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?

19. 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