tb programs and migrant clinicians network collaborations ed zuroweste, md chief medical officer...
TRANSCRIPT
TB Programs and Migrant Clinicians Network
Collaborations
Ed Zuroweste, MD Chief Medical Officer Migrant Clinicians Network
16th Annual IUATLD Conference San Antonio, Texas February 23, 2010
Migrant Clinicians Network
10,000 constituents
Oldest clinical network serving the mobile poor
MCN’s primary constituents are clinicians working in federally funded Migrant and Community Health Centers and in state and local health departments.
Photo © Alan Pogue
Photo © Alan Pogue
A national, clinical network founded in 1984
We believe no one’s health should be compromised because of her/his mobility and because s/he may be seen by multiple providers and clinics.
MCN MissionA force for Health Justice for
the mobile poor
Migrant Farmworkers
Longer stays in the US/more “settled out” immigrants.No accessible means to obtain citizenshipFurther disenfranchised/isolated immigrantsMore FearMore confusion
Access to Health CareFear + policy + enforcement + reality of
being an immigrant:LanguageSocial/cultural differencePovertyLack of trustLack of health insuranceLack of “Know How” to access the systemMobility (Continuity of care difficult)
= LIMITED ACCESS TO HEALTH CARE
What happens when there are numerous barriers to health care?
Individuals present with advanced health care problemsThe ultimate cost of treatment is higherThe outcomes of treatment are significantly poorerMorbidity and Mortality rates are higher
MCN Health NetworkGoal: eliminate health disparities due to patient mobility Responds to challenges in providing continuity of care through patient navigation; medical record transfer and bridge case management program Health Issues:
Tuberculosis (TBnet)Diabetes (Track II)Cancer (CAN-Track)PrenatalH1N1 flu, HIV, Hansen’s diseaseGeneral health issues
Services free of charge to clinics and participants
What is Bridge Case Management? Bridge between mobile patients and their providers
Provides care coordination services and health education to mobile patients Expert bilingual, culturally-competent
case managers Transfers medical records Central storehouse of patient medical informationOffers toll-free access for patients and clinicians
TBNet
TBNet began in 1996Funding:
Immigration and Customs Enforcement since 2005HRSA/BPHC since 2010New Mexico Dept. of Health through US/Mexico Border Health Commission since 2010Funding from CDC ended 2008
Health Network Enrollment Criteria
Patient who is:Mobile Likely to be lost to follow-up
Patient who has:Active or latent tuberculosisDiagnosis or at risk for diabetesNeeds testing or breast, cervical or colon cancerIs pregnant Is HIV +, H1N1, Hansen’s disease Any general health issue that requires follow-up
Pre-enrollment Education/Assurance to the patient
MCN Health Network does not discriminate on the basis of immigration status and will not share personal patient information without patient permission
Forms Required for Enrollment
Consent Form
Gives MCN staff legal permission to transfer participants’ medical records and contact participantsThis form must have the participant’s signature Participants may renew their consent after it expires if they still need assistance
Maintaining a Patient in Care…
Contacting patients on a scheduled basis. TB patients monthly.Contacting TB clinics on monthly basisAssisting patients in locating services and resourcesReporting back to the enrolling clinic and notifying them of patient status and
final outcomes
Photo: C. Kugel
Maintaining a Patient in Care
Patient Role:
Inform Health Network of address changes or phone number changesWhen looking for health services in a new area, call the 800 number for help Receive calls from Health Network staff following up on the patient’s health status
TBNet Bridge Case Management
TBNet, an innovative approach to tuberculosis management in migrating patients, has demonstrated for 17 years how TB control can be successfully accomplished in highly mobile populations, even those traveling internationally. 4,330 total TB enrollments since 19962,951 total clinics, in US and over 70 countries, participated since 1996
Impact
Table 1: TBNet Enrollment
2005-Present • 60 countries served• Total 1,803 pts
1996-Present • 71 countries served• Total 4,330pts
Impact
Table 1: TBNet Enrollment
Country 2005-Present • 60 countries served• Total 1,803 pts
Mexico 691 (38.3%)
Honduras 368 (20.4%)
Guatemala 245 (13.6%)
El Salvador 143 (7.9%)
% of TOTAL 80.3%
TB Control Among Detainees: An Innovative Public/Private Collaboration
U.S. immigration laws have no provisions addressing health status with regard to removal Culture-confirmed case rate 2.5 times higher than other foreign-born individuals. (Am J Prev Med 2007;33(1):9–
14) Detainees often return to countries where access to health care is limited, or fail to complete treatment due to mobility. (Am J Prev Med 2007)
Contract with TBNet started 2005.
TB Control Among Detainees: An Innovative Public/Private Collaboration
Works because of dedicated clinical and administrative staff at ICE facilities and in DCOpen communication between ICE Health Service Corps (IHSC) and MCN with continuous quality improvement philosophyMutual goal—Provide culturally competent compassionate high quality services to the individuals dealing with Tuberculosis
TB Net’s International Reach
Belgium, Belize, Bolivia, Brazil, Cameroon, China, Canada, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Etiopía, Guatemala, Haití, Honduras, India, México, Micronesia, Nepal, Nicaragua, Perú, Philippines, Romania, Russia, Somalia, South Korea, Sri Lanka, Taiwan, Turkey, United States, Vietnam
TBNet Statistics 2005-2010
A review of all referrals made for ICE detainees and State Health Departments to TBNet was completed January 1, 2005, through December 31, 2010A total of 937 active (Class 3) cases reviewed
Nationality TBNet 2005-2010Country Total Class 3
patients(937 total patients)
Percent of total patients
Honduras 345 36.8%
Mexico 161 17.2%
Guatemala 154 16.4%
El Salvador 103 11%
Nicaragua 22 2.3%
Peru 18 1.9%
China 17 1.8%
Ecuador 16 1.7%
India 10 1.1%
Haiti 10 1.1%
Honduras; Mexico; Guatemala; El Salvador
763 81.4%
Class 3 Active TB: TBNet Treatment Success (2005-2010)
937 Class 3 Active TB Cases Referred29 treatment not recommended by destination country
908 Treatment Recommended7 deceased
901 Followed by TBNet for Active TB95 lost to follow up49 refused treatment
757 Complete Treatment = 84%
25
Treatment Goals / Benchmarks
Healthy People 2010 target for TB treatment completion is 90%. [i]
WHO’s Stop TB Partnership sets that goal at 85% of smear-positive cases. [ii]
In 2007, the latest data available, 84.5% of patients requiring treatment of less than one year successfully completed their drug regimen in the U.S. [iii] [i] Morbidity and Mortality Weekly Report. Trends in tuberculosis—United States, 2008. Center for Disease
Control and Prevention. Mar 2009; 58(10): 249-253.[ii] WHO Report 2009. Global tuberculosis control. Mar 2009. Also available at
http://www.who.int/tb/publications/global_report/2009/en/index.html. [iii] MMWR Weekly. Trends in tuberculosis—United States, 2010. Center for Disease Control. Mar 2011;
60(11): 333-337.
Case StudyFeb. 2010 screened in ICE facilityNegative smear, RUL consolidation, TST 20 mm, asymptomatic, medication not startedFeb. 2010 enrolled TBNet and then deportedMarch 2, 2010 TBNet notified positive cultureClinic identified in Central America and medical records sentContacted family in Central America but patient had left for USMay 4, 2010 wife called stating patient in US being held by coyotes
Case StudyTBNet case manager called coyote West CoastSpoke to patient and explained culture results and need for treatmentImmediately after call TBNet contacted ICE, initiated human trafficking investigationJune 11, 2010 patient contacted TBNet was released by coyote now on East CoastAppointment made/medical records sent to local health departmentPatient started on 4 drug regimen DOT
Case Study
September 28, 2010 patient called TBNet he had moved to another East Coast StateClinic found, appointment made, medical records transferred from both previous clinicsPatient resumed therapy per DOTWife updated on patients treatmentTreatment completed April 7, 2011
TBNet Successes
Treatment equal to that among geographically stable populationsDisease surveillance role Consistency between international protocolsPolicy recommendations – identify difficult to treat populationsModel for management of other diseases in mobile populations
Commitment
Health Network Staff with TB nurse and patient El Salvador
Connection
Guatemala NTP
Communication
El Salvador NTP
Consistency
CMO with Honduras NTP staff
Resources
Division of Tuberculosis Elimination (DTBE): http://www.cdc.gov/tb/
Stop TB USA: http://stoptbusa.org/
International Union Against Tuberculosis and Lung Disease: http://www.theunion.org
Migrant Clinicians Network:http://www.migrantclinician.org/
Contact:
Ed Zuroweste [email protected]
www.migrantclinician.org
1-800-825-8205 (U.S.)
01-800-681-9508 (from Mexico)