Private/public blend is the key in Tacoma
Experts work closely with TB infrastructure
When Pierce County, WA, decided it was time to overhaul its public health infrastructure, no one guessed it would work so well. The Tacoma/Pierce County transformation, which blends private- and public-sector expertise, has cut costs by 30% overall and trimmed staff expenses by 50%, says Dian Sharma, PhD, senior epidemiologist the Pierce County health department.
At the same time, the remake has boosted patient care. "Under the old organization, we were having some slippage in terms of adherence to TB guidelines," says Sharma. That’s completely changed, and TB control staff members avow that patient care is better than ever.
"When I talk about this at meetings, people say, You must be not telling us something. You’re leave something out!’" says Sharma. "I tell them, Come look at what we’re doing.’"
There’s no reason the model won’t work anywhere else, Sharma says, and that includes typical high-incidence urban areas as well as smaller communities such as Pierce County, where the population is 700,000 and TB cases total no more than about 35 to 40 per year.
"It’s an interesting mix of private and public," says John Sbarbaro, MD, professor of medicine at the University of Colorado Health Sciences Center in Denver. "They’ve taken experts from the private sector, had them work hand-in-glove with the public sector and with the community clinics. If we’re about to go back to privatization again, this is a neat way to do it." (Sbarbaro saw the Pierce County program firsthand when an Institute of Medicine panel toured the county recently.)
Three elements working in concert
According to Sbarbaro, the Tacoma model features three important elements: the infectious disease (ID) group from which the county buys services; the TB clinic staff that monitors patient compliance; and the TB-related educational services the ID docs provide to other private practitioners, many of them less experienced, who provide primary care for the rest of the county residents.
The transformation of TB control in Pierce County got its start after a new health officer was appointed in an attempt to make the top-heavy public health system run more efficiently. A panel of experts studied the situation and came back with a recommendation: Close the categorical clinics and get patients into private care or community clinics that provide primary care.
Early in 1996, the new health officer took a deep breath and announced his intentions to do just that. The county would shut down all its specialized clinics, TB clinics included. For skin tests and preventive therapy, privately owned community clinics and other private-sector physicians would pick up the slack. To make sure all patients could afford treatment, some of the money saved from the clinic shutdown was made available so services at the private clinics could be provided on a sliding scale.
For treatment of active cases, the semi-retired physician who’d provided care for years would be replaced. Care would be contracted out to a group of physicians who specialized in infectious disease. One of the physicians in the group had trained in the TB clinic in Baltimore; both of the physicians who’d provide most of the TB care were young, full of energy, and thoroughly up- to-date on TB protocol.
News of the coming shutdowns struck many as a recipe for disaster, says Eileen Finegan, the liaison for the health department’s division of communicable disease surveillance. "There were a lot of doubts expressed," says Finegan. "People worried patients would get lost and fall through the cracks."
One reason that didn’t happen was that the county continued providing directly observed therapy (DOT) and continued using the case-management system. The TB case manager — Peggy Cooley, MSN — says she insisted from the start on having weekly case conferences with the ID physicians. "We just started out that way," she says. "It means we’re all on the same page."
Finegan agrees communication between the TB side and the ID group could hardly be better. "We’ve got our data well-organized and well-documented. Anyone of the staff working with a patient can see exactly when and where that patient got his last dose of DOT," she says.
A few problems did crop up. For example, TB nurses checking records for completion of isoniazid preventive therapy soon discovered that among private doctors, confusion abounded when it came to proper protocols.
"So we amended the contract with the ID group to include an education component," says Finegan. Now, the ID physicians spend one day a month educating community physicians and staff. "Maybe they’ll take an especially complicated case and do a case conference," she says. "Maybe they’ll just introduce themselves and chat; that way, if a question comes up, the person is more likely to call and ask for advice."
Tough-love approach applauded
What Cooley especially likes about the new arrangement is the ID docs’ tough-love approach to their work. "They don’t say, Let this patient go back to work after three weeks of treatment,’" she says. "Now I feel like I don’t have to fight so hard for the public health. It feels like we’re in this together."
In addition, having TB care handled by a prestigious ID group has raised the profile of the illness, Finegan says. "Being one of the primary ID sites in the county, these guys work with all kinds of physicians and hospitals. That helps keep TB at the forefront of the discussion. Before, it was like, TB? Oh, let the health department take care of it.’"
Their new jobs have helped the ID physicians grow, too, says Sharon Reinsvold, RN, nurse epidemiologist for the county. "Seeing all that we have to do has kind of opened their eyes," she says. "None of this happened by magic. It’s been an unfolding process." As public health budgets grow tighter, Reinsvold says more places will want to explore the process.
Best, says Cooley, the new arrangement lets her do her job the way she wants. "I used to have a purple Post-it note on the wall in front of my desk," she says. "It said, Protect the public.’ This way, that’s what we’re all able to do."
[Editor’s note: For more details on the Tacoma/ Pierce County program, readers can contact Dian Sharma at (253) 798-3475 or e-mail her at dian [email protected]. wa.us.]
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