 Tuberculosis has plagued humanity for thousands of years. Dr. Robert Koch identified the bacterium that causes TB in 1882. But another 70 years would pass before this important discovery would lead to a cure. At its peak at the turn of the century, TB was the leading cause of death in the United States, killing one out of every four people. Popular remedies ranged from tonics laced with opium to sulfuric acid applied to the chest. For many years, patients were placed in sanatoria where the only treatments available were rest and fresh air. Real progress in the fight against TB did not arrive until after World War II when general public health conditions improved and effective chemotherapies such as streptomycin and isoniazid were discovered. After decades of decline, TB was thought to have been conquered. As a result, TB programs lost funding in the 1970s and 1980s. But by the late 1980s, TB was on the rise again with more than 26,000 cases reported in 1992. Several factors were behind the resurgence of TB. Chief among those was a change in social conditions that resulted in a number of people being homeless, being crowded in shelters, in addition, the occurrence of HIV infection. And perhaps most important of all was the deterioration in the public health infrastructure and in the control programs that to that point had been quite successful in bringing tuberculosis to very low rates in this country. To regain control of the disease, Congress increased funding for TB programs in the early 1990s. These programs made tremendous strides and annual TB cases fell 31% between 1992 and 1998. But while the overall incidence of TB in the U.S. is falling, rates of TB in certain groups remain alarmingly high. They tend to be the groups that are socially most marginated, homeless persons, persons with substance abuse problems, HIV infected persons, persons from countries where there's a high prevalence of tuberculosis. Internationally, TB continues its deadly rampage. According to the World Health Organization, one third of the world's population is infected with the tuberculosis facilities with 7 to 8 million people developing the disease each year. TB accounts for more than one-quarter of all preventable adult deaths in developing countries. We can expect that in the next 20 years, nearly 1 billion more people will become infected. 200 million people will develop the disease. And 70 million people will die from TB if global control is not strengthened. Multi-drug-resistant TB is now found on five continents. One of the most effective strategies against TB is Directly Observed Therapy, or DOT. That involves, as the name would imply, a healthcare worker directly observing the patient taking the medications. Another effective strategy is screening high-risk populations and increasing the number of people who receive treatment for latent infection. Despite recent gains in prevention and control, however, TB continues to be a major health threat. In order to win the war against TB, healthcare providers and public health workers need access to information, technical assistance, and training about TB control strategies. To provide these services, the Centers for Disease Control and Prevention established in 1993 three model centers. The Francis J. Curry National Tuberculosis Center in San Francisco, the Charles P. Felton National Tuberculosis Center at Harlem Hospital in New York City, and the New Jersey Medical School National Tuberculosis Center in Newark, New Jersey. Each year, the model centers train thousands of health providers and TB program staff to help them in the fight against tuberculosis. In 1995, the CDC's Division of TB Elimination produced five self-study modules on TB to provide basic information about TB to entry-level public health workers and others who serve persons with or at risk for TB. That year, the CDC also produced a Satellite Primer on Tuberculosis, a national five-part satellite course based on the self-study modules that reach TB programs across the country. TB Frontline continues this tradition of excellence. This three-part course is based on four new self-study modules developed by the CDC covering contact investigation, confidentiality, surveillance and case management in hospitals and institutions, and patient adherence. TB Frontline is brought to you by the Francis J. Curry National Tuberculosis Center in collaboration with the Division of Tuberculosis Elimination, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, the Charles P. Felton National Tuberculosis Center at Harlem Hospital, the New Jersey Medical School National Tuberculosis Center, and the Public Health Training Network. Welcome to TB Frontline. Satellite Primer continued Module 6-9. I'm Dr. Gisela Schechter of the Francis J. Curry National Tuberculosis Center, and I'm moderating this three-part course. We're broadcasting live from San Francisco, California to over 7,000 of you who work on the frontlines of TB control. Once again, we thank the site coordinators who are managing course logistics at each downlink site and making it possible for us to reach so many of you. If you registered for the course with the TB Frontline office by the registration deadline last December, you should have received a set of the four self-study modules upon which this course is based. If you were unable to register for the course last December and would like to order the modules, we will provide ordering information at the end of today's program. Please be sure to read the module that corresponds to each course session before that week's broadcast. Today, we feature Part 2 of TB Frontline. This to our session is based on Module 7, Confidentiality in TB Control, and Module 8, TB Surveillance and Case Management in Hospitals and Institutions. I'd like to introduce our faculty members for this session. Barbara Cole is Director of Disease Control at the Riverside County Department of Public Health in Riverside, California. Welcome, Mrs. Cole. Good morning. Dr. Masai Kawamura is Director of the TB Control Program here in San Francisco. Hello, Dr. Kawamura. Good morning. Glad to be here. Charles Wallace is Division Director of the Tuberculosis Elimination Division at the Texas Department of Health. Dr. Wallace is unable to join us here in the studio, but we will hear from him via an audio bridge from Austin, Texas. Hello, Dr. Wallace. Good morning. It's good to be with you. Thanks. We will hear presentations from both Mrs. Cole and Dr. Wallace on various aspects of confidentiality and surveillance and case management in hospitals and institutions. We will also apply the course content to a series of video dramatizations. We will conclude our broadcast with a question and answer period. You may fax in your questions for our faculty at any time during the broadcast. Ask your site coordinator for a fax form to submit your questions. The fax number is 415-626-3110. We will accept your telephone calls later in the broadcast. Watch your screen for the toll-free telephone number to call. Your feedback about this course is important to us. At the end of this broadcast, we will ask you to complete a few evaluation questions. Right now, let's hear TB Control staff from San Francisco asking the questions that we plan to address in today's broadcast. What negative consequences can result if I reveal personal information without the patient's permission? How can I protect patient confidentiality in healthcare settings in the field and during data collection? How is TB surveillance and case management done in hospitals and institutions? How can I establish a relationship with a patient during the initial interview? What's the best way to work with interpreters? What is the discharge planning process? Confidentiality is a key component to protecting the rights of patients and establishing the trust that is so essential to the patient-provider relationship. Confidentiality applies not only to the TB diagnosis but also to other aspects of a patient's life. If private information about a patient is revealed to unauthorized persons without the patient's permission, the potential consequences for the patient can be devastating. We asked several TB experts and practitioners to share their insights into this important topic. Confidentiality means that you want to protect the patient from other people knowing information that they shouldn't know, especially the medical information about TB. Confidentiality is important because there are certain rights that patients have and one of them is a right to privacy. We have patients that actually still lose their jobs because of tuberculosis. There's still a lot of stigma to TB. We recently had a patient who was sprayed with Lysol and thrown out of the house. So if we did not maintain confidentiality, we would probably not get the cooperation of our patients. I think it's very important that the patient be able to trust you. If that is undermined, you may find that your patient is no longer adhering to treatment and the key to success for cure is the completion of therapy. You have to rely on the patient to tell you who is he spending time with, who may have infected him. And without that bond that you develop between yourself and the patient, that makes it very difficult. Often people will test us to make sure that we do keep confidentiality. Someone will call and say, well, we know that there's a case of tuberculosis out at the fishing pole plant and I want you to tell me who that is. I think I might have been exposed to that person. And often I feel like that probably is the person themselves calling to test us about whether we'll give out that information and we just won't do it. It's especially difficult to protect a patient's confidentiality in, especially in school investigations and in workplace investigations because rumors start to fly. People get very anxious and become very demanding. Sometimes we'll go out to do a screening and we'll include the patient and we'll screen the patient, the index patient, as if they've never been screened before and we may give them a saline solution instead of the PPD solution. So there won't be any reaction and they won't be targeted by other people in the office who know who look or other people in the shelter who know to look for a positive reaction. We had a situation in a large workplace where there were 500 workers and the person with tuberculosis did not want her name revealed to anyone. And we were faced with having to test all 500 people even though we knew she probably didn't have any kind of contact with all those people. I protect the privacy of my own patients by first of all letting the patient know what information I'm going to tell anyone that is about the patient and certainly if I'm going to give the name of the patient to anyone I will let the patient know and discuss it with the patient so that the patient feels okay about it. It's a challenge in a very small busy clinic so I attempt to have any paperwork with patients' names on it unavailable to other people who don't need to see it. And if you're leaving the patient an appointment or a message card it really should be in a plain envelope that doesn't have anything associated with TB control on it. If you're calling the patient you shouldn't say, you know, I'm the nurse from the TB clinic calling to this patient. If you don't educate the patients about when confidentiality will be broken and for what reasons you're going to run into problems with therapy. We're very, very careful because we want to protect all rights of the patient but if it's impossible the rights of the public and the public health certainly supersede this. When the patient is unwilling or unable to assist you in the contact investigation then I think it is appropriate to break confidentiality. Especially if the patient is very contagious, is smear positive and is putting the public at risk. For example we had a patient that was homeless and substance abusing. He wasn't working with us, he wasn't coming in for his therapy and he was still contagious and he disappeared for a while. So at a certain point when we couldn't find him after searching for him our TB controller decided that we had to alert the shelters that he was frequenting that he was a case of tuberculosis and not to let him have admittance to the shelters. Spanish confiar means to have faith and I feel that that gets to the key of the issue that confidentiality is not some kind of puritanical not talking about things but rather having the faith and trust of a person who's sick. People are putting their lives in our hands as healthcare providers and with that faith in us we need to honor that trust as an integral part of what we do. How can confidentiality be protected in the real world? What are some safeguards we can use to decrease the chance that confidentiality will be breached during patient provider encounters? How can we protect private patient information during the collection, sharing and management of patient data? To further explore the specific ways that confidentiality can be maintained in TB control activities we turn now to a presentation by Barbara Cole. Thank you. In this presentation I'd like to discuss the issue of confidentiality and why it's so important in TB control activities. I will focus on specific steps that can be taken to protect patient confidentiality in the office, the clinic or in the field. Confidentiality can be defined as the protection of private information revealed during patient provider encounters including all written or electronic records of these encounters. Confidentiality also extends beyond the TB diagnosis to other aspects of the patient's life. For instance, what if a patient is living in the United States without documentation? Or what about the patient who is engaged in the use of illegal substances? To build a trusting cooperative relationship the patient must feel confident that the healthcare worker will not report him or her to law enforcement or immigration officials. It is critically important to maintain patient confidentiality because the diagnosis of TB can have serious consequences for a patient. For many people TB still carries a strong stigma and a patient can be shunned by their family, their friends or employers if the information is revealed. Protecting patient confidentiality will help sustain the ongoing trust and cooperation needed between a patient and the healthcare worker for the long period of treatment. I'd like to share a personal experience involving confidentiality where we had a junior high school student with TB and the principal actually announced on the PA system that anyone having contact with this child should report to the school office. This was such a severe breach of confidentiality. It was very difficult to maintain the patient provider relationship. I will now review five general principles for maintaining confidentiality in any situation. When you first encounter a patient it's important to confirm his or her identity. It's also important that you don't discuss the patient's case with anyone without the patient's permission. This includes your own family and friends during your off-duty hours. Never leave records of forms where an unauthorized person may access them. And today when we do a lot of faxing it's really important to use only secure routes to send patient information. Always mark their information confidential. Make sure any interpreters who are involved in a case understand the importance of confidentiality. Now the following steps may be taken to protect confidentiality in an office, clinic or institution. It is important to use a private room or area to conduct patient interviews. Never use patient names or discuss cases in a public area. And before you divulge patient information to another healthcare worker be sure that the person is authorized to receive it. Keep patient records in a closed locked file and safeguard computer screens. We should also restrict access to electronic databases, carefully protect passwords and keys. You should also remember to keep computers in a restricted area and safeguard the hard disk. Keep printouts in a locked or restricted area and remember to destroy printouts that are no longer needed. Now to safeguard patient confidentiality in the field some steps include to never conduct a patient interview where it can be overheard by the public. Don't leave messages containing confidential information on doors and if you must leave a note make sure the message is in a sealed envelope addressed to the specific patient and that is marked confidential. Don't leave revealing information on an answering machine that other people can access and don't leave messages containing confidential information with a patient's neighbor or friends. It's also important that you don't disclose the patient's condition when gathering information about his or her whereabouts. At times a public health nurse or a health worker may need to take the record out on a home visit. It's very important to safeguard the patient record not leaving it around where the patient's family might access it not leaving it in your home if you end up taking it home that someone else might see it. Now to quickly review my main points about the important topic of confidentiality. Confidentiality refers to all communications of private information revealed during patient provider encounters including records of these encounters. Confidentiality extends to other aspects of the patient's life including issues around illicit substance use or immigration status. Confidentiality is critically important to protect the patient from serious consequences if the information became public also to gain the trust and cooperation needed from the patient to complete treatment. Confidentiality measures should be taken in the office, in the clinic and in the field. These measures include never discussing patient information with any unauthorized person never discussing patient information where it can be overheard by the public taking care not to leave revealing messages for a patient on paper or on an answering machine also closely safeguarding paper and electronic files, computer screens and databases. To demonstrate some of the concepts covered in Barbara's presentation we have three dramatizations of situations in which confidentiality is breached. Each dramatization will be shown twice the first time when confidentiality is compromised and the second time when measures are taken to prevent that. The actors you will see in these dramatizations are staff from our local TV program in San Francisco who kindly gave their time to appear in these vignettes. We thank them. Let's see our first scenario in which a healthcare worker struggles to maintain patient privacy when confronted by a nosy neighbor in the field. Watch closely for words or actions that you'd want to avoid. How would you respond in this situation? Charlie? He's not home right now. Oh, God, we had an appointment at nine. Did you see him leave? Yeah, he took off a while ago. I've seen you around here before. I just saw you pull up in the city and county car. Who are you? Well, I work with public health. Did Charlie say when he was coming back? No idea. Is Charlie sick? Well, no, he's doing a lot better now. Better? What is Charlie sick with? It must be pretty bad if the health departments come over here all the time. Is it AIDS or Ebola? No, it's nothing serious like that. Serious? Is it contagious? You know, Charlie's not infectious. He stopped coughing. Coughing? You mean he has TB? You know, I really, really can't say. Okay? I just can't. Hey, George, the guy downstairs has TB. What went wrong in this scenario? Well, a whole host of things went wrong in this scenario. Clearly, the worker was not thinking about the patient's confidentiality. The worker responded directly to questions without considering the impact on the neighbor, figuring out what was wrong with the patient. The worker revealed their identity as a health department worker. I think it's important to acknowledge, though, that can be a challenge and that most health departments require workers to have an identification badge on, so you have to balance showing who you are without reaching confidentiality. I think another area was that the worker revealed or implied that indeed Charles was sick, mentioned coughing, and the neighbor figured out, yes, it must be tuberculosis. This points out how important it is for staff to be trained in how to address these situations. And then a very basic thing was that they put a note on the door. That was in plain sight that anyone could read. Let's revisit the scenario and see how the nosy neighbor might be handled differently. Hey, Charlie's not home right now. Oh, really? Okay, thanks. Yeah, he took off a while ago. Who are you? I have seen you around here with the city and county car. Yeah, it's a county car. Is Charlie behind on his taxes? Oh, you know, I hope not, but, um, look, did Charlie tell you when he was coming back? No, I'm not his social secretary. What is in that bag? What is this, neighborhood watch? No, but we tell each other when suspicious characters are knocking on the door. Well, look, um, when you see Charlie, would you let him know that Candy came by and that I'll stop back by again this afternoon? Well, why should I tell him this is all about? Oh, Charlie'll know. Thanks for your help. Do you want to leave that bag with me or make sure that he gets it? No, that's okay, but thanks. Bye. How did the DOT worker in this scenario protect the patient's confidentiality? Charles? Well, there are a number of things that went right in this particular scenario that protected the person's confidentiality. One of the first things is the worker remained friendly. He decided to accept the neighbor's intrusive questions, which was really a good effort. The worker was able to protect her identity as a health department worker, which is often critical in these situations. The worker used humor and answered the neighbor's questions with the question, which is a very unique way of handling these particular kinds of neighbors. And especially critical in this scenario, the worker did not leave the bag of meds with the neighbor or by the door. This is really critically important. And the worker continued to protect the patient's confidentiality by removing the note that was going to be left. And the envelope had the patient's name marked confidential. And even more important about this thing is that the patient slipped the note under the door instead of leaving it on the door. Very, very important. I think another precaution, and I certainly agree with the comments that Charles made, but another precaution that the worker could have taken would have been to disguise the bag of medication, either putting in a different type of bag or at least not have it visible to be suspicious by the nosy neighbor. Good point. Thank you. Our second dramatization highlights how patient data in a clinic office can fall into the wrong hands. So be sure to call us if you have any more problems with. Excuse me, just one second. Hi, this is Marie. Oh, yes. Please put them through. Excuse me, just one second. Hi, this is Marie. Yes, I've been waiting on the Jones chart. Oh, you faxed it this morning. Great. Great. It's been such a madhouse around here. I haven't had a chance to check the fax machine. It's right in the hallway. If you hold on, I'll check. I'll be right back. Okay? Yes. Yes, it was in the fax. Thank you. Yes. Oh, you want to leave a message? For Dr. Peters regarding the Jones chart? No. Oh, regarding Wilma. Fredrickson. Okay. Abnormal. Chest X-ray. Smear. Positive. Call. Regarding interactions with protease inhibitors. Okay. I'll make sure Dr. Peters gets the message. Thank you. Okay. I'm sorry. Okay. So again, if you have any more problems, be sure to call us. Okay? Take care. How was confidentiality breached in this scenario? Well, Gisela, you know, the health care worker did an excellent job at communicating with the person on the phone, repeating the message. However, it was done right in front of another patient. And as you notice, she mentioned the name of the patient, you know, medical information that should have not been repeated in front of the patient who was there, and also left documents right out there in plain view for the patient to see. And in addition to that, you notice that she went right outside to where the fax was right outside the hall, which is not a really secured area, and left those documents alone with the patient in the room. Let's visit that office again to see how patient data could be better protected. So be sure to call me if you're having any problems with it. Excuse me. Hi. This is Marie speaking. Yes, put them through. This call is urgent. So I'll take a quick message and I'll get right off. Hi, this is Marie. Yes, you faxed it this morning. Great. Thank you. The fax machine is in the clerk's office and he processes each incoming fax. So we'll be able to confirm that. Okay. Oh, okay. You wanted to leave a message for Dr. Peters? Okay. Can you spell that? Okay. All right. I'll be sure Dr. Peters gets the message. Thank you for calling. I'm so sorry about that. Okay. So if you have any more problems, give us a call. I'll see you next month. How was confidentiality protected in this scenario? Okay. So certainly this healthcare worker did a much better job in protecting the patient's confidentiality. Basic thing, the fax was in a secure area and one person was responsible for it. She was careful not to leave the patient in the office by themselves and made sure that the message she took was covered so the patient couldn't see it. She didn't repeat the information out loud so the patient could hear it and she didn't mention any of the other medical conditions. One other thing I thought though that might have enhanced the protection of confidentiality was the healthcare worker could have gone into another room to take the message or if she was almost completed with the caller, she could have asked them to hold until she finished with the patient and then took the message. Our third dramatization takes place during a contact investigation in the workplace. Hi, is this how I'm supposed to do my skin test? It sure is. Hi, my name is Patrick Fian. I'm with the Davis County Health Department. Why don't you come and sit down? Okay, but I hope this doesn't take long. I've got a ton of work to do. No, no, no. It shouldn't take much time at all. I'm just going to ask you a few questions and I'll give you a quick skin test. You'll be on your way. So first of all, what's your name, please? My name is Alexis Martinez. Listen, I can save some time. I don't have TB if that's what you're wondering. And I never hang around the legal department. The legal department? Yeah, the legal department. We all know that that's where TB started. So since I never go over to legal. See, the thing is you might have shared airspace with her somewhere else in the building. Her. You mean Jennifer? Actually, no, I don't mean anyone. We're screening everybody who spent time on the second floor in November. So just tell me this, have you been coughing lately? No. Jennifer coughs, but I thought that's because she smokes. She's it, right? I'm not supposed to say, actually. I just know that your name is on a list as a second floor employee. So I'm just going to have to finish asking these questions and give you your skin test so we can determine if you're infected. Okay, whatever. Man, poor Jennifer. I should warn everyone in accounting. How was confidentiality breached in this situation? Charles? Well, this healthcare worker was certainly not ready for this interview. And one of the things he did not do, and we must always do, is think confidentiality first. In this scenario, the healthcare worker breached confidentiality in a number of ways. First, he left the door open so anyone passing by the door could hear the conversation and broadcast it even further than he was as the interview was underway. His clipboard was visible to the employee, so that patient information was exposed. He used the pronoun her, which narrows the potential list of patients down rapidly. And the healthcare worker indirectly confirmed the employee's guess that the patient is from the legal department. And then the healthcare worker revealed the scope of the screening, second floor, narrowing things down quickly, and even went further to indicate the time period that the case had been exposed or revealed. And that's just not good. I kind of confused the whole issue and exposed the confidentiality setting altogether. I must say that protecting confidentiality can be a balance and act. However, it is our responsibility to do everything we can to protect the patient's confidentiality so we can assure that that patient receives the best possible care. Thanks. A comment to add to that, Charles. As we know that sometimes it's difficult to clearly define the exposure period. At times you need to have a balance between providing sufficient information so someone can self-identify if they were missed in terms of the line listing you have for knowing who needs to be tested. But there's several approaches you can use to avoid revealing information about the index case. For example, the worker might have asked the employee what department they were in and they could also ask them when they started to work. So if this exposure period was in November and the worker didn't start working until December, then clearly they were not exposed. One other thing to add, Barbara, is that it's very natural for coworkers to have this kind of curiosity. I think they want to assess their own risk of transmission. And what you can do as a healthcare worker is tell them that, as you mentioned, ask them those questions about where they work and how long they've been working there and tell them that the health department is conducting the investigation and will determine who the significant contacts are. Good point. Let's see if this situation can be turned around. Hi, is this where I'm supposed to get my skin test? It sure is. Hi, I'm Patrick Fian. I'm with the Davis County Health Department. Would you mind getting the door for me, please? My name's Sid Allen. Okay, but I hope this doesn't take long. I've got a ton of work. No, no, no. It won't take long at all. I just have a few questions to ask you and we'll do a quick skin test. You'll be on your way. Okay? So first, what's your name? My name's Alexis Martinez. Listen, I can save us some time. I don't have TB if that's what you're wondering. And I never hang around the legal department. No TB. Great. And that's why I'm here today to confirm that. But this isn't about any particular department. Now, as that letter from the company president said, you may have been exposed to an active case of TB here at work. And we want you to stay well. So I'm going to ask you a few questions about how you've been feeling lately and I'll place a skin test on your forearm. Now on Thursday, I'll be back to look at the test and depending on the reaction, we'll be able to tell if you've ever been infected with a TB germ. Yeah, but who's been spreading TB? It's somebody in legal, right? Bob or Jennifer? We know as much as I appreciate your curiosity, the identity of the patient is going to be confidential. I'm sure if the situation were reversed, you'd want us to protect your identity, too. And we would do that. Everybody knows it's either Bob or Jennifer. And we have a right to know who's spreading the disease. I mean, we're concerned about him or her. You don't have anything to worry about. The person with TB is going to be just fine. Today we want to make sure you're okay. So have you been coughing lately? No. Bob had a cough last month. Wait a second. I can only interview one person at a time. So he's not the one? Well, people cough for different reasons. Let's just focus on you right now, okay? Have you had any fevers or night sweats? Well, how was confidentiality protected in this situation? It was much better. And the door was closed. The clipboard was out of sight from the contact's view. The healthcare worker was very focused on the contact, acknowledged the curiosity, but managed to sidestep the implicating questions. And so in this scenario, the healthcare worker did an excellent job. I'd just like to add, if I can, that Patrick really had a great comeback when he told the patient on the contact, put yourself in the patient's shoes. That's a nice response to her inquisitive questions about who the person is. Reversing the situation is a key way of demonstrating how to deal with that particular kind of patient or particular kind of contact. I thought that was good, too. And I think it demonstrates any time you do in a workplace investigation, it's so important to get the managers involved so that you have a key contact person that you can educate the managers and have it trickle down to the employees so they can understand, yes, there's a need for testing, but it's very important to protect the patient's confidentiality. One of the points is, and I think maybe Barbara had mentioned this one, is that the patient, the healthcare worker, needs to be certain of themselves. If the focus is not there, the contact or even the patient can certainly manipulate that particular individual and have the healthcare worker responding to them in a way that they're in control. So I think the healthcare worker needs to be in control of the situation in order to get the maximum out of that particular person. We turn our attention now from confidentiality to the subject of surveillance and case management in hospitals and institutions. Here again is Barbara Cole to share her insights. In the next few minutes, I'd like to review a four-step process for conducting surveillance and case management in the hospitals and institutions with a special focus on the patient interview. Let's begin with a definition of terms. Surveillance is the ongoing and systematic collection and analysis of data needed to plan and implement public health practice. Surveillance also involves the data being shared in a timely fashion with the public health staff that need to receive it. Case management is the primary responsibility for coordinating patient care to ensure that the patient's medical and psychosocial needs are met through appropriate utilization of resources. For TB case management, it is also important to make plans to address any barriers to adherence. The basic process of surveillance and case management can be described in four steps. The first step is the identification of suspected or confirmed TB cases. This can be done through routine case reporting when someone like a physician an infection control practitioner or a pharmacist makes a required report of a TB case to a public health authority. Now, most states have specific laws requiring health care providers to report TB. In California, which is where I live, TB must be reported within one day of identification. Now, the identification of cases, however, can also take place through active case finding in which the TB program actively searches for cases by collaborating with staff and reviewing records in hospitals, institutions, pharmacies, and laboratories. An example would be a TB program that has established a relationship with specific laboratories to review their AFB or TB logbooks for results of AFB smear examinations. Or a public health worker may regularly review certain pharmacy records to identify patients who have been placed on tuberculosis drugs. Now, the second step in the process is to collect patient information. This includes locating the patient, identifying where important patient information can be found, and reviewing the patient's medical record. Collecting patient information is very important for the preparation of a contact investigation to identify potential adherence problems and to fulfill reporting requirements. The third step in this process is the initial patient interview, which I'd like to explore in more detail. During the initial interview, the public health worker can establish a foundation of trust and start building an effective partnership with the patient. This is also an opportunity for collecting information that will be vital to the contact investigation and case management activities. It is important to keep in mind that the initial interview may occur soon after a patient has been diagnosed with TB. He or she may be feeling overwhelmed or fearful. Lack-wise, the patient may still be feeling very sick or may be unable or unwilling to cooperate. It is likely that more visits will be needed. Now, here are a few guidelines that can contribute to the success of an effective initial interview. One, it's important that you have a clear idea of your objectives in the interview, allowing enough time to cover each objective. Conduct the interview in a location that's as private as possible and free from distractions or interruptions. Explain to the patient why you are there and the reason for the questions you will be asking. Otherwise, the very personal questions we need to ask will seem unnecessarily intrusive and may make the patient suspicious or feel uncomfortable. It's also to explain why identifying contacts is so important. This includes how contacts may already have disease and need to receive treatment or how contacts may be just infected but need to receive treatment to prevent active disease. It's important to begin to assess the patient's knowledge, feelings, and beliefs about TB. The healthcare workers should educate the patient about TB as needed. To be sure the patient has an accurate understanding ask the patient about what he or she has understood from what you've told them. Listen attentively and respectfully to the patient's concerns and fears about TB and its treatment. Be open-minded about the patient's beliefs and above all, treat the patient with dignity and with respect. One very important skill to explore during the initial patient interview is the use of open-ended questions. These are questions that elicit more explanation than a simple yes or no. Open-ended questions begin with words like where, who, what, why, when, and how. Rather than asking are you feeling better which can be answered either yes or no an open-ended question of how are you feeling opens a much wider door for information from the patient. Some examples of open-ended questions that might be used during an initial interview include what symptoms do you have, when did they begin, who are the people who visit your home, how do you get to work, what are the people you see each day, what is your daily routine, where do you sleep. When you're asking these questions it's important to obtain as much information as possible for locating the patient in case you're unable to locate them at a later date. Now sentences that begin with tell me about or explain to me are also a good way to avoid simple yes or no responses. Some initial interviews may require the use of an interpreter. These situations involve several challenges. For instance, the interpreter may not accurately convey what the interviewer or the patient has said or may add their own ideas. The patient may feel hesitant to share personal information in the presence of an interpreter. Interpreters may have difficulty interpreting medical terms into the patient's language. Also, there can be cultural issues where certain topics are not culturally acceptable to ask another person. Because of these challenges, it is ideal if a program can use trained medical interpreters. If this is not possible, other healthcare staff can also be used to interpret. In cases where no other alternatives exist, other members of the patient's community or family can be used. But be aware that maintaining confidentiality in these situations may be problematic. If you must use a family member, you should not use a patient's children. Some information may not be appropriate for children to hear or to translate, and this will be upsetting to the patient. The following guidelines can help ensure a successful interpretation during an initial interview. Interpreters ask the patient's permission to use an interpreter. It's important to meet with the interpreter beforehand to discuss the goals for the interview and to review the questions to be asked. Remind the interpreter that all information during the interview is confidential. Keep the messages short and focus on one topic at a time. It's important to address the patient directly, not the interpreter, and ask the interpreter to interpret the questions and answers as exactly as possible. During the initial interview, a patient may not be able to recall all the names of possible contacts. The health care worker can encourage the patient to telephone him or her at the health department as other names are remembered or questions arise. A follow-up interview with the patient should be scheduled to collect additional contact information. Now, to review the first three steps in surveillance and case management, four-step process. The first step is the identification of suspected or confirmed TB cases, which can be done through routine case reporting or through active case finding. The second step is to collect patient information. This includes locating the patient, identifying where important patient information can be found, and reviewing the patient's medical record. The next step is the initial patient interview, during which the public health worker can establish the foundation for an effective partnership with the patient. This is while collecting vital information for contact investigation and case management activities. Using open-ended questions, which begin with words like where, who, what, why, and how, elicits more information than simple yes or no questions. When using the interpreter during an initial interview, it's important to meet with the interpreter in advance to discuss the questions and to stress the importance of confidentiality. You should request that the interpretation be as exact as possible. Now, the fourth step in surveillance and case management process is to plan for follow-up care. This step will be covered in a presentation later in this broadcast. Barbara shared several points with us about how to make that all-important initial patient interview as effective as possible. But a picture is worth a thousand words. Watch the following dramatization to see how a typical interaction might unfold. This scenario is located in a patient's hospital room, where initial interviews often take place. In this initial interview, what objectives does the health care worker achieve? What interviewing skills does the health care worker demonstrate? How would you handle a similar situation? The Centers for Disease Control and Prevention recommends that health care workers wear a personal respirator during an interview when a TB patient may be infectious. However, in the dramatization you are about to see, the health care worker is not wearing respiratory protection. This is to be sure that you could hear the dialogue between the characters as clearly as possible. Hi, Mr. Daly. My name is Steve Jones, and I'm a nurse with the Davis County TB control program. We spoke on the phone yesterday. Oh, yeah. Hi. Right on time. Thanks, Bernard. I appreciate you taking some time for me. As I mentioned on the phone yesterday, I wanted to meet with you to talk about your TB, your treatment, and how we can find out if anyone else close to you also became infected with TB. So how do you feel? I'm better. Still pretty tired. I can understand that. You've been through a lot. So, about your TB, how do you think you got it? Hell, I don't know. Maybe I got it from someone at work drinking out the same cup or something. Actually, TB is spread through the air when one person with TB coughs, talks, or laughs into the airspace of someone else who can breathe the TB germ into their lungs. Man, I hate this cough. It's nasty. When did your cough start? What's with all these questions? The reason I ask about your cough is to help us figure out the period of time when you may have spread the TB germ to other people. It's not that my questions are meant to be nosy. I just need to get some more information to follow up with other people who could have been exposed to your TB. About your cough, when did it start? Was it before or after Halloween? Bernard and Steve further discuss Bernard's symptoms. Steve then turns the conversation to Bernard's living situation, asking him where do you live? Who do you live with? Who else lives or stays with you? He asks questions about Steve's work. Where do you work? What kind of work do you do? Who shares your workspace with you? After taking down the names and locating information for Bernard's contacts at home and at work, Steve continues his questions. So, beside your wife and two kids at work, who else do you spend time with? Well, I play on the basketball team once a week and never mind. What? No, I just don't want to get into it. Bernard, if there's anyone else you spend time with that you'd rather keep quiet about, I understand, but it's important for us to contact anyone who may have been exposed to your TB. Whatever you tell me won't be divulged to anyone if you don't want it to. You mean that? I do. I don't know. Let me think about it. Okay. We can talk about that later. So, what questions do you have about your medications? Steve and Bernard talk more about his treatment. Bernard then starts to show signs of fatigue. Listen, my wife is coming to visit me pretty soon. Can we wrap this up? Sure. Thanks again for your time today. When would it be a good time in the next day or two for us to meet again to talk more about the people that might have been exposed to your TB? How many hours if that would be more private? Tomorrow afternoon might work around 4 o'clock. Okay. What important objectives did Steve achieve in this initial interview? One of the first things he tried to do was establish rapport with the patient. Of course, this is very important for building a trusting foundation with the patient. He gave good patient education. The first thing the patient was saying was that he might have gotten TB from drinking from the same cup. So, he took the time to address that and really explain to the patient how TB is transmitted. And that's very important because a lot of people have a lot of misconceptions about how TB is transmitted. He established onset of symptoms. And you need that in order to plan your contact investigation. You really have to establish the potential period of infectiousness for when people might have been exposed. He gave information that was simple for the patient while he was asking questions. He got information on the patient's work, home setting, as well as leisure. Although, if you notice, the patient was somewhat hesitant when he got into leisure types of activity. He took the time, though, to acknowledge the patient's concerns. He backed off when the patient was uncomfortable. And then he set an appointment for a follow-up interview, which was very important. You know, not all patients are going to be like Bernard. And this is a very big interview requiring a lot of information to be extracted from the patient. And it's important to know that sometimes you won't get a bit of information, but that first interview is just really to establish the rapport. But that's also very important because you can meet again, and again with the patient, that will really serve you well. One additional comment in our scenario, the health care worker didn't wear a respirator because we wanted everyone to hear. But in reality, when you're trying to interview that patient and you have a respirator on, it is very difficult. It's difficult for the patient to understand sometimes what you're asking. It also can make the patient feel very ostracized. And just think about patients in isolation. People don't want to go in. And then they come in with all this garb on. So I think in reality, we have to recognize, yes, we need it to protect the health care worker. But the health care worker might have explained to the patient the need. And I think that really eases, makes it easier for the patient to accept health care workers coming in with respirators on. That's a good point. How would you rate Steve's skills as an interviewer? Charles? Well, you know, I really celebrate the skills of this interviewer. I feel it was a very good interview. Steve took the time to explain the reasons for the questions, which I think are very critical. And Steve was compassionate and showed empathy toward Mr. Daly, which really makes the setting, the trust, the relationship a lot better and hopefully make the questions come, response to the questions come a lot better. I cannot really overemphasize the need to be courteous. I think so many times we talk in a whole different mindset when we walk into a room where a TB patient is and our beliefs and our fears and our concerns overwhelm us before we even sit down to talk to the patient. And we lose our personal touch. Steve was courteous. He was on time. He thanked the patient for granting him the interview and participating in the interview. And that's very important to be grateful to be expressive and your thanks to this particular individual. A few other things too. Steve did not push Bernard earlier to reveal everything that he knows, all of his contacts. But he worked very hard to establish a relationship, a partnership and establish trust between he and the patient, which is really a critical element in trying to develop that first relationship, that first contact, that first encounter. Steve was willing to listen to the patient's concerns about TB and its treatment. Being very sensitive to the patient's condition over all is very, very important. Steve recognized when Bernard was tired and overwhelmed and it was said earlier, you've got to be in a giving atmosphere, a giving environment when it comes to this particular patient and concern for the patient and show that. Steve recognized that Bernard had additional information to share and set up that second interview to expose or explore for additional contacts. And Steve had something else that many of us don't have as we interview patients and that's the luxury of Bernard in a setting that was private and confidential and gave him the kind of freedom from distraction that we often need to have if we're going to interview a person and try to get the maximum out of that interview. Let me just say something else very quickly, too. I think the whole idea of beliefs and concerns across cultures is very, very critical. We must be understanding that different cultures have different beliefs about TB and different kinds of fears and we must be paramount on our minds as we begin the interview process with persons of different cultures. I think all that's true. I agree completely with Charles and all the points that he made. I agree that Steve was a very good interviewer. He listened, he was empathic, he was caring and he met the patient where he was. I'd like to remind you now that you can start calling in with any questions that you have. The first call is 888-565-8673 If you're located outside the U.S. you'll call 415-861-8543 and remember you can also fax your questions to 415-626-3110. Another important step in case management in hospitals and institutions is discharge planning. The initial good start in TB case management is undermined by a lack of continuity after discharge. This can be especially challenging when more than one jurisdiction is involved. Charles Wallace shares with us an overview of this topic. Thank you. In my presentation today I will cover an important phase in TB case management in hospitals and institutions. Discharge planning. I will describe main components I will also highlight the special challenges involved when patients are discharged from a facility in one jurisdiction but moved to another jurisdiction. For patients who are leaving a hospital or other institution such as a correctional facility discharge planning will help ensure that their treatment, TB treatment continues. Ideal discharge planning is a team effort headed by a nurse or a designated discharge planner for the facility. Team members may also include social workers, the patient's position, expert consultants if needed and outreach workers. I want to stress that discharge planning teams should meet before the patient has been released from the facility. One of the most important tasks of the team is to develop an adherence plan for the patient to keep his treatment on track after his release. Meeting with the patient prior to discharge to discuss his future plans will help you to avoid losing the patient to follow up. The adherence plan should address the following questions. What are the patient's understanding and acceptance of his TB? What are potential barriers to this patient's adherence and how will treatment be delivered and monitored? The adherence plan should be developed with input from the patient if possible and his family if appropriate. The treatment that spells out the responsibilities of each party can be an effective tool in the adherence plan. These and other adherence strategies will be covered in much more detail in the third broadcast of this course. In addition to discussing the patient's TB treatment, the discharge planning team may identify other problems that the patient will face upon release. A patient may be liking and housing and employment. He or she may be struggling with HIV infection. Perhaps the person needs treatment for a chemical addiction. These issues may interfere with adherence and DOT should be strongly considered as a possible strategy. The discharge team can help the patient by making referrals for support and assistance. Linking the patient with social services or emergency assistance programs can help the patient in general and help them to finish their treatment What about situations in which the patient has already been discharged or has left the hospital against medical advice? A good place to start in is the medical record of that patient. Often a discharge summary is in the record and contains key information about the patient's stay in the hospital or institution. The patient's discharge diagnosis and a plan for follow-up care you may also be able to find more information about the patient in the medical record. Now I'd like to turn our attention to inter-jurisdictional referrals. Inter-jurisdictional referrals present a major challenge for health departments. These referrals can occur within one state between two states or between two countries. They can involve the following kinds of cases. A patient at any point during the course of TB treatment simply moves. A patient living in the hospital in one jurisdiction but lives in another. Our patient is confined in a correctional facility in one location but will move to another area when he or she is released. Finally, a patient may be a seasonal migrant worker who moves between jurisdictions often. Let's remember that the end goal for all cases is to complete therapy. More than one jurisdiction is involved. First of all know your department's guidelines and processes for inter-jurisdictional referrals. Here are some steps to consider if you are in the jurisdiction that the patient is leaving. If a patient is mid-treatment and is going to move, give him a copy of his records and complete instructions for how to continue to take medicines. Make sure he has information about where to go in a new jurisdiction for more medicine and care. Forward all relevant medical information to the new jurisdiction. Sometimes a standard form is used. As an inter-situation of which TB patient data is being transferred, take proper steps to protect the privacy of the patient's information. Another strategy to consider is if you are in the jurisdiction that the patient is leaving is to contact the state health department, TB control officer about the need for follow-up and next destination of the patient if you know that information. Even after the patient has left your jurisdiction, continue to forward any additional information about that patient that becomes available, such as laboratory information to the referring or receiving jurisdiction. Finally, if the receiving jurisdiction is out of state, route communications regarding TB care through the state health department, if you are in the jurisdiction that is receiving the patient, here are a few guidelines to consider. Verify and visit any forwarding address for the patient that the other jurisdiction provides. Stay in contact with the referring jurisdiction. Let the referring jurisdiction know if you have any trouble locating the patient and work with the referring jurisdiction and the state TB control office to explore options for locating the patient. I'd like to close with the summary of my main points. Whether a patient is leaving the hospital or leaving prison, discharge planning is an essential component to ensuring a successful TB treatment outcome. Discharge planning should be a team effort. Developing an adherence plan with the patient is one of the most important steps of discharge planning. The team should also help the patient connect with any other resources needed, such as housing, mental health services, HIV or substance abuse treatment. In our highly mobile society, many TB patients will find themselves moving between jurisdictions. Patients should be provided with documents and information to prepare them to continue their treatment in the new jurisdiction. Whether a jurisdiction refers to TB patients or received them, careful and continuing communication with the TB program staff and other jurisdictions . The state TB program should also be involved in efforts to track patients who move to new jurisdictions. Discharge planning that involves more than one jurisdiction is often a feature of TB cases in correctional institutions. Now correctional facilities are not primarily medical settings, nor is healthcare one of their core functions. This makes it especially challenging to form effective liaisons with correctional facilities. Let's see a dramatization of how discharge planning with an inmate who has just been released is handled. The case of James McMurtry offers one example of how continuity of care is coordinated when an inmate is released from a correctional facility in one jurisdiction and re-enter society in another. Hello, Jefferson County TB control program. Yes, hi, this is Irene Platt calling from the state prison in Lawrence. Yes, we have an inmate with TB who's being released the day after tomorrow and he says he's planning to resettle in your county. I'd like to fax over his records and locating information. Who can I send this to directly to maintain confidentiality? Okay, is the fax machine in a secure area? Great. He was diagnosed on May 4th and started four drugs the same day. Since then, he has converted to smear negative and switched to two drugs as of last Tuesday. He needs DOT for the rest of his treatment because the file shows a history of IV drug use. Okay, we're planning to send him off with two weeks medication and the address and phone of the clinic. Okay, his name is James McMurtry. He's assigned to Larry Vance in your county's parole department. Thanks. Hello, Mr. Vance. This is Vivian Drake. I'm a public health nurse with the Jefferson County Health Department. I understand that you're the parole officer for James McMurtry. We've been trying to locate Mr. McMurtry ever since he was released last week from the state prison in Lawrence. I understood that he was going to stay with his cousin, let's see, John Lipton at his house on Charter Way, out there. We really need to make contact with Mr. McMurtry. Uh-huh. You have a new address for him? His brother's house. May I please have that address and phone number? Okay, great. I'll go out there today. But in case I don't connect with him, could you please let him know next time he contacts you that I really need to talk to him? Okay. The number for him to call is 555. Mr. McMurtry, I'm really glad we've gotten together. Thank you for meeting with me and thank your sister-in-law for taking all those messages from me. That's okay. You can call me Jimmy. Okay, Jimmy. How's your first week back in Jefferson County been? It's been all right. Lots of changes since I went to prison. How are things at your brother's house? They're a bit crowded, but he's okay with it. I was going to stay with my cousin, but he's all messed up. Not a good place for you, huh? I want to stay clean and get a fresh start. I want to talk with you about how we can work together to help you stay clean and healthy, too. The prison contacted us before you released to let us know you were coming back and that you're taking TB medication. You have about three and a half months of treatment still to go. How are you feeling? Mmm, fine, lately. No coughing, and I've been eating a lot. But I lost the pills that they gave me when I left prison. Actually, right now I need to look for work so I can get my own place. I'm glad you're feeling better. You know, job hunting and feeling sick don't mix at all. But the key to feeling completely well is to make sure that you take all six months of your TB meds. So, you lost your pills? Yeah. When was the last time that you took them? Mmm, the day or so after I got out. Well, let's come up with a plan today to make it easy for you to take your meds. I'll also hook you up with the county's job training and placement program. There may also be some other services that can help you get that fresh start. How does that sound? Okay, I'm listening. Okay, well, the first thing is... Remember, the toll-free number to call with your questions is 888-565-8673. From outside the U.S., you call 415-861-8543. Or your fax questions should be faxed to 415-626-3110. Now, let's get back to our case study. Who was involved in the discharge planning of James McMurtry? Charles? In the case of James McMurtry, the discharge was planned by the referring nurse from the prison system, which was really quite good, and the nurse from the receiving county. And that's the structure of it. The nurse-the nurse relationship in this situation was really quite good. Who else can be involved in the discharge planning of the patient? Well, actually, in this particular patient situation, a number of disciplines could be involved in the planning process. Medical social worker would be an ideal person to be involved. Physicians could be involved. Prison staff could be involved. The parole officers should definitely be involved because many times the person when parole either stays in the location where they're paroled or they leave is very key in this situation. And the parole officer, one other point, could also have an influence on making sure that person shows up at the health department for their treatment. The patient's family can be a definite influence on that person's compliance adherence and should be involved, but I think it's very critically important that the patient gives consent for the family to be involved. And most of all, the patient really needs to be involved in the discharge planning process. I think the other critical thing is that the confidentiality is a core of what happens around this patient's whole treatment. Let me quickly add a couple other things if I can. And looking at the discharge planning process between two countries, and I say that because so many of our states, a number of our states, are located on the border, I think it's very important to understand that when you have two countries like the U.S. and Mexico where there's a discharge planning process needed, that it sometimes may involve the coordinate of a bi-national TB project. It may also involve the positions of the U.S. and Mexico. It may very well also involve DOT workers, the average workers from Mexico as well. And the personnel, the process males also involve TB tracking programs like TBNet and CURE-TV, which track patients up and down the migrant stream and across states. And it's critically important to realize that you're going to have a whole different focus when it comes to looking at how to discharge that person from one country to another. Those are real good points. Let me add one other thing. I think particularly in California where we have a law that actually requires notification of the health department prior to discharge that it points out the need to have someone that's designated as a TB liaison because that person can facilitate adherence with that law. In this scenario it went well. We know in reality a lot of times it doesn't go well. So having people aware of the requirement for notification and approval from healthcare facilities and then having a person that's designated as a liaison or contact person can really facilitate the discharge planning. And one last point to add. You can't have case management unless you locate that patient. And often the locating information changes over time. And it's important to know when that information was obtained from the patient. Sometimes the information when the patient was admitted to the prison or the jail and the information that you get right before they leave is different. Well, I could add one other quick point here and that's that those are very critical points to keep in mind as we work through this process of discharging patients. The other thing is in the prison system sometimes the discharge planning process is not near as neat as the scenario has pointed out. Many times the process may be a 5 or 10 minute process where the patient is told you're now going to have to report to the local health department. And they're more or less left on their own to go to the local health department and seek out medical care after they've been discharged. So we need to be aware that it's not always as nice as the scenario has made it and that a nurse is not always the referring entity but sometimes it's just a matter of giving the person information with direction where the local health department is located. Now in this case study the meeting between the public health nurse and Mr. McMurtry took place after he was already discharged. Ideally, when should discharge planning take place? Well ideally it should be prior to the person being released. Again, that doesn't always happen in the real world because for one thing to know in advance would give the health receiving jurisdiction the ability to make a home visit to make an assessment of who's really in the home because sometimes you get information from the patient or inmate that's inaccurate. In this scenario home visit would have identified the fact that drugs or some improper activity was going on in the cousin's home and so we would have known up front or they would have known that that was not a suitable environment for this particular inmate to return to. Making a home visit prior to discharge also allows an opportunity to assess the physical environment in terms of air flow how many people are in the room. Sometimes they'll say there are no children in the home and you go out and you see toys or there are babies. So a home visit is very important of the discharge planning process to ensure the environment is conducive to treatment that you have a plan for adherence are there resources where that inmate or patients going in order to carry out DOT. At one last point obviously when the patient or the inmate is not in your jurisdiction this can often not take place but if it's possible to contact either by phone or if the patient is in your jurisdiction to go and visit them prior to the discharge that makes a huge difference in them following up once they are released. What additional services might James need to help him complete therapy? Charles? The discharge planners need to be aware of other problems associated with the patient the patient has to be looked at in his or her totality as much as possible. There may be other medical conditions that need to be considered in the whole process there may be a need for housing there may be a need for job training and placement and substance abuse counseling and treatment may very well be a part of this person's whole persona. It is our responsibility as I see it to work with the patient to assure adherence to the treatment regimen to make sure the patient keeps all DOT appointments. DOT is extremely extremely critical and one additional benefit in this whole scheme is that we may have the opportunity to make sure the patient gets treated which is our goal but we also may be contributing to keeping this person out of prison and working to make this person a more productive citizen. Well, thank you Barbara, Masai and Charles now the faculty would like to respond to your questions Please call the toll free number 888-565-8673 or outside the U.S. 415-861-8543 and again you can fax questions as well to 415-626-3110 Our first question comes from San Francisco Go ahead please Uh, is this me? Yeah. Okay, thank you very much for these excellent programs. My question is how can DOT workers protect patient confidentiality during DOT visits when they are seen interacting with the patient practically every day? Masai, do you want to take a crack at that? Well, that's a very, very good question and I think first of all you need to discuss with the patient if DOT is occurring at the clinic what DOT is actually going to be like and whether they are comfortable in the open clinic setting to take their medications in front of others or not. Otherwise it's really working with the patient to find a location that the patient is comfortable with in taking the medication. If it's DOT out in the field again you need to work with the patient as to how comfortable they are taking their medications at the door or inside the house again weighing the issues of how comfortable the healthcare worker is going into the environment of the individual. One quick point to add to that when you're doing DOT in the home if the patient is still communicable and the healthcare worker needs a respirator you want to not put your respirator on in the car and then walk up to the door so that nosy neighbor can see. So it is challenging but by working with the patient you can work out a plan to safeguard their confidentiality while you're doing DOT. One other, and let me reinforce what you've said is important for the DOT worker and the patient to decide on a comfortable location where the DOT can be delivered. It doesn't have to be delivered where it's exposed but it certainly should be delivered where everyone's comfortable with that particular setting. Another thing to mention of course is twice weekly therapy so you're not going out there every day but you're only going twice a week and also maybe a little less obvious. The next question is going to be a fax and this is from Portland, Oregon and it's a good question. Are there any legal risks to healthcare workers for not revealing their knowledge of illegal activity or the residents of undocumented immigrants to the authorities? Barbara? Well actually at least in California we're not mandated to report illegal activities versus if you're aware of someone with a communicable disease or child abuse we are mandated reporters and we would have to report. So there should not be legal consequences for not reporting illegal activity. You just want to be sure that you take steps to protect worker safety and then try and remove yourself from that setting. In terms of immigration obviously there have been laws that have been attempted to be passed in California it was Prop 187 where we were required as healthcare workers to report people who were not documented. However for communicable diseases there was a waiver and so we are not mandated to report them. Let me add to that from a Texas perspective basically what we practice here in the state of Texas is somewhat similar to what California practices in managing, especially those individuals who are coming to the country who may be undocumented. We practice what I call don't ask, don't tell and we provide services to all who come because we feel that a person in this country has tuberculosis they're putting our state and other Texans at risk other persons in the country at risk and we want to make sure that that person is treated. Now we're going to Chicago go ahead please. Hello, hi, my name is Jonathan I work with the Chicago Department of Public Health My question is field work comes with inherent risk and more often than not we do need to reveal our identity as public healthcare workers for our own safety. In those instances it's common for neighbors, friends, relatives to form assumptions that may be and I want to emphasize wrong and harmful about the patient that you're looking for relative to your job. In those circumstances what do you suggest is a proper action to take to correct such misunderstandings by so-called concerned parties? Well, Masai, would you like to take that? That is a very difficult question and I understand your concern about worker safety and that it would be safer for you if you're identifying yourself as someone from the public health department however you do need to maintain the confidentiality of the patient you need to discuss the issues around that with the patient himself and perhaps that location is not a good site for you to perform DOT. I would agree with that. Now we're going to go to a fax from Las Vegas, Nevada and the question is in the case of a non-compliant patient where health officers must use a court order to secure compliance how can confidentiality be maintained given the court proceedings are open to the public and media? Well, at the point you're into doing legal proceedings that means you've used all the least restrictive measures to try and get this patient to be adherent with their treatment and if they're presenting a risk to the public health then at that point the rights to protect the public or the obligation to protect the public override the individual rights of the patient for confidentiality. Our next question is from Arnold Merritt. You give that particular patient due process and that would be a part of the whole court proceedings process but you're right the patient has now put themselves in a position where they are compromising their confidentiality by simply being a public threat or a risk to the public with that public health situation and you must put them in a situation where you get them quarantined or medically isolated so that they don't continue to be a public threat. All right, good point. Next we're going to go to a phone call from Arnold Merritt. Go ahead please. Thank you. The question is our facility maintains contact in the patient's medical record. If the record is subpoenaed are we required to include the names and information of contact when releasing the record? And if not must we notify the attorneys of the exclusions? Boy, that's a tough question. Masai, why don't you? I don't think you're obligated to reveal the names of the contacts in this situation but... I think the subpoena would be specific for that patient and if they don't have the names of the contacts and if not in the subpoena then you would not be obligated to release that information but I think it's very important that different states have different laws that you know for your particular state what the public health law is around that issue also that you check with either the city or county council in terms of how they interpret it. For us and our jurisdiction if we got a subpoena we would produce only what was asked for and if they didn't ask for those contacts names that would not be provided. In our medical records in San Francisco too the contact information is not in the patient's medical chart. So it's kept in a separate location so that would be perhaps another solution. Our next question is from Berkeley, California go ahead please. Hello? What are some of the ways that TV programs can work with prisons to ensure good follow-up before release and before patients are lost? Barbara? I mentioned earlier the concept of having a TV liaison so having a correctional liaison that works between public health and the prisons so that there's good communication that you provide updates regularly to each other that you have periodic meetings. In California we have regional correctional groups that are comprised of public health staff parole, prison and we meet regularly to discuss our interface communication problem-solve and that really helps a lot in establishing good communication leaks around discharges or other problems. I agree. Texas has probably one of the largest one or two next to California probably largest prison systems in the country and it is critically important that you build a relationship with the corrections medical staff to assure that when patients are released to discharge from the prison system that they follow the requirements that you have for parole officer on down to the health department activity connection. You must have a link with those individuals ongoing. It can't be a sporadic relationship. You need to meet the nurses in charge, the medical records in charge, the position to have seen those persons and develop a strong relationship to assure that when something happens with release or when an outbreak occurs in the prison system they know who to call and public health should be linked to that very closely. Let me just add one other thing that you can do is have protocols that you work together on in terms of what you do in different situations, screening guidelines treatment guidelines correction obviously they have to have certain protocols but we can work together in making sure they're consistent with public health protocols. Let's go now to Oakland, California. Go ahead please. Call from Oakland. Hi. Does a patient's death relieve healthcare workers from maintaining confidentiality and isn't the death certificate public record? That's interesting. We had a fax question exactly the same. Miss I? Usually after the patient's death and confidentiality is not an important issue. However I think that should be discussed with the family of the individual as it may affect them if the diagnosis is revealed. All right. Let's go on to our next faxed question and this is from El Dorado, Illinois. Should clerical staff be allowed to open mail inter-office memoranda and other communications and then route them to nursing and clinical staff? I think from a practical standpoint there's no other way but to do that and you should actually include the clerks as part of your healthcare team. I agree 100%. I don't see the nursing staff having to open. I'm talking about a safe perspective now. An awful lot of communication that comes in on cases. The clerical staff should be treated as a part of the confidentiality setting, the confidential team that manages that medical information and certainly you want to reinforce that in all levels of staffing in your particular facility. That medical information is confidential information and that's a part of your part of this system as well. And the same training that goes to healthcare workers, disease control investigators, nurses and doctors as far as confidentiality should be also available to clerks and mandatory. We'll go again to our next fax and this is from Santa Maria, California. With respect to confidentiality, what are your recommendations for a work environment situation when the source case is unable to provide a list of contacts and the manager doesn't respect confidentiality? Barbara, do you want to try that? Good question. In terms of the patient themselves not being able to provide the list, this is a situation where you have to provide some limited information concerning the scope of the investigation and perhaps a range of the possible exposure period so that employees could then self-identify. Obviously you would never give the individual's name. If the manager is not protecting confidentiality that manager has a supervisor and it really should be bumped up the chain or to the health officer to someone that can deal with that manager. So there's a way to conduct that investigation without giving the name of the individual or if you really feel you can't get enough information to ensure people are evaluated, you have to then talk to the patient and get their permission so that they are comfortable with whatever information you have to reveal to ensure people are protected. What about the manager has already blown it and announced it at the workplace? What happens then? Well there's nothing that much you can do except damage control after that point and basically I think the most important thing to remember from this scenario is to prevent that from happening and you can actually prevent this from happening by as soon as possible meeting with management staff educating them about TB about confidentiality. They too need to learn about confidentiality and the rights of patients and in that way all of these kind of mishaps can be prevented. Alright. We'll go now to Montgomery, Alabama. Go ahead please. Thank you for taking my call. When information may be released to an employer during a work site contact investigation or to school officials during a school contact investigation. Barbara did you want to? Yes. If you're doing a school contact investigation you have to deal with someone. Let's say you have a junior high school student who has six different classes. You have to be able to get a line listing of the students in the classroom. You have to get addresses in order to be able to properly notify the parents of those children. So the approach would be that you deal with the highest person in that school. It might be the principal. In some areas they want you to go to the superintendent's office you inform them as strictly confidential. If you have to break confidentiality in order to ensure people are protected you do it on the basis of need to know. It can backfire. I will have to acknowledge that. At times you go through all of those steps and they still tell everyone. So you work very hard on the education as Messiah said earlier stressing the need. You send out your notices without the individual's name. You never confirm with anyone asking you who it is and you do the screening and you can have the individual let's say the student actually go through the line with everyone else. I think you saw one of the scenarios they were talking about. You can skin test that individual say using normal saline or that student could just be absent that day to protect their confidentiality. People might think they know but if you don't confirm it if you don't say yes you're right they're still wondering and we just keep saying it's confidential the patient has a right to privacy. I think 1.2 that you made is that again responding to the question you do need to notify someone at the work site and they do need to know what the problem is or you're not going to get the cooperation. Now we'll go to a fax. This is a fax from Denver, Colorado. Regarding confidentiality if the patient is off from work for a long period of time and they are the only worker on sick leave co-workers often know who to suspect. How do you handle that situation? Charles, do you want to take a crack? Let me take a crack at that one. I think it's still up to the patient to reveal their illness. I don't think anyone should give that information away. The patient, the person I think we just lost Dr. Wallace so maybe we'll finish that thought that people may think they know who the case is but they don't know and it's still your responsibility not to give them any further clues and not to respond if they suggest a certain person. Let's go on to Dallas, Texas for our next question. Hello, I'd like to know what the concerns are with researchers in confidentiality. When can we release research and under what circumstances? What type of research are you talking about? Basically just papers that we're going to write about patient data. Masai? You're never revealing the identity of the patient in your research without the consent of the patient. It's really getting the consent of the patient and you're getting consent the whole way through your research project anyway if you're going to reveal any sensitive individual information. Certainly any research involving impact on patients requires institutional review board and I think part of that is to ensure that the patient's rights are safeguarded. Good point. Dr. Wallace is back with us just to let you all know. Next we'll take a fax from Alpina, Michigan and this is a question on discharge planning. Shouldn't the patient be included in the discharge meeting? Yes, indeed. The patient is the center of attention in this particular setting and I don't think you should ever discharge a patient without discussing and having them to talk back and forth with you about what the process should be. I think that assures adherence, that assures comprehensive management of that particular patient and certainly you want to have that patient as much as possible be a part of that process. All right, thank you. That's certainly ideal. However, that happening is also a rare occurrence. Let's have a phone call now from Tampa, Florida home of the Buccaneers. Hello? Hi. Hi, thanks for taking my call. We have no discharge planner at our facility so who should be responsible for the treatment follow-ups of PB patients? And what type of facility do you have? Oh Are at our facility It's a hospital or a? It's a hospital. Okay. Well, if you don't have someone that's specifically the discharge planner, most hospitals have someone designated as the infection control practitioner. Sometimes they take the lead in coordinating discharges. There might be someone that's from social services that can assist with discharge planning and it points out once again the importance of having someone designated as a TB liaison because from a public health perspective that person can help facilitate the discharge planning with whoever that lead person is in the hospital. So if you don't have someone, I think that's something the administration at the hospital or the infection control committee has to really address and sit down and decide administratively who it will be and then make sure health department staff are aware of that and contact person. Alright. Next we have a fax from Tucson, Arizona. We have a lot of patients who are from other countries and who may return to their country of origin or who go back and forth between the U.S. and their country. How can we contact the health departments in other countries to share information with them? Charles, did you want to start off with that? Let me tell you, that's really a challenge if you don't know how to locate your partner in a specific location. You know, at one time, CDC was intervening and helping us facilitate that particular process. For those of us who live on the border, we are finding that it's a lot easier to deal with our partners in Mexico because of relationships like the Ten Against TB project where never before have we had this collaboration between the public health systems in Mexico and the U.S. countries, the U.S. states here. So I think it's very important to identify those individuals who are key in bi-national projects who can facilitate opening other doors for them to the interior of Mexico or in other countries and utilizing the public health system as much as possible. I'll focus on Mexico because so many of our foreign-borne TB cases come from Mexico. I think you need to still rely on CDC as a resource for identifying other health departments in other countries and utilize that particular connection as much as possible. Yeah, I'd like to emphasize that CDC does have, in fact, a form to use for transmitting information to other countries and they do maintain a listing of the health registries for the 15 countries from which we get most of our TB cases. So CDC is a resource when you want to communicate with other countries. And also in California there is the Cure TB that is a project out of the San Diego Health Department where you can give the patient a 1-800 number so that if they end up on the Mexico side of the border they can call Cure TB. If you've notified the Cure TB liaison, they can hook up with medical services and that person on the San Diego side will also make sure that happens on the Mexico side. Let me just add too on the Texas side of things we have a similar tracking project called TBNet and TBNet's main objective of course is to follow patients upstream and make sure that they've received their treatment when they're traveling from the Texas-Mexico border upstream to assure that patients receive treatment as they travel upstream and back down through the south Texas area into Mexico as well and the linking of that patient and making sure that the continuity of care is continued into Mexico. Let me just push one of the points real quick too. We have the Texas-Mexico border that has served as a tremendous link in making sure that patients who travel back and forth are treated for their tuberculosis so that they don't become so much of a risk to Texans and the other 18 or so other states where migrants flow upstream with their tuberculosis and back downstream. We have a call now from Washington DC go ahead Washington. Hi, when Steve interviewed Bernard in the hospital why didn't he ask the patient to cover his cough because the mask protects him but other people around Bernard won't be wearing masks. That's a very good point. So that indeed was an oversight because one of the basic things a patient can do obviously to help protect others is covering their mouth when they cough. I want to comment on that too. One thing our caller mentioned was other people in the area won't be wearing a mask. Now that hopefully is not the case because everyone who goes into an isolation room with an active TB should be wearing a mask. So, you know, others including visitors should have access to the mask. And that's a very excellent point and my fear of course in this particular scenario was Bernard's wife was coming in soon and I could see those droplet nuclei kind of floating through and she was not protected with the mask so she'd be the next patient up. Hopefully not. All right now we have a fax from San Diego, California. How do you protect confidentiality information is shared with providers via email? Uh oh, we're in the year 2000. Masai? Well, providers should know confidentiality rules and the email system because of hackers and so forth may not be as secure as you would like it. But it is a very convenient tool to communicate with busy physicians and nurses who often you can't get on the phone. So, aside from them being trained in confidentiality, I don't, I can't offer any solutions for that. Encryption I guess, huh? Encryption is really the solution because the internet is still fairly insecure and to transmit medical information as far as this state is concerned is really a no-no until we have a more safe secure system for transmit that kind of information. We cannot afford to breach the confidentiality of these patients information as we well know. So, encryption. Next is a fax from Racine, Wisconsin. We have a difficult enough time getting the correctional facility to refer TB patients to the health department for follow-up TB treatment. Those are the patients. Should they also be referring patients who are on treatment for LTBI? Someone is actually using that term. What do you think Masai? I think in the case of the very, very high risk individual who for example is HIV positive, recent contact to an active case in the prison or jail system that is a person that we would like to know about because that's an individual who really needs to complete preventive therapy. But if it's a low risk situation or not as high risk situation, I wouldn't require reporting in our jurisdiction. I'd like to add to that. It's sometimes a dilemma though in terms of a sense of accountability and you know this person needs to complete treatment for an infection. They're going to another jurisdiction and if they don't get referred, do they have any opportunity of completing? And so on the one hand you say if it's not high priority don't refer. Our position is more you refer it and it's up to the receiving jurisdiction to make use to do about it. You've met your obligation to notify and hopefully given that patient or inmate an opportunity to finish their treatment of a latent infection because we realize that if we don't really take care of that reservoir or infection we're going to have a hard time eliminating tuberculosis. Now we have a fax from New Orleans, Louisiana. When doing a contact investigation at a large facility i.e. school or work site sometimes helps to have the patient identify a key administrative person with whom we can use the patient's name. Please give suggestions on how we can handle this situation with both the patient and the administrative person. I think there are a lot of people dealing with these issues obviously. Yes, I think you need to decide who would be the most appropriate person to have this information and then discuss with the patient what you're planning to do because of the public's health safety and usually there's no disagreement in that regard as long as you respect the patient's right to confidentiality and that piece is also explained to the individual who you're giving the information to. And the patient is a resource too to find that out. Alright, let's have a question from Lexington, Kentucky by fax. If a suspected non-atirid patient stated that he obtained his medication at a particular pharmacy, can the pharmacy confirm this without violating confidentiality? Charles, do you... What would happen in Texas? Well actually, you know, we don't have in Texas a pharmacy reporting act of any sort which I wish we really did. I think I can't see the patient's confidentiality really being breached if it's a health professional lack of pharmacist transmitting information that's necessary. We have that information just because it's information that's going to be pertinent to that patient's management as well as to the process of identifying additional cases and contacts. That's about all I can say about it except if anyone has a pharmacy reporting act, we like to have that in Texas. Information on how to secure it. Alright. Next question is from Des Moines, Iowa. Go ahead, Des Moines. Thanks. Do you want to release information to another provider or jurisdiction? Yes, it is. Ashley's health department to health department for continuity of care. We can actually transmit the information that's needed. This is in California for continuity of care. We really don't require the patient's consent to let's say the patient's moving from Los Angeles County to San Francisco. We would make an inter-jurisdictional referral without the patient's consent. But indeed, if a non-health department jurisdiction is asking or a private physician is asking for information on the patient, we would require a consent form to be filled out and signed by the patient in Texas. But the jurisdiction between health departments and health departments is a pretty standard practice in public health. We transmit that kind of information. Because of the public's health. Right, because of the public health threat. So we're making a distinction really between public health and other people wanting that information. Next is a caller from Miami, Florida. Go ahead, Miami. Good day. This is Samuel Brown calling you from Miami, Florida from the TB surveillance department. I just want to make a comment on the observation that was made before on the issue of email as a means of gathering and sharing information on the physicians. I would suggest that the information that is transmitted from the physician's office to the TB unit should be done using initials only. Maybe also accompanied by the date of birth, and that way the information would not be leaked out. We would be protecting the patient's confidentiality. That sounds like a good suggestion. At least at the health department you would know who that individual is, but anybody intercepting the communication wouldn't have any idea. Good suggestion. Next we have a fax from Missoula, Montana. Exactly who can we share confidential patient information with? I need to talk about patients with my coworkers in order to make sure they receive the best treatment. Who should be privy to patient information and who should not? Missai? We are involved with the management of the patient. We extended that to the clerks who are receiving the mail. Then that information should be shared among the health care team. Selected information as well. You need discretion for, of course. I think our last question is probably going to be this one from Philadelphia, Pennsylvania. Go ahead, Philadelphia. If I got a question it's confidentiality broken if you go into a house doing contact investigation. We're getting a lot of feedback. Can you repeat that and turn down your monitor? Okay. Oops, I guess you had to go away as you turned that down. I had an incident where I had went out to do an assessment, a contact assessment and a few contacts were identified when I went out to do a PPD testing. There were several other people waiting inside the house that was named. It's confidentiality broken if I go ahead to actually do contact testing on the people who wasn't identified. Well, should we have a quick answer? That's a very good question. I think in that situation you just need to be very politically correct and if there are concerns of the individuals who have come to be tested because they are very scared, then you should invite them to be tested for tuberculosis, but without revealing the source of the patient's identity. Again, using the techniques as we already saw in the video. Okay. That concludes the time we have for our question and answer period. We're sorry if we couldn't get to your call or fax. Following today's broadcast, our faculty will be available for another half hour or so to take some additional telephone questions from you. Use the toll free telephone number on your screen. At the end of this course, we will assemble a list of the most commonly asked questions and our responses to them and post them on our website. Before we close with some final housekeeping details, let's hear TB Control staff from San Francisco summarize the main points from today's program. Never discuss patient information with any unauthorized person. Never discuss patient information where it can be overheard by the public. Don't leave revealing messages for a patient on paper or on answering machine. Closely safeguard paper and electronic files, computer screens and databases. The four steps to TB surveillance and case management in hospitals and institutions are Number one, identify suspected or confirmed cases of TB. Number two, collect patient information. Number three, conduct an initial interview using open-ended questions. And number four, plan for follow-up care. Next week on Thursday February 10th, at this same time we'll be covering material contained in the last self-study module in your series. Number nine, patient adherence to TB treatment. Please remember to read this module in advance of the broadcast. If you did not receive a set of the self-study modules prior to viewing this course, they can be ordered directly from the CDC. Call 4046398135. We thank you for joining us in this second session of TB Frontline. Thank you Barbara, Masai and Charles for your participation. We'll see you next Thursday February 10th at this same time for our final session of this three-part course. Have a great day.