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

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I will if i have to

I Will If I Have To…

The Kansas Cohort Conversion Experience


State of kansas

State of Kansas


State of kansas1

State of Kansas


State of kansas2

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.


Tb in kansas 1985 2010

TB in Kansas 1985 - 2010


Tb in kansas 1985 20101

TB in Kansas 1985 - 2010


Tb structure in kansas

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


Tb structure in kansas1

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


How kansas did it

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


Kansas 2008

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


Kansas 2009

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


Kansas 2009 the beginning

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


Kansas 2009 the beginning1

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


Kansas 2009 the beginning2

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


Kansas 2009 off and running

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


How can kansas help

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


Kansas nebraska merger

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


Kansas nebraska merger will it work

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?


Kansas nebraska merger it will work

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


Kansas nebraska merger it will work1

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


Nebraska lessons learned

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


Nebraska going forward

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


Regional lessons learned

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


Kansas choices of outcome monitors

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


Documented culture conversion within 60 days in kansas

Documented Culture Conversion within 60 Days in Kansas


Initiated tx within 7 days of diagnosis in kansas

Initiated TX within 7 Days of Diagnosis in Kansas


Initiated recommended four drug therapy in kansas

Initiated Recommended Four Drug Therapy in Kansas


Infected contact treatment

Infected Contact Treatment

* 2010 Preliminary ARPE


Other measures considered in kansas

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


Significant program impacts in kansas

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!


Kansas nebraska final thoughts

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.


Kansas nebraska final thoughts1

Kansas NebraskaFinal Thoughts

If asked, we advise:

Just Do It,

You may be surprised!


I will if i have to

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


I will if i have to

Contact InformationPhil GriffinKansas TB ControllerKansas Department of Health and Environment1000 SW Jackson, Suite 210Topeka, KS [email protected]


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