Using Telemedicine for Tuberculosis Care Management:a Three County Inter-Municipal Approach

State: NY Type: Promising Practice Year: 2020

Orleans County is a small agricultural community located approximately midway between Rochester in Monroe County and Buffalo in Erie County. Orleans County sits north of Genesee County and boarders Lake Ontario. According to the 2018 United States Census Bureau estimates, the population of Orleans County is 40,612 with 50.1% of the population being female. 19.3% of the total county population is under the age of 18 years old, while 17.9% is 65 years or older. The Orleans County population is fairly homogeneous in race with 90.0% of its citizens being white, 6.6% black or African-American, 4.9% Hispanic or Latino. Approximately 15.2% of the total county population is living at or below the Federal Poverty Level. 15% of related children under the age of 18 are living in poverty, as well as 7% of those aged 65 years or older. There are approximately 1,299 migrant or seasonal farm workers who move to Orleans County during the growing season, departing at the completion of the harvest season. There are an estimated 69 camps for Migrant and Seasonal Farm workers located in Orleans County.

Genesee County is also a small agricultural community. The population of Genesee County according to the 2018 Census population estimate is 57,511. Genesee County is 50.3% female with 18.7% of the population over the age of 65. The county is 93.0% White, 3.2 % Black or African American, 1.2% American Indian or Alaska Native, and 0.7% Asian, with 3.4% of the population identifying as Hispanic or Latino. In Genesee County, the poverty rate is significantly higher in the City of Batavia: an estimated 21.8% of the total population of the city live below the poverty level, while the percentage is 10.8% for the county overall. In comparison, children under 18 in Genesee County overall have a poverty rate of 17.5% and children under 5 have a rate of 23.5% below the poverty level. Genesee County has special populations with the Tonawanda Reservation and Migrant and Seasonal Farmworkers. The Tonawanda Reservation according to the 2000 Census, the population was 517 with a median age of 36.3. There is an estimated number of 784 migrant and seasonal farmworkers that reside in Genesee County.

Residents of each county have limited local access to experts for diagnosing, treating and managing Tuberculosis (TB) disease and latent tuberculosis infection (LTBI). Orleans ratio of population to primary care physicians is the worst in the state at 13,780:1 according to the 2019 County Health Rankings & Roadmaps”, and that for Genesee County is 2,920:1. Individuals residing in these counties requiring care have to travel significant distances to access care. Goals included to seek out inter-municipal agreement with Monroe County Health Department (MCHD) an urban county to the east, to provide specialty care for Genesee and Orleans County residents with TB, develop a telemedicine process for TB care management, share an electronic medical record system between the three counties.

The TB inter-municipal agreement was written by MCHD attorney. The agreement was submitted to Genesee and Orleans County attorneys for review. After each county attorney approved of the inter-municipal agreement it was then submitted to each county's legislature for adoption. The inter-municipal agreement was adopted by all three counties in 2016.

MCHD has been seen patients from both counties since the inter-municipal agreement was put in place in January 2016. MCHD saw 16 Genesee and Orleans County TB patients at their clinic and there were 32 telemedicine appointments from 2016-2019.

All of the objectives were met to implement the TB inter-municipal agreement. The TB program in both Genesee and Orleans Counties have been utilizing this operational process since 2016.

The inter-municipal agreement between the three local health departments has streamlined and achieved efficiencies within the TB Control Programs in Genesee and Orleans Counties by diagnosis and treatment, accessibility and convenience of TB care that allows rural residents access to expert TB care. With the increasing threat of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis and the complex management of these infections this agreement helps align Genesee and Orleans Counties with the five recommended priority actions of the World Health Organization's End TB and Elimination Strategies. The utilization of an inter-municipal agreement between rural and urban counties with more robust  services can be reproduced throughout the country.

Orleans County Health Department website:

Genesee County Health Department website:

We believe that utilizing a rural urban inter-municipal agreement to provide TB services to rural patients while utilizing telemedicine and a shared electronic medical record system between counties in new to the field of public health. The MCHD inter-municipal agreement with Genesee and Orleans County Health Departments provides clinical expertise and comprehensive TB services to patients residing in Genesee and Orleans counties with TB disease and LTBI. Patients residing in Genesee and Orleans counties have a comprehensive medical home for TB services, which will include chest x-ray, sputum induction, medication, physician management, and phlebotomy on-site at the MCHD TB clinic. Patients have access to TB specialists with telemedicine for routine follow-up; the utilization of telemedicine can eliminate barriers for residents in rural counties and improve access to expert TB care. Telemedicine provides face to face visits with the pulmonary TB specialist. The three counties utilize a share EHR, which allows the telemedicine visit to proceed as if the patient was in the MCHD TB clinic. The public health nursing staff in all three counties have adopted the same policies and procedures for TB care management which improves the efficiency of this inter-municipal agreement. 

Genesee and Orleans County sought out Monroe County Health Department to enter into an inter-municipal agreement to provide TB specialty care for their residents. MCHD has a comprehensive TB Control Program that provides clinical services, disease reporting/surveillance, directly observed therapy (DOT) and provider/community education and consultation to prevent and treat TB. MCHD operates a New York State Article 28 licensed diagnostic and treatment facility that in addition to medical management, provides screening of high risk populations, case management and consultation, contact investigation and outreach program that provides DOT to all cases of TB and high risk cases of LTBI. The staff is expert at managing TB, and currently serves 20-25 new cases of disease and provides treatment to over 550 persons with LTBI, per year. MCHD contracts with a group of nationally-recognized, board-certified attending pulmonary/critical care physicians from the University of Rochester, to provide medical care and oversight.

The TB inter-municipal agreement was written by MCHD attorney. The agreement was submitted to Genesee and Orleans County attorneys for review. After each county attorney approved of the inter-municipal agreement it was then submitted to each county's legislature for adoption. The inter-municipal agreement was adopted by all three counties in 2016. Costs in the annual agreement include a flat fee for electronic health record access, VPN services, IT consultations and continuing education, telemedicine access and for ongoing clinical support including policies and procedures, quality assurance/quality improvement, clinical education and staff development. Additionally direct, patient consultative services will be paid at an hourly rate for physician and registered nurse consults. MCHD bills Genesee and Orleans Counties annually for the TB services incurred during the year. 

Telemedicine equipment was puchased in both counties, this consisted of a camera, mobile cart, computer, two monitors, bluetooth keyboard and mouse. We utilize Zoom, HIPPA compliant video conferencing software. 

Evaluation of this practice is unique in that prior to this inter-municipal agreement it was a challenge to find a provider with the expertise in Genesee or Orleans County that wanted to manage our TB patients. Since this agreement with MCHD we have utilized their expertise by clinically managing our TB clients. MCHD has seen patients from both counties since the inter-municipal agreement was put in place in January 2016. From the years of 2016-2019, there were 16 MCHD office visits and 32 telemedicine consultations. During this time there were 7 active cases of TB and 21 cases of LTBI.

Genesee and Orleans nursing staff have strengthened their knowledge base of TB by attending bi-monthly TB rounds at the University of Rochester for the education of all personnel who work with patients in the TB clinic. The collaboration has greatly enhanced the relationship between the three county nursing staffs.

MCHD uses Netsmart Technologies Insight electronic health record (EHR). The shared HER allows the telehealth visit to proceed as if the patient was in the MCHD TB clinic. Genesee and Orleans county RN's were oriented to clinic flow and procedures at MCHD TB clinic thus allowing the telehealth visits to simulate a face to face clinic visit. Electronic prescribing and faxing or orders and other written documents facilitates the process. All three nursing staffs follow the same procedures for accessing on call physician services, managing lab results, etc. Complex clinical management decisions are made twice per month during the TB rounds at the University of Rochester pulmonary offices. All nursing staffs are present with the attending physicians thus allowing the team to make cohesive management decisions.

Quarterly, we evaluate the TB charts to make sure staff is following the appropriate policies and procedures.  Annually we review all policies and procedures to ensure to capture any changes that might have occurred during the year.  Policies and procedures are then approved by our board of health annually.

New York State Public Health Law requires all county health departments to be responsible for providing or securing TB care and treatment. With this law, it has been challenging for local health departments such as Genesee and Orleans to find expert TB specialists to effectively diagnose and manage infection with their counties. This makes the inter-municipal agreement between the three local health departments sustainable. Each agreement is approved yearly by the legislature in each county.

The relationship between the three counties not only provides expert TB care but it has served to enhance the counties ability to work seamlessly together in disease investigations and other essential program enhancement. The counties have provided a collaborative approach with TB by looking past jurisdictional boundaries at times to provide directly observe therapy or TB testing in an outbreak investigation.

The initiation of Public Health 3.0 by the U.S. Department of Health and Human Services in 2016, local health departments should be looking to develop partnerships to provide community-wide prevention. With rural counties struggling with access to care issues especially with TB specialists, partnerships such as this can generate a collective impact to improve the overall health of a population. With the success of this inter-municipal agreement, Monroe County wants to explore contracting with the other rural neighboring counties.  

NACCHO Website