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TB Notes 1, 2002
Highlights From State and Local Programs
Housing Homeless TB Patients
Homelessness has long been recognized as an important predictor
of poor adherence to TB therapy. During the years from 1994 to 1996,
the California Department of Health Services (CDHS), TB Control
Branch (TBCB), received Report of Verified Case of TB (RVCT) forms
that identified an average of 339 (7.36%) TB patients as having
been homeless each year.
Homeless patients are among the most difficult to cure because
they are often difficult to locate. In order to ensure that patients
could be located for the administration of consistent directly observed
therapy (DOT) and thereby complete therapy within 12 months, TBCB
decided that a housing component should be added to the TB control
In 1996, at the behest of the California Tuberculosis Controllers
Association and the California Conference of Local Health Officers,
TBCB proposed a change to the Governor's budget that added $2.9
million for fiscal year 1997/98 for a program addressing the needs
of homeless and unstably housed TB patients in California. The funds
were also to be used to detain persistently nonadherent patients.
TBCB allocated housing funds to local health jurisdictions (LHJs)
by a formula based on the number of homeless patients they had reported.
Soon after the inception of the program, it became clear that providing
housing alone was not the solution. In addition to housing, patients
needed food, transportation, and other services. Some homeless patients
who did not want housing could be kept on treatment by being provided
with other incentives and enablers. Finally, it was determined that
other solutions were needed to prevent patients from becoming homeless
in the first place, and the problems that lead to homelessness should
be addressed. Providing additional funding for other compliance-enhancing
measures and for less restrictive alternatives to detention might
reduce the need for detention and improve completion of treatment
Therefore, about 6 months into the program, TBCB broadened the
scope of services provided to include compliance-enhancing measures
and less restrictive alternatives to detention. The branch also
extended the target population served by this program to include
persons at risk of becoming homeless as a result of their TB diagnosis.
TBCB increased services to homeless patients who refused housing
in an attempt to stabilize their lives enough to improve compliance
Broadening the scope of services provided, however, created a need
for additional personnel at the local level to provide these services.
Not only were homeless patients provided with shelter and food;
they now received increased DOT, case management, and social services.
Since FY 1999, approximately 47% of the total housing budget allocated
to the LHJs is currently spent for personnel who provide direct
services to clients. It supports 22.7 positions statewide (13.1
outreach, 0.9 field investigation, 6.0 case management, 2.5 social
work, and 0.2 miscellaneous; numbers rounded to one decimal). The
remaining 53% of the housing budget is spent on food and shelter.
BCB collected data over the 2-year period of January 1, 1998, through
December 31, 1999, using a data collection instrument called the
Report of Homeless Tuberculosis Patient or Suspect (RHTP). Local
health departments were asked to complete an RHTP on each patient
with known or suspected TB who was homeless within the 12 months
prior to diagnosis, at the time of diagnosis, or at any time prior
to the final disposition of treatment, whether or not housing was
provided. The purpose was to ascertain the outcome of housing and
treatment for every homeless TB patient or suspect identified in
the state during that period. The RHTP collected information on
whether or not the patient had been offered and accepted housing,
how long the patient was actually housed, the type and duration
of housing provided, and the reasons for which the patient left
housing. By linking the RHTP to the RVCT for the same patient, the
demographic characteristics and the outcome of therapy could be
correlated to the housing provided. Additionally, the RHTP was linked
to the system by which LHJs invoice the State to determine the cost
per day and per patient for providing the housing.
TBCB received 620 RHTPs of suspects and cases over this 2-year period
for both homeless cases and suspects. Of the 620 patients, 327 (52.7%)
were offered housing. However, when the analysis excludes one jurisdiction
in which only 24.2% (70/289) were offered housing, the percentage
for the remainder of the State jumps to 73.1%.
The branch examined RHTPs to determine the reasons for which the
remaining 293 patients were not offered housing; we were able to
determine the reason for 228 of these. Of the 228, 144 (63.1%) actually
had some form of shelter, although technically homeless because
they had no official address. TB was ruled out in another 35 (15.4%)
patients. An additional 38 either moved, died, or were lost to follow-up,
leaving only 11 (4.8%) patients who were not offered housing for
Of those offered housing, 92.3% were actually housed. In fiscal
year 1998/99, the only year for which we had complete fiscal data,
263 patients were housed for 19,078 days at a cost to CDHS of $586,538,
an average of $2,230 (73 days) per patient and $30.74 per day of
housing. We were unable to determine the amount of local funding
spent on housing or the number or additional patients that may have
been housed using local funds.
The majority (73.8%) were housed in single room occupancy (SRO)
hotels. An additional 21.4% stayed in "other" facilities. The category
"other" includes apartments, homes, and some inpatient facilities.
Only a very few patients were housed in YMCAs (<1.0%), rehabilitation
centers (<1.0%), or board and care facilities (4.1%).
Thirty-nine patients were offered housing, but were not actually
housed using CDHS funds. Of these, 7.7% refused housing, 46.2% were
actually housed by another program, and 18% were detained, incarcerated,
or hospitalized. Treatment was terminated for one patient, leaving
10 (25.6%) patients who were not housed for various other or unspecified
We received follow-up RHTPs on 243 (84.3%) of the 288 patients
housed by the program. Of these, 87 (35.8%) patients left housing
because their treatment was terminated. Another 93 (38.2%) either
moved to or were detained in other facilities. They therefore remained
housed for the continuation of their treatment.
We attempted to determine the treatment status of each patient
at the time housing was terminated. As mentioned above, over 35%
left housing because treatment was terminated. Another 22.2% left
housing but continued treatment in the community and 22.6% left
because TB was ruled out as a diagnosis. Only 19.3% left because
they moved out of the area or died, or for unknown reasons. It is
important to remember that these figures do not necessarily reflect
the final outcomes of these cases.
How well does the RVCT capture the extent of homelessness among
To better understand the magnitude of the problem, we compared RHTP
and RVCT data for 1998, the year for which RHTP data were most complete.
Together, these two data sources identified 287 homeless TB patients,
45 (16%) of whom were not identified as homeless on their RVCTs.
This suggests that the RVCT may underestimate the number of homeless
persons with TB by 16%. A possible reason is that incarcerated patients
are not usually reported as homeless, but may actually be homeless
when released from jail. Nor does the RVCT system capture the number
of patients who become homeless subsequent to diagnosis.
We determined patient characteristics of 585 persons with TB reported
as homeless on either the RHTP or RVCT in 1998/99. Eighty-two percent
of homeless persons were men, and 38% were foreign-born persons.
Fifty-eight percent were non-Hispanic white persons, 29% were black
persons, 8% were American Indians, 2% were Asian/Pacific Islanders,
and 2% were unknown. In terms of substance abuse, 15% of homeless
patients reported injecting drug use, 30% noninjecting drug use,
and 49% excess alcohol use in the past year. The RHTP captured homeless
patient demographics that were significantly different from those
captured on the RVCT. This comparison suggested that more American
Indian, Hispanic, and foreign-born persons may be homeless prior
to or at the time of diagnosis than was previously thought.
Trends in treatment outcomes for homeless persons with TB identified
on RVCT. We also looked at treatment outcomes for homeless patients
(as identified on the RVCT) before and after the implementation
of this program. The analysis is based on the most recent follow-up
RVCT available, and is restricted to patients who began treatment
and had no resistance to rifampin. The rate of completion in less
than 12 months had already risen from 57.4% in 1995 to 66.3% in
1996 and then to 69.2% in 1997. In 1998, the first year of the program,
the rate of completion in less than 12 months fell to 66.0%, but
rose again to 69.3% in 1999. The rate of completion in over 12 months
fell from 13.8% in 1995 to 8.9% in 1996 and 8.4% in 1997, rose to
12.9% in 1998 and then finally fell to 7.5% in 1999. Similarly,
the rate for the category of "died" fluctuated between 6.3% and
10% in these years.
Categories for outcomes that may have been influenced by the housing
program are "lost" and "moved." The proportion of homeless patients
listed on the most recent Case Completion Report as "lost" has decreased
steadily from 7.8% in 1996 to 3.3% in 1999. The proportion listed
on the most recent Case Completion Report as "moved" dropped from
8.9% among the homeless in 1996 to 4.2% in 1999.
We also analyzed the Case Completion Report (RVCT Follow-up 2)
submitted by the jurisdiction that originally reported the case,
disregarding subsequent Case Completion Reports submitted by other
jurisdictions into which the patient moved. This allows us to determine
the outcomes of case management in the jurisdiction that originally
reported the case. We were interested in determining if the provision
of housing services stabilized patients' living conditions so they
would not need to move. This analysis showed that the proportion
of homeless patients classified as "moved" decreased from 14.8%
in 1996 to 10% in 1998 and to 7% in 1999.
There is evidence to suggest that housing patients had a positive
effect on the outcome of therapy. The implementation of this program
corresponded with a decreasing proportion of homeless patients whose
most recent RVCT 2 indicated that their status was "lost" or "moved."
However, since the implementation of the housing program coincided
with the implementation of other interventions (e.g., food, increased
incentives, enablers, social services, and DOT), it is difficult
to precisely determine the effect of the housing program in California.
The housing program also coincided with intensified efforts by the
CDHS TB Registry to follow up with local health departments to ensure
that "moved" was not a final disposition. The latter intervention
would not have impacted the proportion of homeless TB patients who
move out of the jurisdiction that originally reported them. The
trend toward decreasing movement out of the original reporting jurisdiction
suggests more successful case management in the original jurisdiction,
which may have been aided by the provision of housing.
Housing can be one way to improve TB control while improving patients'
lives for at least a short period of time. In addition, while patients
are housed, the job of providing DOT and support services is made
easier and more cost effective by reducing the time health workers
spend searching for patients. However, completion of therapy rates
among the homeless remain unacceptably low. The persistent application
of many interventions tailored to the individual needs of homeless
patients is needed to further improve treatment outcomes.
Submitted by Steve Roger,
Cathryn Fan, and Jan Young
California Department of Health Services Tuberculosis Control Branch
Application of Aggregate Reports to Program Management
The Aggregate Reports for TB program Evaluation marked
a dramatic shift towards improved TB program management and accountability
when they were introduced in 1999. Only after completing two cycles
of the Contacts Report and one cycle of Targeted Testing did we
begin to realize the full potential of these reports.
The reactions of the Florida Department of Health
(DOH) TB program field staff were probably much the same as those
of staff in other states when the seemingly complicated report formats
and new definitions first appeared. They had to learn not just a
new vocabulary and new definitions but, in some ways, a completely
different way of looking at TB control. This new view of affairs
meant that more is not necessarily better; that priorities must
be set and results measured. The focus is not on numbers, but on
Florida already had in place the nucleus of a TB case
management information system before TIMS came along with its case
management capabilities. The Florida system, the Health Clinic Management
System, or HCMS, contained a registration module, a TB case management
and RVCT module, a laboratory module, and limited ad hoc report
generation capability. It was logical, if not simple, to base a
management reports module for the Aggregate Reports on this platform.
We reached the decision to automate the Aggregate
Reports after completing the preliminary contact reports for 1999.
With the realization that Florida's 67 county health departments
(CHDs) were required to consult treatment records and manual statistical
tabulations on approximately 9500 contacts for nearly 1200 cases
just for one report, we had to rethink our approach to the preparation
of these reports. Through the statewide Quality Improvement process,
we also discovered that the old CDC Program Management Reports were
being completed and interpreted differently among CHDs. The inescapable
conclusion we reached was the necessity of designing a system to
standardize and automate the reports.
There is no way to express in simple terms the programming
requirements for automating these reports. It is not simply a matter
of designing a set of screens that can be used to load the HCMS
database to produce the reports for a given cohort year. The committee
of users we convened to assist in developing the specifications
was forced to develop decision rules applicable to a variety of
situations. For example, what cutoffs should be used to count the
contacts to cases reported late in the cohort year whose evaluation
and treatment took place in the next year?
The initial reports had to be tested, compared to
audit reports, and completely validated or returned to the programmer
for correction over a period of months, in the course of which the
program identified some stellar analytic thinkers. The Contacts
Report was completed first, followed in late August 2001 by the
Targeted Testing Report. The system was then used to produce the
final Contacts Report for 1999, the Preliminary Contacts Report
for 2000, and the preliminary Targeted Testing Report for 2000.
If this article were only about the automation of
the Aggregate Reports, it could stop here with grateful congratulations
to the project managers and programmers who designed the system.
But happily the story doesn't stop here.
It is a truism more often expressed than acted upon
that data are not collected for their own sake but to serve a purpose.
The Aggregate Reports were designed for TB program evaluation as
their title indicates, not simply at the national or even the state
level but locally as well. Florida has discovered that the aggregate
reports can help the CHD TB programs obtain a snapshot of their
To serve this purpose, we have developed a summary
report that compares operating results at the local level to state
averages and state goals. This enables each health department TB
program to see how it compares to other health departments, whether
it is using its resources in the most efficient way, and whether
its program is effective in meeting the highest priority needs.
The measures used in the Contacts Report include the
- Other contacts as a percentage of total contacts
- No contacts rate for smear-positive cases
- No contacts rate for smear-negative cases
- Contacts per smear-positive case
- Contacts per smear-negative case
- Evaluation rate for contacts to smear-positive cases
- Evaluation rate for contacts to smear-negative cases
- Evaluation rate for contacts to "other" cases
- Disease rates for smear-positive, smear-negative, and "other"
- LTBI rates for smear-positive, smear-negative, and "other"
- Treatment rates for contacts with LTBI
- Contacts chose to stop plus contacts lost to follow-up, as
a percentage of total contacts who began treatment
- Completion rates for contacts with LTBI
Certain assumptions underlie these measures. First, a decision
to test is a decision to treat. And second, a decision to treat
is a decision to complete. Thus, the program should allocate resources
to ensure completion of therapy for contacts found to have LTBI.
Line 1, "other" contacts as a percentage of total contacts, is
measured to show the percentage of effort given to lower-priority
contacts. The amount is not an issue as long as the local TB program
has the resources to serve these clients, and its evaluation, treatment,
and completion rates for higher-priority contacts meet state standards.
In Lines 2 and 3, the goal for "no contacts" is zero. The state
program assumes that every TB case has contacts; and the objective
of a contact investigation is to find and evaluate those contacts.
There is no goal for number of contacts to "other" cases that presumably
have a lower priority.
The goal for lines 4 and 5 is 10 contacts per smear-positive and
For lines 6-8, Evaluation, the goal is 90%. The whole idea of a
contact investigation is to identify and evaluate contacts for possible
disease or infection resulting from their exposure to the index
case. If the contacts aren't evaluated, the contact investigation
is just wasted effort.
There is no goal for lines 9 and 10, TB disease or LTBI, but these
measures do serve a beneficial purpose. They show that the contact
investigations are achieving tangible results. Also, the LTBI rate
may reflect the LTBI background rate in certain population groups.
Certainly if the LTBI rate is higher than expected for that community
or population group, this may be an indication that the contact
investigation net was not spread widely enough, particularly when
combined with a low ratio of contacts per case or a high no-contacts
rate (or both).
Finally, the goal for lines 11 and 12, Treatment and Completion
rates, is 90% for each category. This is the bottom line, both figuratively
But if line 12 fails to meet expectations, the reason might be
found in Line 13, "Contacts who choose to stop or who are lost to
follow-up." This rate is compared to a standard of <10%. The rationale
underlying this measure is that all contacts receiving treatment
for LTBI should be case-managed, and case management should concentrate
on persons who show signs that they may not complete treatment.
If more than 10% of those who begin treatment fail to complete it,
the local program cannot possibly meet the State's 90% completion
While the preceding analysis has focused on identifying weaknesses
in the CHD's contact investigation program, the reverse also applies.
Strong points are highlighted and documented so that we also know
whom to praise for good work as well.
Clearly, it is not sufficient to simply compare health department
TB programs one to another or to the state goals. For this process
to be useful, it should lend itself to program analysis and management
purposes. Also, it should be reproducible at the local level so
managers can see how they are progressing periodically. To achieve
the second purpose, the program proposes to develop a special HCMS
screen that can be accessed locally to display the summary report
at any given time for any given time period.
The first priority, program analysis and management, is achieved
by understanding what the report shows, and the process to that
end seems self-evident. Low contacts per case or high "no-contacts"
ratios suggest problems with the contact identification process.
This is a critical deficiency, because persons who are not identified
cannot be evaluated.
If the evaluation rate is low, it is equally obvious that the deficiency
is critical, because persons who are not evaluated cannot be treated.
This deficiency may indicate problems in an aspect of the program
other than the contact identification process. If this is the problem,
the corrective action will differ from that required if the contacts
are not being identified. One may be an interviewing deficiency,
the other a deficiency in the follow-up procedure to locate and
test the contact.
There are also different interpretations that can be given a finding
that LTBI rates are too low or too high. The program manager must
give some thought to the findings to determine what, if anything,
is the significance of the variance from the expected rates.
Persons who have LTBI associated with an infectious TB patient
with whom they have contact should be treated. This is the only
way to interrupt the transmission of TB. If the treatment rate is
low, why is this so and what measures are needed to improve program
performance? The same is true for treatment completion. If a person
starts treatment, he or she should finish unless there are clinical
reasons why completion is not possible. The percentages shown for
"contact lost to follow-up" or "contact chose to stop" may provide
an explanation as to why treatment completion is low.
It should be evident by now that many of the same measures can
be applied to the targeted testing report. Certainly the same principles
apply. It should be noted that the Florida DOH chose to implement
the targeted testing report beginning with cohort year 2000 for
all clients tested or "screened" for LTBI by the county health
departments. By doing this, we get summary data of all TB "screening"
being done by CHDs across the state and an indication of the degree
to which targeted testing guidelines have been implemented throughout
Florida. It seems clear that these reports give management a powerful
tool with which to analyze their programs' effectiveness. In a time
of diminishing resources, programs need every tool possible to deliver
Reported by John T. Miller, Bureau of TB
and Refugee Health
Florida Dept of Health