Barriers and facilitators of implementing a latent tuberculosis infection (LTBI) case management program in a primary care setting
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Context
Approximately 80% of tuberculosis (TB) disease in the United States arises from untreated latent TB infection (LTBI). Primary care clinics are well positioned to address LTBI in populations disproportionately affected by TB, yet implementation barriers remain poorly characterized.
Objective
Identify barriers and facilitators encountered during early implementation of a multidisciplinary LTBI case management intervention (CMI) in a federally qualified health center (FQHC) serving predominantly non-U.S.–born patients.
Design
Qualitative study using structured key informant interviews, analyzed with iterative thematic analysis. Staff and patients were conveniently sampled; patients were limited to those who completed treatment.
Setting and Participants
Three clinics within a FQHC in Seattle, Washington. Thirty-seven interviews were conducted (32 staff, 5 patients) from February 2023-May 2024.
Main Outcome Measures
Staff- and patient-reported barriers and facilitators to CMI implementation.
Results
Staff identified three barriers: 1) adapting to a new workflow, including technical challenges and role ambiguity; 2) clinic capacity and resource constraints, including staffing and limited language support; and 3) gaps in LTBI care, particularly chest radiograph access and patient questions after a positive test. Staff reported three facilitators: 1) division of labor through role-shifting, enabling detection of side effects and dosing errors; 2) standardized communication tools and educational materials improving consistency and staff confidence; and 3) collaboration via electronic messaging and structured meetings supporting iterative improvement. Patients mostly reported facilitators only, citing the proactive follow-up as central to treatment completion. Both groups cited the drug shortage as a barrier to treatment completion.
Conclusions
Multidisciplinary case management revealed facilitators and barriers in delivering coordinated care. Staff identified division of labor, standardized tools, and structured communication key to care coordination while patients emphasized staff encouragement and pro-active follow-up as central to treatment completion. Workflow integration, resource capacity, and post-diagnosis patient support should be considered when implementing or scaling similar models.
