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I Will If I Have To…The Kansas Cohort
Conversion Experience
State of Kansas
State of Kansas
Population: 2,853,118 or 35 people/square mile Cattle Population of Kansas: 6.4 million (2.24
times the human population 2010 TB Data: 46 TB cases (1.63/100,000) vs.
(4.8/100,000) incidence in the U.S.
State of Kansas
TB in Kansas 1985 - 2010
TB in Kansas 1985 - 2010
3.12.6 2.7
1.92.3 2.6
3 3.32.8
2.3 2.23
2.1 2 2.31.6
8.78
7.46.8
6.45.8 5.6
5.2 5.1 4.9 4.8 4.6 4.4 4.23.83.6
0
1
2
3
4
5
6
7
8
9
10
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010R
ate/
100,
000
Year
105 Counties/Independent Health Departments – Home rule State
State program comprised of TB Controller, TB Nurse Consultant and TB Information Specialist
TB Disease Suspect or Confirmed reportable to the state within 4 hours via telephone
TB Infection Reportable with 72 hours 7 counties receive direct funding for indigent care,
3 counties receive staffing support funding
TB Structure in Kansas
CHEYENNE RAWLINS DECATUR NORTON
SHERMAN SHERIDAN GRAHAM ROOKS
WALLACE
GREELEY
HAMIILTON KEARNY FINNEY
LOGAN GOVE TREGO ELLIS
RUSHNESSLANESCOTT
HODGEMAN
PAWNEE
STANTON GRANT HASKELL
STEVENS SEWARD
MEADE CLARK
GRAY
FORD
KIOWA
COMANCHE
BARBERHARPER
KINGMAN
PRATT
MORTON
RENO
EDWARDS
STAF-FORD
RICE
ELLSWORTH
LINCOLN
MCPHERSON
HARVEY
SEDGWICK
SUMNER
MARION
DICKINSON
CLAY
WASHINGTONREPUBLICJEWELL
MITCHELL
CLOUD
OSBORNE
RUSSELL
BARTON
OTTAWA
SALINE
SMITH MARSHALL NEMAHA BROWN
RILEY
MORRIS
CHASE
BUTLER GREENWOOD
LYON
OSAGE
WABAUNSEE
DOUGLAS
SHAWNEE
POTTAWA-TOMIE
JACKSONATCHISON
JEFF-ERSON
JOHNSON
MIAMIFRANKLIN
LEAVEN-WORTH
WYAN-DOTTE
COFFEYANDERSON LINN
WOODSONALLEN BOURBON
COWLEY
ELK
CHAUTAUQUA
WILSON NEOSHOCRAWFORD
LABETTECHEROKEE
MONT-GOMERY
1 - 2 Cases 9 Cases 4 - 5 Cases
Kansas 2010 TB Case Distribution
12 Cases
All medications for disease or infection are provided by the state
State Nurse Consultant monitors and provides TA for Case Management of all Disease cases
Medical consultation provided by state program with support from one Physician in community associated with local health and KU School of Medicine
State TB Care Program administered in collaboration with State Medicaid Agency, but only uses SGF
TB Structure in Kansas
TB Controller not really on board…that was me◦ Small number of cases◦Closely monitor each case◦We know names and situations from the start◦We are meeting or exceeding most objectives◦We have no authority over local health departments◦One more unfunded mandate
How Kansas Did It
I may not like it…but it is going to be a requirement a requirement
Reviewed models and talked with people who had experience
Study the manuals and tools available I will show them why and how it will not add
value
Kansas 2008
Scheduled a presentation and training as part of World TB Day Awareness Symposium (April 9, 2009)
Brought Kim Field in from Washington state to share the Washington experience at symposium
Held training the next day with practice, simulated cases (April 10, 2009)
Found fear, confusion but a willingness to try
Kansas 2009
Cohort Review – The Preparation Stage◦April 13 – memo thanking all who were trained and
plan for preparing for 1st CR◦April 13 – invite to all LHD to at least listen in on the
1st CR◦April 17 – completed draft CR forms due to State
Nurse Consultant◦April 20 – 23 – mock CR with Nurse Consultant◦April 23 – final CR forms due◦April 30 – held first CR
Kansas 2009 – The Beginning
Cohort Review – The First Event◦Held during CDC Site visit◦Live audience and phone audience
Live audience in Wichita 4 LHD CDC (Program Consultant, Team Chief, Lab
Consultant State (TB Controller, Nurse Consultant,
Microbiologist) Medical Consultant
Phone audience 13 LHD
Kansas 2009 – The Beginning
Cohort Review – The First Event◦ 21 Cases Reviewed in 4 hours◦ Successes
Completed all scheduled reviews No one died or cried Good feedback from CDC TB Controller admitted it may work and may have value Staff at all levels agreed it could be useful and educational
◦Challenges Forms need to be worked a little better Some terms need clarifying
Kansas 2009 – The Beginning
Completed 2 more CR on a quarterly basis◦ 14 cases in August◦ 16 cases in October
Updated forms as we went LHD Nurses became more excited LHD nurses began challenging private providers
to participate
Kansas 2009 – Off and Running
January 2010 CR 16 cases◦CR went quick and many LHD comments about value ◦An idea to offer a new opportunity, innovation
Called Nebraska to share what I had learned and offer to listen in and consider participation◦Kansas had established a system◦Kansas had an infrastructure in place◦Learning was happening because of shared experiences◦Nebraska was struggling on how to approach with
limited resources
How Can Kansas Help?
Note Timing…Nebraska is Succeeding from the Big 12…
April 2010 – Nebraska State Staff listen in on CR call◦ Skeptical but wanting to meet new requirement◦Unsure how local staff would respond◦Kansas Medical Consultant willing
July 2010 – Nebraska presented their first cases◦Kansas 13 cases, Nebraska 9 cases◦Nebraska consultants/private providers on call◦ Some challenges with form language and slightly
different approaches between states◦Greater opportunities to learn from each other◦Additional cost to Kansas $5.32 plus Mock time
Kansas Nebraska Merger
Kansas concerns◦Did we overstep with our comments or
recommendations?◦Was there added value for Kansas staff?
Nebraska concerns◦Will the Advisory Committee go for it?◦Can we adapted to some different language?◦Will local staff rebel or buy in to different ideas?◦How do we respond to the challenge of different
resources?
Kansas Nebraska MergerWill it work?
Kansas concerns◦Different approaches has allowed for better
understanding of adaptability◦Local staff have found new confidence in sharing their
successes and learning from others with different types of challenges
◦Medical consultant has been open to sharing and having ideas debated
Kansas Nebraska MergerIt will work
Nebraska concerns◦Advisory Committee met in September and
overwhelming endorsed the merger approach◦Local staff have been very engaged and willing to
accept feedback◦The use of the CR forms has added to ability to
monitor cases more closely and achieve better outcomes
◦Case managers have become stronger advocates◦ Providers are asking more questions
Kansas Nebraska MergerIt will work
Several cases showed a need for more education for providers.
Issue of understaffing stood out on many of the reviews and the impact it has on cases. (Cannot always do 5 day a week DOT or DOT for extra pulmonary cases)
Each review requires getting one or more case managers “up to speed” with the process.
Process provides a good, efficient teaching mechanism.
Provides documentation of how our limited resources impact our program.
More to learn when there are more cases to be reviewed.
Nebraska Lessons Learned
Slides borrowed from the Nebraska presentation at the NTC 2011 – Pat Infield , Nebraska TB Controller
Need to get more providers on the calls. We are still missing lab data (i.e. culture conversion
dates) and other information such as HIV status that should improve as we use the cohort form during the treatment of a case.
Process will help us get closer to meeting the national objectives that have been difficult for us.
Nebraska Going Forward
Slides borrowed from the Nebraska presentation at the NTC 2011 – Pat Infield , Nebraska TB Controller
It works! Having good neighbors who are willing to share
their expertise is priceless. Shows how regionalization can work; can learn
from each other and you don’t have to “re-invent the wheel”.
Form needed some clarification on the nomenclature used for the lab tests. Changes made with input from us and Kansas.
Process not “set in stone” – evolves as necessary.
Regional Lessons Learned
Slides borrowed from the Nebraska presentation at the NTC 2011 – Pat Infield , Nebraska TB Controller
Meeting or exceeding most common national objectives
National objectives which offered opportunities◦Culture conversion◦Treatment start within 7 days◦ Initial Treatment regime by guidelines◦Evaluation of Contacts◦Contacts started on treatment◦Contacts Completing Treatment
Other measurers to consider? First Cohort April 2009
Kansas Choices of Outcome Monitors
Documented Culture Conversion within 60 Days in Kansas
2008 2009 2010 20110
10
20
30
40
50
60
70
80
90
48 51.4
78.3 85.7
Year
% D
ocu
me
nte
d
Initiated TX within 7 Days of Diagnosis in Kansas
2008 2009 2010 201175
80
85
90
95
100
84.3 86.4
100 100
Year
% S
tart
ed w
ith
in 7
day
s
Initiated Recommended Four Drug Therapy in Kansas
2008 2009 2010 20110
10
20
30
40
50
60
70
80
90
100
77.2 85.5 95.5 100
Year
% S
tart
ed 4
Dru
g I
nit
ially
Infected Contact Treatment
2007 2008 2009 2010*0
10
20
30
40
50
60
70
80
90
100
7497 91 94
76 79 91 85
TX Rate Completion Rate
Year
Per
cen
tage
* 2010 Preliminary ARPE
HIV missing in only one county in the state repeatedly
◦Recognized there was no single Physician expert and local private providers would not order
◦Provided resources for small consultation contract resulting in 100% HIV known results the last three cohort reviews
PZA and or ETH continued longer than recommended
◦Monitors now in place to follow up for appropriate medication change orders
◦Collecting data, but anecdotal information demonstrated significant improvement
Other Measures Considered in Kansas
Improved case management at the state and local levels
Growing provider involvement with Cohort Reviews as a learning platform
Enthusiasm of local case managers has increased and they encourage provider participation
Focused process now in place allowing for cost effective monitoring of objectives
The trees are seen within the forest!
Significant Program Impacts in Kansas
Even though we both had strong doubts, we pushed forward anyway knowing it was at least worth a try and a better argument could be had
if we could at least say we had tried it.In the end, we have adapted a method which is providing great benefit on many levels. We have much to learn and we continue to strengthen our
process even as our resources decline.
Kansas NebraskaFinal Thoughts
If asked, we advise:
Just Do It, You may be surprised!
Kansas NebraskaFinal Thoughts
Acknowledgements:Ginny Dowell, Kansas TB Nurse ConsultantGarold Minns, MDPat Infield, Nebraska TB ControllerAll Kansas and Nebraska Local Nurses and ProvidersMark Miner, CDCRegina Gore, CDCKim Field, Washington State TB Controller, Retired
Contact Information
Phil GriffinKansas TB Controller
Kansas Department of Health and Environment1000 SW Jackson, Suite 210
Topeka, KS 66612785-296-8893
