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Collaborating with Federally Qualified HCs:
The NJ ExperienceThomas D. Privett
CDC Sr. Public Health Advisor
NJDHSS TB Program Manager
FQHC Infrastructure in NJ
NJ Primary Care Association supports 20 FQHCs which operate 100 Satellite Clinics where patient services are delivered
Satellite Clinics operate in 19 of 21 counties
Types of Satellite Clinics
76 Primary Care Health Center Sites16 School-based Service Delivery Sites 8 Mobile Health Care Units
5 Sites are also Migrant Health Centers
5 Sites are also Homeless Health Centers
Percentage of Satellite Clinics Providing Specific Services
Primary Care 100%BP Monitoring 100%Vision Screen 100%Health Ed 100%Eligibility Screen 100%Case Mgmt. 94%Hearing Screen 94%Interpretation/Translation 94%
Mental Health TX 89%Diabetes Screen 89%Prenatal Care 78%PreventiveDental Care 72%Blood Cholesterol Screening 67%Substance AbuseTX/Counseling 56%
Visits by Diagnosis & ServiceCY2009
Diagnosis or Service
Well Child: Age 0-11yrs
Dental Exams
Hypertension
Mental Health/SA
Diabetes mellitus
Asthma
Heart Disease
Visits
132,573
93,013
63,348
52,406
51,348
19,148
6,226
Income & Insurance StatusCY2008
100% & below poverty level 75.0%
101-150% poverty level 14.5%
151-200% poverty level 5.3%
Over 200% poverty level 5.3%
Medicaid 44.6%
Uninsured 42.5%
Private 9.1%
Medicare 3.8%
Percentage Revenue by SourceCY2009
Medicaid 40.6%
State Uncompensated Care Funds 21.8%
Bureau of Primary Health Care 17.9%
Other, including self pay 14.9%
Medicare 2.5%
Other Third Party Funds 2.3%
Patient DemographicsFQHC vs. TB Cases 2008
White
Black
Asian/Pacific
Multi-Racial
American Indian/
Alaskan Native
Hispanic
FQHC TB
46.1% 40.8%
48.3% 18.2%
3.8% 39.8%
1.1% 0.0%
0.7% 0.0%
47.5% 30.3%
MMWR, Controlling TB in the USNov 4, 2005 / 54 (RR-12)
Community Health Centers should: Have the capacity to diagnose & treat TB & LTBI Develop close working relationships with the public
health agency serving their jurisdiction Arrange for reporting patients with suspected TB Make prevention, diagnosis & treatment of TB and
LTBI a high priority Motivate their patients to accept TB prevention
services
TB Clinical Operations in NJ
Regional TB Specialty Clinics (6)TB cases, suspects, contacts & reactorsExpert physician and specialty services availableAccept referrals from other LHDs (569 patients from 2006-2010)Provide interim coverage when local clinic operations are interrupted
Local & County Chest Clinics (12)TB cases, suspects, contacts & reactorsServe residents of their health jurisdiction only
County & Local TST Reactor Clinics (12)TST reactors only, excluding contacts, all othersby referral to a regional specialty chest clinic
Priorities of Public Health TB Clinics(in order of importance)
1. Early identification & treatment completion of TB cases & suspects
2. Identification, evaluation and treatment completion of contacts to infectious or potentially infectious TB disease
3. Targeted testing, evaluation and treatment completion of population groups at increased risk for LTBI and progression to active disease
Why Collaborate? Objectives Targeted Testing & Treatment of LTBI in FQHCs
Expanded access to diagnostic & treatment services for LTBI One stop shopping for FQHC patients with LTBI Fewer referrals of TST reactors to TB clinics Increased focus on TB cases, suspects and their contacts by TB
clinic staff
Referral of the Uninsured to Primary Care Ensures that TB clinic patients with non-TB conditions identified
during the TB evaluation, but beyond the scope of the TB clinic receive appropriate evaluation and case management services
Both are safety net providers and should be natural allies foruninsured patient population
What Won’t Work?
Negotiating with State PCA ONLY
Negotiating with FQHCs ONLY
Negotiating with Satellite Clinics ONCE
Any initiative not incorporating routine communication between Satellite & LHD
Why Can’t It Be Easier?
State PCA has no real authority to dictate FQHC or Satellite Clinic policy
FQHC Organizational Structure is Loose: Satellite Clinics are Mostly Independent
Staff Turnover is significant in Satellite Clinics
Initiation and Completion of Treatment for LTBI
Advantages of FQHCs Access to populations at high risk for TB
and LTBI, such as minorities & the foreign-born Providers of primary health care services
Enhances the likelihood of initiation & completion of treatment for LTBI over a public health clinic that ONLY offers treatment for LTBI
Most patients perceive access to primary careservices as more significant than treatment of anasymptomatic latent infection
FQHC Initiatives 2008 - 2010 Individual Meetings with FQHC Mgmt Statewide
Initiated in January 2008 and on-going Infrastructure assessment
(CXR, pharmacy, MD expertise, RN assessment) Rapport building/education/consultation Offer individualized training for FQHC physicians & nurses
Statewide Webinar – Dec 11, 2008 (DX & TX of LTBI)
NJPCA Annual Meetings – May 29, 2009 & June 4, 2010 Role of FQHCs in TB prevention & control in NJ Diagnosis and treatment of active TB disease & LTBI Examples of successful past collaborative efforts
Varied Capacities Within Community Health Centers in New Jersey
All can TST the patient population Most must refer for radiology services at a
reduced cost to their patient population Most can prescribe treatment for LTBI if
physicians are adequately trained Most cannot dispense medications Some cannot provide monthly nursing
assessments prior to refilling medications as required by the DHSS TB Standards of Care
Nature of Collaboration in NJ
All TB suspects & cases are referred to public health TB clinics by the FQHCs
If sufficient FQHC infrastructure exists to diagnose and treat LTBI: State provides training for FQHC physicians and nurses,
TST materials & medications at no cost
If not: Public health TB clinics accept referrals of TST reactors in
high risk populations
Results FQHC satellite clinics accept referrals of TST reactors for
diagnosis and treatment from 12 LHJs in NJ
All FQHC satellite clinics identified as having adequate infrastructure diagnose & treat the TST reactors they identify
TST of low risk patients and consequently, referrals to TB clinics has decreased statewide
Most TB clinics routinely refer uninsured patients with non-TB conditions to FQHC satellite clinics for appropriate medical evaluation
Latest FQHC Collaboration Mercer County TB Clinic ended July 2011, including nurse
case management State RN consultants provided interim NCM and regional
sites provided interim clinical coverage Both Mercer County and Trenton HD had nursing layoff lists
due to recent personnel cuts, so the FQHC in Trenton agreed to provide NCM for Mercer County stationed at Trenton HD (hired October 2011)
State RN consultants participated in selection of new NCM and provided on-site training and mentoring
First clinic will be held at Trenton HD February 29, 2012 State’s investment in Mercer County TB services decreased
from $140K in 2010 to $45K in 2012
Case Study #1 - Background
35yo woman from the Dominican Republic started the US immigration process in late May 2008
TST (+) with an abnormal CXR
Smears (-) for AFB, no cultures done
Diagnosis LTBI, no treatment recommended
Cleared for immigration in June 2008
Developed hemoptysis one week later in Dominican Republic
Background (continued) Upon examination: CXR abnormal, 3 smears (+) for AFB, but
cultures not done
Diagnosed with active pulmonary TB
4-drug treatment initiated 6/23/08
After 6 months of treatment on 1/13/09 smear & culture (+), DST ordered & hospitalization for MDR-TB recommended
Despite recommendation, patient immigrated to US in late Jan before her VISA expired
Arrival in the US Within one week of US arrival , she had hemoptysis X 4 days
Advised by PMD in the Dominican Republic to go to the local “TB” clinic
1/30/09 presented at an FQHC in Jersey City with TB-like symptoms & medical records from the Dominican Republic
Immediately triaged to on-site respiratory isolation and evaluated by the FQHC’s Medical Director, active pulmonary TB suspected
Collaboration The FQHC advised the Hudson County Chest Clinic (HCCC) of
TB suspect and faxed patient’s medical records
The FQHC was advised to mask the patient & send her to the Jersey City Medical Center (JCMC) ER for admission
HCCC TB NCM advised ICP, ER MD and charge nurse @ JCMC of patient’s pending arrival
HCCC staff went to the JCMC ER with the patient’s record
Patient was admitted to respiratory isolation as a TB suspect
Diagnosis After discussion with a state TB Medical Consultant, JCMC
admission diagnosis was changed to suspected MDR-TB
Treatment with second-line drugs was initiated
PCR & molecular DST were ordered and testing was facilitated by the state TB Program for a smear (+) specimen
MDR-TB was confirmed 2 days later
XDR-TB was subsequently confirmed by second-line DST
Lessons Learned FQHCs are the health care providers to many populations in which
TB is prevalent, not public health clinics
Having FQHCs as educated partners is never a “bad” thing
FQHCs can successfully screen, evaluate & treat LTBI with adequate training, if sufficient infrastructure exists
FQHCs are valuable TB case finding partners
A collaborative working relationship between FQHCs and LHJs will limit the spread of TB in the community
Collaboration with FQHCs is arduous, but essential to good public health practice and well worth the effort!!!
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