TB Challenge: Partnering to Eliminate TB
in African Americans
A Successful Intervention to Improve TB Treatment
Outcomes in Georgia’s Homeless: An Interview with Pamela Collins,
American Lung Association of Georgia
Michael Fraser, DTBE/ FSEB
Michael Fraser: How and when did the homeless TB patient
program get started?
Pam Collins: It started after the closing of the TB inpatient
unit—a wing at the Northwest Georgia Regional Hospital in
Rome — in June 1996. This wing could house up to 10 in a semi-secured
area for TB patients and had done so for some 50 years. With the
closing of the unit, the alternative housing project, which is a
collaboration between the American Lung Association of Georgia (ALA
GA) and the Georgia Department of Human Resources (DHR) Division
of Public Health, Prevention Services, Tuberculosis Program, was
begun to provide housing for homeless TB clients in the state of
Georgia. Today, we can provide housing for homeless or inadequately
housed TB clients within their locale; we work closely with DHR
to locate motels, trailers, or apartments that will house infectious
TB patients in the various health districts. Funds allocated for
this project pay for rent, meals, and personal supplies, and even
provide transportation to medical appointments that are unrelated
to TB. We also offer social service referrals and make various accommodations
for patient families; some of these include shared housing for spouses
and children. Project funds are used to ensure that clients with
little or no income, and those who cannot work because of their
infectiousness, maintain their basic necessities. There is no assistance,
however, for such amenities as phone or cable services.
MF: How did you come up with this intervention and get
support for it?
PC: The GA DHR TB control program manager, Beverly DeVoe-Payton,
had been in communication with the ALA of North Carolina and learned
that they had a project that provided housing for TB clients. However,
we decided to take a different approach in the design and implementation
of our project. For example, in North Carolina, funds were provided
directly to the health districts for overall management of their
housing program. Here in Georgia, we wanted to have staff directly
oversee project activities and funding. We worked closely with the
state's TB control program to remove obstacles that may present
barriers to completing treatment; also, our monitoring/case management
efforts have ensured that clients receiving our services are not
lost to medical follow-up in the process.
MF: What are the criteria for TB clients to enter into this
program and who makes the decision about who is eligible?
PC: First of all, the patient must be infectious, or if
the infectious status is unknown, a determination is made through
medical consultation at the local health department referring the
client for housing. The TB client must also demonstrate that he/she
has an unstable home environment. If they are in the hospital and
they're saying that they can't go back home because they do not
have a home to go to, then an assessment is made by the health department
and hospital social service staff to confirm this. Clients may have
been residing, prior to admission, in a homeless shelter and quite
frankly we would want to pull them out of that setting. If a client
is indicating that he/she does not wish to return to a housing environment
that is with family, but unstable, then we work with the client
to provide housing.
MF: Can you indicate how successful this project has been?
PC: Sure. From July 1, 1996, through June 30, 2004, we
have had 538 clients utilize our services. We have been successful
in that there was a 97% compliance rate with directly observed therapy
and a 91% completion of therapy rate in this cohort of TB clients.
MF: What is the racial and demographic profile of clients
PC: For the cohort mentioned earlier, 77% were reported
as black or African American; 12%, Caucasian; 8% percent, Hispanic;
and 2%, Asian. In addition, 82% were male and 18% were female.
MF: What is the length of stay for TB clients in alternative
PC: It just depends. Even if a TB client becomes sputum-smear
negative, the health department may feel strongly that a TB client
may become noncompliant with TB treatment; then all efforts for
that client to remain are made, up to completion of therapy. Ordinarily,
TB clients in the metro Atlanta area will stay in the program until
they have three negative smears and one negative culture. Usually
that takes up to 90 days from the time residency begins. Ninety
days is our target; however, discharge from alternative housing
in the state could occur before 90 days are up. There are other
sources in the community that the ALA works with for continued housing
of TB clients, when necessary. Some of these include the Antioch
Urban Ministries, along with many others. We have 159 counties in
Georgia that we provide services for. If a patient is in Blakely
County, we're there, and if they are in Catoosa County, we're there
MF: What are some of the rules that TB clients must adhere
to in order to remain in the program?
PC: TB clients are expected to keep their rooms clean and
undamaged. As a matter of fact, we don't want them to damage any
property. At the end of their stay, we want them to make sure that
their room is left clean. After a new client is placed in alternative
housing, there is follow-up from the ALA and DHR. Of course, directly
observed therapy for the client's TB is a requirement for housing.
There is accountability for TB clients receiving alternative housing
during their treatment for TB; patients who are recipients of alternative
housing are periodically reviewed by the state TB control program
during regularly scheduled case reviews, although there is co-management
MF: Finally, are there any plans to house persons diagnosed
with HIV who are infected with TB? As you know, these are persons
who are at high-risk for developing TB disease.
PC: Yes. We are always looking for new projects and the
opportunities to work collaboratively across disease programs.