I Will If I Have To…

1. I Will If I Have To… The Kansas Cohort Conversion Experience

2. State of Kansas

3. State of Kansas

4. State of Kansas • Population: 2,853,118 or 35 people/square mile • Cattle Population of Kansas: 6.4 million (2.24 times the human population • 2010 TB Data: 46 TB cases (1.63/100,000) vs. (4.8/100,000) incidence in the U.S.

5. TB in Kansas 1985 - 2010

6. TB in Kansas 1985 - 2010

7. TB Structure in Kansas • 105 Counties/Independent Health Departments – Home rule State • State program comprised of TB Controller, TB Nurse Consultant and TB Information Specialist • TB Disease Suspect or Confirmed reportable to the state within 4 hours via telephone • TB Infection Reportable with 72 hours • 7 counties receive direct funding for indigent care, 3 counties receive staffing support funding

9. TB Structure in Kansas • All medications for disease or infection are provided by the state • State Nurse Consultant monitors and provides TA for Case Management of all Disease cases • Medical consultation provided by state program with support from one Physician in community associated with local health and KU School of Medicine • State TB Care Program administered in collaboration with State Medicaid Agency, but only uses SGF

10. How Kansas Did It • TB Controller not really on board…that was me • Small number of cases • Closely monitor each case • We know names and situations from the start • We are meeting or exceeding most objectives • We have no authority over local health departments • One more unfunded mandate

11. Kansas 2008 • I may not like it…but it is going to be a requirement a requirement • Reviewed models and talked with people who had experience • Study the manuals and tools available • I will show them why and how it will not add value

12. Kansas 2009 • Scheduled a presentation and training as part of World TB Day Awareness Symposium (April 9, 2009) • Brought Kim Field in from Washington state to share the Washington experience at symposium • Held training the next day with practice, simulated cases (April 10, 2009) • Found fear, confusion but a willingness to try

13. Kansas 2009 – The Beginning • Cohort Review – The Preparation Stage • April 13 – memo thanking all who were trained and plan for preparing for 1st CR • April 13 – invite to all LHD to at least listen in on the 1st CR • April 17 – completed draft CR forms due to State Nurse Consultant • April 20 – 23 – mock CR with Nurse Consultant • April 23 – final CR forms due • April 30 – held first CR

14. Kansas 2009 – The Beginning • Cohort Review – The First Event • Held during CDC Site visit • Live audience and phone audience • Live audience in Wichita • 4 LHD • CDC (Program Consultant, Team Chief, Lab Consultant • State (TB Controller, Nurse Consultant, Microbiologist) • Medical Consultant • Phone audience • 13 LHD

15. Kansas 2009 – The Beginning • Cohort Review – The First Event • 21 Cases Reviewed in 4 hours • Successes • Completed all scheduled reviews • No one died or cried • Good feedback from CDC • TB Controller admitted it may work and may have value • Staff at all levels agreed it could be useful and educational • Challenges • Forms need to be worked a little better • Some terms need clarifying

16. Kansas 2009 – Off and Running • Completed 2 more CR on a quarterly basis • 14 cases in August • 16 cases in October • Updated forms as we went • LHD Nurses became more excited • LHD nurses began challenging private providers to participate

17. How Can Kansas Help? Note Timing…Nebraska is Succeeding from the Big 12… • January 2010 CR 16 cases • CR went quick and many LHD comments about value • An idea to offer a new opportunity, innovation • Called Nebraska to share what I had learned and offer to listen in and consider participation • Kansas had established a system • Kansas had an infrastructure in place • Learning was happening because of shared experiences • Nebraska was struggling on how to approach with limited resources

18. Kansas Nebraska Merger • April 2010 – Nebraska State Staff listen in on CR call • Skeptical but wanting to meet new requirement • Unsure how local staff would respond • Kansas Medical Consultant willing • July 2010 – Nebraska presented their first cases • Kansas 13 cases, Nebraska 9 cases • Nebraska consultants/private providers on call • Some challenges with form language and slightly different approaches between states • Greater opportunities to learn from each other • Additional cost to Kansas $5.32 plus Mock time

19. Kansas Nebraska MergerWill it work? • Kansas concerns • Did we overstep with our comments or recommendations? • Was there added value for Kansas staff? • Nebraska concerns • Will the Advisory Committee go for it? • Can we adapted to some different language? • Will local staff rebel or buy in to different ideas? • How do we respond to the challenge of different resources?

20. Kansas Nebraska MergerIt will work • Kansas concerns • Different approaches has allowed for better understanding of adaptability • Local staff have found new confidence in sharing their successes and learning from others with different types of challenges • Medical consultant has been open to sharing and having ideas debated

21. Kansas Nebraska MergerIt will work • Nebraska concerns • Advisory Committee met in September and overwhelming endorsed the merger approach • Local staff have been very engaged and willing to accept feedback • The use of the CR forms has added to ability to monitor cases more closely and achieve better outcomes • Case managers have become stronger advocates • Providers are asking more questions

22. Nebraska Lessons Learned • Several cases showed a need for more education for providers. • Issue of understaffing stood out on many of the reviews and the impact it has on cases. (Cannot always do 5 day a week DOT or DOT for extra pulmonary cases) • Each review requires getting one or more case managers “up to speed” with the process. • Process provides a good, efficient teaching mechanism. • Provides documentation of how our limited resources impact our program. • More to learn when there are more cases to be reviewed. Slides borrowed from the Nebraska presentation at the NTC 2011 – Pat Infield , Nebraska TB Controller

23. Nebraska Going Forward • Need to get more providers on the calls. • We are still missing lab data (i.e. culture conversion dates) and other information such as HIV status that should improve as we use the cohort form during the treatment of a case. • Process will help us get closer to meeting the national objectives that have been difficult for us. Slides borrowed from the Nebraska presentation at the NTC 2011 – Pat Infield , Nebraska TB Controller

24. Regional Lessons Learned • It works! • Having good neighbors who are willing to share their expertise is priceless. • Shows how regionalization can work; can learn from each other and you don’t have to “re-invent the wheel”. • Form needed some clarification on the nomenclature used for the lab tests. Changes made with input from us and Kansas. • Process not “set in stone” – evolves as necessary. Slides borrowed from the Nebraska presentation at the NTC 2011 – Pat Infield , Nebraska TB Controller

25. Kansas Choices of Outcome Monitors • Meeting or exceeding most common national objectives • National objectives which offered opportunities • Culture conversion • Treatment start within 7 days • Initial Treatment regime by guidelines • Evaluation of Contacts • Contacts started on treatment • Contacts Completing Treatment • Other measurers to consider? • First Cohort April 2009

26. Documented Culture Conversion within 60 Days in Kansas

27. Initiated TX within 7 Days of Diagnosis in Kansas

28. Initiated Recommended Four Drug Therapy in Kansas

29. Infected Contact Treatment * 2010 Preliminary ARPE

30. Other Measures Considered in Kansas • HIV missing in only one county in the state repeatedly • Recognized there was no single Physician expert and local private providers would not order • Provided resources for small consultation contract resulting in 100% HIV known results the last three cohort reviews • PZA and or ETH continued longer than recommended • Monitors now in place to follow up for appropriate medication change orders • Collecting data, but anecdotal information demonstrated significant improvement

31. Significant Program Impacts in Kansas • Improved case management at the state and local levels • Growing provider involvement with Cohort Reviews as a learning platform • Enthusiasm of local case managers has increased and they encourage provider participation • Focused process now in place allowing for cost effective monitoring of objectives • The trees are seen within the forest!

32. Kansas NebraskaFinal Thoughts Even though we both had strong doubts, we pushed forward anyway knowing it was at least worth a try and a better argument could be had if we could at least say we had tried it. In the end, we have adapted a method which is providing great benefit on many levels. We have much to learn and we continue to strengthen our process even as our resources decline.

33. Kansas NebraskaFinal Thoughts If asked, we advise: Just Do It, You may be surprised!

34. Acknowledgements: Ginny Dowell, Kansas TB Nurse Consultant Garold Minns, MD Pat Infield, Nebraska TB Controller All Kansas and Nebraska Local Nurses and Providers Mark Miner, CDC Regina Gore, CDC Kim Field, Washington State TB Controller, Retired

35. Contact InformationPhil GriffinKansas TB ControllerKansas Department of Health and Environment1000 SW Jackson, Suite 210Topeka, KS 66612785-296-8893pgriffin@kdheks.gov