2007 Model Practice Application (Public)

POWER Teen Clinic

Municipality of Anchorage, Department of Health & Human Services, Reproductive Health Clinic

POWER Teen Clinic targets teens age 19 and under, who are at-risk for pregnancy and addresses the issues of STI's and teen pregnanices. The goal of this program is to promote healthy life choices that decrease unintended pregnancy and the spread of sexually transmitted infections by increasing access to high quality clinical family planning and reproductive health care for Anchorage at-risk teens. The program objectives include:

• RHC PHN will provide clinical services at the POWER Teen Clinic in two four hour clinics per week in 2006.
  
  
• Maintain at or above 95% the percentage of teens who test positive for Chlamydia (CT) or Gonorrhea (GC) who will be treated within 14 days of RHC being informed of positive results.
  
  
• 100% of female clients at risk for pregnancy will choose a FDA approved method of contraception at the end of the visit.

RHC PHN's have conducted this off-site clinic for ten years. In 2006, 100 clinic sessions resulted in 419 additional teens receiving reproductive health services who might not have received care if the POWER Teen Clinic did not exist. Staff note that these teens frequently have no family support system. Unlike typical teen clients seen at the primary RHC clinic site (located in a government building), many of them "couch surf" from place to place, some are staying in shelters and others are trading sex for housing. 97% of teens testing positive for CT or GC were treated within 14 days of RHC receiving the positive results. 95% of female clients at risk for pregnancy chose abstinence or an FDA-approved method of contraception at the end of the visit. The remaining may include women using oral/anal sex or sex with same gender as their reason for no method. This compares to 86% for the overall teen population receiving services in RHC in 2006.

The project of staffing the POWER Teen Clinic is to address Healthy People 2010 and Healthy Alaskans 2010 objectives for decreasing sexually transmitted infections (STI's) and unplanned pregnancies. Untreated STI's may lead to complications that result in poor pregnancy outcomes and infertility. Alaska has had the highest or second highest Chlamydia rates in the United States for the past ten years. The DHHS RHC has offered services for teens since the late 1960's. The staff identified that homeless or runaway teens presented extra challenges to the delivery of these services. Nationally other family planning programs were facing similar situations. Locally the Mayor of Anchorage established a Youth Task Force to address issues for this population. In the mid 1980's a Youth Commission composed of adolescents was created to provide suggestions on outreaching homeless/runaway/troubled teens. The RHC program established the first Troubled Teen project in US DHHS Region X. An outgrowth of that was the collaborative effort of the POWER Teen Clinic that started in 1997. The current RHC and AYPF programs focus on education promoting healthy choices, use of family planning, and risk reduction activities. Both programs support the increased access to direct clinical services for the early detection and prompt treatment of STI's with referral for pregnancy, social, economic and mental health issues as appropriate.

Using off-site teen friendly clinics staffed with teen peer counselors to support the clinical staff and to recruit high-risk teens was discussed with other Region X (WA, ID, OR & AK) management by the DHHS Family Planning program manager in the mid 1990's. The DHHS program had already been the first in US DHHS Region X to have a Troubled Teen Project. This program was innovative in its success with teens who are less likely to have family support and stable housing. During the past ten years staff have noted the difference in the characteristics of the teens who present at the POWER Teen Clinic compared to the teens that attend the primary RHC site. The POWER Teen Clinic serves many teens who do not have a family support system. Many of them "couch surf" from place to place, some are staying in shelters, others are trading sex for housing. The POWER teen peer educators provide referrals for housing, food, as well as health concerns. The typical teen presenting at the primary RHC clinic is in school, has a stable family situation and is comfortable entering a government building. Still, virtually all clients to the POWER Teen Clinic are treated for STIs and choose an appropriate contraceptive method by the end of the visit. A similar model practice in the NACCHO database targets students in high schools. Also, the current RHC collaborative effort with AYPF uses teen peer health educators to recruit teens to the clinic, provide education and referrals for troubled teens and assist the PHN with clinic flow. The PHN's use non-invasive testing technology, delayed exams with initiation of contraceptives and intensive disease intervention strategies to insure all teens with STI's are treated appropriately and promptly.

DHHS as the LHD supports the POWER Teen Clinic as a community collaborative effort which promotes the health of the high-risk teens within the Anchorage community. Resources are allocated to RHC for the provision of clinical staff, supplies, and medications. The PHN functions as a mentor to POWER teens to increase their reproductive health knowledge, presentation and communication skills. There is support of the POWER Teen Clinic by local businesses within the downtown bus transit center that is shared at the annual Anchorage Parking Authority (APA) Board meetings. APA has continued to provide a reduced cost lease agreement for the space occupied by the clinic. Other teen related agencies, the police department and school district make referrals for teens to the POWER Teen Clinic DHHS RHC maintains a close working relationship with Covenant House Teen Shelter. Covenant House assists RHC staff in their efforts to provide intensive disease investigation, treatment and partner notification activities for all teens with STI's. POWER teen outreach workers participate as members of the RHC Consumer Advisory Committee that reviews all educational materials used in RHC. They are also a source of information to RHC management regarding services provided or unmet needs within the community. AYPF recruits and trains peer health educators who provide street outreach and referrals to high-risk teens. They also conduct education presentations at the local Boys & Girls Club. Topics include sessions on HIV, STI's, birth control methods, building communication skills, smoking cessation, substance abuse and safety in relationships.

RHC is supported with Municipal operating funds, a federal Title X Family Planning grant and state HIV/DIS Partner Notification grant. AYPF is funded by a grant from the Family and Youth Services Bureau and a state HIV grant.

The Anchorage Department of Health & Human Services (DHHS) Reproductive Health Clinic (RHC) originally had a project in which teen peer health educators would work within the clinic. Staff Public Health Nurses (PHN's) would provide training and mentoring for the teens. In 1992 a contract was established with Alaska Youth and Parent Foundation (AYPF) program in which they coordinated the hiring and training of outreach workers. The AYPF program was called POWER for Peer Outreach Worker Education and Referral. The peer outreach workers continued to receive training from the DHHS PHN on reproductive health topics. Other professionals provided training for mental health, substance abuse and other related topics. The PHN's would then support teens coming to RHC and provide educational sessions for youth in the community. RHC lost the ability to pay for AYPF outreach workers in the early 2000's; AYPF has since funded those staff with state and federal grants. In 1997 the DHHS RHC management approached the program manager of AYPF clinic with a proposal to have an off-site teen clinic in the downtown bus transit center mall. All city buses rotate through this center. The Anchorage Parking Authority (APA) was willing to donate a vacant space formerly occupied by a barber shop until a new occupant was found. A nurse practitioner and PHN were originally assigned to work at the POWER Teen Clinic on Tuesday and Thursday afternoons. With the advent of the urine test for CT and GC, exams no longer are necessary. The clinic is now staffed with a PHN who can offer a "delayed pelvic contraceptive start", urine screen for CT, GC, pregnancy and venipuncture for HIV, Hepatitis and syphilis. The POWER peer educators staff the front counter, assisting teens with paperwork and providing education. They also do street outreach and encourage the homeless youth to come to the clinic. The DHHS staff provide an exam table and supplies that remain at the POWER Teen Clinic. The clinicians take medications and testing equipment to the clinic on scheduled clinic days. Services offered include initial and annual exams with pap smears, full sexually transmitted infection (STI) screening exams with wet mounts, gram stains and blood draws for HIV, Hepatitis and syphilis and pregnancy tests with options counseling. A wide range of contraceptive methods are available and initiated for those teens requesting birth control. The POWER Teen Clinic is located about four blocks from the DHHS/RHC site. The only expense incurred in this collaborative effort is the parking fee for the clinical staff and in-kind management involvement with AYPF and annual meetings with the Anchorage Parking Authority. The site of the clinic has changed as the barber shop space was needed and now the POWER Teen Clinic is located next to a convenience store. Mall Security staff support/monitor safety concerns for staff and teens waiting for clinical services. The APA has negotiated a greatly reduced rental lease for AYPF to continue this clinical offering.

The PHN maintains an adequate level of supplies, medications and forms for efficient clinic flow. Any items needing to be replaced are collected so the PHN working the next day will take with her to the off-site clinic. The PHN has a cell phone to use for consultations with RHC nurse practitioners and emergencies. The PHN completes client visits under the same scope of practice and standing orders used in the RHC primary clinic site. All patient information is entered into the medical record and internal computer system upon return to the primary clinic. Specimens collected are processed with regular RHC specimens. RHC staff functions as Disease Intervention Specialists (DIS) for the state of Alaska. In that role program staff will notify patients of positive STI's, assure adequate treatment, offer appointments for evaluation, treatment and assistance with partner notification activities. These DIS activities include phone calls, clinic visits and home visits if transportation is an issue. RHC also has a strong collaborative relationship with the nurse practitioner at the Covenant House Teen Shelter as teens may go there when the POWER Teen Clinic is closed. All entities work closely to notify and treat teens with STI's as quickly as possible. The primary reason teens give for coming to the POWER Teen Clinic is concern for pregnancy or STI's. The PHN assesses each teen for STI and pregnancy and providing evaluation, treatment, education and counseling, infection and contraceptive needs. The PHN has standing orders for treating STI's and providing each teen with the appropriate contraceptive method of their choice. The ability to start hormonal contraception with out an initial pelvic exam has greatly enhanced females with initiating an effective contraceptive method. These teens are then appointed to complete an initial exam with the nurse practitioner in RHC within the next three months. All teens are given information or supplies for emergency contraception. RHC program managers assign a PHN to conduct Tuesday and Thursday four hour clinics at the POWER Teen Clinic located off-site in the downtown transit bus center mall. POWER peer outreach workers supervised by AYPF management staff recruit teens from the street, provide education and referrals and assist PHN`s in clinic flow. The POWER Teen Clinic was originally established within less than one week after RHC became aware of the vacant space and discussed the project with AYFP.

Currently the POWER Teen Clinic is the primary focus of the AYPF program. AYPF is supported by federal and state grant funds. As AYPF is in the last year of their current project, they are submitting applications for continuation of funding from the Family and Youth Services Bureau and the state of Alaska. APA offers continued low cost lease agreements. There is public and local business support of services offered through the POWER Teen Clinic. The clinic receives referrals from the Anchorage School District. The Municipality of Anchorage supports RHC in maintaining this off-site clinic. RHC receives state and federal grant funds specifically directed for family planning services, screening, treatment, management and partner notification activities for sexually transmitted infections. RHC continues to provide PHN staff time, clinic supplies and medications. Attendance and positive outcomes shared by staff and patients over the past 10 years have demonstrated community acceptance and the necessity for this POWER Teen Clinic.

The goal of this practice is to promote healthy life choices that decrease unintended pregnancy and the spread of sexually transmitted infections by increasing access to high quality clinical family planning and reproductive health care for Anchorage at-risk teens.

Objective 1: RHC PHN will provide clinical services at the POWER Teen Clinic in two four hour clinics per week in 2006.

Performance Measures: Number of clinics conducted in 2006 were 100.

Outcome: 419 teens received services during 100 off-site clinics conducted in 2006.

Objective 2: Maintain at or above 95% the percentage of teens who test positive for GC or CT who will be treated within 14 days of RHC being informed of positive results.

Performance Measures: 97% of teens testing positive for GC or CT were treated within 14 days of RHC being informed of positive results.

Outcome: 385 (92%) of teens were tested for CT/GC. The remaining 8% had a negative test within the previous 12 months. Infections were found in 35 teens. 34 were treated within the 14 days; one was treated in 17 days.

Objective 3: 100% of female clients at risk for pregnancy will choose an FDA approved method of contraception at the end of the visit.

Performance Measures: 95% of female clients at risk for pregnancy chose abstinence or an FDA approved method of contraception at the end of the visit. The remaining may include women using oral/anal sex or sex with same gender as their reason for no method.

Outcome: 419 teens received services during 100 off-site clinics conducted in 2006.