TB in a Low-Incidence State:
Best Practices in New Hampshire
Presented by Judy Proctor, RN, BSN
New Hampshire TB Program
Coordinator
May 14, 2007
Division of Public Health Services
New Hampshire Department of Health and Human Services
Overview
New Hampshire (NH) TB Program
model of care
Common challenges in low-incidence
states
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Building Partnerships
Communication
Training and Education
Standards of practice
Practical approaches in NH:
snapshots to generate discussion
Division of Public Health Services
New Hampshire Department of Health and Human Services
DANGER
In Low-Incidence Areas
KEEP TB ON THE
RADAR SCREEN
Division of Public Health Services
New Hampshire Department of Health and Human Services
Snapshot of New Hampshire
Primarily rural, 10 counties
Population: 1,299,500
96% Caucasian
4.4% Foreign-born
1.7% Latino
 1.3% Asian
 0.7% Black/African American
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Division of Public Health Services
New Hampshire Department of Health and Human Services
New Hampshire
A Low TB Incidence State
Mean:17 cases annually over 15 yrs
Rate 1.3/100,000
78% FB, 2002 – 2006
85% in 3 SE counties since 2002
10 counties
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7 PH districts
2 city health departments
LTBI reportable: high-risk group
case management
Division of Public Health Services
New Hampshire Department of Health and Human Services
New Hampshire TB Program
A Centralized State Program
No county health departments
2 large city health departments;contracts for
services
Manchester
 Nashua
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Information flow is bi-directional
Nurse-case management/home-based model
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Patients rarely hospitalized
Division of Public Health Services
New Hampshire Department of Health and Human Services
NH TB Structure
No TB Clinics
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No infrastructure for direct management of
patients
Private providers diagnose & treat TB & LTBI
State doesn’t provide medications directly
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Income eligibility
Cases usually referred to specialists for
treatment: infectious disease or
pulmonologists
Reliant upon other agencies for
diagnosis/treatment: “THINK TB”
Division of Public Health Services
New Hampshire Department of Health and Human Services
New Hampshire TB Staff
2.4 State staff dedicated to TB
TB Nurse Manager
 Part-time Training & Education Coordinator
 Medical Secretary (vacant)
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7 State communicable disease public
health nurses (PHNs) with geographic
districts and competing priorities
2 communicable disease epidemiologists
Division of Public Health Services
New Hampshire Department of Health and Human Services
NH TB Staff
Medical consultants
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State Epidemiologist & Deputy State
Epidemiologist
2 city Health Departments; nurse case
management
Public Health Laboratory
Division of Public Health Services
New Hampshire Department of Health and Human Services
NH TB Program Philosophy
Collaborative, communitycentered approach
Public and private sector
“We need you; you need us”
Division of Public Health Services
New Hampshire Department of Health and Human Services
Division of Public Health Services
New Hampshire Department of Health and Human Services
“Successful patient and program outcomes
rely upon close communication and
collaboration of the public and private
sector in TB prevention
and control efforts.”
Division of Public Health Services
New Hampshire Department of Health and Human Services
Common Challenges in
Low-Incidence States
Partnership Building
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Building personal community relationships
Communication
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In-state: centralized
Training & education- maintain expertise
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HR development funding
Implementing standards of practice
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DOT
Division of Public Health Services
New Hampshire Department of Health and Human Services
Building Partnerships
Division of Public Health Services
New Hampshire Department of Health and Human Services
Building Partnerships
Regional PHN case manager outreach
Personal relationships over time
Program relies upon personal bonds to
provide high-quality care
Visibility within the community
Based upon respect and trust
“Meet and greet” approach
Build bridges in the community
Division of Public Health Services
New Hampshire Department of Health and Human Services
Building Personal
Relationships/Partnerships
NHICEPs/board liaison
TB Medical Specialists
Home Health Agencies
Health-care Facility
Licensing
Correctional Facilities
Lung Association of NH
Refugee Resettlement
Agencies
Universities
Division of Public Health Services
New Hampshire Department of Health and Human Services
Building Personal
Relationships/Partnerships
Getting to know your community
Who are the ICPs at facilities? Meet them & help
them!
Which practices are knowledgeable and
comfortable treating pts with TB? Meet & help.
Who is willing to learn? Help them.
What pharmacies stock TB medications?
Which HHA will accept Medicaid reimbursement?
Ask who knows the PHN in this community?
Who else needs to “THINK TB”?
Division of Public Health Services
New Hampshire Department of Health and Human Services
Correctional Facility Example
Over years, PHN established
relationship with county nursing
home and jail through periodic
disease investigations and
outreach visits.
Impromptu meeting with jail
Superintendent; discussed TB
testing practices
Left business card
Division of Public Health Services
New Hampshire Department of Health and Human Services
Correctional Facility Example
2005: call from county jail about an inmate
who might have TB
Inmate had been arrested 48 hours earlier
after a car accident
Had been transported by officers to the
hospital, the jail, the court, back to the jail
CXR now suspicious for TB
Plan: transport out of state
PANIC in the community- court, police, CF,
hospital
Division of Public Health Services
New Hampshire Department of Health and Human Services
Correctional Facility
Superintendent remembered and called PHN
Prompt interventions- Same day met with CF
officers,sheriffs dept, police depts, jail
leadership and medical staff
IC: AII cell, N-95 masks, sputum collection,
transport protections
Able to defuse the situation quickly
Confirmation of TB
Division of Public Health Services
New Hampshire Department of Health and Human Services
Education and Training
Division of Public Health Services
New Hampshire Department of Health and Human Services
Human Resource
Development Funding
2005: new directive from CDC
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HR development plan required
Target training of staff & providers
Who will do it?
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Already wearing many hats
Reliant upon outside partners for care deliveryHow to keep them informed and updated?
How to accomplish with limited resources?
Division of Public Health Services
New Hampshire Department of Health and Human Services
HR Development Funding
Hired part-time (15 hours/week) TB focal point
Conducted provider/program training needs
assessment in conjunction with evaluation project
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modified survey tool from RTMCC to better meet needs
in low-incidence state and included evaluation project
1230 surveys mailed to select providers in 4 highest
incidence counties
targeted specialty areas: family practice, internal
medicine, pediatrics, ID and pulmonology
398 responses received (32 % response rate)
Division of Public Health Services
New Hampshire Department of Health and Human Services
HR Development Activities
Based on the provider survey data received
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Developed TB training and HR development plan
Developed email list-serves for distribution of information and
resources
 i.e. Corrections, ICPs, IDs and Pulmonologists
Distribution of new products, guidelines and
educational opportunities through list-serves
Annual TB conference focusing on areas of
greatest provider need and interest
Plan: program brochure to better educate
providers about our program and services
Division of Public Health Services
New Hampshire Department of Health and Human Services
Education and Training
of Program Staff
New employee orientation
On-going training
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Staff case conference meetings every other month;
training component included
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Examples: New Diagnostics in TB, Refugee Health, XDR-TB,
New guidelines
Weekly outbreak team meetings- teaching moment
Webinar trainings/tracking: encourage attendance
NHICEP meetings
Limited attendance at RTMCC,regional or national
trainings
Division of Public Health Services
New Hampshire Department of Health and Human Services
Health Care Provider Training
“THINK TB” message
Medical case consultation easily accessible
TB 101, DOT and TST workshops
Targeted annual TB conference in collaboration
with local hospitals and NJRTMCC
Dartmouth Medical School residents on site
Brown bag presentations to medical resident
training programs
Local, regional and national conferences
Webinars: New England TB Case series
Division of Public Health Services
New Hampshire Department of Health and Human Services
Communication
Division of Public Health Services
New Hampshire Department of Health and Human Services
Communication
Small size and centralized structure facilitates
the mechanism of communication
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Same people wear multiple hats
Meetings
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Weekly and PRN Communicable Disease team
meeting conference call
Every other month case conference with TB
program updates and educational session
NHICEP state update every other month
Providers: THINK TB
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Office visits: meet and greet, phone, email
Newsletter, annual report
Division of Public Health Services
New Hampshire Department of Health and Human Services
Standards of Practice
Universal Directly Observed Therapy (DOT)
Division of Public Health Services
New Hampshire Department of Health and Human Services
Universal DOT
National recommendation
Administrative and TB Advisory Committee
support: 1997
Delivery model:Home Health Agencies (HHA)
Challenge to engage:
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Program staff
Home Health Agencies (HHA)
Providers
Clients
Resulted in routine standard of practice
Division of Public Health Services
New Hampshire Department of Health and Human Services
DOT
By PHN or HHA
Contract with HHA for DOT
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Reimburse at current Medicaid rate
Train HHA staff: TB 101 With DOT
DOT letters for HHA
DOT Calendars
Monthly pill boxes
PHN maintains case management responsibilities
Incentives as needed- local grocery stores
Division of Public Health Services
New Hampshire Department of Health and Human Services
Percentage
TB in NH 1991-2005: DOT vs Self Administered Therapy
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Count Year
Division of Public Health Services
New Hampshire Department of Health and Human Services
No DOT
Both
100% DOT
Summary of NH Strategies To
Enhance TB Control Efforts
Regional PHN outreach
Market “THINK TB” message
Engage community in TB Control
Maintain internal and external TB
training efforts
Ongoing communication between the
public and private sector
Division of Public Health Services
New Hampshire Department of Health and Human Services
Regional Efforts
Partnership,
communication,
standards of practice,
E&T
Facilitated by Mark
Lobato, CDC Regional
Medical Officer
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Periodic conference calls
NewEnglandTB.org
Genotyping workgroup
Training
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Qtrly case series
Shared resources
Division of Public Health Services
New Hampshire Department of Health and Human Services
New Hampshire TB Program
Phone: 603-271-4496
Fax: 603-271-0545
Email: Judy Proctor

Jproctor@dhhs.state.nh.us
Address: 29 Hazen Drive
Concord, NH 03301
Division of Public Health Services
New Hampshire Department of Health and Human Services
Acknowledgements
Lisa Roy, TB Education & Training
Coordinator
NH Communicable Disease Control Staff
New England Regional TB Group
Jose T. Montero MD, State Epidemiologist
Elizabeth A.Talbot MD, Deputy State
Epidemiologist and Assistant Professor
Medicine at Dartmouth College
Division of Public Health Services
New Hampshire Department of Health and Human Services
Division of Public Health Services
New Hampshire Department of Health and Human Services