Collaborating with Federally Qualified HCs: The NJ Experience

1. Collaborating with Federally Qualified HCs:The NJ Experience Thomas D. Privett CDC Sr. Public Health Advisor NJDHSS TB Program Manager

2. 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

3. Types of Satellite Clinics 76 Primary Care Health Center Sites 16 School-based Service Delivery Sites 8 Mobile Health Care Units 5 Sites are also Migrant Health Centers 5 Sites are also Homeless Health Centers

4. 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% Preventive Dental Care 72% Blood Cholesterol Screening 67% Substance Abuse TX/Counseling 56%

5. 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

6. 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%

7. 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%

8. White Black Asian/Pacific Multi-Racial American Indian/ Alaskan Native Hispanic FQHCTB 46.1% 40.8% 48.3% 18.2% 3.8% 39.8% 1.1% 0.0% 0.7% 0.0% 47.5% 30.3% Patient DemographicsFQHC vs. TB Cases 2008

9. 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

10. TB Clinical Operations in NJ Regional TB Specialty Clinics (6) TB cases, suspects, contacts & reactors Expert physician and specialty services available Accept 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 & reactors Serve residents of their health jurisdiction only County & Local TST Reactor Clinics (12) TST reactors only, excluding contacts, all others by referral to a regional specialty chest clinic

11. Priorities of Public Health TB Clinics(in order of importance) • Early identification & treatment completion of TB cases & suspects • Identification, evaluation and treatment completion of contacts to infectious or potentially infectious TB disease • Targeted testing, evaluation and treatment completion of population groups at increased risk for LTBI and progression to active disease

12. 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 for uninsured patient population

13. 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

14. 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

15. 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 care services as more significant than treatment of an asymptomatic latent infection

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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!!!