Program Details

Practice Type:	Promising
Program Name:	Idaho Tuberculosis Case Management Teleconference
Organization:	North Central District Health Department
Web site:
Overview:	Goals and Objectives: The teleconference (practice) is a collaboration among all seven Idaho public health districts and the Idaho Department of Health & Welfare, the National TB Controllers Association, and the Francis J. Curry National TB Center, San Francisco. The goal of the teleconference is to enhance the quality of TB case management. The objectives are to: improve patient care; increase case management skills of local public health staff; improve understanding of TB standards and guidelines; provide a forum for TB staff to learn about incentives and enablers; promote a multidisciplinary approach to patient care; provide a safe environment for identifying and resolving issues in case management. TB case management is considered an essential component of TB control in the United States. "The fundamental focus of case management is to integrate, coordinate, and advocate for individuals, families, and groups requiring extensive services, ensuring that patients receive appropriate, individualized and cost effective care within a system of services.” TB case management is crucial to ensure patients complete an appropriate and effective course of treatment, to prevent drug resistance, and to halt TB transmission in the community. Case management of patients with multidrug resistant (MDRTB) is especially challenging because therapy is protracted, often as long as 18-24 months, and patients may be tempted to stop their medications when they become asymptomatic. TB case management encompasses an array of activities including the following: ensuring provision of directly observed therapy (DOT); monitoring treatment for adverse effects; identifying barriers to adherence; and conducting contact investigations. TB case management is especially challenging in low incidence areas where public health professionals are often “generalists”, with responsibility not only for TB, but for other public health services like WIC and immunizations, and where infrequent contact with TB patients may result in lack of familiarity with basic TB case management activities. Description of the teleconference: How and when: The teleconference takes place every other month during one hour telephone call in sessions to the Idaho State TB Program. Who: The teleconference is moderated by the Idaho State TB Controller and Epidemiology Program Specialist. Participants include public health nurses, epidemiologists, and outreach workers from all seven Idaho public health districts, nurse and physician TB experts, and staff from the Francis J. Curry National TB Center. The process: Preparation before the teleconference Prior to the teleconference, the Epidemiology Program Specialist and State TB Controller identify the case and the presenter (district TB case manager) and a theme for the discussion, for example, using legal actions effectively in managing TB patients. The presenter completes a standard worksheet and provides it to the Epidemiology Program Specialist, who then distributes the worksheet (without patient identifiers) and a teleconference agenda to participants. During the teleconference The Epidemiology Program Specialist convenes the teleconference, highlighting the session’s learning objectives, and the district TB case manager presents the case. The worksheet provides a standardized format to assist the presenter with the case description. The State TB Controller facilitates discussion, clarifying various points and encouraging questions from district public health staff. External TB experts provide comments and feedback. By design, local community physicians do not participate, as it was felt that their presence might hinder the promotion of a supportive environment for peer learning and discussion. After the teleconference the presenter provides a brief follow-up of the case using a standard worksheet during the next teleconference. REFERENCES 1) For a comprehensive discussion of TB case management, see New Jersey Fundamentals of Tuberculosis Case Management http://www.umdnj.edu/globaltb/products/tbcasemgmtmodules.htm. 2) Massachusetts tuberculosis nursing case management protocols, 2001. http://www.mass.gov/dph/cdc/tb/cmsprotocols.pdf.
Year Submitted:	2008
Responsiveness and Innovation:	What is the public health issue the practice addresses? TB, in particular, quality improvement of TB case management. State and local public health agencies have legal responsibility for TB control and ensuring the provision of a core group of functions, including diagnostic, clinic, and preventive services. Personnel with special skills are needed to manage or coordinate the medical and the social behavioral concerns associated with the prevention and treatment of TB. In most health departments, public health nurses fulfill this role by providing TB case management. Their training includes 1) designing contact investigations; 2) educating patients, contacts, and families; 3) identifying ineffective drug therapy regimens and drug toxicities; 4) recognizing patient behaviors that might lead to poor adherence; and 5) developing strategies to encourage completion of therapy. Case managers promote high quality care for persons with or suspected of having TB. What process was used to determine the public health issue’s relevancy to the community? In 2003, an assessment of TB prevention and control activities was conducted in four western states (Idaho, Montana, Utah , and Wyoming) as part of Task Order 6, a project on “Regional Capacity Building for Low Incidence Areas” funded by the Centers for Disease Control and Prevention (CDC) through the TB Epidemiologic Studies Consortium. The assessment used a variety of methods and strategies including the following: literature review, surveys, key informant interviews, and site observations. The assessment was conducted by a team of experienced TB clinicians and managers who met with state and district health department staff and community representatives. Based on findings from the assessment, enhancement of TB case management was identified as a priority intervention. The teleconference was created to address quality improvement of TB case management. How does the practice address the issue? The teleconference format provides a safe learning environment among peers to gain knowledge and skills in TB case management. The practice (teleconference) is especially tailored to public health professionals who, because they work in low TB incidence areas and see TB patients infrequently, may have little familiarity with TB. A literature review and correspondence with TB professionals throughout the US, the National TB Controllers Association and CDC. This practice differs from “cohort review”, another approach to ensuring improved outcomes of TB case management. Cohort review is defined as “a systematic review of the management of patients with TB disease and their contacts.” A “cohort” is a group of TB cases usually counted over 3 months (or longer in low incidence areas). State and district TB professionals review the cases approximately 69 months after they are counted when many of the patients will have completed treatment or are nearing the end of treatment. Details regarding the cohort review process are available at http://www.cdc.gov/tb/pubs/cohort/default.htm. The case management teleconference is not offered as an alternative, but rather as a complement to cohort review. Unlike cohort review which focuses on the end of treatment and future improvements to the system, the case management teleconference provides an opportunity for “real time” improvement as patients are discussed at the time they are receiving treatment.
Agency and Community Roles:	District public health professionals participate in the teleconference as case presenters and discussants. In addition, they are key stakeholders for evaluating the teleconference. Stakeholders were involved in planning, implementation, and evaluation of the practice. The evaluation enabled the refinement and improvement of the practice. Lessons learned were described and key recommendations have been shared with other local, state, and national public health professionals. What does the local public health agency do to foster collaboration with community stakeholders? The teleconference is a collaboration among Idaho Local Public Health District and state and public health agencies, the National TB Controllers Association, and the Francis J Curry National TB Center. Representatives from all agencies actively participate as peers. Peer learning involves an active, constructive process to learn new information and skills. Ideas about how to enhance relationships with local private providers, homeless shelter staff, and other community service providers are often weaved into discussions during teleconferences.
Costs and Expenditures:	The pilot phase and evaluation were funded by the Centers for Disease Control and Prevention through the TB Epidemiologic Studies Consortium and cost approximately $50,000, including the conduction of an online evaluation survey (approximately $300 for the vendor per year for an unlimited number of surveys). In-kind costs include contributions from the State Epidemiology Program Specialist who spends about two hours once a month preparing for the teleconference in the course of her TB work (.50 FTE in the TB Program). Often, the Idaho State TB Controller (.25 FTE in TB Program) has already discussed the patient with the district case manager as part of his/her responsibilities. The cost of arranging the phone lines is approximately $200 per year. Nurse and physician TB experts from outside of Idaho participate in the teleconference as volunteers. The funding required to support and sustain this practice has been minimal. The cost of arranging the phone lines, approximately $200 per year, is covered by the Idaho Department of Health & Welfare.
Implementation:	What is the public health issue the practice addresses? TB, in particular, quality improvement of TB case management. State and local public health agencies have legal responsibility for TB control and ensuring the provision of a core group of functions, including diagnostic, clinic, and preventive services. Personnel with special skills are needed to manage or coordinate the medical and the social behavioral concerns associated with the prevention and treatment of TB. In most health departments, public health nurses fulfill this role by providing TB case management. Their training includes 1) designing contact investigations; 2) educating patients, contacts, and families; 3) identifying ineffective drug therapy regimens and drug toxicities; 4) recognizing patient behaviors that might lead to poor adherence; and 5) developing strategies to encourage completion of therapy. Case managers promote high quality care for persons with or suspected of having TB. What process was used to determine the public health issue’s relevancy to the community? In 2003, an assessment of TB prevention and control activities was conducted in four western states (Idaho, Montana, Utah , and Wyoming) as part of Task Order 6, a project on “Regional Capacity Building for Low Incidence Areas” funded by the Centers for Disease Control and Prevention (CDC) through the TB Epidemiologic Studies Consortium. The assessment used a variety of methods and strategies including the following: literature review, surveys, key informant interviews, and site observations. The assessment was conducted by a team of experienced TB clinicians and managers who met with state and district health department staff and community representatives. Based on findings from the assessment, enhancement of TB case management was identified as a priority intervention. The teleconference was created to address quality improvement of TB case management. How does the practice address the issue? The teleconference format provides a safe learning environment among peers to gain knowledge and skills in TB case management. The practice (teleconference) is especially tailored to public health professionals who, because they work in low TB incidence areas and see TB patients infrequently, may have little familiarity with TB. A literature review and correspondence with TB professionals throughout the US, the National TB Controllers Association and CDC. This practice differs from “cohort review”, another approach to ensuring improved outcomes of TB case management. Cohort review is defined as “a systematic review of the management of patients with TB disease and their contacts.” A “cohort” is a group of TB cases usually counted over 3 months (or longer in low incidence areas). State and district TB professionals review the cases approximately 69 months after they are counted when many of the patients will have completed treatment or are nearing the end of treatment. Details regarding the cohort review process are available at http://www.cdc.gov/tb/pubs/cohort/default.htm. The case management teleconference is not offered as an alternative, but rather as a complement to cohort review. Unlike cohort review which focuses on the end of treatment and future improvements to the system, the case management teleconference provides an opportunity for “real time” improvement as patients are discussed at the time they are receiving treatment.
Sustainability:	Is there sufficient stakeholder commitment to perpetuate the practice? There is great enthusiasm for the teleconference among all participants. Financial resources required to support the teleconference are minimal. The State TB Controller has made a commitment to provide necessary resources into the foreseeable future. Ongoing evaluation ensures that stakeholders are actively engaged with improving the teleconference, increasing the likelihood of sustaining the project. Expert volunteers are identified through the National TB Controllers Association and Francis J Curry National TB Center. These partnerships help to sustain the practice over time and leverage resources. Teleconferences are easy to arrange (low tech and inexpensive) and are a way to engage staff who work only part-time in TB. In addition, teleconferences provide a nonthreatening environment for learning and are applicable to other low incidence areas. Information about the teleconference has been shared at state, regional, and national meetings including the following: Idaho State Epidemiology Training, May 2006; CDC poster session, American Thoracic Society, May 2006; oral poster presentation, National TB Controllers Association, 2006; Task Order 6 annual meeting, August 2006; and invited presentation, CDC Division of TB Elimination webinar, September 2006.
Lessons Learned:

Back to main page.