Thanks Ken. This sounds right and I’m not suggesting you wait to start, but just that you start with small, exploratory steps. take care, neal
···
From: Ken Bayona [mailto:kenbayona@yahoo.com]
Sent: Saturday, April 16, 2011 4:22 AM
To: neal lesh; Nick Amland; commcare-users
Cc: Brian DeRenzi; Amelia Sagoff
Subject: Re: Looking for Thoughts - Referral Process and Nurse's Module
Thanks Neal,
Points noted and let us think about this a little bit more. There is a clear need and want from the nurses to do more and we will try and accommodate their thoughts. I agree with you on looking at what's practical on the ground without creating workload plus extra expenses.
I dont think we are in a rush on this but its something to think about as we aim on creating a better understood program.
Ken
From: neal lesh nlesh@dimagi.com
To: Nick Amland namland@dimagi.com; commcare-users commcare-users@googlegroups.com
Cc: Brian DeRenzi bderenzi@gmail.com; Amelia Sagoff asagoff@dimagi.com; Ken Bayona kenbayona@yahoo.com
Sent: Fri, April 15, 2011 10:13:48 PM
Subject: RE: Looking for Thoughts - Referral Process and Nurse's Module
Hi Nick and Ken,
Thanks for this—and great for you to engage the nurses in this way and also educate us about the outcome.
I think it’s worth some exploration of nurse follow up visits but that we should start small. Don’t try to put a formal practice in place that might generate too much work. Instead, have them follow up on just some cases. Maybe ask some or all of the CHVs to report cases (by SMS or phone) that they think should be followed up on during a given week and then see how it goes.
Clearly, we need to ]avoid putting something in place that would create more demand than we can handle. But even if we could handle it, it might be a problem if it meant that we’d have to hire a lot more nurses in order to expand or the nurses couldn’t do other things that we want them to (even if right now they have more time) or if we can manage it but the system isn’t at all practical for Tanzania.
But in general, it’s great the nurses want to get out to the community and I think we’ll learn a lot by trying it out.
Keep us posted!
neal
From: Nick Amland [mailto:namland@dimagi.com]
Sent: Friday, April 15, 2011 8:22 AM
To: commcare-users
Cc: neal lesh; Brian DeRenzi; Amelia Sagoff; Ken Bayona
Subject: Re: Looking for Thoughts - Referral Process and Nurse's Module
Hey,
We met with the nurses yesterday to first get their ideas about how they (the nurses) could be more effective in our program. Then after they voiced their opinions, we asked to get there's about the nurse module in terms of effectiveness and practicality.
Nurses had two ideas:
-
Be more involved in CHV household follow-ups - the nurses think they would be very effective if the visited each household along with the CHVs on the CHVs normal daily household follow-up routine. During these visits, the nurses think they could resolve/treat many of the small issues that arise during normal CHV visits, but the CHV doesn't have the knowledge/training/tools to handle. Therefore (as we've know), the CHV refers these clients. Additionally, the nurses presence during household follow-up visits makes people more willing to come forward with problems (and potentially more severe). The nurses are a trusted figure in the community (not just in a health context), and clients are more willing and more honest about problems they've experiencing.
-
Increase the concentration on the the "Outcome" of Emergency transport cases - the nurses aren't satisfied by simply dropping off the emergency transport patient and then leaving them to wait for a doctor's attention,etc. The nurses only sometimes wait for the patient to be seen by the doctor. So, the nurses would like:
- to make sure the patient is admitted
- to make sure the patient is seen by a doctor
- to know if medication is given
- to know when the patient is discharged
- know what the problem is/was
So, they proposed that we set a requirement for nurses to follow-up with emergency transport patients after they are discharged from the hospital. That way they can collect the information above and also make sure the patient is heading towards recovery (i.e. getting better, taking medications as prescribed, etc.). We told them about the problems with tracking patients after they are released, particularly patients that aren't clients. They said that it would be okay to concentrate this effort on patients that were only clients.
Feedback:
In response to option 1, we told them that going on every household visit would make it very hard for the nurses to be as effective as they could be. For instance, some of the household visits might not need a nurse because no one is sick or suffering from anything. Also, we told them that it would take a really long time for the nurses to visit the clients when we have so many CHVs (~16 months for the nurses to visit all clients at 25 households/week). This doesn't seem like the best way to use the nurses.
In response to option 2, we told them that this aligns with our interest in tracking outcome data. We would need to figure out how this process would work specifically a little more because they are some gaps. We also told them that we also want to be careful not to overload the nurses because we want to over work them, but we also want to make sure that whatever they are doing, they are doing it well.
Response to Nurse's module
They liked the idea particularly when we explained this very similar to what they wanted to do with their household follow-up visits. This module allows them to concentrate their efforts where they are needed most. We asked them about the how many referrals they could do in a day considering some optimization of their route. (i.e. staying in one district), and they said they could do 10-15 referral follow-ups and airing on the side of 10.
This is an update, and I'm going to discuss with Ken a little more. Digest a little and let me know what you think.
Thanks,
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Wed, Apr 13, 2011 at 11:54 PM, Nick Amland namland@dimagi.com wrote:
Ha, we're not sure about that as well. We think it sounds reasonable, but we're going to ask the nurses for their input on this estimation.
I'll let everyone know what comes of the meeting with the nurses which is scheduled for tomorrow.
Thanks,
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Wed, Apr 13, 2011 at 7:11 AM, neal lesh nlesh@dimagi.com wrote:
i hope it sounds funny when i ask if you all know how things work in tanzania?
you are saying that with 1,000 Tsh for 4 public transport rides you expect a nurse to be able to do 7 (or 14?) visits in a day following an optimization routine that will ensure she visits houses that are clustered together?
-n
From: Nick Amland [mailto:namland@dimagi.com]
Sent: Monday, April 11, 2011 3:18 PM
To: commcare-users
Cc: neal lesh; Brian DeRenzi; Amelia Sagoff
Subject: Re: Looking for Thoughts - Referral Process and Nurse's Module
Hey,
Agree it is fun to think this through.
I don't think that I envision this completely replacing clinic-based nursing but potentially in supplement. Clearly mobile nurses aren't going to have the resources (simply from being mobile) that clinics will have. There will still be a need for higher level care by clinics staffed by nurses. Mobile nurses are trying to treat low-level cases (potentially medium level cases) which don't require higher (and more expensive) treatment at the moment. A secondary premise is that left untreated (in a timely manner) these low-level cases could eventually worsen and then need higher-level more expensive care which is unfortunate for everyone. If these nurses are effective at reducing the number of cases that reach the clinic, then less staff will be needed at clinics which is where the mobile nurse fleet could get it's staff.
In terms of the time requirement for nurses, we're thinking that we could provide a bit of logic into the "To follow-up" list where we can populate the list (or the nurse) can sort by geographic area, in this example probably by district. This would allow a nurse to be able to walk around to referral follow-ups that are relatively close together rather than going from one district to another and back again. In addition, we're thinking that the nurses will be able to also prioritize referral follow-ups which will decrease the timeline.
For the travel expense and means of travel, we're still thinking for them to take local transport seems the most reasonable and economical to me. For the Tsh30,000, we estimated Tsh1,000 per day which is the equivalent to 4 rides in local transport.
I thought it would be great to have them ride bikes, but in our particular context, one of our nurses doesn't know how to ride. Thinking at scale, bikes seem like the most reasonable, quick way of getting around although you would have to think about bike maintenance among other issues.
Thanks,
nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Mon, Apr 11, 2011 at 4:52 PM, neal lesh nlesh@dimagi.com wrote:
Hi Nick,
Is good/fun to play this out.
Am I right you are evaluating this as a model that would replace or partially replace clinic-based nursing? That is, you’re thinking through what it would look like if the 3,000 nurses currently working in facilities in TZ shifted to a referral-based outreach program? I think there are a variety of issues here, including those related to the CHVs only visits households once a month. (But also, would be a radical shift in the health system—not sure that is in scope for us.)
And in your model you are assuming 30 minutes per visit including transport time, e.g., that you could do 14 visits per day in 7 hours? I would think it would be more like 90 or 120 minutes including transport, social stuff, waiting, etc.
And how did you get 30,000 Tsh per month for transport costs? How will nurses get around?
take care,
neal
From: Nick Amland [mailto:namland@dimagi.com]
Sent: Sunday, April 03, 2011 9:05 AM
To: commcare-users
Cc: neal lesh; Brian DeRenzi; Amelia Sagoff
Subject: Re: Looking for Thoughts - Referral Process and Nurse's Module
Hey,
Attached is a quick Excel document which includes some more analysis. Just in case, this could persuade anyone. 
One thing that is different is the inclusion of a Priority Referral Activity which I've bounced off of Deborah and Ken and they seem to like this better.
Let me know if you have any additional thoughts based on this excel stuff. Ken and I are hoping to hear back from the nurses about their ideas to potentially be more effective in this program. I'll let you know what comes of that.
Thanks
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Thu, Mar 31, 2011 at 12:20 AM, Nick Amland namland@dimagi.com wrote:
Hey,
Thanks for the comments. My comments in line.
I'm going to quickly make another Excel model to show you guys implications for the activity as well as making clear we have two potential options for the nurse referral activity: full referral and priority referral. Detailed in the model. Also included, we'll be tentative assumptions of cost implications for nurse scale up.
Excel model to come soon.
Thanks,
nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
Email: namland@dimagi.com mailto:namland08@gmail.com
On Tue, Mar 29, 2011 at 9:03 PM, neal lesh nlesh@dimagi.com wrote:
Hi Nick,
First, let me compliment you on the clarity of your thought here. The document lays out the model really clearly. And I think the basic impulse of addressing the barriers to active care seeking makes a lot of sense.
Thanks!
However, I do want to press a little on the scalability a bit. Even if i just think of our operations, suppose we wanted to scale to 200 CHVs. Hiring and supporting 10 nurses seems a bit daunting and expensive to me—to cover training, transport, management, etc. Would they need a space to stay or would they always be roving?
Always healthy for thorough thinking. 10 nurses does sounds like a lot, but I'm not certain what the cost implication is for expanding. We could potentially find nurses in the community so we wouldn't have to pay for living quarters - in fact, two of the CHVs are actually nurses.
On a nationwide scale. If we say that there is 1 nurse for every 3000 population and in this program 1 nurse could cover 10,000 populations isn’t that still a pretty big increase in the number of nurses required per population? Something like a 30% increase in the number of nurses? That might both be impractical and also not the most efficient uses of the nurses workforce. I would think even asking for a 10% increase in the nurses would be a pretty big deal.
This plan actually increases the number of people they are able to serve - less nurses would be needed to serve 3,000. 1 nurse is able to serve more people, 300% more - from 3,000 to 10,000. However, I can't really comment on if this is the "most efficient" use of their time.
And is the cost of supporting a nurse to do five home visits a day considerable? It’s more than a CHV doing five visits because they will be more spread out.
Again, not sure here. Will include in the concept excel model.
I was enthusiastic about the plan when I first heard it and it does sound great to bring nurses to the homes...but looking at the numbers I think it’s worth thinking through what it would look like on a large scale and to think about if we’d rather scale up that way or to more CHVs. I don’t think groups like Partners in Health even do this level of routine outreach with nurses.
I still agree that we should decide if we like this change in delivery service model and if we agree this is the most effective way to utilize the nurse's time/effort.
And also seems good to brainstorm on alternatives. Just to throw one out, could a nurse talk to a client using a CHVs phone?
Hold that thought until I've come back with the excel model. 
Also, we've asked the nurses to come up with some ways that they think they could be more helpful to our program. Hoping to get that feedback this week.
take care,
neal
From: Brian DeRenzi [mailto:bderenzi@gmail.com]
Sent: Friday, March 25, 2011 11:37 AM
To: commcare-users@googlegroups.com
Cc: Nick Amland; Amelia Sagoff; Neal Lesh
Subject: Re: Looking for Thoughts - Referral Process and Nurse's Module
Hey Nick,
Good question. My initial reaction is no. I'm not sure that's really based on anything though. It seems like the referral is when they think things are serious enough that the health facility could do something about it. Feels like higher prevalence of a symptom wouldn't impact that.
Not sure though. Will be interesting to see what happens.
Brian
On Wed, Mar 23, 2011 at 1:03 PM, Nick Amland namland@dimagi.com wrote:
Yeah, thanks for this data. Hmmm, I was kind of thinking that initial estimate of 5% was going to be low.
With the new cough/diarrhea/fever question set, would you expect this referral rate to be affected at all?
Thanks,
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Wed, Mar 23, 2011 at 9:10 PM, Brian DeRenzi bderenzi@gmail.com wrote:
Hey Nick,
I realize this will all change under the new plan you're proposing, but just to give you some real data to make estimates from I looked at all of the data from the field as of jan 1 this year. Here's what we've got:
1094 client was unavailable
4145 no referral
720 referral given
It looks like--at least in the old system--the referral rate is 14.8% or so. As a comparison point, the "is anyone sick?" rate is 15.3%, so not a huge difference.
The data is a little messy because of the migration to 1.0, but contains at least a couple of months.
Brian
On Tue, Mar 22, 2011 at 2:09 AM, Nick Amland namland@dimagi.com wrote:
To clarify because I now realize that the table wasn't clear. If there was 1 nurse covering 20 CHVs (assuming the clients visited per week and % of visits resulting in referral), that would average out to about 5 visits per day for that 1 nurse.
Then, given that 1 nurse covers 20 CHVs, that would effectively have a nurse covering a catchment area of around 10,000 people.
Sorry for that unclear table.
Thanks,
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Tue, Mar 22, 2011 at 9:16 AM, Nick Amland namland@dimagi.com wrote:
Yeah, if you estimate on average that one CHV visits 25 households per week and only, more importantly, 5% of visits yields a referral case. My initial reaction to that referral percentage is that it is probably low, but I don't have anything else to go off of.
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Tue, Mar 22, 2011 at 5:47 AM, Amelia Sagoff asagoff@dimagi.com wrote:
Not sure I'm reading this table right - if there are only 5 nurse followups daily, do you really need one nurse per CHV (20 nurses)?
Users, I'd love to hear comments about whether this makes sense outside the context of Dodoma.
Thanks,
Amelia
On Tue, Mar 22, 2011 at 1:23 AM, Nick Amland namland@dimagi.com wrote:
Hey,
I threw these numbers together but they seem potentially plausible and reasonable.
20
CHVs
25
client visits per week
0.05
% of visits with a referral cases
25
follow-up visits required per week by nurse
5
follow-up visits required per day by nurse
then
1
Nurse per CHV
20
Number of CHVs
100
Clients per CHV
5
Family individuals per client
10000
Individual catchment area
Thanks,
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
TZ Mobile: +255 762 740 996
Email: namland@dimagi.com mailto:namland08@gmail.com
On Mon, Mar 21, 2011 at 8:27 AM, Amelia Sagoff asagoff@dimagi.com wrote:
Hi Nick,
Thanks for sending this out! I think this could be a great way to take advantage of nurses attached to a community health program. When nurses are pretty much the only available source of medical knowledge around, it seems especially important to utilize them to the fullest. CommCare users, are there any other programs out there that have nurses on staff?
One question I have is about nurse workload. What do you think the CHW:nurse ratio needs to be for this to work well?
Thanks!
Amelia
On Sun, Mar 20, 2011 at 5:42 PM, Nick Amland namland@dimagi.com wrote:
Hey CommCare Users,
Here in Dodoma, we've had the luxury of being able to step back and analyze our program, from top to bottom. Naturally, this has resulted in a lot of brainstorming about how to potentially improve processes and data collection efforts.
As a by product, we've come up with a proposed alternative for how the client referral process could be designed. In Dodoma, a client referral is when a CHV (CommCare user) visits a household and observes a client (or client's child) who is either suffering from a sickness, injury, or pregnancy-related condition. The CHV recognizes this condition as needing treatment (though she, herself, can't provide), so the CHV tells the client to seek medical care. In CommCare, the CHV will start a "referral case". As designed, the CHV is supposed to follow-up with the patient 3 days after the initial referral was given to make sure the client has sought medical care.
There are a couple of weaknesses in this process, so we've drafted a concept proposal as a potential alternative process to the current one. In the concept proposal, there is a better description of the current referral process, its weaknesses, and the potential alternative. I'm punting this idea to this group to get feedback on the process not so much the technology required, at this point, but in terms of practicality, effectiveness, general comments, etc. I'm just trying to get some feedback on what other people think about this.
A couple of things to think about when thinking about this process. This process implies a paradigm shift from requiring clients to actively seek health care (seeking-care behavior) to healthcare services actively seeking clients. I'm not completely sure what is involved in this shift but should be considered.The nurse per capita ratio in sub-Saharan Africa is around 1 nurse per 3,000. So, this should also be a factor when considering practicality and sustainability.
Thanks,
Nick
Nick P. Amland
CommCare Field Fellow
Dimagi, Inc.
Dodoma, Tanzania
Google Voice: 253.642.7790
Email: namland@dimagi.com mailto:namland08@gmail.com