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TB Nurse Case ManagementSan Antonio, TexasJuly 18 – 20, 2012

Working with Private Providers and the New Federally Qualified

Health CentersLinda Dooley, MD

July 20, 2012

Linda Dooley, MD has the following disclosures to make:

• No conflict of interests

• No relevant financial relationships with any commercial companies pertaining to this educational activity

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Public Private Roles in TB

Linda Dooley, MD

Austin-Travis County HHSD

Austin, Texas Joint city/county health department Population 1,024,266 (county 2010)

Had 68 TB cases in 2010; 52 in 2011

35 suspects not TB in 2011: about 1/3 got TB meds by DOT

Latent TB: 768 started on INH last year; usually about 4000 patient on INH at one time

Communicable Disease Unit TB/ STD/ HIV

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TB Clinic in Austin

One MD position (shared) 3 RN nurse case managers 1 LVN latent TB case manager 2 contact investigators 4 outreach workers for DOT X-ray tech for on-site x-rays Sputum booth for induced sputum

collection

TB Goals

Cure TB Treatment DOT Prevention of resistance

Prevent TB Render patient non-contagious Contact investigation LTBI treatment Window period prophylaxis

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Who does what???

Roles may vary by setting

Public Health always has certain responsibilities

Private doctors always have some requirements always in place

What is Public Health always responsible for? We are the agency to whom reporting is

done

TB reporting is required within a single working day Texas Health and Safety Code, Chapters 81

and 89

Texas Administrative Code, Title 25, Part 1, Chapter 97

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More Public Health Roles

DOT

Quarantine when necessary

Contact investigation

AUSTIN HEALTH AND HUMAN SERVICES DEPARTMENTTRAVIS COUNTY HEALTH DEPARTMENT

TUBERCULOSIS ELIMINATION PROGRAMORDER TO IMPLEMENT AND CARRY OUT MEASURES

FOR A CLIENT WITH SUSPECTED OR CONFIRMED TUBERCULOSIS

I have reasonable cause to believe that your diagnosis, based on information available at this time, is (probably/definitely)

TUBERCULOSIS (TB), which is a serious communicable disease. Adequate Directly Observed Therapy (see below) is usually very

effective in curing an individual with TB and may quickly decrease the likelihood of TB being spread to others. Therefore, by the

authority given to me by the Texas Health and Safety Code, Chapter 81, I hereby order the following control measures:

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1. Follow all orders regarding your treatment given to you by the physicians of the Tuberculosis Elimination Program (TBEP). Keep all clinic appointments ordered by the TBEP clinic staff. Several appointments will be necessary to be sure your treatment is working. The treatment for tuberculosis is usually for six or more months. It is very important for you to keep all of the appointments made for you. __________________

(client’s initials/date)2. Come to the TBEP clinic or be at an agreed place at agreed times for

Directly Observed Therapy (DOT). Taking DOT means that a health care worker will meet you at a scheduled time and place and observe you take your medication as ordered by the doctor. This ensures that you will receive the treatment necessary to fully cure your tuberculosis. __________________

(client’s initials/date)

3. Report changes in your health to TBEP staff. Provide sputum, urine and blood specimens as ordered by the clinic physician. _________________

(client’s initials/date)

4. Provide identifying information to TBEP staff regarding those individuals with whom you have contact at your home, your job and through other activities.

__________________(client’s initials/date)

5. Since you are capable of spreading TB to others, you must stay in your home except as authorized by your clinic physician. Do not return to work or school until authorized. Do no allow anyone other than those already living with you or health department staff into your home until authorized to do so.

_______ (Initials and date)

6. Report any temporary or permanent changes in address to health department staff.

________ (initials and date)

7. Special orders___________________________________________________________

________(initials and date)

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Examples of “Special Orders” Abstain from alcohol since it interferes

with your treatment.

Meet your outreach worker within 15 minutes of scheduled time.

Do not go to church or teach Sunday School until cleared to do so.

Do not curse at TB staff.

Give the warning letter at the first visit

to all your cases/suspects.

Never wait until you have a problem to tell the patient what

he should have been doing.

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New warning Letters may be given at any time during treatment to reinforce previous health authority orders or add new orders

What does Public Health usually do? Toxicity monitoring LFT’s, CBCs

Eye exams

Case management Work issues, FEMLA, disability, dealing with

employers

Referrals for food or temporary shelter

Referrals for medical care for other problems

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What is the private doctor always responsible for?

Thinking of TB as a possible diagnosis

Reporting, including suspected TB, within ONE working day

Taking care of the patient until the Health Department takes over

What does the private doctor sometimes do? evaluation of the patient

CXR interpretation

prescribe TB medications

monitor and manage treatment and toxicity

manage co-morbid conditions

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Federally Qualified Health Centers Not new but expanded under Health Center

Consolidation Act and increased funding under Affordable Care Act ($11 billion)

Community-based; comprehensive care including preventive care and substance abuse treatment

Provide care to all regardless of ability to pay (sliding scale fees), age, or legal status

Resources

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Heartland National TB Center

State TB Experts: Dr. Armitige Dr. Connelly-Smith Dr. Griffith Dr. Seaworth

State and regional TB Nurse Consultants

Other National TB training Centers Check Heartland Website under “Products” (top right of opening page) Look also at other TB training centers products at bottom of list (“Joint RTMCC

Products”)

Stop TB Website: http://www.stoptb.org/resources/publications/technical_docs.asp

Encouraging Reporting:EDUCATE

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Know your most likely referral sources

Cultivate key contacts such as infection control nurses, jail or homeless clinic staff, university student health centers

Work with the training programs in your area

Explain that services are at no cost to doctor or patient:“pre-paid” service rather than

free.

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Be visible Be knowledgeable Be competent Be available Be helpful Assist with transfer if patient won’t belong to

your TB Control area Clarify arenas of responsibility Offer to do paperwork Be persistent Stay cheerful

Use your back-ups:

Heartland and other TDSHS consultants or your regional TB Nurse.

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Putting It All Together

Case Studies

Case 1 40 year old woman with recurrent

bronchitis sent by local MD

One year history of cough, hemoptysis

6 courses of antibiotics in past 6 months: 4 of these were levofloxacin or ciprofloxacin

Improved briefly or had no response to these

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Does she have TB?

When should TB be suspected?

What else would you like to know about her

Does the health department have a role at this point?

If you are called at this point, what would you recommend?

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AFB cultures grew MTB in 3 days after collection

TST was negative

Sensitivities??

One year later……

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29 year old man from Mexico seen in ER

1 year history of cough, night sweats but no fever, hemoptysis, 20 pound weight loss

Several rounds of antibiotics from ER or Mexico did not help or helped only briefly

Case 2

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Does he have TB?

Patient has no health insurance

What role does the health department have at this point?

If you are called by the ER doctor, what do you recommend?

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Initial lab normal including HIV, blood sugar, CBC, LFT’s, BUN, creatinine

Started on 4 drug DOT

No improvement after 2 months; multiple AFB cultures negative; CXR stable; weight loss continued (3# more while on TB meds)

Referred for pulmonary evaluation

Bronchoscopy scheduled for this month after many delays

It’s not always TB!

Give patient written statement at start of treatment that you can’t treat if not TB

Start looking for a primary care home for all patients as soon as you see them: can’t go until out of isolation but you may need it later

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Coordinate care of co-existing diseases HIV: consider drug interactions, timing of

ART, access to state med programs

Diabetes: monitor sugar; don’t let care lapse while patient in isolation

Hypertension: monitor blood pressure

Anticoagulation: watch out for coumadin especially: may not be able to use intermittent therapy

Don’t forget about their birth control pills Women may not think of this as medicine

Depo-Provera is OK

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21 year-old woman from Mexico, pregnant with her first baby

Developed cough, fever, night sweats

At 6 mo, weighed 5# less than pre-pregnancy weight

Went to ER where CXR was done

Case 3

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Is this TB?

What next?

Should she be admitted to the hospital?

What treatment and when?

Seen by a second year family practice resident who had rotated through TB Clinic

Skin test, CXR, and AFB studies ordered in the emergency room

Patient placed in respiratory isolation in the ER and then admitted for treatment

4 drug TB therapy started after sputum for AFB obtained

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Referred to TB for management after discharge

DOT: 4 drug standard treatment

TB NCM worked with OB to see patient after clinic hours while still in respiratory isolation

Initial positive smears became negative

Good clinical response immediately with weight gain but…..

AFB studies showed TB resistant to INH and EMB Consultation done for drug resistant TB Medication regimen changed to include

levoquin and PAS Contacts also had med change Healthy baby delivered at term to culture

negative mom (TB NCM had to go to hospital at delivery to reassure nervous neonatologists)

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Case 4 23 years old, pregnant with first child

Pregnancy diagnosed when went to LMD with cough, fever

referred for OB care to different clinic

Screened for TB with TST, which was negative

No CXR done although cough and fevers persisted

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Delivered baby outside Austin, still coughing (no CXR done)

Baby seen in ER in 1st wk of life and had wk-up for FUO including CXR (abnormal)

Fever resolved and baby sent home

Mom had appendectomy 1 month later

CT Abdomen

Inflamed swollen appendix

Bilateral infiltrates seen in both lung bases

Patient had appendectomy and sent home

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Taken to pediatrician age 2 mo. with cough and lethargy

Deteriorated while at doctor’s office and sent via EMS to hospital where required high frequency ventilation, pressor support for hypotension

4 drug TB meds started after baby’s and mom’s hx taken by ID consult

Mom sent for CXR at insistence of ID consult

Case 5: her newborn son

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Case 6: What about dad?

Father of baby also had CXR at insistence of ID consultant

Told by doctor that there was “a little something on CXR” and he should check with TB clinic

Dad came next AM to TB clinic and…

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6 months later

Baby required re-admission to hospital after initial improvement but did well after with quick resolution of need for supplemental oxygen

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One year later Came back to clinic to see NCM

Mom had cough and wanted flu shot

CXR improved over end of therapy

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This is why we are here!