Nurse Managed 12 week Latent Tuberculosis Infection Treatment Contra CostA county Health care for Homeless Jo Elliff, FNP Rose Vigil, RN

HCH Mission statement Our mission is to reach out and serve homeless adults, children and families of Contra Costa County by providing accessible, culturally sensitive services in order to promote wellness, prevent illness and to provide care when needed so that ultimately, we may improve the health status of this vulnerable population.

Who Qualifies as Homeless? Lacking a fixed, regular, adequate nighttime residence Primary night-time residence in a shelter, welfare hotel, transitional housing or street “Doubled-up” without name on a lease, couch surfing, etc.

Funding for hch services Section 330(h) Public Health Services Act Health Care for the Homeless grant from the Federal Government (Health Resources and Services Administration, HRSA)

HCH Types of services HCH Ambulatory Clinics HCH Mobile Clinics Respite Care HCH Behavioral Health Services HCH Dental Clinics Medical Outreach Team Eligibility Services Linkages to Care (Specialty services, establishing a medical home, PCP)

HCH Team Medical Director Program Manager Family Nurse Practitioners (FNP) Registered Nurses (RN) Community Health Workers (CHW) Certified Enrollment Counselors Consumer Liaison Senior Health Education Specialist Mental Health Specialist Licensed Clinical Social Worker (LCSW) Dentist Registered Dental Assistant

Homeless population served The number of homeless patients served by Contra Costa Health Services in 2015 31, 093 Unduplicated Homeless Patients Medical Visits: 100,532 Dental Visits:4,058 Mental Health Visits: 33,321 Substance Abuse Visits: 11,623

Patients completed treatment

Entry into rehabilitation centers Foreign born General health screen Who gets tested? Entry into shelters Entry into rehabilitation centers Foreign born General health screen

If initial screening is positive: Testing process Health Screen Initial testing TST (Tuberculosis Skin Test) QFT (Quantiferon) If initial screening is positive:  chest x-ray  if chest x-ray negative and patient is asymptomatic = consider LTBI treatment

Result Follow up Discuss diagnosis Discuss treatment options Discuss the risks/benefits of treatments Physical evaluation Importance of medication adherence Asses adherence to treatment plan Provider order medications Schedule follow up with RN for 12 week nurse managed LTBI treatment

nurse managed ltbi treatment Directly observed treatment Starting Treatment Discuss possible side-effects to treatment resistance Weekly symptom screen Positive symptom screen follow protocol Reinforce importance of medication adherence Identify potential barrier to adherence Establish plan to ensure adherence

Challenges of medication adherence Lack of access to health care Co-existing medical conditions Unstable housing Require weekly visits Low health literacy Alcohol/substance use High number of life stressors Language barrier

Why it works Initial testing to follow up  1 week Shorter duration of treatment Extended shelter stay Part of comprehensive care Mobile Provide transportation vouchers (i.e. bus tickets) No cost medication Medications kept centralized Spanish speaking providers Core Outreach team PHN referral

Lost to follow up – moved out of area Hospitalizations On going challenges Lost to care – jail Lost to follow up – moved out of area Hospitalizations Non – compliance Transportation