2008 Model Practice Application (Public)

Sexually Transmitted Disease, Fast Track Treatment

Brevard County Health Department

Brevard County is a geographically and socioeconomically diverse community with a high degree of tourism and a resident population of greater than 500,000 citizens. Brevard, like Florida and the rest of the nation, is challenged with an increasing rate of sexually transmitted disease (STD) defined here as Gonorrhea and Chlamydia. These two STDs account for approximately 80% of all reportable disease within the county if Hepatitis C is excluded from the list. The sequela of these two infections is well documented and quite costly in terms of emergency room visits, infertility, pelvic inflammatory disease and ectopic pregnancy. The rate of STD for Brevard County in 2006 was 335.9/100,000 which is the highest rate over the past ten years. Brevard County Health Department (BCHD) has had a long standing rapport with the private medical providers within our community. Various partnerships and services have developed which include in-services directed at HIV updates for licensure, tuberculosis control, vaccine preventable disease, infection control and epidemiology. In addition, the STD staff reached out to private providers with updated educational materials, BCHD services information, and treatment guidelines in a face to face manner. This robust marketing has proven invaluable in terms of phone calls querying treatment options and appropriate management of STD’s. As the private sector became increasingly challenged to ensure treatment of identified cases of STD, BCHD responded by developing a fast tract system designed to ensure all known cases of STDs and their contacts would have access to definitive medical treatment in a timely manner. The goals and objectives are as follows: 1) Ensure access to medical treatment for known cases of STDs identified in the community and provide treatment in a timely fashion. 2) Timely administration of medication to reduce spread of infection. 3) Increase utilization of personnel within clinic. 4) Provide access for partner treatment in an expeditious and timely fashion. 5) Increase the number of contacts to cases being treated. 6) Decrease the wait time in terms of service delivery (in and out in less than 20 minutes). Assumption: Customer marketed approach meaning if the customer is satisfied with the quality and efficiency of care, they will more likely refer and convince their contacts to seek and obtain treatment. 7) Reduce workload on Emergency Departments and private practitioners with regard to follow-up care. 8) Respond to the needs of the community while balancing our mission and our resources. 9) Reduce the burden of STD within the community and the associated complications to untreated STD. Goal Summary: The practice is intended to systematically increase the number of persons with a known STD, and their partner(s), to seek prompt treatment through easy and expeditious access to care and thereby reduce the disease burden.

Sexually transmitted diseases (STD), gonorrhea and chlamydia, account for well over 60% of all reportable diseases. The rates are increasing locally, statewide and at the national level. This practice is intended to decrease the disease burden by ensuring access to treatment of cases and increasing access and treatment to contacts to cases. Brevard County Health Department (BCHD) accounts for over 25% of all STD diagnosis and treatment in the county while making up less than 0.2% of providers. BCHD’s relationship with the local providers and emergency departments facilitated a solution whereby known cases of STD could be referred and treated by BCHD in a timely and efficacious manner. Communicable disease rates are consistently evaluated by BCHD. Through established relationships with community partners, awareness of difficulties in getting known positive cases of STDs treated came to light. BCHD is in a unique position to respond, yet has the added challenge of capacity issues related to utilization. The private sector was contacted and specific concerns and challenges were elicited. BCHD STD and clinical staff conducted a brainstorming session to determine plausible approaches and solutions and executive management was presented with recommendations. Intuitive understanding of the difficulty in getting contacts to cases to seek and receive care was factored into the process. BCHD staff restructured the process of how to manage STD cases identified in the community being referred to BCHD for treatment. In addition, how are contacts to cases being evaluated and treated within BCHD clinics? A new direct line process ensued whereby the disease intervention specialists will process cases and contacts in concert with clinic staff. By decreasing time in clinic required to obtain treatment, referral numbers increased dramatically. Cases were ensured of treatment and contacts willingly came in for treatment as well. The program made every effort to respond to a community need by focusing on overriding objectives and reestablishing priorities. Budget reductions and staff utilization were factored into the existing process in order to obtain a different perspective and move forward the overarching goal which was to get people treated who need treatment. Developing a process whereby known cases and known contacts receive treatment became a high priority and represented a shift from the usual methodology of offering screenings where the yield is less assured and reliance is on high risk patients to seek care. Who is more high risk than a known case? The process of having a client call the existing appointment number, then wait in full clinics to get treated was a known barrier to care and reduced the likelihood of compliance. Under this new process, clients are directed to call the clinic or the disease specialist, and they are seen the same or next day and are processed in under 20 minutes. Contacts to known cases are processed the same way regardless of where they were screened. Business cards are given to the index case to give to their partners to call with the assurance of the same expeditious treatment and contacts to the case are responsive. Instead of following a typical process map based on current practice, this process was approached from an end result perspective “What do we want to happen? What is the overarching goal or desired result?” Cases have already been evaluated, diagnosed and informed of the need for treatment, they simply need to be treated. Programmatic barriers were removed to increase communication and focus efforts on the end result. This approach is simple, direct and makes a difference to both clients and staff.

BCHD pursued this initiative because it is essential to the public health mission and we are the resident experts in dealing with this population. Our data indicate that while we make up less than 0.2% of the medical provider community, we provide over 25% of all STD diagnosis and treatment. Since it is required by law to report STDs, it is logical for the community to look to BCHD for assistance in addressing this growing problem. BCHD is the primary agency for providing disease investigation and encouraging contacts to cases to seek and obtain treatment. Many community partners have communicated to us regarding difficulty in follow up care for STD patients who were screened and tested positive. They were commended for doing the testing and we gladly embraced the opportunity to partner with them to ensure treatment. Emergency departments and walk in clinics particularly have difficulty in providing follow-up care and they initiated this practice by contacting BCHD for assistance. They are a primary source of referrals for known cases of STD. Several venues are used to foster community collaboration between the private and public sectors. Articles are submitted and published in the medical society bulletin, office visits are made, personal contact with infection control and emergency department managers, in-services and staff education are provided, and the reportable disease placard is either mailed or hand delivered to providers within the county. Our community partners are well aware of our expertise mostly through face to face contact or telephone. They know us by name and rely on us to support their efforts when we can. STD evaluation and treatment are historically a health department strength. We promote that strength through providing direct service and communicating with our partners.

Existing staff were oriented to goals and objectives of this initiative and process. Internal meetings were conducted with regard to feasibility, costs, staff burden, client processing, and benefit versus risk. Estimated fixed costs: $500 - $750. Funding Source: Existing public health department budget. Local resources were used.

Ensure access to medical treatment for known cases of STDs and increase the number of cases receiving appropriate treatment. Phone calls from Emergency Departments (EDs) and private practitioners alerted Brevard County Health Department (BCHD) of difficulty getting patients testing positive for STD treated. BCHD STD section contacted community partners and verified difficulties they were having getting patients treated after they had tested positive for STD, primarily EDs, walk in clinics. BCHD STD section met and discussed viability of support and to identify potential roadblocks. STD and clinical staff met together to discuss approaches to ensure patients have easy access to treatment. STD staff met with senior leadership to obtain buy in on responding to community need and to discuss strategic planning and financial impact. Process developed which ensures access to treatment within 48 hrs as well as fast track treatment. Trained STD and clinic staff as to roles and responsibilities. Developed simple data set to demonstrate utilization and impact. Developed referral mechanism to encourage partners to seek treatment. Provide access for partner treatment in an expeditious and timely fashion. STD and clinical staff reviewed existing procedures for treatment of partners and identified wait time and access as being barriers to care. Brainstormed methodologies for improving partner treatment process. Established goals for care with focus on expediency and access. Process developed which ensures easy access and reduced wait time.Trained STD and clinic staff as to roles and responsibilities and expanded training to family planning and obstetric clinics to enable contacts to cases within said clinics to access care with the same ease. Developed referral mechanism to encourage additional partners to seek treatment. Reduce workload on Emergency Departments (EDs) and private providers in follow-up care. Contacted community partners to inform them of our new process and delivery of service. Trained key staff (social workers, ED managers) on new process to expedite care and gave points of contact. Contacted community partners four months after implementation to ensure awareness exists within EDs for treatment option. Process verified by increase numbers of clients seeking fast track treatment at BCHD. Reduce the burden of STD within the community and the associated complications to untreated STD. Implemented a fast track system which treats community identified STDs in a timely fashion. Provision of access to definitive treatment of know cases of STD will intuitively result in less disease burden. The total timeframe to accomplish these tasks encompassed nine months. Three months for strategy and implementation and a six month pilot to validate viability.

The treatment of sexually transmitted disease (STD) by the health department (HD) is a recognized priority for the public and private sector. Staff are convinced and are passionate that the BCHD is the most appropriate venue for counseling and treating persons who have STD. External stakeholders are highly motivated to continuing this process as it ensures treatment occurs while relieving them of the burden of follow-up. They recognize the expertise of the BCHD in interfacing with clients on such a sensitive and potentially complicated intervention. Internal stakeholders are equally motivated as the benefit of reduced valuable staff time enables additional services to be rendered. STD staff has reduced time in contacting private providers and have a prime opportunity to elicit contacts for treatment to occur. Management recognizes the reduced burden on staff and the heightened job satisfaction for all involved as well as providing support to the community. This process has the added benefit of staff buy in through process improvement. The overall process accomplishes set forth goals of ensuring access to care, and delivering that care in less time with better efficiency of personnel. Current resources are being maximized and as a side note, there has actually been a slight increase in revenue which was not anticipated. Clinic staff no longer have dissatisfied customers who are aggravated due to wait times to receive treatment or who simply leave the clinic prior to being treated. Frustration levels by staff are lower, productivity is higher, and objectives are accomplished all in the midst of budget reductions. The expectation is the program will be sustained and grown as long as health departments are in the business of treating sexually transmitted disease.

The practice has been successful in strengthening relationships with community partners in the treatment of sexually transmitted disease (STD). The effect on patients seeking treatment is an increase is satisfaction as evidenced by partner referral for treatment. The effect on staff and agency is increased productivity and job satisfaction. In two years of practice over 400 patients have been referred from the community and medically treated. The assurance of treatment for known cases and contacts to STDs has presumptively reduced the burden of disease within the community in some manner.