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2012 Model Practice Application (Public)Application Name: 2012 Model Practice Application (Public) : Florida Department of Health in Clay County : "First-in-Florida" STD text messaging Applicant Name: Ms. Connie Wolfe Application Title: "First-in-Florida" STD text messaging Please enter email addresses you would like your confirmation to be sent to. Connie_Wolfe@doh.state.fl.us; Nancy_Mills@doh.state.fl.us Practice Title "First-inFlorida" STD Text Messaging Submitting LHD/Agency/Organization Clay County Health Department Head of LHD/Agency/Organization Nancy Mills, Administrator Street Address 1305 Idlewild Avenue Practice Contact Person Connie Wolfe Title Program Coordinator Epidemiology Connie_Wolfe@doh.state.fl.us Submitting LHD/Agency/Organization Web Address (if applicable) www.HealthyClayCounty.org 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 Clay County Health Department (Clay CHD), Florida, developed a “First-in-Florida” text message notification program for health department clients diagnosed with sexually transmitted diseases/infections (STD/STI). The Clay CHD program is based on a model from Peoria Illinois Health Department. Florida has a centralized health department with local county health departments managed by the Florida Department of Health (FL DOH). The county health departments work closely with and are co-funded by Boards of County Commissioners. While county health departments have the authority to implement innovative pilot projects, such projects must be vetted through centralized legal and information technology departments to assure the pilot meets all FL DOH policies and practices.
Central to this project is the public health issue of increasing STI morbidity among Florida youth. The vision of the project is to reduce the burden of STI among the 15 to 24 year old age group in Florida using Clay County data as representative of the state. The goal of the project was to decrease the time between notification and treatment for STI among the target group through more efficient use of staff time and technology. Project objectives were three-fold. The first was to validate the reported outcomes from the Peoria model through a pilot project in Clay County Florida. The second was to determine whether this process could be replicated statewide in a centralized health department structure. The third was to increase awareness of other text message applications among Clay CHD partners.
The first objective (validating the model) was achieved as the Clay CHD pilot results mirrored those of the Peoria model. Clay County has an estimated population of 194,000 people and reports an average of 700 Chlamydia cases and 90 cases of Gonorrhea each year. In 2010, the 15-24 year age group represented 77% of the reported Chlamydia cases and 60% of the reported Gonorrhea cases. Staff has had difficulty notifying these clients of their STI results. The conventional methods of contact (i.e., telephone, letters, and home visits) were time consuming and inefficient, delaying medical intervention and treatment. Experts state that the majority of this age group use cell phones for telephone calls and texting friends and/or family. Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. Text messaging gave Clay CHD the opportunity to connect with this hard to reach population. There were no additional costs as the Clay CHD staff have access to all technology needed to implement the program. Patient confidentiality and data security were assured. Practitioners participated in the implementation and were able to explain the advantage of text notification to their patients. Since implementing the program in mid-December 2010, an average of 70% of the targeted age group has authorized text messaging notification. The program decreased the time between diagnosis and notification from six hours to thirty minutes. Time between notifications to treatment decreased from six days to four hours. Staff expenditures were reduced $115.50 per client or $6,150 annually. Clay County STI statistics have shown a slight downward trend since January 2011.
The second objective (potential for statewide implementation) has also been met. Five county health departments in Florida are adopting the process and reporting similar efficiencies (Sarasota, Seminole, Broward and Escambia). The FL DOH Bureau of STD estimates a potential statewide savings of $3.23M. The Bureau is looking to automating the text messaging process into PRISM, which is the statewide STD online reporting data base serving public and private practitioners. Clay CHD and Duval CHD will be piloting the PRISM process. If this becomes a reality, even greater effectiveness and efficiencies will be realized.
Finally, the third objective (raising awareness) has been met as alternate uses of text messaging within the public health system are being investigated. They include the use of text messaging for appointment notification (Volusia County Health Department); expansion of text messaging for client notification into the private medical provider community (Orange Park Medical Center); and a pilot between the University of West Florida and Escambia CHD to text message all laboratory results to patients.
Describe the public health issue that this practice addresses. (350 word limit)
Central to this project is the public health issue of increasing STI morbidity among Florida youth, with Clay County data as representative of the state. This practice addresses the issue by implementing systems to interrupt the cycle of transmission and morbidity. This is accomplished by providing medical information quickly to a population that is often transient and difficult to reach. Without being aware of their medical condition they would go longer than necessary without treatment. Due to confidentiality requirements, conventional methods of client notification (voice mail messages, direct mailings, home visits) do not work well for this population and are time intensive for the staff. This program addresses the need to conserve diminishing public health resources, while improving notification time and subsequent treatment. In addition, prompt treatment should reduce the numbers of newly infected partners in this targeted age group. What process was used to determine the relevancy of the public health issue to the community? (350 word limit) The increasing incidence of STI morbidity among Florida’s youth and the need for improved disease intervention is proven by examination of disease trends. Data was reviewed of reported Chlamydia and Gonorrhea cases in Clay County. Between 2006-2010, reported Chlamydia cases increased by 100.4%; whereas reported Gonorrhea cases showed an overall decrease by 21.5%. Data from 2009 revealed this age group accounted for 60% of the reported Gonorrhea cases. This identified a need to contact the infected cases as soon as possible to prevent the spread of disease, to provide treatment and prevention education as quickly as possible. How does the practice address the issue? This practice enables the health department staff to provide timely health information to an at-risk population through a confidential, convenient and cost effective venue, reducing the time between notification and treatment as well as optimizing staff time. The process was embraced by the target population who most often rely on nontraditional modes of communication. Seventy-one percent of the health department clients chose text message notification over conventional methods, proving patient satisfaction. Prompt notification assured clients quicker access to treatment. The community is positively impacted by the decreased opportunity for disease transmission in partners and the community-at-large. Tax payers enjoy the benefit of savings from increased staff efficiencies. In addition, the practice has stimulated investigations for use of text messaging to address similar notification issues including implementation statewide through a public/private partnership using a statewide STD data base, a study to investigate the use of text messages for patient appointment notifications, and the use of text messages for patient notification of other important laboratory results.
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?
The Clay County Health Department practice is based on the Peoria, Illinois Health Department model for text messaging STD results to clients. The practice is found in the NACCHO Toolbox. The Clay County Health Department is the “first-in-Florida” utilization of the text messaging process. The goal of the project was to decrease the time between notification and treatment for STI among the target group through more efficient use of staff time and technology. While similar to the Peoria model, the Clay CHD model objectives were more expansive. The objectives of the Clay CHD project were three-fold. The first was to validate the reported outcomes from the Peoria model through a pilot project by adapting the model to the local public health environment in Florida. The second was to investigate whether this process could be replicated statewide in a centralized health department structure. The third was to increase awareness of other text message applications among Clay CHD partners. 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. Review of the Florida County Health Department STD programs identified no other health department was utilizing a text messaging program. This provided Clay Health Department an opportunity to implement the text messaging program using modern technology with no additional cost to the health department. Statistics presented by Pew Internet and American Life Project show that nationwide 54% of teens are using text messaging as compared to 30% of teens who talk on a land line. The Agency for Health Care Research and Quality recently reported three sexual health clinics in the United Kingdom have used cell phone technology since 2004. These clinics communicate a variety of test results to patients via text messaging. How does this practice differ from other approaches used to address the public health issue? Conventional approaches have always been used to contact clients regarding STI results. These methods include making telephone calls and leaving messages, mailing letters to have the client call the clinic, and/or home or school visits. These conventional methods are labor intensive without being highly effective. With dwindling health department resources and increasing STI morbidity among our youth, it is necessary to use innovative programs such as text messaging to reach clients and optimize staff resources. Introducing this program to the Florida centralized public health system provided the opportunity to have an impact on the health of Floridians beyond Clay County. Also the successful demonstration of text messaging for the purposes of Clay CHD program has stimulated investigations into other applications within the greater public health system in the state. Our practice is similar to the model practice of Peoria Illinois with a major difference. The difference is in the public health systems of Illinois and Florida. Illinois is a decentralized system where Florida is a centralized system under the jurisdiction of Florida Department of Health (FL DOH). Our practice was conducted as a pilot with FL DOH approval as a pilot for duplication by other county health departments and to set the groundwork for a possible statewide implementation. Who were the primary stakeholders in the practice? The primary stakeholders in this practice were patients presenting with STIs; the Clay CHD Epidemiology Program, Clay CHD clinic nursing, laboratory and local information technology (IT) staff; the FL DOH Bureau of STD; FL DOH Office of General Counsel; FL DOH Division of Information Technology and the Peoria City/County Health Department STD Program; and Orange Park Medical Center (OPMC) Emergency Room Quality Assurance. The lead staff member for this project was the Clay CHD Epidemiology Program Coordinator. What is the LHD's role in this practice? As this was a local public health department internal initiative, the Clay CHD Epidemiology staff took the lead in planning and implementing this practice within Clay CHD. The lead staff member was Connie Wolfe, BSN. The plan was designed to fit a Florida county health department environment. A policy with procedures and associated forms was developed. A “no reply” mail box was established through Microsoft outlook by our local IT department, who assured all work stations were equipped with necessary hardware and software. Prior to integrating the process into the clinical environment, several months of testing were conducted by the Epidemiology staff to learn the process and work out unanticipated problems. Upon completion of the testing period, the process was integrated into the clinic setting. The processes of patient counseling, consent form collection, data entering and sending of text messages were taken over by clinic nurses, laboratory staff and clerks.
What is the role of stakeholders/partners in the planning and implementation of the practice? Patients were interviewed as to their willingness to receive notifications in the form of text messages through their cell phones. The Peoria City/County Health Department STD Program staff was consulted and an implementation plan was developed. The plan, policy, procedures and forms were reviewed and approved according to legal requirements, HIPPA protections, and technical standards by the FL DOH Bureau of STD, the FL DOH Office of General Counsel, and the FL DOH Division of Information Technology, respectively. The Florida DOH of Health, Bureau of STD, has followed our progress and reviewed our results. The Bureau of STD is moving forward to pilot STD text messaging from the statewide STD reporting database, PRISM. This database collects all STDs reported statewide from all practitioners, private and public. The local hospital (OPMC) Emergency Room sees a large number of STD patients from Clay County and the surrounding geographical area. Their Quality Assurance staff followed the planning, implementation and success of Clay CHD text messaging notification procedure with an eye toward implementing a similar process. What does the LHD do to foster collaboration with community shareholders? Describe the relationship(s) and how it furthers the practice's goals. The collaborations the Clay CHD has with community partners are active and ongoing and STIs are reported in a timely manner. The Communicable Diseases/STI staff encouraged community partners to adopt text messaging for their clients. Community outreach has been done through press releases and the health department newsletter. Presentations and updates of the project have been made locally and regionally including the School Health Advisory Committee, the Hospital Infection Control Committee, and the Northeast Florida Public Health Association. At a statewide level, presentations of the project have been made at a state meeting of the Florida Public Health Association, Statewide Bureau of STD videoconference, and six individual county health departments. Finally, information has been shared with other state and local health departments, as well as a short article in the “States, Tribes, Locals and Territories News: in the DSTCP Connect, Vol. 1, Issue 1, October 2011, Centers for Disease Control. Describe lessons learned and barriers to developing collaborations One major logistical barrier was the geographic separation between the offices of the STI prevention and clinical staff, which are separated by approximately 20 miles. Logistically, copies of the authorization information were sent between the programs via courier. This barrier was solved by scanning the consent forms into the department electronic medical record. Another barrier was staff acceptance. Initially, nursing staff was reluctant to send text messages versus calling the client directly. Although it takes more time to contact a client via telephone, staff initially viewed telephone contact as customer service with a personal touch. This was perhaps a generational difference as nursing staff have come to realize that our target population prefers text message contact over telephone contact. The best lesson learned was perseverance. Although we had to vet the project through a centralized system, and initially faced obstacles with garnering approval at the state level and the support of staff, we persevered and did not become discouraged. Keeping our vision of better health outcomes for the young people of Clay County and Florida kept us focused. 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.
Performance Measures:
Decrease length of time to notify clients of test results
• Decrease length of time between diagnosis and treatment
Client acceptance
• Percentage of participating clients
Cost effectiveness
• Reduction in staff costs
Data:
The length of time between diagnosis and treatment prior to implementing text message notification was determined by historical data collected via interview and chart review. The nursing staff and STD DIS staff were asked the average amount of time per week spent attempting to contact a client. The number of clinic nurses and DIS working this task on a weekly basis was collected from the interviews. After text message implementation, the data collected was the date and time the text message was sent, the date and time the client replied and the date of treatment. Staff recorded date of the client appointment and verified treatment on a spread sheet.
Client acceptance was measured by monitoring the percentage of STI clients accepting the text message option
Cost effectiveness was measured by analysis of staff time via interview and chart review prior to and after implementation of the project.
Evaluation Results:
Prior to implementation the average length of time one nurse spent per week trying to contact a client was approximately one hour. At any given time two clinic nurses and the STD DIS would be attempting to contact different clients, minimum of 3, for positive results. This was an estimated time of at least 3 hours a week for 3 clients. After implementation the time to contact several positive clients via text messaging was approximately 15 minutes. The program has decreased the time between diagnosis and notification from six hours to thirty minutes. The program also reduced the time between notifications to treatment from six days to four hours.
Client acceptance was measured after the pilot initiation and subsequent to the full Clinic roll out. The acceptance rate was 51% initially and increased to 71% after the roll out.
Staff expenditures were reduced $115.50 per client or $6,150 annually.
Feedback: The results of the pilot were shared with all primary stakeholders. There were no recommendations to modify the current practice as the expected outcomes were achieved.
Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Investigate whether this process could be replicated statewide in a centralized health department structure
Performance Measures:
Number of Florida county health departments implementing text message program for STIs
Incorporation of the project from FL DOH Bureau of STD as an expected statewide program
Data:
Number of Florida county health departments (FL CHDs) reporting successful implementation text message programs for STIs.
Incorporation of project from FL DOH Bureau of STD as an automated system for an expected statewide program.
Evaluation Results:
Five county health departments in Florida are adopting the process and reporting similar efficiencies: Sarasota, Lake, Seminole, Broward, Miami-Dade and Escambia. This quantitative data was self-reported by the FL CHDs to Clay CHD Lead Staff Member.
Incorporation of automated text messaging into PRISM statewide online STD data reporting system pilot process. This process will begin internal to FL DOH with two pilot county health departments November 2011: Duval CHD (metro) and Clay CHD (medium-sized). This qualitative data is reported by FL DOH Bureau of STD.
Feedback: Results from FL CHDs who have fully implemented the text messaging system as designed in Clay CHD have reported back similar improvements in effectiveness and efficiencies. Feedback on statewide roll out is pending.
Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Objective 3: Increase awareness of other text message applications among Clay CHD partners
Performance Measures:
Number of spin off applications across the public health system in Clay County or statewide
Number of Presentations/Publications
Data:
Spin Off applications across public health system in Clay County or statewide as reported by participating entities
Number of Presentations/Publications documented in Clay CHD files
Evaluation Results:
Three spin off applications - Text messaging for appointment notification (Volusia County Health Department); expansion of text messaging for client notification into the private medical provider community (Orange Park Medical Center); and a pilot between the University of West Florida and Escambia CHD to text message all laboratory results to patients.
Presentations/Publications - 13 items: Presentations to Clay County School Health Advisory Committee; the Hospital Infection Control Committee; the Northeast Florida Public Health Association; regional meeting of the Florida Public Health Association; Statewide Bureau of STD videoconference, and six individual county health departments. Articles in Health Happenings Newsletter, Clay CHD community e-newsletter; “States, Tribes, Locals and Territories News: in the DSTCP Connect, Vol. 1, Issue 1, October 2011, Centers for Disease Control.
Feedback: Project has been well received as evidenced by interest from the CDC as well as regional and state public health partners.
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? The Plan-Do-Act-Check cycles were used for this project. The first cycle began with a review of the Peoria best practice model. A written plan of action was developed to implement STD text messaging for Chlamydia and Gonorrhea results. A policy with procedures and forms was created. The plan was submitted to the Clay County Health Department Administrator, the FL DOH Office of General Counsel and the FL DOH Division of Information Technology for review and approval. The Epidemiology staff managed the limited pilot program. Key clinic staff were identified and trained in the text messaging procedures. The clinic launch of the pilot program occurred three and a half months after implementation, March 2011.
Discussions were initiated with the FL DOH Bureau of STD after reporting the success of the Clay CHD Text Messaging Program. The Bureau has set up an initiative using a CDC public health fellow with staff from Clay and Duval CHDs to pilot text messaging capability into the PRISM online STD database. Concurrent with centralized discussions, several other FL County Health Departments adopted the Clay model for text messaging. Volusia CHD began the process to pilot text messaging for clinic reminders and Escambia CHD in conjunction with University of West Florida is investigating a project to expand the notification for other laboratory results.
Once our pilot was completed and data obtained proving the effectiveness and efficiency of the new notification system, a variety of outreach methods were used. Presentations to local entities (e.g. the hospital) were made. Presentations at regional and state venues were also done.
What was the timeframe for carrying out these tasks? Planning started mid-October 2010, the limited pilot ran from mid-December 2010 to March 2011 at which time the Clinic launch occurred. The anticipated time frame for replicating the project statewide was not set by the Clay CHD. Centralizing the project has now become a project owned by the FL DOH Bureau of STD who is in the process of setting up a work group. The formal presentations began in April 2011 and continue. In addition, staff continues to respond to inquiries from health departments in Florida and other states. Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. The primary stakeholder commitment to the practice within the Clay CHD is very high. This program has been well received by the Clay CHD clients as evidenced by the 71% whose chose to have STD results texted to them. Clients with have multiple clinic visits continue to have their STD results texted. Staff continues to support the program and obtain authorizations to send text message results. This program has proven to save staff costs and has not burdened the health department with increasing operating costs.
Stakeholder commitment to expanding the project statewide through the FL DOH Bureau of STD is also very high as they are planning to pilot the integration of an automated text message patient notification system into the statewide online PRISM STD data base. This data base collects all STD laboratory results from public and private providers. Clay CHD and Duval CHD will be part of the initial internal pilot project for this PRISM implementation.
Stakeholder Commitment to increasing awareness of other text message applications among community partners is also high. Clay CHD continues to serve as a resource for local and state health departments around the nation for information on our project. In Florida, text message applications for appointment reminders other laboratory result notifications are being explored.
Describe plans to sustain the practice over time and leverage resources. Once integrated to existing internal processes, whether at Clay CHD level, statewide level (such as PRISM integration described above) necessary resource expenditures, if any, could easily be justified when compared to the cost savings in labor and increased interventions and cost savings through reduction of morbidity among the target populations. Practice Category Choice 1: Infectious Disease (HIV) Practice Category Choice 1, Part 2: Primary Care Practice Category Choice 2: Infectious Disease (HIV) Practice Category Choice 2, Part 2: Primary Care Practice Category Choice 3: Infectious Disease (HIV) Practice Category Choice 3, Part 2 Check all that apply. Colleague in my health department E-mail from NACCHO NACCHO Web Site |
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