Model Practice Title
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Please provide the name or title of your practice
Implementation of a Shelter Card System in Duval County, Florida-- One Step Toward Ending TB
Practice Categories
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Model and Promising Practices are stored in an online searchable database. Applications may align with more than one practice category. Please select all the practice areas that apply.
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- Conference Theme: Bridging Clinical Medicine and Population Health
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Other:
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Is this practice evidence based, if so please explain.
This system of care is innovative and it incorporated evidence based practice by using short course direct observed treatment with 3HP (Isoniazid and Rifapentine combination) for all of the homeless LTBI clients (high risk). References Int J Tuberc Lung Dis. 2013 Dec;17(12):1531-7. doi: 10.5588/ijtld.13.0423. and http://www.cdc.gov/tb/topic/treatment/ltbi.htm
Winnable Battles
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To keep pace with emerging public health challenges and to address the leading causes of death and disability, CDC initiated an effort called Winnable Battles to achieve measurable impact quickly.Winnable Battles are public health priorities with large-scale impact on health and known effective strategies to address them. Does this practice address any CDC's seven Winnable Battles? If so, please choose from the following:
- Food Safety
- HIV in the U.S.
- Nutrition, Physical Activity, and Obesity
- Tobacco
- Healthcare-associated Infections
- Motor Vehicle Injuries
- Teen Pregnancy
- None
Overview: Provide a brief summary of the practice in this section (750 Word Maximum)
Your summary must address all the questions below:
- Brief description of LHD- location, demographics of population served in your community
- Describe public health issue
- Goals and objectives of the proposed practice
- How was the practice implemented/activities
- Results/Outcomes (list process milestones and intended/actual outcomes and impacts.
- Were all of the objectives met?
- What specific factors led to the success of this practice?
- Public Health impact of practice
- Website for your program, or LHD.
750 Word Maximum
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Please use this portion to respond to the questions in the overview section.
DEMOGRAPHICS: The Florida Department of Health in Duval County (DOH-Duval) is in Jacksonville, Florida which has over 1 million residents. The population is closely split between male and female residents with 48.6% of population being male and 51.4% female. The average household income is $63,979. With regard to race and ethnicity, 61.1% of the population is Caucasian, 30.1% African American, 4.5% Asian, 0.2% Native American, and 1.3% Other, with 8.6% of the population being Hispanic.
BACKGROUND: From 2004-2011, Duval County experienced one of the most extensive tuberculosis (TB) outbreaks within the homeless population in local area shelters. The CDC was invited to assist DOH in the investigation. Cases genotyped revealed the increase in a specific cluster of TB as well as a proportionate increase amongst the homeless population in this cluster, indicating an increase in transmission. Statistics from 2004-2012 noted by the CDC report indicate homeless clients made up 43% of the active TB cases of this outbreak. (MMWR/Notes from the Field/July 20, 2012/Vol. 61/No. 28). The goal of implementing the DOH Duval shelter card system and partnering with local homeless shelters was to decrease the spread of TB.
METHOD: A system of routine testing and assessment of the county's homeless clients seeking admittance to area shelters was implemented. The clients must have a current "shelter" card that indicates they have been tested (annually) and assessed by DOH for symptoms of TB every 2 months. Through informal and formal agreements with area homeless shelters, clients are required to have a shelter clearance card the next business day after initial check in with the shelter.
RESULTS: During 2013, shelter card clients were not delineated separately from other walk-in clients for the clinic. As a result, no data for shelter card clients in 2013 can be assessed. During 2014, 16 shelter card clients were found to have latent TB infection (LTBI). Of those identified, 12 (75%) started LTBI treatment and 7 (58%) completed treatment. Of those who did not complete treatment, 1 chose to stop, 2 had adverse reactions, and 2 refused further treatment. During 2015, 35 shelter card clients were identified as LTBI. Of those identified, 16 (46%) started treatment and 7 (44%) have completed treatment. Of those who have not completed treatment, 5 were lost to follow-up and 3 moved with follow-up unknown and 1 chose to stop due to adverse reaction. During 2014 and 2015, no clients were identified through our screening process as active disease. However, there were 4 active disease cases in 2014 and 5 active disease cases in 2015 that had a history of using the local shelters. These were discovered after being admitted to a local hospital.
CONCLUSIONS: This system has been instrumental in interrupting the transmission of TB amongst the homeless population in area shelters. Routine assessment and annual testing have been effective in early detection of clients with symptoms of TB and improved diagnosis and treatment of clients exposed to TB.
We learned that although we initiated informal agreements with all of the local shelters, there were shelters that required a formal agreement in order to ensure continued participation in the program. We have initiated formal memorandums of agreement with local shelters and are in the process of completing the final versions of those agreements. The DOH-Duval program administrator provides ongoing support, training, and education for the shelter by meeting with the shelter administrators and attending the local homeless coalition meetings. The medical director also meets with the DOH-Duval TB team and shelter administrators as needed to provide agency updates, troubleshoot, and to show support for the collaboration.
As a best practice, we use short course therapy on our shelter card clients to promote adherence and completion. Use of incentives such as gift cards or bus passes for return appointments or directly observed therapy (DOT) also helps promote medication adherence.
When setting up your shelter card walk-in schedule, it is important to know when the check-in time and line formation starts at your local shelters. The clients will be eager to get their shelter card and leave to get in line at the shelter.
Above all it is important to be flexible!
http://duval.floridahealth.gov/
Responsiveness and Innovation
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be (1) new to the field of public health (and not just new to your health department) OR (2) a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.
- Statement of the problem/public health issue
- What target population is affected by problem (please include relevant demographics)
- What is the target population size?
- What percentage did you reach?
- What has been done in the past to address the problem?
- Why is the current/proposed practice better?
- Is current practice innovative? How so/explain?
- Is it new to the field of public health
OR
- Is it a creative use of existing tool or practice:
What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.)
- Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
2000 Word Maximum
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Please state the Responsiveness and Innovation of your practice (2000 Word Maximum)
The DOH-Duval Shelter Card System was developed in 2013 response to a TB Outbreak in Jacksonville, Florida which made local and national news. What was concerning about this outbreak was that it was tied to a specific genotype and it occurred predominately in the homeless population. The homeless point in time counts for 2014 and 2015 were 2049 and 1853 respectively. We managed to screen 75% of the homeless population in 2014 and 81% of the homeless population in 2015. Prior to DOH-Duval implementing the Shelter Card System, there was no screening process in place for the homeless population. The current process provides an established method of screening the homeless population to ensure that we are able to eliminate transmission and prevent outbreaks. This system of care is innovative and it utilizes evidence based practice by using short course direct observed treatment with 3HP (Isoniazid and Rifapentine combination) for all homeless LTBI clients. References include CDC guidelines found at http://www.cdc.gov/tb/topic/treatment/ltbi.htm and the article "Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States." Int J Tuberc Lung Dis. 2013 Dec;17(12):1531-7. doi: 10.5588/ijtld.13.0423.
LHD and Community Collaboration
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
- Goal(s) and objectives of practice
- What did you do to achieve the goals and objectives?
- Steps taken to implement the program
- Any criteria for who was selected to receive the practice (if applicable)?
- What was the timeframe for the practice
- Were other stakeholders involved? What was their role in the planning and implementation process?
- What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
- Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.
5000 words maximum
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Enter the LHD and Community Collaboration related to your practice (5000 words maximum)
The goal was to eliminate transmission of TB in the homeless population. We dedicated staff members to do shelter cards. There is a Licensed Practical Nurse assigned to do shelter cards and a Registered Nurse to assist when needed. Meetings were held with homeless shelter administrators to make them aware of the problem and discuss implementation of the Shelter Card System. Initially, the agreements were verbal and we got support from the shelters; however, in order to ensure the sustainability of the program we initiated memorandums of agreement with each of the 3 local shelters-- Trinity Rescue Mission, City Rescue Mission, and Sulzbacher. The final versions of the MOAs are in the process of being completed. The DOH-Duval program administrator provides ongoing support, training, and education for the shelter by meeting with the shelter administrators and attending the local homeless coalition meetings. The medical director also meets with the DOH-Duval TB team and shelter administrators as needed to provide agency updates, troubleshoot, and to show support for the collaboration. There were no startup costs. We utilized staff that were already employed by DOH-Duval and created the shelter cards internally. No cost analysis was done.
Evaluation
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
- What did you find out? To what extent were your objectives achieved? Please re-state your objectives.
- Did you evaluate your practice?
- List any primary data sources, who collected the data, and how (if applicable)
- List any secondary data sources used (if applicable)
- List performance measures used. Include process and outcome measures as appropriate.
- Describe how results were analyzed
- Were any modifications made to the practice as a result of the data findings?
2000 Words Maximum
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Please enter the evaluation results of your practice (2000 Words Maximum)
The goal was to eliminate transmission of TB in the homeless population.This system has been instrumental in interrupting the transmission of TB among the homeless population in the homeless shelters. In the process, we were able to heighten the public's awareness of TB and provide education on environmental controls for the shelters. Routine assessment and annual testing have been effective in early detection of clients with symptoms of TB and improved diagnosis and treatment of clients exposed to TB. The DOH-Duval program administrator provides ongoing support, training, and education for the shelter by meeting with the shelter administrators and attending the local homeless coalition meetings. The medical director also meets with the DOH-Duval TB team and shelter administrators as needed to provide agency updates, troubleshoot, and to show support for the collaboration. When initiating a shelter card program, it is important to plan data collection and tracking of the program data before the system is initiated. DOH Central Office in Tallahassee, Florida was extremely helpful with providing programmatic guidance and help with gathering and analysis of data. Our local DOH lacked the resources at the start of the program implementation to do all of the analysis. We are now able to track the data ourselves, but continue to consult with them as needed. We have decreased our rates in Duval and increased the number of clients we screen.
Sustainability
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
- Lessons learned in relation to practice
- Lessons learned in relation to partner collaboration (if applicable)
- Did you do a cost/benefit analysis? If so, describe.
- Is there sufficient stakeholder commitment to sustain the practice?
- Describe sustainability plans
1500 Words Maximum
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Please enter the sustainability of your practice (2000 Words Maximum)
DOH-Duval is committed to sustaining this program. To that end, we have entered into formal agreements with the local homeless shelters. Without formal agreements, we run the risk of shelters opting not to enforce the process when the weather turns cold and more people require sheltering. When we can, we have employees go directly to the shelters to provide the cards. Occasionally we have clients who are difficult and don't comply with treatment or the shelter card process. We have incentives available to encourage compliance. The local shelter executives are excited about the program, in fact, for a time one of the shelters instituted their own shelter card program, but decided to encourage their clients to come to us because of the level of resources that we have. We also have local support from the executive team, as well as support from the TB Control Section of the Bureau of Communicable Diseases at the state level Department of Health (Central Office). The program is woven into our current clinical practices and multiple team members are well versed in the program. It is important for us to continue to communicate with our local partners to make sure we continue to provide education and training for them, as well as educational materials. We do not want people to become lackadaisical in their processes, nor do we want to lose the support we have gained over the years. While we have not done a cost/benefit analysis we do know that our efforts have aided in quelling the transmission among the homeless population. And where we once made front page news for what was probably the worse TB outbreak in the history of Duval County, we are now looked at as a source of innovation and public health expertise. We want to encourage other counties to institute similar practices, so that one day we truly can eliminate TB.
Additional Information
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How did you hear about the Model Practices Program:
- I am a previous Model Practices applicant
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