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Collaborating with
Federally Qualified HCs:
The NJ Experience
Thomas 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 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
Percentage of Satellite Clinics
Providing Specific Services
Primary Care
BP Monitoring
Vision Screen
Health Ed
Eligibility Screen
Case Mgmt.
Hearing Screen
Interpretation/
Translation
100%
100%
100%
100%
100%
94%
94%
94%
Mental Health TX
Diabetes Screen
Prenatal Care
Preventive
Dental Care
Blood Cholesterol
Screening
Substance Abuse
TX/Counseling
89%
89%
78%
72%
67%
56%
Visits by Diagnosis & Service
CY2009
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 Status
CY2008
100% & below poverty level
101-150% poverty level
151-200% poverty level
Over 200% poverty level
75.0%
14.5%
5.3%
5.3%
Medicaid
Uninsured
Private
Medicare
44.6%
42.5%
9.1%
3.8%
Percentage Revenue by Source
CY2009
Medicaid
State Uncompensated Care Funds
Bureau of Primary Health Care
Other, including self pay
Medicare
Other Third Party Funds
40.6%
21.8%
17.9%
14.9%
2.5%
2.3%
Patient Demographics
FQHC vs. TB Cases 2008
White
Black
Asian/Pacific
Multi-Racial
American Indian/
Alaskan Native
Hispanic
FQHC
46.1%
48.3%
3.8%
1.1%
TB
40.8%
18.2%
39.8%
0.0%
0.7%
0.0%
47.5%
30.3%
MMWR, Controlling TB in the US
Nov 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 & 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
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 for
uninsured 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 care
services as more significant than treatment of an
asymptomatic 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!!!