Primary care clinics boost completion rate

Prevention works well at community level

Boston TB controllers have doubled completion rates for preventive therapy by using a simple strategy: recruiting help from the community-based health centers.

The program is working so well, in fact, that among the 350 to 400 patients who are currently enrolled in a new program, completion rates have climbed to about 80%, says John Bernardo, MD, Boston's TB controller. That compares especially favorably to patients at the hard-to-reach downtown TB clinic, where completion rates languish at about 30 to 40%.

The plan Bernardo hit upon combines the expertise of the specialized clinic downtown with the easy access and cultural compatibility afforded by the city's Neighborhood Health Centers. The result is a system that pulls patients in, refers them for a one-time visit downtown at the TB clinic, and then brings them back to the local health clinics, where staff keep an eye on the patients and stay in close touch with the specialists downtown.

Before, TB care got lost in the shuffle

The first step, says Bernardo, was to convince the community health centers they had a part to play. Without any amenities such as labs or X-ray facilities, the health centers weren't equipped to provide TB care and they weren't especially interested in doing it, says Bernardo. "It's not that providing preventive therapy is so difficult," he says. "TB just isn't a priority. Their patients have so many other problems that TB tends to get lost in the shuffle."

For starters, TB controllers approached some of health centers that serve patients at high risk for TB. Would they be interested in the program?

Six health centers were chosen for the initial part of the program. (Two more centers are scheduled to come on board.) Each catered to one of the city's ethnic groups at high risk for TB: Haitian, Hispanic/Portuguese, Vietnamese, or Chinese.

In addition, the centers were within easy walking distance of patients' homes, offered quick service, and had the advantage of staff who spoke the language and knew the culture of most of their patients.

"The way we pitched it was that instead of losing their clients to the TB clinic downtown, they would get to keep them," says Claire Murphy, RN, BSN, Community Health Center Coordinator for the city's TB control program.

Staff at the health centers received several days of formal training and instructions, including lectures on skin-testing, preventive therapy, and management of active disease. In addition to the training, employees attended two workshops - one on case management, which included a discussion of several case studies, and another on skin-testing.

`Oh, we already know how to do that'

At the second workshop, "we brought in the artificial arm and everything," says Murphy. "Everyone looked at it and said, `Oh, I already know how to do that.'" She chuckles. "They didn't, of course."

Once they completed training, health center staff were ready to start doing what they'd done before: skin-testing patients at risk for TB infection and sending them downtown to the TB clinic. But this time, there was a difference. After a single clinic visit to rule out active TB and get the requisite liver function tests, patients were now sent back to the health centers to complete their therapy.

There were a few hitches, Bernardo says. For example, a lot of patients only presented in the first place to fulfill requirements for employment. Once they'd been seen at the downtown clinic, there was a good chance they'd take their paperwork and pills and simply disappear, he says. To prevent that from happening, some extra steps were added to the process, says Murphy.

Now, as patients are departing the TB clinic downtown, they are asked to telephone the health center where they will be followed. An appointment for follow-up is made. Paperwork is forwarded back to the clinic, along with a refill for five more months' of medication.

Back at the health center, if patients don't show up, someone on staff makes a phone call, explaining to the patient why it's important to continue the therapy. In most cases, patients come back, says Murphy.

24-hour access

At the downtown clinic, the TB control staff keep in close touch with the health centers, Murphy says. "We have 24-hour accountability," she says. "If they have a problem at the center [such as side effects from the medication] they can page me, and I'll return the call right away." There's no phone menu to get through, no delays, and no paperwork.

Some issues remain unresolved. The health centers traditionally charged a small copayment - about $7 - to cover part of the cost of the patient visit, says Murphy. Care at the TB clinic, though it involves several bus rides and lots of long lines, is at least free; so some were patients doggedly continuing to make the trek downtown for refills, says Murphy.

After some discussion, the health centers decided they could waive the copayments.

Even now, some centers are not as accessible as Bernardo would like them to be. "[For instance], if you can't come to the TB clinic on Monday at 6 p.m., that's too bad." Still, every clinic has someone on board who can handle urgent problems that arise, says Murphy.