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.
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
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 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
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
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
Cohort Review – The Preparation Stage ◦ April 13 – memo thanking all who were trained and plan for preparing for 1 st CR ◦ April 13 – invite to all LHD to at least listen in on the 1 st 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
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
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
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
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 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 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 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
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
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. 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. 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. 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
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
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!
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.
If asked, we advise: Just Do It, You may be surprised!
Acknowledgements: Ginny Dowell, Kansas TB Nurse Consultant Garold Minns, MD Pat Infield, Nebraska TB Controller All Kansas and Nebraska Local Nurses and Providers Mark Miner, CDC Regina Gore, CDC Kim Field, Washington State TB Controller, Retired