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2012 Model Practice Application (Public)Application Name: 2012 Model Practice Application (Public) : Hennepin County Public Health : Comprehensive Approach to Prevention, Testing, and Treatment of Sexually-Transmitted Infections and HIV within a Local Health Department Applicant Name: Ms. Lisa Mueller Application Title: Comprehensive Approach to Prevention, Testing, and Treatment of Sexually-Transmitted Infections and HIV within a Local Health Department Please enter email addresses you would like your confirmation to be sent to. lisa.m.mueller@co.hennepin.mn.us Practice Title Comprehensive Approach to Prevention, Testing, and Treatment of Sexually-Transmitted Infections and HIV within a Local Health Department Submitting LHD/Agency/Organization Hennepin County Human Services and Public Health Department Head of LHD/Agency/Organization Todd Monson Street Address 525 Portland Avenue, MC963 Practice Contact Person Lisa M. Mueller lisa.m.mueller@co.hennepin.mn.us Submitting LHD/Agency/Organization Web Address (if applicable) www.hennepin.us Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:
• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?
• Lessons learned from the practice Target Population: The Hennepin County Public Health Clinic Red Door Services is the largest STI/HIV testing and counseling site in the state. Our clients include Hennepin County residents (pop. 1,152,425), residents of the greater Minneapolis—St. Paul metropolitan area, and residents of greater Minnesota.
In 2010 the Public Health Clinic provided 32,612 clinic visits to 11,922 unique patients. Clients of all ages, races, genders, and sexual orientations are referred to the clinic from emergency rooms, primary care providers, schools, social services, and other community agencies as a result of outreach efforts by Red Door prevention staff. Current outreach sites include chemical dependency treatment centers, bars, community events (Pride), and jails.
Innovation: Clinical, prevention, and disease investigation services are co-located within the clinic. This unique model allows immediate and timely referral and consultation between services. Patients often receive a combination of services in a single visit to the clinic.
Nature and gravity of the public health issue: The testing and treatment of HIV and STDs is an important public health endeavor. Prevention, testing, and treatment programs play a vital role in controlling the spread of infections that can lead to recurring disease, infertility, and chronic health conditions, some with potentially deadly consequences. Treatment of common sexually transmitted infections can be an effective tool in preventing the spread of HIV, the virus that causes AIDS. Individuals who are infected with STIs are two to five times more likely than uninfected individuals to acquire the HIV infection if they are exposed to the virus through sexual contact. Reduction in sexually transmitted infections (STIs) reduces HIV acquisition and limits the development of other serious health conditions. HIV-positive individuals who are concurrently infected with another STI are more likely to transmit HIV. HIV-positive individuals who are not receiving health care are at greater risk of transmitting the virus and of developing serious and chronic health issues.
Goals and objective(s) of the practice: A priority of Hennepin County Public Health is to reduce the rates of HIV, Chlamydia, Gonorrhea, and Early Syphilis infections by 10% by 2014. The comprehensive approach we have implemented will help us reach this goal.
History: The Red Door Clinic was established in 1970 to provide sexual/reproductive health care. The Health Assessment Clinic has been providing
Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. TB and Refugee services for more than 30 years. These clinics were merged in 2007 to create the Hennepin County Public Health Clinic with Red Door Clinical Services. This merger allowed us to capitalize on the combined resources of staff, funding sources, and clinical expertise. Each year since the merger we have added programmatic and clinical tactics to enhance our comprehensive approach to prevention, testing, and treatment.
Implementation: The innovation is the integration of four kinds of service in the clinic: The outreach, education and testing services of the Health Interventions for Men (HIM) program, which focuses on the needs of men who have sex with men; the Care Access and Prevention (CAPS) program, which seeks to identify individuals with HIV and connect them to care; clinical testing and treatment services; and Disease Intervention Services (DIS), otherwise known as Partner Services. All of these programs are housed in the clinic and staff interact on a daily basis. These are the most recent updates in these integrated services to improve and expedite care:
2010 – Expanded health education and behavioral counseling through both traditional methods (group sessions and face-to-face interactions), and use of new technologies and enhanced social media networking strategies.
2010 – Expanded field testing for Early Syphilis by expanding community-based opportunities for testing, in locations such as chemical health treatment facilities.
2010 – Added an in-house Disease Investigator to allow for rapid identification of sexual partners, and to facilitate faster linkages for testing and treatment for those who have been identified as “at risk” due to their direct exposure to a suspected or confirmed case of HIV or STI.
2011 – Expedited access to medical care for patients who test positive for HIV through the implementation of a “fast-track” model. Time lags of two or more weeks between initial testing, and full confirmation, assessment, and treatment planning were reduced by adding diagnostic testing to the patient’s first clinic visit.
2011 – Created a “Care Navigator” position to improve attendance at healthcare appointments, provide support, and eliminate common barriers to accessing care and treatment for HIV positive patients.
2011 – Established a program to recruit and train peer educators to expand outreach to young men who have sex with men (MSM)social networks.
Describe the public health issue that this practice addresses. (350 word limit)
Despite long term efforts within traditional clinic models to control HIV and STIs, rates of STIs and HIV continue to rise, especially in high risk populations. New comprehensive and integrated strategies to optimize prevention efforts are needed. What process was used to determine the relevancy of the public health issue to the community? (350 word limit) STIs and HIV are significant health issues. By studying patterns of infection we can identify opportunities for prevention and implement effective programs to decrease morbidity and mortality.
HIV/AIDS: Currently, our population rate for new HIV infections is 15.2 per 100,000 persons. Treatment and management of HIV has improved significantly since the advent of Highly Active Anti-Retroviral Therapies (HAART) in 1995, resulting in a rising number of individuals living with HIV/AIDS. The increase in new cases of HIV since 2004 is a significant concern.
In Hennepin County (HC), as in Minnesota and the U.S., HIV infection rates are highest in men who have sex with men (MSM), intravenous drug users (IDU), young adults, and some communities of color.
MSM accounted for 62% of new HIV infections. MSM is the only risk group in the U.S. in which infections have been steadily increasing since the early 1990s. MSM who are also injection drug users (IDU) account for 75% of new HIV diagnoses.
Young Adult residents aged 20-24 years old had the highest rates of new HIV infection (36.8 cases per 100,000). 51% of the new cases were among adults aged 20 to 34 years old.
Race/Ethnicity data indicate that populations of color, particularly Blacks and American Indians, consistently have significantly higher rates (38.2 and 85.0 cases per 100,000 population, respectively) of new HIV infection than whites (9.8 cases per 100,000). While Blacks make up only 11% of our population, they account for 30% of new HIV infections.
Chlamydia is the most frequently reported infectious disease in HC and statewide. The infection rate in 2010 was 455 Chlamydia cases per 100,000 persons. One-third of Minnesota Chlamydia cases are in HC.
Gonorrhea decreased from 154 to 93 cases per 100,000 persons (down 40%) between 2005 and 2010. Still, the City of Minneapolis, where our clinic is located, accounted for the highest Minnesota rate of gonorrhea infection (195 cases per 100,000 persons).
Early Syphilis increased to 9 cases per 100,000 persons in 2010. Since 2002, Minnesota primary/secondary syphilis rates have fluctuated, but remain significantly elevated over rates in the previous decade.
How does the practice address the issue? Case study (a recent, actual patient situation): a 24 year old male who has been HIV positive and out of care for 5 years presented to the clinic appearing very ill. He was diagnosed with thrush and a skin rash (thought to be another manifestation of systemic fungal infection.) He was screened for STIs, prescribed an oral antifungal medication, and scheduled for follow up care one week later. HIV labs were drawn. He was immediately connected to a Care and Prevention staff person to help him establish HIV care. His Syphilis and Chlamydia results were both positive. His CD4 count was 100. He missed his follow up appointment. Disease Investigation Services (DIS) was engaged to attempt contact with him. DIS worker sought him at his apartment, through Facebook, and was ultimately successful in reaching him at his employer. By helping him establish care for his HIV we expect to avert his otherwise inevitable health decline, perhaps requiring hospitalization. Treating his Syphilis and Chlamydia will make him less infectious to partners and identifying partners in need of testing and treatment will help stem the spread of these infections.
This thorough care, with potentially widespread implications, is only possible when prevention, clinical and partner services work in tandem.
Is the practice new to the field of public health? If so, answer the following questions. No What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review. How does this practice differ from other approaches used to address the public health issue? Is the practice a creative use of an existing tool or practice? If so, answer the following questions. Yes What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?
What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review. Literature Review: The World Health Organization (WHO,) in a 2002 Fact Sheet on prevention work notes, “All too often, health care workers fail to seize patient interactions as opportunities to inform patients about health promotion and disease prevention strategies.” This failure results from packed provider schedules and assumptions about the boundaries of one’s responsibilities. It is reinforced by the outreach, education, and follow up services of multiple city, county, and state agencies. Working in parallel, these agencies do important work, but the lack of coordination of services means that too often clients receive incomplete services.
The WHO further suggests that “optimal outcomes occur when a health care triad is formed. This triad is a partnership among patients/families, health care teams, and community supporters that communicates and collaborates.” It is exactly this kind of partnership that we are creating in our Public Health Clinic.
Integrating prevention into health care. Fact sheet No.172, October 2002 World Health Organization
How does this practice differ from other approaches used to address the public health issue? Partner Services has always been a function of state departments of health. Finding untreated patients and their partners has been a key strategy in addressing rising STI and HIV infection rates. Success varies.
LA County Department of Health is one of a number of Health Departments who have implemented the Community-Embedded Disease Investigator Specialist (CEDIS) model in an attempt to improve this service. In a 2010 evaluation report, LA describes their process this way:
First, the CEDlS was stationed at the diagnosing clinic rather than at central headquarters. This allowed information to be rapidly routed to the CEDlS about newly identified syphilis cases. Second, the CEDlS was a peer of the community and the clinic agency, not a Department of Public Health employee, and the job activities were fully integrated into the clinic's normal work flow.
LA reports that utilizing CEDIS has been effective in “significantly reducing the time-to-interview of cases, increasing the number of partners elicited, and increasing the number of partners that could be preventatively treated.”
Responding specifically to the problem of HIV and Syphilis co-infection, the Arizona Department of Health Services embedded DIS in three HIV primary care clinics between February 2008 and September 2009. They studied the change in the number of patients interviewed, the time from testing to treatment, the time from testing to DIS interview, and the number of locatable and treated partners as a result of this intervention. Improvement was noted in each area. Who were the primary stakeholders in the practice? Local Public Health Department Clinic, Minnesota Department of Health (funding/lab services), Hennepin County Medical Center (lab services/HIV clinic), and community clinics (specializing in HIV care) What is the LHD's role in this practice? Hennepin County Public Health Clinic with Red Door Clinical Services (HCPHC/RDS) is the local Public Health Department. In June 2007 PHC/RDS was created by the merger of Red Door Clinic (established 1970) and the Heath Assessment Clinic (TB and Refugee Services). In 2010 Health Care for the Homeless services were added to the HCPHC/RDS. What is the role of stakeholders/partners in the planning and implementation of the practice? HCPHC/RDS has a long standing history of collaboration with other community agencies and the state health department through formal and informal contractual relationships. Some collaborating agencies include MN AIDS project Rainbow Health Coalition, Access Works, Streetworks, University Schools of Nursing, Medicine and Public Health, Aliveness Project, The City, Inc, the Urban League, and surrounding county local public health agencies. What does the LHD do to foster collaboration with community shareholders? Describe the relationship(s) and how it furthers the practice's goals. The Public Health Clinic has formal and informal networking with our community shareholders. We actively participate in Ryan White All-Provider meetings held regularly to network with other organizations doing HIV prevention, clinical care, and case management. We do mutual clinic referrals with community clinics and clinics specializing in HIV care. We work with our community partners to maximize and compliment quality services to clients without duplication of effort. Describe lessons learned and barriers to developing collaborations One particular lesson learned was the effectiveness of having the Disease Investigator (DI) both hired and supervised by the local health department. Previously the DI for our large metropolitan service area was an employee of the state health department. This model had the DI housed in our facility, but supervised by the state. Having an in-house DI allows for better referrals between the DI, clinic providers, and outreach staff. Additionally the in-house DI has access to the same electronic medical record. Another lesson learned was the value of engaging an external consultant for the strategic planning process around "expedited access to medical care for patients who test positive for HIV" and the design of the "Care Navigator" position to streamline access to healthcare appointments. Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)
• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
Objective One:
The in-house disease investigator (DI) was added to clinic services to ensure timely notice of STI infection or exposure, testing and treatment to cure infection, prevent disease complications, and prevent the spread of disease.
In the first half of 2011, 31 syphilis cases or 26% of the state total were referred to the PHC in-house DI. Sixty five percent of the cases were interviewed within seven days of assignment. The interviews generated 80 contacts. This number represents 60% of the contacts generated by the entire team of disease investigators in the state of MN. Thirty two persons were treated preventatively. This represents 70% of the total presumptive treatments in the state of Minnesota. Eight new syphilis cases were identified and treated in the clinic. This is 100% of the new cases in Minnesota based on Disease Investigation Services intervention.
Time is of the essence in getting people treated and limiting the impact of sexually transmitted infections. What makes this all the more challenging is symptoms for diseases such as syphilis can take up to 90 days to appear. Addressing the primary patient’s needs and establishing a trusting relationship can make all the difference in whether contact information is shared in a timely manner, if at all. Having an in-house disease investigator versus a state department of health staff member who made the rounds in the past helps people work through the process and more readily share information.
Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Objective Two:
Historically, people who came to the Red Door clinic for HIV testing had to return for the results of a confirmatory test. It could be a 2-4 week wait in some cases and some people did not return for their results delaying the start of HIV primary medical care until the disease had progressed. Red Door developed a process which expedites getting people who are HIV into care and staying in care. All people who receive a positive rapid test in the Public Health Clinic are immediately referred to HIV care either in our Public Health Clinic or a private clinic in the community. This greatly reduces the waiting time for clients, improving their health outcomes, and increasing adherence to treatment. The broad strategy is to draw blood for all tests based on a positive rapid test for uninsured clients and get the client into care in two visits rather than three or four.
In the first quarter of 2011, prior to the initiation of the Fast Track process, there were 15 positive rapid HIV tests in clinic. Six clients (40%) returned to start HIV medical care in 1–2 weeks, two clients returned in 3 weeks and others returned in 5-12 months.
In the second quarter of 2011, after the initiation of the Fast Track process, there were 14 positive rapid HIV tests. Nine of the 14 clients (65%) returned within one week of diagnosis to begin HIV medical care.
Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits. What are the specific tasks taken that achieve each goal and objective of the practice? Key staff in the Public Health Clinic researched and developed the following tactics to provide a comprehensive plan to improve the detection, treatment, and care of patients with HIV and sexually transmitted infections using the following tactics.
2010 Expansion of health education and behavioral counseling through both traditional methods (group sessions and face-to-face interactions), and use of new technologies and enhanced social media networking strategies.
2010 – Expanded field testing for Early Syphilis by expanding community based opportunities for testing, in locations such as chemical health treatment facilities.
2010 – Added an in-house Disease Investigator to allow for rapid identification of sexual partners, and for facilitating faster linkages for testing and treatment for those who have been identified as “at risk” due to their direct exposure to a suspected or confirmed case of HIV or STI.
2011 – Created a policy and clinical practice to expand comprehensive testing for STIs (including HIV rapid tests) as a routine feature of all health examinations for TB, refugee, and homeless patients seen in the clinic.
2011 – Expedited access to medical care for patients who test positive for HIV through the implementation of a “fast-track” model. Time lags of two or more weeks between initial testing, full confirmation, assessment, and treatment planning were reduced by adding a full diagnostic screening as a part of the patient’s first clinical contact.
2011 – Created a “Care Navigator” position to streamline access to further healthcare appointments, provide support resources, and eliminate other common barriers to accessing care and treatment for newly diagnosed HIV positive patients.
2011 – Established a program to recruit and train peer educators to expand outreach to young MSM social networks.
What was the timeframe for carrying out these tasks? The tactics outlined above were researched, developed, and implemented over the course of 2010 and 2011. These tactics will be sustained in 2012 and beyond. Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. Support from stakeholders in the form of grant funds and contracts demonstrates a commitment to the continuation of co-located clinical, prevention, and Disease Investigation Services (DIS) within the Hennepin County Public Health Clinic. The first Disease Investigator was added to the Public Health Clinic in 2010 through funding from the Minnesota Department of Health (MDH). All state DIS services were previously housed within the MDH. Describe plans to sustain the practice over time and leverage resources. Due to the overwhelming success of the in-house DIS, another Public Health Clinic Community Health Specialist received DIS training sponsored by the Minnesota Department of Health in 2011.
Additional Ryan White Care Act funds were received in 2011 to fund the Care Navigator position and the Social Networking Peer Recruiter program.
Hennepin County also supports the important work of the Public Health Clinic through a large block grant from the state health department, as well as local property taxes. As mentioned previously, the clinic was first established in 1970, and we plan to continue to provide these integrated and comprehensive services in the years ahead.
Practice Category Choice 1: Infectious Disease (HIV) Practice Category Choice 1, Part 2: Practice Category Choice 2: Access to and/or Equality of Care Practice Category Choice 2, Part 2: Practice Category Choice 3: Practice Category Choice 3, Part 2 Check all that apply. E-mail from NACCHO NACCHO Web Site Colleague in my health department |
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