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Video Recorded Directly Observed Therapy

State: CO Type: Model Practice Year: 2018

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El Paso County Public Health 
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Video Recorded Directly Observed Therapy
EPCPH serves the 663,519 residents of El Paso County, Colorado. Located 60 miles south of Denver, El Paso County is the most populous county in Colorado. EPCPH's mission is to protect and promote public health and environmental quality across El Paso County through people, prevention and partnerships. Our vision is for all El Paso County residents to live in thriving communities where every person has the opportunity to achieve optimal health. In 2013, EPCPH became the first public health agency in Colorado to receive accreditations from the Public Health Accreditation Board. TB is caused by a bacterium called Mycobacterium tuberculosis, that usually affects the lungs, but can also affect any part of the body such as the kidney, spine, and brain. Not everyone who is infected with TB becomes sick; as such there are two TB-related conditions: latent TB infection (LTBI) and TB disease. Only persons with active TB disease are able to spread TB to others. It is extremely important that persons who have TB disease are treated with the correct medications, and take the medication as prescribed for the length of time prescribed. If the medication is stopped too soon, or is taken incorrectly, the TB bacteria that are still alive may become resistant to the medications. Drug resistant TB is more difficult to treat, and is more time consuming and expensive. TB disease is treated with multiple medications for a minimum of six months. LTBI is also treated for a minimum of three months, either with a single medication or a combination of two drugs (3HP). In Colorado, LTBI treatments for adults using 3HP and children under the age of 18 are required to have DOT or directly observed preventive therapy (DOPT) by an EPCPH TB program nurse. In response to an increase in TB and LTBI DOT cases in El Paso County, concomitant with a change in Colorado regulations requiring all children under 18 years of age with LTBI to have DOT or DOPT, EPCPH implemented a VrDOT program to meet the increased demands for home visits for DOT. The goal of the project is to protect the health of El Paso County residents by preventing and controlling the spread of TB. The objectives of the project were two-fold: Improve patient adherence to TB medication requirements by offering a convenient, non-invasive VrDOT option to qualified patients Improve EPCPH TB staff efficiency for DOT/DOPT home visits by utilizing VrDOT technology VrDOT was implemented in October 2016 with permission and support from CDPHE. Activities for implementation included adopting policies and procedures for VrDOT, training for staff on VrDOT, purchase of VrDOT application and loaner smart phones, and providing VrDOT education and equipment for patients. Success of EPCPH's VrDOT implementation are well substantiated. In the first year of the project, VrDOT has allowed patients to record and share treatments on holidays, weekends, after hours, and during travel out of the area, which has shortened the treatment period for some TB patients from six months (five days/week) to four months (seven days/week). VrDOT has proven to be a cost-effective program, saving EPCPH $35.70 per home visit. The average VrDOT home visit costs EPCPH $1.10 while the average in-person home visit costs EPCPH $36.80. VrDOT is convenient for patients, cost effective for EPCPH, and has allowed EPCPH to increase its capacity to provide DOT to the increasing number of persons with TB and LTBI without hiring additional staff. Web address: https://www.elpasocountyhealth.org/service/tuberculosis-screening
In 2016, CDPHE revised its procedures for LTBI DOT/DOPT for children age 18 years and younger by requiring EPCPH TB nurses to conduct home visits for all youth with LTBI for DOT/DOPT. EPCPH employs two TB nurses who are trained to provide DOT. This new requirement increased the caseload for required home visits substantially in 2016. Monthly DOT home visits prior to the change in regulation averaged less than 10 per month. After the rule change, monthly home visits rose to an average of 42 home visits per month. Because of the increase in caseload and the travel distance across the county to DOT sites, which were an average of 17.5 miles with a range of five to 50 miles, EPCPH worked with CDPHE to seek alternatives for in-person DOT. An application that can confidentially transmit live or recorded DOT with qualified adult patients was the solution. Use of this technology for adult patients has allowed EPCPH to address the growing caseload for youth with LTBI that require DOT/DOPT through actual home visits. EPCPH created criteria for inclusion in the VrDOT program in order to assure that only those patients capable of correctly utilizing the technology as well as fully understanding medication compliance requirements were included in the program. Inclusion requirements are: Understand the need for treatment and are motivated to complete treatment Completion of two months of in-person TB treatment Age 18 years or older Able to accurately identify each medication Able to demonstrate proper computer, tablet, or smart phone equipment use Has reliable internet connection EPCPH enrolled 16 patients in the VrDOT project between September 2016 and July 2017. By race, enrolled patients were 63% White, 19% Black, 12% Asian, and 6% Other, and 63% born in the United States, 19% born in Mexico, 12% born in the Philippines, and 6% from the Central African Republic. Seventy-five percent of enrolled patients spoke English, 19% spoke Spanish, and 6% spoke French. Every patient on VrDOT therapy successfully completed treatment. VrDOT technology for virtual home visits is an innovative practice that achieves better outcomes for the patient, the community, and for EPCPH. For patients, VrDOT reduces barriers to treatment because it accommodates work and school schedules, accommodates religious holidays and observances, accommodates travel, and offers a convenient way to record treatment when it occurs after EPCPH business hours. For the community, VrDOT prevents the spread of TB by supporting TB patients with completion of the long, daily regimen of required medicines, which are necessary to reduce the creation of drug-resident TB bacteria. For EPCPH, VrDOT is a workforce multiplier and cost saver. EPCPH is able to maintain its current staffing level and provide DOT to more patients, and saves expenses associated with mileage and time spent traveling for DOT. A review of the literature and the NACCHO Model Practices database indicates that other local public health agencies have used a form of technology for DOT for limited engagement with some patients, but may not have established this as a routine practice. Further, the use of a tool that allows for both live and asynchronous viewing of DOT appears to be a new use of technology for DOT. The evidence base for DOT is well established by the CDC and WHO. According to the CDC, DOT increases cure rates among patients with TB, and is also effective in decreasing drug resistance, treatment failure, relapse, and mortality. VrDOT is the next iteration of DOT, capitalizing on new technologies to solve existing problems with TB treatment, medication adherence, patient satisfaction, and the spread of TB. In designing the program, EPCPH TB nurses also used reference materials and templates from the Minnesota Department of Health for its VDOT program.
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The goal of the VrDOT project is to protect the health of El Paso County residents by preventing and controlling the spread of TB. The objectives of the project were two-fold: 1) Improve patient adherence to TB medication requirements by offering a convenient, non-invasive VrDOT option to qualified patients 2) Improve EPCPH TB staff efficiency for DOT/DOPT home visits by utilizing VrDOT technology EPCPH completed several activities to implement the program. First, EPCPH worked with CDPHE TB staff to create policies and procedures for VrDOT to assure that the technology was capable of delivering the same observation as an in-person home visit. Second, EPCPH created inclusion and exclusion criteria for adult participation in the program. Third, EPCPH worked with CDPHE's vendor of choice for the VrDOT application. CDPHE vetted the technology to assure patient privacy and confidentiality were protected, and that the technology was viable in El Paso County. Fourth, EPCPH trained its TB staff on the technology, policies and procedures, and charting requirements for VrDOT. The inclusion criteria for VrDOT is a patient 18 years of age and older that is prescribed 3HP treatment. The patient must also be capable of correctly utilizing the technology as well as fully understanding treatment compliance requirements. Other inclusion requirements assessed by the TB staff were: Successful completion of at least two months of in-person TB treatment Demonstrated accurate identification of each medication Able to demonstrate proper computer, tablet, or smart phone equipment use Has reliable internet connection A patient in the VrDOT program could be engaged in DOT for up to six months. With VrDOT, a patient can significantly reduce the amount of time it takes to complete the required treatment with 3HP by including medications taken after business hours, on EPCPH holidays, and over the weekend as recorded and validated by EPCPH TB nurses. This process can reduce the time of DOT from six months to four months. If a patient encounters difficulty with VrDOT compliance, the patient can be reverted back to in-person DOT to assure completion of the treatment protocols without extensions in treatment time. EPCPH's key partner in this endeavor is CDPHE. CDPHE supported EPCPH's adoption and implementation of VrDOT through technical assistance and securing the technology vendor for VrDOT. Prior to supporting VrDOT, CDPEH supported EPCPH with Skype and Facetime protocols for VDOT. This program has enabled CDPHE to better understand the reliability of VrDOT, to reduce the amount of financial support it must provide to local public health agencies to provide TB DOT when using VrDOT, and to allow for EPCPH to adapt its DOT program to meet CDPHE's new requirements for in-person DOT with children under the age of 18 with LTBI. Because CDPHE absorbed the cost of the VrDOT application, EPCPH's start-up costs were limited to the purchase and monthly expenses of an additional iPhone to serve as a loaner phone for patients with technology barriers.
EPCPH was able to accomplish its goals and objectives for the VrDOT project. The goal of the VrDOT project is to protect the health of El Paso County residents by preventing and controlling the spread of TB. The objectives of the project were two-fold: 1) Improve patient adherence to TB medication requirements by offering a convenient, non-invasive VrDOT option to qualified patients 2) Improve EPCPH TB staff efficiency for DOT/DOPT home visits by utilizing VrDOT technology For Objective 1, EPCPH evaluated patient adherence by reviewing treatment completion for patients enrolled in VrDOT. All sixteen patients, or 100% of enrollees, completed treatment. Videos were reviewed daily by qualified TB nurses against the VrDOT protocols for verbal and visual confirmation of medication ingestion with each patient. For Objective 2, EPCPH used financial data for salary and benefit costs for TB nurses, mileage costs for home visits, and DOT reimbursement rates from CDPHE to determine if VrDOt was a more efficient process for staff. Financial data showed the cost for each VrDOT, inclusive of the financial indicators above, was $1.10 while estimates of the costs if these visits had been in-person showed the costs per DOT would have costs $36.80. VrDOT saved $35.70 in salary, benefit, and mileage costs for EPCPH and allowed 16 patients to complete TB treatment. For overall staff efficiency, between September 2016 and July 2017, TB nurses conducted 505 home visits at one hour per visit (505 hours total), 359 office visits at 30 minutes per visit (119 hours total), and 681 VrDOT visits at roughly two minutes per visit (22 hours total). EPCPH was able to complete 681 VrDOT visits in the time it normally takes to conduct 44 office visits or 22 home visits. This represents a nearly 3000% increase in efficiency in completing DOT visits in a 22-hour window of work time. EPCPH did make modifications to the VrDOT program after implementation. Some EPCPH patients lacked the smart phone technology or sufficient data packages to manage the VrDOT process without incurring extra costs. EPCPH created an iPhone loaner program for income-restricted participants to reduce the barrier to treatment. EPCPH also had to provide repeated training support for some patients that experienced difficulty using the technology (e.g., poor lighting, poor camera placement, blurry images). Patients were receptive to the additional training and support, which generally corrected any issues and allowed the patient to remain in the VrDOT program.
VrDOT is a self-sustaining project. While VrDOT will not replace in-home or in-office DOT with every TB patient, it significantly expands EPCPH TB staff ability to provide DOT with all required TB patients. CDPHE currently provides a payment to EPCPH for each DOT visit. A home visit is reimbursed at $25 per visit; however, EPCPH's costs for those visits average $36.80. EPCPH has little flexible funding to cover the gap in CDPHE payment making in-person DOT unsustainable when visits exceed more than 10 per month. Requiring a person to come to EPCPH's office for DOT is equally untenable as patients have transportation and time barriers, and the reimbursement from CDPHE of $12.50 per visit doesn't fully cover costs for staff time. CDPHE reimburses EPCPH $2.50 for each VrDOT visit, which has a cost to EPCPH of $1.10. This allows enough funding for VrDOT and helps defray other costs associated with the program including loaner phones. This funding structure allows the VrDOT program to be sustainable. Further, our key partner, CDPHE, is committed to the continuation of VrDOT as an important component in the effort to prevent and control the spread of TB in Colorado and El Paso County.
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