In 1992, Congress enacted a TB services mandate for all substance abuse programs that receive funding through the Substance Abuse Prevention and Treatment (SAPT) Block Grant.1 That mandate requires those programs to make TB screening, evaluation, and followup routinely available for their patients.
Department of Health and Human Services regulations require States to monitor, enforce, and facilitate program compliance with that mandate.2 Complementing that mandate are State laws that require many AOD treatment providers to report cases of communicable disease, including TB, to local or State public health officials and to cooperate with them in patient followup.
The purpose of both the mandate and State communicable disease reporting laws is to protect patients, program staff, and the public at large from the dangers of TB.
Yet those laws will not accomplish that objective unless public health officials and AOD treatment providers cooperate with each other.
As we will see below, there are many good reasons for -- and no significant impediments to -- such cooperation.
The Federal TB mandate requires AOD programs to provide or arrange for TB screening, evaluation, and followup for their patients. (The particular services that might be provided to discharge that obligation are discussed in chapter 5.) Depending on their resources, programs can provide those services directly or indirectly.
Programs with limited resources may have to turn to public health officials for assistance in discharging those obligations.
The control of communicable disease is generally a matter for the States.
Toward that end, States typically require designated individuals or institutions -- so-called mandated reporters (including many AOD programs) -- to report cases of suspected or confirmed communicable disease to local or State public health agencies.
The purpose of those laws is to enable public health officials to identify, locate, evaluate, treat, and monitor individuals and their close contacts who may have, or may have been exposed to, a communicable disease.
Reporting laws vary from State to State.
Some States require all AOD providers to report cases of communicable disease to public health.
Others require only some providers, such as those who provide primary health care to their patients, to make such reports.
Generally -- and this can create confidentiality problems for AOD providers -- reporters must identify both themselves and the individual who is the subject of the case report.
The confidentiality problems raised by those requirements are compounded when States also demand information on the patient's substance abuse history, if any.
The report is used by local or State public health officials to follow up on the patient's case, find contacts who may have infected or been infected by the patient, develop appropriate treatment plans, and monitor the treated individual's progress.3
All States authorize or require their public health officials to investigate reported TB cases to confirm the case, ensure treatment, identify and locate contacts, and discover and treat new cases.
However, where the case report is made by an AOD provider, or where the individual who is the subject of the report is a participant or resident in an AOD program, the success of subsequent case and contact investigations may depend on the program's willingness to cooperate with the public health investigators.
State TB control laws authorize public health officials to monitor individuals with TB disease to ensure that the prescribed treatment regimen is followed, that the regimen is having the desired effect, and that the patient is not suffering harmful side effects.
To fulfill their duties properly, investigators may need access to the patient, the patient's records, or both.
The Federal TB services mandate and State infectious disease reporting laws are vital to preventing the spread of TB in the AOD setting.
However, AOD treatment programs in every State must comply with coordinate Federal laws that prohibit the disclosure of the identity of persons in alcohol or other drug abuse treatment.
To the extent, then, that the TB laws and the TB services mandate hinge on the identification, location, evaluation, and monitoring of infectious or possibly infectious individuals who are in alcohol or drug treatment, they appear to conflict with the Federal confidentiality laws.
Fortunately, that conflict is more apparent than real, since the Federal confidentiality laws contain mechanisms that make it possible for AOD providers to comply with both the TB services mandate and State TB reporting and followup laws without violating patient confidentiality.
The Federal laws governing the confidentiality of AOD patient records are found in 42 U.S.C. § 290dd-2, a Federal statute, and in the regulations contained in volume 42 of the Code of Federal Regulations, Part 2.4 Enacted to encourage substance abusers to seek treatment without fear of disclosure or stigmatization, the Federal confidentiality regulations5 essentially provide that no federally assisted program that specializes in the treatment or diagnosis (or referral for treatment or diagnosis) of alcoholism or drug addiction may reveal the identity of anyone who has ever received or applied for its services.6 Before looking at the exceptions to that rule, let us take a closer look at its elements.
A program is a federally assisted entity that provides (and holds itself out as providing) individualized drug or alcohol abuse diagnosis, treatment, or referral for treatment.7 A program may be an individual, e.g., a psychologist or counselor, or an organization.
The regulations do not reach individuals or organizations that do not provide, and hold themselves out as providing, such specialized services.
A program is federally assisted, and therefore covered by the regulations, if it receives Federal funds in any form, even if the funds do not directly pay for alcohol or drug abuse services.
A program is federally assisted if it receives reimbursements from Medicaid or Medicare, is exempt from Federal taxation, is licensed or certified by the Federal Government, for example, to dispense methadone, or receives State or local funds that can be traced to Federal funds.8
The regulations apply to programs that diagnose, treat, or make referrals for treatment for drug addiction or alcoholism.
A program need not provide all three services to be covered by the regulations.
The diagnosis of alcoholism or addiction need not be made by a physician in order for the regulations to apply.
Similarly, the regulations apply even if the treatment itself is provided by a non-physician.
The regulations protect any person who has applied for, participated in, or received an interview, counseling, or any other service from a federally assisted alcohol or drug abuse program.9 The regulations protect the records and identities of current, former, would-be, and even deceased patients.10
The regulations prohibit AOD programs from disclosing the identities of the individuals they serve or have served.
A "disclosure" is a communication that identifies an individual as having participated in, participating in, or seeking to participate in drug or alcohol abuse treatment.11 Both explicit and implicit disclosures are prohibited.12 However, a communication that does not reveal an individual's status as a patient in alcohol or drug abuse treatment is not a "disclosure" for purposes of the regulations.
Thus, a communication that reveals a person's name and address is not a disclosure so long as it does not reveal that the person is in AOD treatment.
What is protected is not the person's identity per se, but his or her identity as a person who is dependent on alcohol or drugs.
Despite their strictness, the Federal AOD confidentiality regulations contain a number of exceptions that allow AOD programs to, first, cooperate with public health officials in providing TB services to their patients, and, second, comply with virtually all State TB reporting, disclosure, and followup requirements.
Specifically, disclosures are permitted:
Where authorized by patient consent
Under a qualified service organization agreement
To report a medical emergency
Where they do not reveal that the patient is in treatment for alcohol or drug abuse
To report a crime on the program's premises
To report child abuse or neglect
Where authorized by a court order
For an audit or evaluation
For research
For purposes of internal program communications.
The following discussion will focus on the four exceptions that would be most useful to AOD programs in their interactions with public health: patient consent, non-patient identifying disclosures, qualified service organization agreements, and medical emergencies.
The best way, both legally and ethically, for an AOD provider to comply with State-mandated TB reporting requirements and to cooperate with State or local public health officials in providing TB services to patients -- without violating the Federal confidentiality regulations -- is to secure patient consents to needed disclosures.
A valid consent allows a program to disclose almost anything about a patient.13 To be valid, however, a consent must be in writing and must include all of the following elements:
The name of the program authorized to make the disclosure
The name of the person or organization that is authorized to receive the information
The name of the patient who is the subject of the disclosure
The purpose of the disclosure
A description of the information to be disclosed (which must conform as narrowly as possible to the purpose of the disclosure)
A revocation provision which states that the patient may revoke his or her consent at any time except to the extent that action already has been taken in reliance upon the consent14
An expiration date (or the specification of an event that will cause the consent to expire)
The date
The patient's signature.
A consent that does not include each of the foregoing elements, e.g., a general medical records release, is invalid for purposes of disclosing AOD information. (A sample consent form is included in appendix C.)
A disclosure made pursuant to a consent -- whether oral or written -- must be accompanied or followed by a written notice warning the recipient that the information being disclosed is protected by Federal law and may not be redisclosed except as allowed by another consent or pursuant to an exception in the Federal regulations. (The necessary redisclosure prohibition notice is included in appendix C.)
In the public health context, a properly executed consent can (1) authorize the patient's AOD program to comply with State-mandated TB reporting and followup requirements, (2) permit the program to communicate with the appropriate public health officials on an ongoing basis for the purpose of treating or coordinating the patient's TB care, (3) allow the recipients to redisclose AOD patient-identifying information, if necessary, and (4) permit the program to cooperate with public health officials should the latter -- as is usually the case -- wish to locate, examine, counsel, treat, or monitor the patient.
As useful as patient consents are, however, they are not without their limits.
Programs that elect to rely on them for purposes of complying with State TB control laws should bear in mind that (1) patients can always refuse to sign them, and (2) patients can generally revoke them at will.
Also, no AOD patient-identifying information that has been disclosed with the patient's consent may be used to conduct any criminal investigation or to substantiate any criminal charges against a patient, unless a special court order authorizing its use for that purpose has been obtained in compliance with the confidentiality laws.15
To avert the problems that can arise where a patient refuses to sign a needed consent, or revokes an earlier one, a program can elect, depending on State law, to condition participation in treatment on a patient's willingness to consent to certain disclosures, including TB-related disclosures. (That would not violate the Federal confidentiality laws.) In deciding whether to pursue that tactic, a program will have to weigh its obligations to the patient against its obligation to prevent the transmission of TB in its facilities.
The decision may come down to choosing between the program's obligations to the one and its obligations to the many, i.e., everyone else in the program.
In any event, patient consent is the recommended mechanism for releasing confidential AOD information.
To protect patients who consent to the release of confidential information to public health officials, AOD treatment providers should:
Explain to patients that a consent to certain disclosures can facilitate both AOD and TB treatment
Emphasize that the program will disclose only information that is relevant to treatment
Reassure patients about the continuing confidentiality of the released information
Ensure that AOD and public health officials who are provided with confidential AOD information thoroughly understand the importance of confidentiality
Respect the patient's right to refuse or withdraw consent
Develop strict guidelines for dealing with breaches of confidentiality.
Some AOD programs may be able to comply with their State-mandated TB reporting obligations by making mandated TB case reports without the disclosure of AOD patient-identifying information.
Under the non-patient-identifying information exception to the regulations, a program may disclose a patient's name and whereabouts as long as it does not reveal that the patient has been in or has applied for substance abuse treatment.
What the regulations protect is not the patient's identity per se, but his or her identity as a person who has been treated, is being treated, or has asked to be treated for drug or alcohol abuse.
However, State TB control laws regularly require disclosure of the addresses of both the individual whose TB case is being reported and the person or institution making the report.
For this reason, resort to the non-patient-identifying exception is feasible only where the patient is in outpatient (as opposed to residential) treatment or where the program can make the necessary report without revealing the nature of its services.
Where the relevant law requires that a patient's address be disclosed, and the patient's address is also the program's address, and disclosure of the program's address would reveal the nature of the program, one cannot rely on that exception without revealing that the patient who is the subject of the report has a substance abuse problem.
But where the patient is not in residential treatment, and where a program need not reveal its address or can use an address that does not reveal its identity as a treatment program (e.g., where the program is part of a general hospital), the program can make the required report without violating the regulations.
Unlike the consent exception, the non-patient-identifying exception allows a program to cooperate with public health officials in their followup activities, i.e., examining, investigating, counseling, treating, monitoring, or contact tracing, only to the extent that the patient's status in AOD treatment is not disclosed.
AOD treatment providers must frequently share patient-identifying information with outsiders who provide services for them or their patients, such as dentists, accountants, and laboratories.
In order to do that without violating patient confidentiality, treatment providers must either secure patient consents or conclude what is known as a qualified service organization agreement (QSOA) with the outside service provider.16
A QSOA is a contract -- a rather simple one (see appendix C) -- that permits an AOD treatment provider to share patient-identifying information with an outside service provider where:
The outside service provider needs that information to provide services for the program or its patients, and
The outside service provider agrees not to redisclose that information.
In effect, a QSOA extends the orbit of the AOD provider to include the services of the outside agency.
Consequently, patient consent is not required for disclosures made between the AOD program and the outside service provider under such agreements.
Nor is the treatment program required, under the regulations, to disclose to its patients that it is or may become a party to such agreements.
Although the Federal confidentiality laws do not require a treatment program to disclose to its patients that it is or may become a party to such agreements, programs may be obliged to do so by State law requirements or may choose to do so out of ethical or therapeutic considerations.17
Reporting communicable diseases under a QSOA.
An AOD treatment provider may comply with State laws that require the reporting of cases of communicable disease by entering a QSOA with an outside service provider, such as a laboratory or private physician.
The outside service provider would make the necessary reports without disclosing that the subject of the report is a participant in a substance abuse treatment program.
Among other things, the outside service provider could report the patient's name, address, social security number, date of birth, communicable disease diagnosis, and other objective data without violating the Federal confidentiality laws.
Providing TB services through a QSOA.
An AOD program that does not have the resources to provide the full array of TB-related services to its patients (see chapter 5) could arrange to have those services provided to its patients through a QSOA with a private physician or local public health officials.
A QSOA with local public health officials would be superior to one with a private physician, because it would give public health officials relatively free access to program patients for followup treatment, monitoring, and contact tracing.18
The confidentiality regulations allow programs to disclose patient-identifying information, even without a patient's consent, to public or private medical personnel who "have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual and which requires immediate medical intervention."19 This exception does not offer programs a blanket authorization to report all their patients' suspected or confirmed TB cases to public health officials (or to communicate freely with those officials in the course of following up reported cases).
This is because the medical emergency exception can only be invoked on a case-by-case basis, after a program has determined that the circumstances justifying a disclosure of information about a particular patient exist in that case.
However, the exception will allow programs in many States to communicate with public health personnel about the TB cases of most urgent concern to everyone: those where an AOD patient is known or suspected to have infectious TB but is not known to be receiving TB treatment.
A disclosure under the medical emergency exception is justified only when a program determines that a patient's condition is one that both poses an immediate threat to his or her health or to that of others, and requires immediate medical intervention.
Because TB can be transmitted by casual contact (that is, the sharing of air space), because infectious TB poses an immediate health threat requiring immediate medical intervention, and because there is generally no way to determine whether an individual is definitely infectious without time-consuming testing, this requirement would be met in a case where a program has reason to suspect that a patient or applicant has infectious TB that needs to be -- but is not being -- diagnosed or treated immediately.
Disclosures under this exception can be made only to "medical personnel" who need information about a patient in order to treat the condition requiring immediate medical intervention (or ensure that someone else does so).
Although the confidentiality regulations do not specifically define the "medical personnel" to whom such disclosures may be made under this exception, a common sense reading of this term would include public health officials in States where the public health authorities are either directly involved in diagnosing or treating reported cases of TB or have the authority to arrange for the immediate medical intervention that is needed in such cases.
Although the medical emergency exception to the confidentiality laws would allow AOD treatment providers to report cases or suspected cases of active TB in the circumstances described above, it would not allow them to cooperate with public health officials for purposes of patient followup and contact tracing.
When a TB report is made under this exception, the reporter must document the circumstances surrounding the disclosure, including the medical personnel to whom the disclosure was made.20
If AOD treatment providers are to comply with State communicable disease reporting laws and the Federal TB services mandate, they will have to cooperate with various outsiders, including public health officials.
Invoking the patient consent and QSOA exceptions to the confidentiality laws would facilitate such cooperation.
Cooperation between the public health and AOD fields in the effort to prevent the transmission of TB in AOD facilities would have the following benefits:
Make it easier to identify cases of TB
Promote adherence to treatment in a troubled population
Facilitate the provision of directly observed therapy
Facilitate followup, including contact investigations
Make it easier to monitor patients on preventive therapy or in treatment.
Collaboration would result in common benefits.
These would include (1) improved services for patients who suffer from both communicable disease and addiction, (2) efficient use of scarce resources, (3) reduced risk for TB for patients, staff, and others, and (4) greater compliance with Federal, State, and local mandates regarding TB screening, evaluation, and treatment.
Even if the Federal TB services mandate were eliminated, the impact of the TB epidemic on those served by AOD programs is so great that collaboration between AOD programs and public health officials would remain crucial and mutually beneficial.
Despite its apparent benefits, collaboration between the public health and AOD fields will not always be easy to achieve.
This is in part because some AOD treatment programs believe that collaboration with public health would compromise their independence or jeopardize patient confidentiality.
On the other hand, some in the public health field think that AOD administrators and counselors get in the way of efforts to combat communicable diseases.
Accordingly, if the AOD and public health fields are to collaborate successfully, they will have to (1) educate one another about their respective objectives, obligations, and cultures, (2) make clear what it is that they can do for each other, (3) clarify boundaries and identify mutually beneficial mechanisms for crossing those boundaries, and (4) be sure to remind one another that, in the end, they share a profound commitment to health.
Mistaken notions about what is permitted by the confidentiality regulations are not the only impediment to collaboration between the AOD treatment and public health fields.
Political and financial concerns can all too easily conduce to suspicion and distrust between individuals who otherwise have much in common.
The public health and AOD fields must be clear about their respective responsibilities regarding TB in the AOD setting.
They must be open and frank about what each can and cannot do in the effort to prevent TB.
Concerns that the one is not doing enough, or that the other is preventing access to patients, must be addressed and overcome.
Misunderstandings over turf, respective responsibilities, and cooperation can result in the loss of patients to both systems.
Inadequate funding can be an obstacle to collaboration.
TB challenges the already stretched resources of both the AOD and public health fields.
Collaboration offers the advantages of saving scarce resources and shoring up everyone's bottom line.
To facilitate collaboration, AOD providers and public health agencies should cooperate in identifying resources and promoting efficiency in the implementation of TB protocols and the provision of TB services.
Patient mistrust can impede collaboration between public health and AOD agencies and can lead substance abusers to walk away from treatment.
By way of reassuring their patients, AOD treatment providers should therefore strive to:
Address patient concerns about sanctions related to TB services
Address concerns about the availability of needed services
Address concerns about confidentiality
Change any negative perceptions that AOD counselors may have of public health, since counselors can influence patient attitudes and perceptions
Use outreach programs and drop-in centers to reach difficult populations and develop patient trust
Make it clear to undocumented aliens that health officials will not contact immigration authorities or investigate their immigration status.
While some degree of cooperation already exists between many AOD and public health agencies, the ultimate goal of both AOD and public health should be a genuine partnership.
Partnership means that both agencies will share responsibilities and work towards mutually agreed upon goals.
To promote the possibilities of partnership, AOD and public health agencies should:
Share and exchange training (for example, AOD providers can train public health officials on alcoholism and substance abuse issues, and public health officials can provide infectious disease education to AOD counselors)
Develop mutually beneficial propaganda, such as brochures and posters aimed at shared patients
Identify which collaborative efforts work and which need improvement
Encourage communication to lessen interagency misunderstanding.
One way of fostering partnership between the AOD and public health fields would be to develop interagency agreements that would set out in detail the roles and responsibilities of each in the screening, treatment, and followup of AOD patients.
Clear and practical agreements can facilitate patient access to TB services and improve patient outcomes.
Such agreements should address:
Cross-training: Training for public health officials should address issues relevant to the AOD population.
Training for substance abuse providers must focus on the origins, identification, and treatment of communicable diseases.
Where appropriate, the parties might wish to collaborate on appropriate training materials.
Risk assessment surveys: Risk assessments are critical to the control of TB infection in AOD facilities.
However, those assessments cannot be made without the assistance of properly trained experts.
Public health officials can provide the necessary expertise to AOD providers.
Record keeping: Record keeping is vital to the control of TB in the AOD setting.
Public health officials can assist AOD providers to develop appropriate record keeping procedures.
AOD providers can help familiarize public health officials with the relevant confidentiality issues.
Review of agreements: Cooperative and partnership agreements must be reviewed periodically for effectiveness.
Contacts: Each party to a cooperative or partnership agreement must have a list of key contacts in the other party's organization.
State-local public health collaboration: State and local authorities should develop top-to-bottom strategies for cooperating with AOD providers and providing effective TB services.
AOD and public health providers agree that TB services for AOD patients could be enhanced by cooperation between all the agencies and institutions that deal with AOD abusers.
These include departments of corrections, HIV/AIDS service providers, social service agencies, immigration services groups, charitable organizations, mental health agencies, Indian Health Services, tribal organizations and institutions, housing authorities, advocates for the homeless, community health centers, migrant health programs, public hospitals, and others who specialize in the provision of services to special care populations.
Successful treatment of shared patients will depend on a comprehensive response from the relevant agencies.
Some States are promoting partnerships between AOD providers and public health.
Those partnerships seek to (1) integrate TB screening, counseling, and medical services with substance abuse treatment, and (2) facilitate TB reporting, followup, and monitoring.
Following is an overview of activities in Arkansas, Massachusetts, Nevada, and New York.
In January, 1993, the Arkansas Department of Health's (ADH) Bureau of Alcohol and Drug Abuse Prevention (ADAP) and Division of Tuberculosis entered into a memorandum of agreement (MOA) that outlined areas of collaboration with respect to drug abusers infected with or at risk for TB.
TB screening, counseling, and treatment services in Arkansas AOD programs. Under the
MOA, ADH staff train designated staff persons from each residential substance abuse treatment program to administer tuberculin skin tests to patients and interpret the results.
Patients are to be screened for TB upon admission and annually thereafter.
PPD-positive patients are referred to local health units for followup testing and evaluation.
Substance abuse treatment programs provide on-site directly observed therapy (DOT) to ensure patient compliance with TB medication regimens.
In addition, the MOA calls for the annual TB testing of treatment program staff.
Recognizing the connection between HIV and TB and the increased dangers that TB poses for immunocompromised individuals, the MOA encourages HIV testing and counseling for patients in treatment, especially for those who are PPD positive.
Infection control in Arkansas AOD programs. The MOA outlines steps to be taken by ADH and ADAP to install germicidal ultraviolet (UV) lights in all residential treatment programs.
ADH staff survey program rooms for size, ceiling height, and patient distribution.
The program then purchases the recommended light fixtures and bulbs.
ADH staff install them.
ADH also teaches programs how to clean and maintain the lights.
Programs must keep records documenting the proper care and replacement of UV lights to ensure their continued effectiveness.
UV lights are now being installed in all residential treatment facilities.
Training. In addition to the training outlined above, ADH gives ADAP staff and AOD providers regular training regarding TB and HIV issues.
In exchange, the MOA calls for ADAP to train ADH on substance abuse issues, particularly those related to injection drug use.
ADAP also conducts regional meetings to inform ADH staff about the services ADAP provides and to establish links to medical care for patients.
Ongoing collaboration. ADH's Division of Tuberculosis staff and ADAP's Infectious Disease Coordinator meet on a quarterly basis to share information and to develop primary care linkages and referral arrangements for patients in drug and alcohol abuse treatment.
ADAP and ADH also conduct joint visits to treatment facilities to monitor the effectiveness of the State's TB control efforts.
Finally, ADH and ADAP providers have entered QSOAs for the purposes of reporting TB-related information and coordinating TB services within the bounds of the Federal confidentiality regulations.
Massachusetts has taken a number of steps to prevent the transmission of TB in AOD facilities, including the following:
In 1990, the Division of Tuberculosis Control (the Division) and the Bureau of Substance Abuse Services (BSAS) collaborated on a policy statement for TB control in AOD facilities. (See appendix D.) That statement outlines procedures for TB screening, followup, reporting, and monitoring of treatment.
In 1991-92, pamphlets were produced on HIV and TB (see appendix E) and on the connection between substance abuse and sexually transmitted diseases, hepatitis B, TB, and HIV/AIDS (see appendix F).
In 1993, the Division and BSAS collaborated with CSAT to provide a 2-day training for substance abuse treatment providers and communicable disease staff.
Since 1989, the Division has received money from the Centers for Disease Control and Prevention (CDC) to provide TB screening, followup, and directly observed preventive therapy at seven methadone maintenance treatment programs.
Massachusetts has drafted a consent form for release of confidential information for AOD patients.
Other activities include educating AOD providers about TB, STDs, and HIV, visits by Division staff to AOD providers, joint mailings, and the creation of links between TB and STD clinics.
Nevada's efforts to provide TB services to substance abusers were a direct response to the Federal TB services mandate.
In December 1992, Bureau of Alcohol and Drug Abuse representatives and Clark County public health officials met to explore ways of integrating TB and AOD services.
That meeting led to the establishment of a pilot project to enhance TB services in Clark County substance abuse treatment programs.
The project was funded by a grant from the Center for Substance Abuse Treatment (CSAT).
TB screening, counseling, and treatment services in Nevada AOD programs. Under the pilot project, a Clark County Health Department nurse travels to publicly funded alcohol and drug treatment centers to administer PPD tests and to make referrals for followup x-rays and treatment.
Patients with positive PPD results are transported to local clinics for chest x-rays.
The nurse also works closely with the treatment programs to ensure proper case management.
Training. Nevada cross-trains AOD counselors and public health staff to promote mutual understanding and an appreciation of each field's concerns and obligations.
Ongoing collaboration. Discussions are underway to replicate Clark County's model elsewhere in the State.
In light of the incidence of TB and HIV/AIDS among substance abusers in New York, the New York State Office of Alcoholism and Substance Abuse Services (OASAS) has pursued policies that emphasize early detection, on-site provision of DOT, environmental control, and collaboration with public health officials to reduce the risk of transmission of TB in AOD facilities.
TB screening, counseling, and treatment services in New York AOD programs. In 1992, OASAS issued two Administrative Bulletins that outlined the minimum TB control procedures for alcoholism and substance abuse treatment programs in New York State.
Those directives recommended:
Incorporating TB screening into the admissions process of all treatment programs
Providing followup chest x-rays and anergy panel testing, where indicated
Annual retesting of PPD negative patients.
OASAS also recommends testing all staff at least once a year, screening staff at highest risk every 6 months, and testing new employees upon hiring.
OASAS has developed several initiatives to link patients with TB treatment.
In New York City, OASAS, the New York City Department of Health (NYC DOH) and the Committee of Methadone Program Administrators match the names of persons on the central methadone registry with those on the TB registry.
Under this arrangement, NYC DOH makes available to the private, nonprofit agency that maintains the methadone registry a list of persons documented as either having active TB or having failed to adhere to treatment.
The nonprofit agency notifies the appropriate methadone program whenever there is a match.
The methadone program then asks the patient for permission to contact the NYC DOH to arrange for followup services.
This arrangement has identified more than 300 methadone patients who have active TB or who failed to complete TB treatment.
OASAS has also collaborated with the New York State Department of Health to enable several New York City methadone maintenance treatment programs (MMTPs) to provide on-site DOT to their patients.
A CDC grant, administered in cooperation with the NYC DOH and the New York State Department of Health/AIDS Institute, has enabled eight MMTPs and one therapeutic community in New York City to develop on-site directly observed preventive therapy for patients with TB infection.
The grant allows Disease Preventive Specialists to perform on-site PPD tests, interpret the results, conduct or arrange followup testing, and provide directly observed preventive therapy.
Disease Preventive Specialists also screen for side effects and anergic reactions.
TB environmental control in New York AOD programs. OASAS has assessed the TB environmental control needs of 36 alcoholism and substance abuse treatment facilities throughout New York State as part of a program to ensure a safe environment in MMTPs and Alcoholism Crisis Centers.
The program is intended to provide UV lights and improve ventilation in those facilities.
To qualify for the program, a program must have a comprehensive TB program in place, including patient and staff screening, and formal linkages with local hospitals to provide x-rays and dispense TB medication.
OASAS hopes to expand the program to other facilities.
Training. OASAS has issued bulletins to providers which include basic educational information on TB.
A TB control plan is a required part of the providers' HIV Program Plan, which is required by regulation of all OASAS-licensed drug treatment programs.
Ongoing collaboration. OASAS has discussed replicating the cross-referencing of TB and methadone registries with the Health Department in Westchester County.
OASAS has had discussions with the Monroe County Health Department regarding the possibility of the latter's conducting on-site testing in the county's AOD programs.
1.Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act of 1992, PL 102-321, § 1924(a)(1), 106 Stat. 391 (1992), 42 U.S.C. § 300x-24(a)(1) (1994).
The SAPT Block Grant is the major source of Federal financing for substance abuse treatment programs.
The Grant is administered by the Center for Substance Abuse Treatment (CSAT) and is funneled to treatment programs through the primary substance abuse agency in each state.
In addition to providing TB services for patients, AOD programs must also provide appropriate referrals for applicants in need of TB evaluation or treatment who are turned away from AOD treatment for lack of space.
Obviously, AOD providers will want to make such referrals for anyone who needs them, not just those who have been turned down for lack of space. 2.The regulations require State substance abuse agencies, departments of health, and medical directors for substance abuse services to cooperate in developing procedures to ensure that programs provide the mandated services, implement infection control procedures, report cases of TB to local or State public health departments, and provide case management for those in need of TB services.
To facilitate the provision of TB services, Single State Agencies are expected to cooperate with local tuberculosis control officers to create the necessary linkages between AOD and other health care providers, 45 C.F.R. § 96.127(b). 3.For a survey and discussion of TB reporting and control laws in the 50 States, see Centers for Disease Control, U.S.
Department of Health and Human Services, Tuberculosis control laws -- United States, 1993, Morbidity and Mortality Weekly Report: 42(RR-15):1, 3, 1993; and Lawrence O.
Gostin, Controlling the resurgent tuberculosis epidemic, JAMA 269:255, 1993. 4.The regulations implementing the Federal AOD confidentiality law were revised by the Department of Health and Human Services in 1987, and more recently on May 5, 1995 (60 Federal Register 22296).
For a thorough discussion of the regulations, see Legal Action Center, Confidentiality: A Guide to the Federal Law and Regulations, rev. ed. 1995. 5.When we speak of the Federal regulations, we are referring to the regulations in the Code of Federal Regulations; the actual statute is rarely referred to. 6.The prohibition on unauthorized disclosure applies whether or not the person seeking information already has the information, has other means of obtaining it, enjoys official status, has obtained a subpoena or warrant, or is authorized by State law. 42 C.F.R. §§ 2.13(b) and 2.20.
State laws permitting or requiring disclosures that are prohibited by the Federal regulations are invalid. 7.42 C.F.R. §§ 2.11, 2.12(a)(1)(ii).
The 1995 revisions to the regulations' definition of covered "program" in §§ 2.11 and 2.12(e)(1), which became effective June 5, 1995, are set forth at 60 Federal Register 22296-22297, May 5, 1995. 8.42 C.F.R. § 2.12(b). 9.The regulations require programs to notify patients of the existence of the Federal confidentiality laws and regulations and to give them a written summary of the confidentiality provisions.
The notice and summary should be provided at admission or "as soon thereafter as the patient is capable of rational communication." 42 C.F.R. § 2.22(a).
The regulations list five items that must be included in the written summary and a sample notice: (1) a description of the few circumstances in which disclosures can be made without consent; (2) a statement that violation of the regulations is a reportable crime; (3) a warning that information can be released if the patient commits or threatens a crime on program premises or against program personnel; (4) a notice that the program must report suspected child abuse or neglect; and (5) a citation to the law and regulations. Id. at § 2.22(b).
The regulations contain a sample notice at § 2.22(d). 10.42 C.F.R. §§ 2.11, 2.15(b). 11.42 C.F.R. §§ 2.11, 2.12(a)(1)(I). 12.42 C.F.R. § 2.13(c). 13.42 C.F.R. §§ 2.31, 2.33.
A consent may authorize the recipient to redisclose patient-identifying information. 14.Consents for persons mandated into treatment through the criminal justice system may be made irrevocable for periods of time, depending on the State law (42 C.F.R. § 2.35). 15.42 U.S.C. § 290dd-2_; 42 C.F.R. §§ 2.12(d)(1) and 2.65. 16.42 C.F.R. §§ 2.11, 2.12(c)(4).
According to the U.S.
Department of Health and Human Services (which revised the Federal confidentiality regulations in 1987), treatment programs can enter QSOAs with a broad array of service providers, though generally not with one another.
Generally, QSOAS are permitted between treatment programs only where the service provided by the second program does not pertain to drug or alcohol abuse education, training, treatment, rehabilitation, or research.
Under no circumstances may an AOD treatment provider enter a QSOA with a law enforcement agency. 17.Although the confidentiality regulations do not require patient consent to enter a QSOA with an outside service provider, many providers believe that it is unethical not to inform clients of the existence of such agreements.
Patient notification of the existence of QSOAS reduces surprise and protects the therapeutic relationship. 18.If the outside agency is a laboratory, it can report its analyses to public health officials.
As a laboratory, however, it cannot follow up on the patients whose test results it reported, i.e., it cannot treat them.
But if the outside agency is a health care provider, it can not only make the necessary reports to public health, it can also provide treatment and followup to the patient in question. 19.42 C.F.R. § 2.51. 20.42 C.F.R. § 2.51(c).
Site Map
Help
Account
Cart
Home
