Transcript Changing Face of Migration

TB Programs and Migrant
Clinicians Network
Collaborations
Ed Zuroweste, MD
Chief Medical Officer
Migrant Clinicians Network
16th Annual IUATLD Conference
San Antonio, Texas
February 23, 2010
Migrant Clinicians Network
A national, clinical network founded in 1984
10,000 constituents
Oldest clinical network serving
the mobile poor
MCN’s primary constituents are
clinicians working in federally
funded Migrant and Community
Health Centers and in state and
local health departments.
Photo © Alan Pogue
Photo © Alan Pogue
We believe no one’s health should be compromised because of her/his mobility
and because s/he may be seen by multiple providers and clinics.
MCN Mission
A force for Health Justice for the
mobile poor
Migrant Farmworkers
Longer stays in the
US/more “settled out”
immigrants.
No accessible means to
obtain citizenship
Further
disenfranchised/isolated
immigrants
More Fear
More confusion
Access to Health Care
Fear + policy + enforcement + reality of being an
immigrant:
Language
Social/cultural difference
Poverty
Lack of trust
Lack of health insurance
Lack of “Know How” to access the system
Mobility (Continuity of care difficult)
= LIMITED ACCESS TO HEALTH CARE
What happens when there are
numerous barriers to health care?
Individuals present with advanced
health care problems
The ultimate cost of treatment is higher
The outcomes of treatment are
significantly poorer
Morbidity and Mortality rates are higher
MCN Health Network
Goal: eliminate health disparities
due to patient mobility
Responds to challenges in providing
continuity of care through patient
navigation; medical record transfer
and bridge case management program
Health Issues:
Tuberculosis (TBnet)
Diabetes (Track II)
Cancer (CAN-Track)
Prenatal
H1N1 flu, HIV, Hansen’s disease
General health issues
Services free of charge to clinics and participants
What is Bridge Case Management?
Bridge between mobile patients and
their providers
Provides care coordination services
and health education to mobile
patients
Expert bilingual, culturally-competent
case managers
Transfers medical records
Central storehouse of patient medical
information
Offers toll-free access for patients and clinicians
TBNet
TBNet began in 1996
Funding:
Immigration and Customs Enforcement since
2005
HRSA/BPHC since 2010
New Mexico Dept. of Health through US/Mexico
Border Health Commission since 2010
Funding from CDC ended 2008
Health Network Enrollment Criteria
Patient who is:
Mobile
Likely to be lost to follow-up
Patient who has:
Active or latent tuberculosis
Diagnosis or at risk for diabetes
Needs testing or breast, cervical or colon cancer
Is pregnant
Is HIV +, H1N1, Hansen’s disease
Any general health issue that requires follow-up
Pre-enrollment Education/
Assurance to the patient
MCN Health Network
does not discriminate
on the basis of
immigration status and
will not share personal
patient information
without patient
permission
Forms Required for Enrollment
Consent Form
Gives MCN staff legal
permission to transfer
participants’ medical records
and contact participants
This form must have the
participant’s signature
Participants may renew their
consent after it expires if they
still need assistance
Maintaining a Patient in Care…
Contacting patients on a scheduled basis. TB
patients monthly.
Contacting TB clinics on monthly basis
Assisting patients in locating services and
resources
Reporting back to the
enrolling clinic and notifying
them of patient status and
final outcomes
Photo: C. Kugel
Maintaining a Patient in Care
Patient Role:
Inform Health Network of address changes or
phone number changes
When looking for health services in a new
area, call the 800 number for help
Receive calls from Health Network staff
following up on the patient’s health status
TBNet Bridge Case Management
TBNet, an innovative approach to tuberculosis
management in migrating patients, has demonstrated
for 17 years how TB control can be successfully
accomplished in highly mobile populations, even those
traveling internationally.
4,330 total TB enrollments since 1996
2,951 total clinics, in US and over 70 countries,
participated since 1996
Impact
Table 1: TBNet
Enrollment
2005-Present
• 60 countries served
• Total 1,803 pts
1996-Present
• 71 countries served
• Total 4,330pts
Impact
Table 1: TBNet Enrollment
Country
2005-Present
• 60 countries served
• Total 1,803 pts
Mexico
691 (38.3%)
Honduras
368 (20.4%)
Guatemala
245 (13.6%)
El Salvador
143 (7.9%)
% of TOTAL
80.3%
TB Control Among Detainees:
An Innovative Public/Private
Collaboration
U.S. immigration laws have no provisions
addressing health status with regard to removal
Culture-confirmed case rate 2.5 times higher than
other foreign-born individuals. (Am J Prev Med 2007;33(1):9–14)
Detainees often return to countries where access to
health care is limited, or fail to complete treatment
due to mobility. (Am J Prev Med 2007)
Contract with TBNet started 2005.
TB Control Among Detainees: An
Innovative Public/Private Collaboration
Works because of dedicated clinical and
administrative staff at ICE facilities and in DC
Open communication between ICE Health
Service Corps (IHSC) and MCN with
continuous quality improvement philosophy
Mutual goal—Provide culturally competent
compassionate high quality services to the
individuals dealing with Tuberculosis
TB Net’s International Reach
Belgium, Belize, Bolivia, Brazil, Cameroon, China, Canada, Colombia, Costa Rica, Dominican
Republic, Ecuador, El Salvador, Etiopía, Guatemala, Haití, Honduras, India, México, Micronesia,
Nepal, Nicaragua, Perú, Philippines, Romania, Russia, Somalia, South Korea, Sri Lanka, Taiwan,
Turkey, United States, Vietnam
TBNet Statistics 2005-2010
A review of all referrals made for ICE
detainees and State Health Departments to
TBNet was completed January 1, 2005,
through December 31, 2010
A total of 937 active (Class 3) cases
reviewed
Nationality TBNet 2005-2010
Country
Total Class 3 patients
(937 total patients)
Percent of total patients
Honduras
345
36.8%
Mexico
161
17.2%
Guatemala
154
16.4%
El Salvador
103
11%
Nicaragua
22
2.3%
Peru
18
1.9%
China
17
1.8%
Ecuador
16
1.7%
India
10
1.1%
Haiti
10
1.1%
763
81.4%
Honduras; Mexico;
Guatemala; El Salvador
Class 3 Active TB:
TBNet Treatment Success (2005-2010)
937 Class 3 Active TB Cases Referred
29 treatment not recommended by destination
country
908 Treatment Recommended
7 deceased
901 Followed by TBNet for Active TB
95 lost to follow up
49 refused treatment
757 Complete Treatment = 84%
Treatment Goals / Benchmarks
Healthy People 2010 target for TB treatment
completion is 90%. [i]
WHO’s Stop TB Partnership sets that goal at
85% of smear-positive cases. [ii]
In 2007, the latest data available, 84.5% of
patients requiring treatment of less than one
year successfully completed their drug regimen
in the U.S. [iii]
[i] Morbidity and Mortality Weekly Report. Trends in tuberculosis—United States, 2008. Center for Disease Control and
Prevention. Mar 2009; 58(10): 249-253.
[ii] WHO Report 2009. Global tuberculosis control. Mar 2009. Also available at
http://www.who.int/tb/publications/global_report/2009/en/index.html.
[iii] MMWR Weekly. Trends in tuberculosis—United States, 2010. Center for Disease Control. Mar 2011; 60(11): 333-337.
25
Case Study
Feb. 2010 screened in ICE facility
Negative smear, RUL consolidation, TST 20 mm,
asymptomatic, medication not started
Feb. 2010 enrolled TBNet and then deported
March 2, 2010 TBNet notified positive culture
Clinic identified in Central America and medical records
sent
Contacted family in Central America but patient had left for
US
May 4, 2010 wife called stating patient in US being held by
coyotes
Case Study
TBNet case manager called coyote West Coast
Spoke to patient and explained culture results
and need for treatment
Immediately after call TBNet contacted ICE,
initiated human trafficking investigation
June 11, 2010 patient contacted TBNet was
released by coyote now on East Coast
Appointment made/medical records sent to local
health department
Patient started on 4 drug regimen DOT
Case Study
September 28, 2010 patient called TBNet he
had moved to another East Coast State
Clinic found, appointment made, medical
records transferred from both previous clinics
Patient resumed therapy per DOT
Wife updated on patients treatment
Treatment completed April 7, 2011
TBNet Successes
Treatment equal to that among
geographically stable populations
Disease surveillance role
Consistency between international
protocols
Policy recommendations – identify difficult
to treat populations
Model for management of other diseases
in mobile populations
Commitment
Health Network Staff with TB nurse and patient El Salvador
Connection
Guatemala NTP
Communication
El Salvador NTP
Consistency
CMO with Honduras NTP staff
Resources
Division of Tuberculosis Elimination (DTBE):
http://www.cdc.gov/tb/
Stop TB USA:
http://stoptbusa.org/
International Union Against Tuberculosis and Lung
Disease:
http://www.theunion.org
Migrant Clinicians Network:
http://www.migrantclinician.org/
Contact:
Ed Zuroweste MD
[email protected]
www.migrantclinician.org
1-800-825-8205
(U.S.)
01-800-681-9508
(from Mexico)