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!!!