streamlineVolume 23, Issue 2 • Fall 2017

In September 2016, the United StatesPreventative Services Task Force (USPSTF)issued a final updated recommendation

on screening for tuberculosis infection. Witha grade “B”, the second highest on its gradescale, the USPSTF sent a powerful message:that all asymptomatic adults from increased-risk populations should be screened fortuberculosis infection.1A “B” grade means the USPSTF recom-

mends the screening, as “there is high cer-tainty that the net benefit is moderate orthere is moderate certainty that the net ben-efit is moderate to substantial,” according tothe USPSTF grading system.2 The final gradeputs the recommendation at the same levelas more commonplace and integratedscreenings such as an annual lung cancerscreening for current smokers aged 55 to 80with a smoking history3 and screening forpreeclampsia in pregnant women throughblood pressure measurements throughoutpregnancy.4There are likely to be 13 million people in

the US infected with Mycobacterium tubercu-losis but not showing active symptoms ofthe illness.5 In general, about five to ten per-cent of infected individuals will flip to activetuberculosis (TB), with about half of thoseprogressing to active TB within two yearsfrom contracting TB infection. Those withweakened immune systems, like HIV-infectedpatients, have a higher risk of developingactive TB disease.5 Once they have active TB,they can spread the airborne bacteriumthrough coughing, sneezing, and speaking.Active TB patients require six to nine monthsof treatment with a complex regimen ofmedications. Side effects are commonplace.There are certain populations who are atincreased risk for TB infection and active TB.The USPSTF states that those with increasedrisk include immigrants or former residentsof countries with high TB prevalence, andthose who live or have lived in “high-risk

congregate settings” like homeless sheltersor correctional facilities. Community health centers may be the

link to significantly reduce TB in the US. One way to prevent the spread of TB is toidentify those with dormant TB infection(sometimes called latent TB infection, orLTBI) and provide them a course of therapyto prevent active TB disease — and commu-nity health centers can lead the way. Such aprevention program can be cost effective.And, for patients who avoid the illness andthe active TB treatment, the shorter or lesscomplex regimens for preventing active disease is less invasive to the patient’s life,easier for health centers to administer, andeasier for patients to complete. Commonlyused regimens for LTBI can have high ratesof completion: the twelve-dose once-weeklyIsoniazid and Rifapentine regimen withdirectly observed therapy boasts a 90 percent completion rate, and the daily, self-administered four-month Rifampin regimenhas a roughly 80 percent completion rate.6,7See CDC guidelines for choosing a LTBI regimen at: https://www.cdc.gov/tb/publications/ltbi/treatment.htm.

A health center-focused strategy toaddress TB infection isn’t just theoretical. InHouston, Texas, HOPE Clinic, a FederallyQualified Health Center, has closely part-nered with the Houston Department ofHealth to make a difference in TB rates intheir community. When the health depart-ment finds that a screened adult refugee ornew immigrant tests positive for TB infec-tion, the health department officials refer thepatient to the community health center,where the patient can not only complete thecourse of therapy to prevent active TB butalso establish a relationship with a new med-ical home. In 2016, through this partnership,HOPE Clinic provided care for 402 patientswith TB infection. If all community healthcenters had the same capacity and expertise,they could screen and treat an estimated875,000 patients with TB infection each yearout of the roughly 13 million cases of TBinfection in the US — a strategy that in justa decade may reduce the reservoir of TBinfection in the US.“We try to approach it from a fairly com-

TB Gets a B: How to Conquer TB Infection with Health Center ScreeningsBy Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

continued on page 5

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S everal years ago, Diana Davis,* an agri-cultural worker with diabetes, made anappointment at her local health center

to refill her prescription for diabetes medica-tion. When a new patient like Davis arriveswith health concerns at a health center thathas implemented a patient-centered medicalhome (PCMH) framework, the patient isoften brought into the fold with a thought-ful, long-term strategy for her care, throughthe activation of a care team around thepatient and her specific needs. This oftenmeans the development of a personalizedhealth plan that is followed up with appoint-ments for support and education from a caremanager, a diabetes educator, and others asdetermined by the primary care provider.A health center that actively creates a

PCMH can improve quality, patient experi-ence, and staff satisfaction, while reducinghealth care costs.1 But the achievement ofthat famed triple aim breaks down when thepatient’s home isn’t stable. In many cases, acare team may have just helped a patientget her diabetes under control when shemoves away — and the team never hearsfrom her again. How can we assure thatmobile patients can continue to stay on thepath to wellness? What does a “mobilehome” version of PCMH look like?Davis had just arrived from Florida, where

she had been diagnosed with diabetes afterhaving a heart attack. With her medicationin hand, she had traveled north toPennsylvania for work, where she got a jobas the cook for 30 agricultural workers at afarm housing kitchen. Ed Zuroweste, MD,Co-Chief Medical Officer for MCN, was herprimary care provider at that first appoint-ment, and immediately saw the predica-ment: how can we keep her on her person-alized plan, if she moves away?“I explained what diabetes was, because

she said that no one had explained that to herbefore, and gave her education on how tomake things better,” Dr. Zuroweste recalled.He spent extra time in the exam room goingover how diabetes works, and how behavioralshifts in diet and exercise can greatly improvea person’s health. He then requested a nutri-tionist to go out to the camp to spend anafternoon teaching her how to cook more dia-betes-friendly, healthy foods. The nutritionistended up going out a second time as well. Dr.Zuroweste recognized that, as a cook, a care-ful, food-based approach might resonate withthe patient — and he was right. By the end ofthe season, her A1c had dropped from 13 tonine, she had lost some weight, and sheunderstood her medications. Then, she disap-

peared for nine months. Just like many work-ers tied to the seasons, she left when the agri-cultural workers left.When she finally returned, she had lost

more weight and her hemoglobin was downto 7.5. Dr. Zuroweste assumed she must’vecontinued with good care at the health cen-ter at her new location, but the patientinsisted it was not the case. She had gone toanother health center, which had not givenher any education but just refilled her pre-scription. “She said, ‘now, I am in charge ofmy diabetes and I know what I need to do.You’ve taught me that diet, exercise, andtaking my medications is what I need to do.I just need you to write the prescription,’”Dr. Zuroweste recalled.“A lightbulb went off in my head. I was

trying to fix patients with diabetes, andmanage their diabetes. This patient taughtme that what I should be doing is teachingthe patients to do all that,” he said. He rec-ognized that sending a nutritionist whospoke the cook’s culinary language mayhave contributed to the success. He alsoemphasized that the patients can beempowered because they’re smart, evenwithout a good education: “We don’t givepeople enough credit. They’re the ones whoget the biggest benefit out of all that, sowhy not put them in charge?”A PCMH approach to mobile patients

includes several approaches, says Dr.Zuroweste. First, the health center can havea coordinated approach to assure the pri-mary care providers in various locations arelinked. “If the person always goes from

Immokalee to South Carolina and then toPennsylvania and back to Florida, they go tothree health centers, and a case manager atone of the health centers can make sure themedical records transfer. But that is a rarity,”Dr. Zuroweste admitted. Few health centershave the resources available to do suchclose, long-term tracking of a patient with achronic concern, but for those that do havethe resources, it can be an effective strategyto a mobile patient PCMH.A second approach is centered on the

patient herself. “Make the patient, the indi-vidual, the expert on her issue,” Dr.Zuroweste offered. As he discovered withDavis, an empowered patient can be a moti-vated patient. “Make them, not the primarycare provider, the expert in their diabetes,taking the self-management to an extremelevel.” In this case, the patient knows aboutdiabetes, understands her medications anddosages, understands the behavioralchanges necessary, and recognizes when shewill need a foot and eye exam. Dr.Zuroweste also notes that portable medicalrecords can be sent with the patient to makeclear to the next health center what stepsshe has already taken. “Give them the tools,a checklist, all the information they need tobecome an expert,” Dr. Zuroweste stressed.“It takes a lot of work from the front end,but it has great results on the back end.” A third approach — perhaps the most

effective for the patient and least resource-intensive for the health center — is enrolling

Approaches for Establishing a PCMH for Mobile PatientsBy Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

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Health Network Associates encounternumerous obstacles to ensuring contin-uous care for the mobile patients

enrolled in Health Network, MCN’s innovativeand effective bridge case management sys-tem. Health Network Associate Olivia Hayes,for example, has occasionally had trouble con-necting with patients’ families in Vietnam.“I call with an interpreter,” she explained,

since she is not bilingual in Vietnamese. Shehas to wait for the family member to pick upthe line, after which she connects with theinterpreter to tell her in English that the linehas been picked up. “But, when family mem-bers hear English, they often hang up!” Health Network Associates employ a great

variety of communication tactics to increasethe likelihood of regular contact with patientsor their family throughout their enrollment.The “anchor contact,” combined with therecent inclusion of communication technologylike Skype, text, and WhatsApp, have beenimplemented to reduce the communicationbreakdowns that result from wrong or out-of-service numbers, poor connections with far-offrural locales, or wary call recipients.For several months every winter, 66-year-

old Phuong* visits family and friends in herhomeland of Vietnam. This year, however,Phuong, a US citizen, tested positive to tuber-culosis in her lungs and spine, requiring a 12-month treatment regimen. After eight monthsof treatment, she was ready to travel, so herlocal health department signed her up withHealth Network to assure that she could con-tinue treatment despite her travel plans. Four days before her planned departure,

Hayes received her enrollment form. She gotahold of Phuong one day before she left.“She said she had refills for all of her med-ications,” Hayes noted, “and I found a localhealth center’s information the day that thepatient departed.” Later that week, Hayesfollowed up with the doctor’s office inVietnam but found the number out of serv-ice, so she called the patient’s friend, who islisted on the enrollment forms as a contactin the US. The friend got Hayes the doctor’semail address.Soon after, she received an email from the

doctor. “She confirmed that she was going tocare for her for the time that she’s there, andshe sent that information to the Health

Department in the US as well,” she said. Thedoctor was in fact the daughter of thepatient’s good friend, and the patient wasstaying in the same residence as the doctor.The doctor told Hayes that the patient wasgoing twice a week for direct observed thera-py. She could also confirm that the patientwas taking daily medications at 6am in thehouse they shared.

Communication TacticsSeveral of Health Network’s communicationtactics lined up to assure that Hayes was ableto keep contact with Phuong despite her rurallocation. First, Hayes made sure that Phuongprovided detailed contact information for heranchor contact — a person in Phuong’s lifewho is not traveling, who can be relied uponto pick up the phone if all other contacts fail.This might not necessarily be the emergencycontact like a mother or a sister; it might be afriend or a mother’s neighbor. Secondly, Hayesdidn’t just stick to calling contacts. As with manypatients, Hayes found that other technologiesare easier to access from abroad and increasethe likelihood of ongoing communication.In the last two years, Health Network

Associates have integrated texting and apps tocontact patients in the way they most like tobe contacted. With careful attention to HIPAAregulations — there is no sharing of medicaldata over such programs — Health NetworkAssociates have used Facebook, WhatsApp,texting, Skype, and other programs asrequested by patients. “Patients with family and friends in other

countries are rapidly employing a variety ofcommunication platforms to stay connectedto the folks back home,” noted DelianaGarcia, MCN’s Director of InternationalProjects, Research, and Development. The var-ious platforms don’t just improve communica-tion between Health Network Associates andpatients; they can serve as a reminder forpatients. “[Patients] prefer in some cases tohave a written record of the information theyare given so that they do not have to recall itfrom memory or look for a pen and paperwhile on a phone call,” Garcia added.

Completing Treatment in VietnamThrough email, Hayes received regularupdates from her anchor contact — the

friend in the US. Two weeks before thepatient’s scheduled return, Hayes emailedthe doctor again to get updated recordsbefore the patient returned. “Five days later,I got a great document. It’s difficult to getcomplete records from Vietnam. The doctorhad made a chart of the medications shewas taking and how often she was takingthem, and the days that the doctor did acheck-up. There were no lab reports, but shedid check blood pressure and pulse duringregular check-ups,” the records noted. Thedoctor also reported that the patient fol-lowed treatment, followed health instruc-tions, ate and slept well during treatment,and gained weight during her time inVietnam. In late spring, the patient returned to the

US. Hayes spoke to her two weeks later tomake sure she had a scheduled appointmentfor a check-up and X-ray. She followed upwith her once a month to ensure the continu-ation of treatment, until late June, when shecompleted treatment, at which time Hayesclosed the case. The case is a typical one in that Health

Network Associates must often try many dif-ferent contacts and various modes of com-munication before making contact with theneeded health authorities and patients, apatient advocate who the patient has indi-cated can speak on his or her behalf, or ananchor contact. The depth of reporting fromthe doctor abroad, however, was unusual, asHealth Network Associates often spend moretime working with the patient’s health clinicabroad to develop health records that areacceptable to US health departments. Themost important aspect of this case, as withall of our cases, was the outcome: throughHealth Network, Phuong was able to contin-ue her treatment, despite travel to a ruralcorner of Vietnam for several months, fol-lowed by a return to the US.

Learn more about Health Network, watch ashort video on the benefits, download enroll-ment forms in four languages, and schedule atraining to get started: http://www.migrantclinician.org/services/network.html. ■

* All names, dates, and locations have been altered toprotect the patient’s identity.

The material presented in this portion of Streamline (pages 1 - 5) is supported by the Health Resources and Services Administration (HRSA)of the U.S. Department of Health and Human Services (HHS) under cooperative agreement number U30CS09742, Technical Assistance toCommunity and Migrant Health Centers and Homeless for $1,094,709.00 with 0% of the total NCA project financed with non-federalsources. This information or content and conclusions are those of the author and should not be construed as the official position or policyof, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Health Network Communication Tactics: A Case StudyBy Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

4MCN Streamline

T his year, Migrant Clinicians Networkwelcomed a new Co-Chief MedicalOfficer, Laszlo Madaras, MD, MPH,

who has joined longtime CMO EdZuroweste, MD in the many efforts thatMCN spearheads to advance health justicefor the mobile poor. Dr. Madaras comes toMCN with decades of experience in healthjustice, international medicine, and mobilehealth, and has swiftly become an integralpart of MCN’s hardworking staff.Dr. Madaras started on the track to a

medical research career during his under-graduate years at Dartmouth, where heresearched muscular dystrophy at the BostonBiomedical Research Institute. Luckily for hismany future patients, Dr. Madaras discov-ered a preference for people over test tubes.A turning point came after college, when hejoined the Peace Corps, which brought himto the Democratic Republic of Congo (thenknown as Zaire). Honing his French andpicking up Swahili and Kikongo, Dr. Madarasworked on a tilapia fish farming project. Healso encountered international doctors forthe first time, which fueled a goal to workon the frontlines as a primary care providerserving underserved patients. When he returned, he took a job at the

Environmental Protection Agency whileprepping for medical school. At the EPA, helearned the ins and outs of environmentalpolicy, in particular working on removingcarbon tetrachloride from food additivesand grains. When he made his way to TuftsMedical School, he was 28. He pursued acombined MD/MPH four-year degree. “Ipretty much went in with the goal of doingprimary care — and I never turned back,”he noted.During his final year of residency, he was

contacted by an international aid group,American Refugee Committee, asking if hewould join them to work in Rwanda. It was1994, and the country was deep in the after-math of a horrendous genocide. “Since I’dbeen a Peace Corps volunteer, I knew thelanguage, I knew the geography of the area,and I could drive a Land Rover, they said Icould come for just three months,” insteadof the more typical six-month deployment. He arrived in a refugee camp of 170,000

refugees. He was one of the youngest doctorsthere; his mentors were international disasterveterans, previously working in the war fieldsof Cambodia and Vietnam. He worked six to12 hours a day, triaging people to the cor-rect spot, with separate tents for cholera,

malaria, dysentery, meningitis, and more. The heaviness of war was hard for Dr.

Madaras as a young doctor. “On one of myfirst days, we had about 500 deaths in 24hours. The old veterans said it was a goodday,” he said. Deaths were declining as moretime passed; when he left three monthslater, less than a hundred people were dyingeach day. “People were very generous, verykind during my time there in the PeaceCorps. It was very hard to see this switchwhere people could be so incredibly cruel toeach other. I had such good memories in thePeace Corps just ten years before! I saw thebest and the worst of Africa in the sameregion, within ten years.” As for many who return from such har-

rowing experiences, it was challenging forDr. Madaras to fold back into his final year ofresidency. His first rotation upon return wasin dermatology. “The derm patients’ con-cerns were real, although some were ‘justcosmetic,’ but it was very different thandealing with machete lacerations,” Dr.Madaras said. “I tried to recognize that, as afamily doctor, I also need to know about skinailments. But it was kind of a shock to gofrom one extreme to the other.” Upon graduation, he was accepted into

the National Health Service Corps loanrepayment program, a popular programoffered by the Health Resources and ServicesAdministration (HRSA) that places cliniciansin underserved areas in exchange for loanrepayments, thereby reducing a new clini-cian’s debt while gaining much-needed pri-mary care services in underserved areas likein Federally Qualified Health Centers aroundthe country. “I had to serve in a physician-shortage

area — and that’s when I met Dr. Ed

Zuroweste,” Dr. Madaras recalled. After asummer in the Dominican Republic on avaccination program, Dr. Madaras could addSpanish to his list of languages in which hecould communicate with patients. Thatbrought his spoken languages up to seven,as he also had Hungarian and German underhis belt. “Seven languages is a huge plus for a

health center — and he used all those lan-guages at our health center. He worked withour mobile population from day one,” Dr.Zuroweste recalled. He jumped at thechance of having Dr. Madaras at KeystoneHealth Center in Pennsylvania, which Dr.Madaras joined in 1996. The two physicians,with similar interests in medicine, hit it off.Dr. Zuroweste was impressed by the interna-tional experience he brought at such anearly stage in his career. “I once saw him ata street fair where five patients came up tohim separately, all speaking different lan-guages. I saw people watch him do that andthink, ‘What the heck is going on?’”Over the years, Dr. Madaras and Dr.

Zuroweste continued to cross paths, evenafter Dr. Madaras left Keystone family medi-cine to become a hospitalist and in-patientdoctor. When volunteering with the localstate department of health clinic, Dr.Madaras would work with mobile agricultur-al workers, referring those who needed casemanagement to Dr. Zuroweste for whatbecame Health Network, and giving him anearly peek into MCN’s work. Starting in 2002, Dr. Madaras began join-

ing Dr. Zuroweste for some of his trips tothe rural mountains of Honduras withfourth-year medical students from JohnsHopkins and elsewhere. The trips serve togive future doctors a low-tech highly neededinternational medicine experience. Dr.Madaras even brought his children, “forhelping in the work and for them to see howmuch of the world really lives. It’s importantto have compassion and understanding forhow people live in the world,” he noted. As he grew more involved in work with

mobile populations, he was invited to pres-ent for the World Conference of FamilyDoctors where he talked about mobile pop-ulations and control of infectious diseaseslike tuberculosis and HIV. While he continuedto enjoy the diversity of work as a communi-ty health doctor — “I was delivering babies!In a small town, I got to do everything

Migrant Clinicians Network Announces New Co-Chief Medical Officer, Laszlo Madaras, MD, MPHBy Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

continued on the next page

Dr. Laszlo Madaras started his career withinternational service in East Africa.Photo courtesy of Laszlo Madaras.

under the umbrella of family medicine,” hesaid — his work with the mobile poor in hiscommunity continued. For the last eightyears, Dr. Madaras cut back to strictly in-patient hospitalist, for better work-life bal-ance. But in 2012, Dr. Madaras added out-patient medicine back to his schedule, as aTB physician with the Pennsylvania StateHealth Department, another place where hejoined Dr. Zuroweste in work for the under-served. Last year, Dr. Zuroweste approachedDr. Madaras to see if he’d want to work withMCN as Dr. Zuroweste eases into retirement.

“He’s the perfect fit for MCN,” Dr.Zuroweste admits, who is thrilled that Dr.Madaras has joined on and has begun along transition during which both doctorsshare the role of Chief Medical Officer. Dr.Madaras currently works about 10 days amonth at the hospital, another day with theTB clinics, and spends the rest of the time ina number of pursuits, including ramping uphis work for MCN. Dr. Madaras is very positive about the

longer transition. “I’ve had enough experi-ence with leadership change in institutions

to know that everything slows down if thenew guy has to figure everything out with-out overlap. But MCN needs to keep movingforward. Ed is still here with the guidinghand and I’m absorbing the way thingswork,” he said. “It’s an ideal way to transition with a

less-than-ideal outside environment in health care. We will continue to be challenged in the coming years, and I’m hoping to help move MCN forward as we figure out which way we need to go.” ■

MCN Streamline 5

prehensive perspective,” noted Kara Green,FNP, Director of Clinical Services andContinuous Quality Improvements at HOPEClinic. “Sometimes patients [think] we’re justhere for vaccines or active TB disease, butwe say that we’re your family’s doctors andwe take care of all your medical needs, andone part of that is this latent TB. I think ithelps that we see other patients at the sametime for diabetes, hypertension, back pain.” With the mission to provide care to med-

ically underserved populations, communityhealth centers like HOPE Clinic are in aunique position to take a sizeable steptoward TB elimination in the US. In 2016,roughly 68 percent of active TB cases in theUS were among foreign born people and 90percent of TB cases in foreign-born patientswere attributable to reactivation of prior,latent tuberculosis infection.8 Given thathealth centers’ patient populations are ethni-cally diverse, with roughly 62 percent ofpatients identifying as a “racial and/or ethnicminority” and almost 23 percent feelingthey are best served in a language otherthan English.9,10 their patient populations are likely to have a higher prevalence of TB infection. “Some clinics don’t have capacity or com-

fort with this issue, but we’ve have goodsuccess so far,” Green said. As treatmentinnovations progress, health centers mayfind management of TB infection doablewithin their settings. For example, Green isexcited about future innovations, like shortertreatment durations and directly observedtherapy over live video chat, both of whichpromise to reduce costs and increase treat-ment completion rates — which can go along way in eliminating TB in the US. Shealso recognizes that the health centerapproach is effective not just because of the provision of medications but the reachinto the community to break down stigmaand increase understanding of TB and TBinfection.“The education [of] one family goes a

long way in their individual cultural commu-nities, so that TB evaluation and treatment

for LTBI or active disease becomes more nor-mative,” Green said. With such a multifac-eted approach, health centers can makestrides toward TB elimination: “Any effortswe are able to accomplish here hopefullyhelp impact the worldwide picture of TB.”The CDC’s page on TB infection treatment

is available at: https://www.cdc.gov/tb/publications/ltbi/treatment.htm ■

References1 US Preventative Services Task Force. Latent

Tuberculosis Infection: Screening. Available at:https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/latent-tubercu-losis-infection-screening

2 US Preventative Services Task Force. Grade Defini -tions. Available at: https://www.uspreventiveser-vicestaskforce.org/Page/Name/grade-definitions

3 US Preventative Services Task Force. Lung Cancer:Screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening

4 US Preventative Services Task Force. Preeclampsia:Screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/preeclampsia-screening1?ds=1&s=preeclampsia

5 Centers for Disease Control and Prevention.

Tuberculosis (TB): Latent Tuberculosis Infection: AGuide for Primary Health Care Providers. Available at:https://www.cdc.gov/tb/publications/ltbi/intro.htm

6 Sterling TR, Villarino ME, Borisov AS, et al; TBTrials Consortium PREVENT TB Study Team. Threemonths of rifapentine and isoniazid for latenttuberculosis infection. N Engl J Med. 2011;365(23):2155-2166. Accessed June 7, 2017. Available at:http://www.nejm.org/doi/full/10.1056/NEJMoa1104875

7 Menzies D, Long R, Trajman A, et al. Adverseevents with 4 months of rifampin therapy or 9months of isoniazid therapy for latent tuberculosisinfection: a randomized trial. Ann Intern Med.2008;149(10):689-97. Available at:https://www.ncbi.nlm.nih.gov/pubmed/19017587

8 Schmit KM, Wansaula Z, Pratt R, Price SF, LangerAJ. Tuberculosis — United States, 2016. MMWRMorb Mortal Wkly Rep 2017;66:289–294. DOI:http://dx.doi.org/10.15585/mmwr.mm6611a2.

9 Shin P, Alvarez C, Sharac J, Rosenbaum S, et al. A Profile of Community Health Center Patients:Implications for Policy. Henry J. Kaiser Family Foun -dation. 2013. Available at: http://www.kff.org/report-section/a-profile-of-community-health-cen-ter-patients-demographic-characteristics/

10 2016 Health Center Data: Health Resources andServices Administration, Health Center Program.Expanded Summary for 2016UDS Tables 3A-9Eand EHR Information. Available at:https://bphc.hrsa.gov/uds/datacenter.aspx

■ How to Conquer TB Infection with Health Center Screenings continued from page 1

the patient in Health Network, MCN’s bridgecase management system for patients whointend on moving, but whose health needsare ongoing. Health centers utilize its servicesin many ways: a patient who got a pap smearbut will be moving to a new state may beenrolled for a short time to assure she receivesthe results despite her new location; a studentwith HIV may be tracked when he leaves forsummer break to visit home, and then returnsto school; or, it may be used for patients withchronic concerns who remain mobile overmany years, like agricultural workers whocontinually move with the seasons. Patientsare enrolled for free by clinicians at thepatient’s health center, after which a HealthNetwork Associate follows up with the patientto confirm their enrollment, offer HealthNetwork services, and assure the patient gets

the follow-up he needs. The Associate trans-fers medical records, sets up appointments,and assists with additional services like trans-portation as needed and as available.“You can do all three,” reminded Dr.

Zuroweste. “If you can create a PCMH for amobile population then you’ve really got asolid PCMH at your institution, because ifyou can address those complex issues ofmobility, then it’s easy to do for people whoare stable.” ■

* The patient’s name has been changed to protecther identity.

1 Science in Brief: The Patient-Centered Medical Home:Current State of Evidence. Centers for DiseaseControl and Prevention. https://www.cdc.gov/dhdsp/pubs/docs/science_in_brief_pcmh_evidence.pdf. Accessed June 5 2017.

■ Approaches for Establishing a PCMH for Mobile Patients continued from page 2

6MCN Streamline

During a prenatal check-up, an agricul-tural worker patient asks a questionabout the mosquito control in her

neighborhood: “They are fogging by air-plane in our community occasionally atnight. I close the windows, but is it safe thenext morning for my young children, andfor me? Should we stay at my sister’s housewhen they spray?” Clinicians are often taxedwith answering pesticide safety questionswith limited information and training — buta careful and clear informational approach,supplemented with reliable resources thepatient can access, can help patients under-stand their pesticide exposure risk and makeinformed behavior changes if they determinetheir risk is high.

Approaching the Conversation with Risk in Mind: A ChecklistFor a comprehensive approach in the examroom, we turn to the National PesticideInformation (NPIC). A cooperative agree-ment between the Environmental ProtectionAgency and Oregon State University, NPICanswers over 11,000 calls and emails from

the general public each year about pesti-cides. Their goal is to help people under-stand their risk through objective, science-based information about pesticides andrelated topics. Their conversations usuallycontain the following elements, all of whichare applicable for patient-provider conversa-tions as well.

1. Risk — not SafetyIt’s critical to frame the conversation interms of a patient’s risk, not their safety, saysAmy Hallman, MS, Project Coordinator ofNPIC. “The safety question is the same forevery person,” Hallman explained during arecent NPIC webinar. “Is it safe?” can endup being a yes or no answer. “Risk, however,has lots of factors that may make somethingmore or less risky,” Hallman said, dependingon their personal circumstances, so a focuson risk can lead to a well-rounded discussionthat is tailored specifically to the circum-stances of the questioner. If a clinician givesthe patient the impression that a given pesti-cide is safe, however, “it can lead to carelessbehaviors, or lack of vigilance, which can

increase their risk,” Hallman noted, and the“safe” pesticide may no longer be safe.Risk is a combination of the toxicity of a

product and the amount of exposure.Exposure can vary greatly. When mosquitofogging occurs, the toxicity of the pesticideremains constant, but the exposure is differ-ent. A pregnant woman with a young tod-dler whose toys are outside will have a dif-ferent risk than a single male living in anapartment in the same area, because herpotential for exposure is greater. Patientsmay not be able to control the toxicity of aproduct — especially agricultural workers,who may be exposed to numerous productsat their workplace — but they may havegreater control over their exposure.

2. Listen, ask questions, and paraphraseJust as in all of our conversations withpatients, a complete and detailed conversa-tion about their physical situation and theirpast experiences can help us better under-

The Risk...Talking to Patients about Pesticides

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stand their needs and exposures. What typeof features in their environment mayincrease their risk — is there a barrierbetween the yard and the field next door? Isthere a windbreak that reduces drift? Habitsof the individual and family may also affecttheir risk. Does the patient utilize personalprotective equipment (PPE) every time, ordoes the patient skip it if it’s too hot out-side? Does the patient wash hands andchange his clothes after returning home andbefore hugging his children? Are shoesallowed in the house?Hallman notes that perceived risk may not

match actual risk. Clinicians may need todelve deeper into a patient’s experiencesand values to unearth how patients perceivetheir risk of exposure. Hallman outlines fac-tors that influence a person’s risk perception.The chemical may be viewed as:

• Out of a person’s control or imposedversus in a person’s control or voluntary;

• Beneficial versus damaging;

• Natural versus manmade;

• Only affects adults/has no effect versusaffects children;

• Unfamiliar and untrusted versus familiarand trusted.

Many clinicians have seen this with agricul-tural worker patients. If an agriculturalworker has applied chemicals many timesbefore, he may not perceive his risk as highbecause the application is routine andfamiliar, and he has not experienced anyacute reactions. Alternatively, a worker whois new to agricultural work may find chemi-cal application concerning, when the rou-tine and the product are untrusted andunfamiliar. To assure that the patient feels their con-

cerns and needs are heard, clinicians canreiterate the patient’s concerns back to thepatient.

3. Toxicity Information:Understanding Signal WordsAnother key aspect of the conversation canbe around the product itself. Helping apatient understand a product’s label canhelp them understand the risk. Critically,product formulation varies from product toproduct and requires the user to pay closeattention to precautionary statements andinstructions for use. The active ingredient byitself may be highly toxic; the formulation ofthe product with the active ingredient mayor may not be.Hallman places emphasis on the signal

word. The product will be labeled with a sig-nal word designated by the Environmental

Protection Agency that is specific to the for-mula: CAUTION, which indicates mild toxici-ty; WARNING, moderate toxicity; and DAN-GER, for high toxicity. A signal word is deter-mined by evaluating all active ingredients fortoxicity through each route of exposure —acute oral or dermal lethal dose, inhalationlethal concentration, primary eye irritation,and primary skin irritation. The product willcarry the signal word of the highest categoryof concern, regardless of route of exposure.For example, if a product is corrosive to theeyes indicating high toxicity for eye expo-sure, but the product is low in toxicity for allother routes of exposure, it will still carry theDANGER label to indicate that at least oneroute of exposure can result in serious injury.If a product is considered low in toxicity forall routes of exposure, then the product willcarry the CAUTION signal word.In many cases, however, a patient may

not have the product with them or haveaccess to the product. In this case, a cliniciancan still have a valuable conversation abouthow to reduce risk, even when the producttoxicity is unknown.

4. Exposure Information: Action ItemsAfter the clinician has a greater understand-ing of the patient’s perceived risk, his or herenvironment, the toxicity of the product,and how it will be applied, the clinician cannow recommend action items in thepatient’s control that will limit the patient’srisk of exposure. For our pregnant agricul-tural worker and her children, this mayinclude bringing in toys and removinghanging laundry for the night, closing win-dows, covering the vegetable garden for thenight, and more vigilance around shoewearing in the house. It may be a goodtime to check in on other possible expo-sures at work that the patient may have notbeen concerned about because of a per-ceived low risk.Clinicians may refer the patient to trusted,

science-based information sources outside ofthe exam room. NPIC’s website features factsheets, FAQs, podcasts, and videos that aredeveloped based on emerging concerns andon the frequently asked inquiries they receivevia phone and email. Access NPIC’s resourcesat: http://www.npic.orst.edu/. NPIC’s “Is ItSafe?” Fact Sheet is at: http://npic.orst.edu/factsheets/isitsafe.html. Their Reading PesticideLabels Infographic is at: http://npic.orst.edu/outreach/labelinfographic.pdf. Watch thewebinar for more information on communi-cating with the public about pesticides:https://youtube/ RRinp6IMH8g. Should the patient’s concern about an

exposure be workplace-related, cliniciansmust report the incident in most states.Please refer to MCN’s Pesticide ReportingMap to see reporting requirements and recommendations for your state:https://goo.gl/ttknSD. ■

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8MCN Streamline

Migrant Clinicians NetworkP.O. Box 164285 • Austin, TX 78716

Non Profit Org.U.S. PostageP A I D

PERMIT NO. 2625Austin, TX

Acknowledgment: Streamline is published byMigrant Clinicians Network (MCN). This publi-cation may be reproduced, with credit to MCN.Subscription information and submission of arti-cles should be directed to:

Migrant Clinicians NetworkP.O. Box 164285

Austin, Texas, 78716Phone: (512) 327-2017Fax (512) 327-0719

E-mail: jhopewell@migrantclinician.org

Hugo Lopez-Gatell, MD, MSc, PhD Chair, MCN Board of Directors

Karen Mountain, MBA, MSN, RN Chief Executive Officer

Jillian Hopewell, MPA, MADirector of Education and Professional

Development, Editor-in-Chief

Claire Hutkins SedaWriter, Managing Editor

Editorial Board – Linda Forst, MD, MPH;Kathy Kirkland, MPH, DrPH; Kim L. Larson,PhD, RN, MPH; Linda McCauley, RN, PhD,FAAN, FAAOHN; Marie Napolitano, RN,FNP, PhD.

November 14Bureau of Health Workforce Grand Rounds Webinar Series:Strengthening the Rural HealthWorkforce. https://goo.gl/92zyWA

November 14-16Detroit, MIClimate, Health, and Equity Meetingand 2017 Health and EnvironmentalFunders Network Annual Meeting. https://goo.gl/aN3cuH

December 4Davis, CAMigrant Farmworker Health,Inequality, and "What Can BeDone?" Seminar.https://goo.gl/wFbBy2

December 7Baltimore, MDMaryland's 14th Annual StatewideHealth Equity Conference. https://goo.gl/xeRkmg

December 5-6Moab, Utah23rd Annual Four Corners TB/HIVConference. http://iz3.me/sQu64z7rLSL1

December 5-7Baltimore, MDNational COSH Conference onWorker Safety and Health. https://goo.gl/AUC1QW

December 10-13Orlando, FLIHI National Forum on QualityImprovement in Health Care. https://goo.gl/yZvroR

February 22-24, 2018Seattle, WA2018 Western Forum for Migrantand Community Health. www.nwrpca.org

calendar