Department of Health in Sarasota County
STD-HIV Intervention Program and Field Delivered Therapy
The Department of Health in Sarasota County (DOH-Sarasota), on the southwest coast of Florida, is one of 67 integrated health departments in the Florida Department of Health system (FL-DOH), and is accredited by the Public Health Accreditation Board. With eight locations throughout the county, it provides primary care at three sites through a Federally Qualified Healthcare Center public-private partnership with Community Health Centers of Sarasota County (CCHSC). It is the county's only safety-net provider. Two clinical locations provide STD/HIV testing and treatment services.
Sarasota County's 395,576 residents are 91.8% Caucasian, 5.0% African-American, 9.4% Hispanic with multiple other ethnicities comprising the total make-up of the community. A well-known retirement community, Sarasota has one of the oldest demographics in the nation, with 42.1% of its residents over the age of 60. Although a wealthy community, 50% of households earns less than $50,000 annually. This large service and working-class segment depends on DOH-Sarasota and CCHCS for primary care and public health care including prevention and treatment for HIV, Hepatitis C and STDs.
The north end of Sarasota has the largest percentage of residents seeking STD and HIV prevention and treatment services. It is also the location of the busiest of the agency's three primary care clinics. As such, the drawback to the STD-positive client was wait time. There was demand for testing that was mindful of the client's time by being convenient, confidential and quick. Timely treatment services, outside of the main primary care clinic, for non-symptomatic, non-HIV STDs were also needed. (Note: DOH-Sarasota does have a same-day HIV Test and Treat program for clients testing HIV positive). Asking non-symptomatic clients to return for a primary care appointment was problematic and resulted in missed appointments, multiple staff hours spent on follow-up and the agency being outside the FL-DOH goal of 14 days between STD testing and treatment.
The need was evident for a public health walk-in testing service for HIV and STDs along with treatment for non-symptomatic clients and contacts. Front-line staff, determined to find a solution, met to discuss and work on a plan and proposed the walk-in testing clinic. Schedules were determined, procedures written, marketing plans created and SHIP (STD-HIV Intervention Program) was opened its doors in February, 2011 utilizing existing staff and space. Since 2011, over 6,800 clients have been tested at SHIP. SHIP is now well-known in the community, has a positive reputation and steady traffic during program hours and additionally utilizes the new FL-DOH process of texting STD test results to clients. It was learned, however, that the program still did not meet the treatment needs of the non-symptomatic client and contacts or the state goal of 14 days from test to treatment.
As with SHIP, front-line staff were the champions of Field Delivered Therapy (FDT). Staff driven discussion resulted in a proposal to utilize the FL DOH Technical Assistance Guidelines for Field Delivered Therapy in the SHIP setting. Building on the success of SHIP and with Medical Director and FL DOH Bureau of STD approval, proposals were written. Multiple work group meetings resulted in processes and protocols generated. The end result was a SHIP-based Field Delivered Therapy program for non-symptomatic clients testing positive for chlamydia and gonorrhea and their contacts. No additional staff was requiredâ€”the Disease Intervention Specialists (DIS) would handle the initial contact and paperwork, with Epi RNs volunteering to administer the IM antibiotics. The program was a success from day one. Clients were eager to participate, knowing that their time would not be spent waiting in a busy clinic before receiving needed treatment.
The goal of the program was to meet or exceed the FL DOH objective of 90% for timely treatment of non-symptomatic positive clients and to encourage their contacts to be treated prophylactically. Results are solid and getting more positive monthly. Since January, 231 persons have been treated at SHIP at no additional cost to the agency. 76.2% of known non-symptomatic clients and contacts have received treatment in SHIP and DOH-Sarasota is at 91% of the state goal for timely treatment. Success can be attributed, in a large part, to the client-service skills of the DIS, good word-of-mouth marketing which has brought more clients to SHIP, and referrals from the local health community.
This agency considers this to have had a positive public health impact on the Sarasota community. STD positive persons have received treatment resulting in less communicable disease on the street. The clinic continues to grow, and the expense to the agency is minimal. Details can be found at www.sarasotahealth.org.
The original Sexually Transmitted Disease-HIV Intervention Program (SHIP) was developed in response to the need for convenient, quick and confidential STD and HIV testing. Of Sarasota's 390,000 residents, 30 percent live at or below 200 percent of the Federal Poverty Level. These persons make up most of the Department of Health (DOH)-Sarasota's client base. The target population for this program could be considered the number of persons who previously tested positive for a STD or HIV throughout Sarasota County (2015 data is 1362). At the time, Sarasota County had only one walk-in testing clinic, DOH-Sarasota provided outreach testing by appointment or in the primary care clinic only. The demand for other options was expressed multiple times by clients. Introducing SHIP to Sarasota has increased access to timely STD and HIV testing.
Developing the SHIP program was championed by the agency's front-line Disease Intervention Specialists (DIS) and involved multiple Department of Health (DOH)-Sarasota areas. Once the skeleton of the idea was developed and approved, buy-in was required from agency areas impacted by increased walk-in traffic. Health Promotions was involved to assist with marketing, reception was impacted and needed a full understanding of the program. Having buy-in from Laboratory staff was integral as all collections would be sent thru them. Input was also required from Facilities, who were helpful in identifying a space for the addition of two SHIP client interaction rooms. Meetings were held and the program explained to all internal stakeholders with input and compromise allowing for a process that worked for all areas. Health Promotions and the agency's public information officer worked with the DIS on marketing the pilot. The process took several months, however costs were minimal other than budgeting for supplies and lab shipping and processing. No additional staff was added, no overtime required.
The SHIP walk-in testing program was designed as a no-fee testing program reaching those who normally may not present for testing. Delayed treatment for STDs can create a cascade effect, leading to increased complications and further transmission of infection. Walk-in testing was scheduled for three days a week for a four-hour window that alternates each day between morning and afternoon to accommodate various work schedules. Testing days were selected to insure that specimens can be sent to the State Bureau of Labs in a timely manner, with minimal turnaround time for results. To further expedite the testing and treatment process, SHIP clients are able to receive test results for chlamydia and gonorrhea via text. This reduces the time DIS need to spend following up on negative cases, and increase the time DIS have to ensure proper treatment and follow up is provided to positives.
This program serves as a triage point for clinical visits. The DIS assess the reason for the visit and send the client to the clinic for an appointment if they are symptomatic. Persons expected to be SHIP clients are diverse in virtually every dynamicâ€”race, gender, age, sexual orientation, ethnicity, income, language, and national origin. It was anticipated that the pilot would be successful and, at minimal cost, sustainable. There were no significant barriers other than clients requesting additional SHIP hours throughout the week. Since inception, SHIP tests approximately 1200 clients per year and identifies approximately 9% of all positive STD cases in Sarasota County.
With regard to STD treatment, historically the DOH-Sarasota process required clients testing positive in the SHIP outreach clinic (and their contacts) to be assessed and treated in the DOH-Sarasota primary care clinic. The lag time between testing, receiving test results from state lab, arranging for clients to return for test results and making appointments for them in the clinic resulted in the client not being treated in a timely manner and the agency not meeting the FL-DOH expectation of 14 days from test to treat. Staff brain-stormed a way to provide treatment to non-symptomatic positives and their contacts quickly and without the need for clinical appointments. It was determined that tweakingâ€ the existing Florida DOH Field Delivered Therapy process was the most effective and efficient method to accomplish this goal.
Developing the added Field Delivered Therapy (FDT) component to SHIP proved, however, to be more complex than developing the basic SHIP outreach clinic. Although the Florida Department of Health has Technical Assistance Guidelines for FDT, developing the local process involved the FL-DOH Regional STD Consultant, FL-DOH attorneys, the DOH-Sarasota Medical Director, Pharmacy Manager, Clinical Services Director, STD Clinic staff, Disease Intervention Specialists, and Epi RNs. After creating all required forms and attachments and writing a process, it was vetted through regional and legal staff and approved by the Medical Director. All DOH-Sarasota DIS and Epi staff received training via CDC's Chlamydia and Gonorrhea Modules and several dry runsâ€ were exercised in order to ensure a professional operation from the first day.
The process was created to be simple and easy to manage with no additional staff. After a client's positive test results for chlamydia or gonorrhea are received at DOH-Sarasota, the client receives a coded text notification to contact the agency. The client is asked if s/he is symptomatic and for the names of any sexual contacts. If the client is symptomatic, a clinic appointment is made for treatment via a provider. Non-symptomatic clients and their contacts are advised to utilize the convenience of the agency's FDT clinic in SHIP. Upon arrival at SHIP, the client is counselled and paperwork is started for treatment. The DIS contacts an RN in Communicable Disease. The RN meets the client (and/or contact) in SHIP, performs a nursing assessment, and collects information regarding any symptoms and contra-indications for the medication. If the client is asymptomatic and all meets the parameters of FDT, s/he receives a one-time IM antibiotic. Although the visits are expedited and designed to get a client in and out of the clinic, staff does take the time to discuss and help address the their most pressing concerns. The client receives further counselling regarding high risk behaviors, waits the appropriate amount of time for safety and is discharged.
No waiting, no unnecessary visit to primary care, no return visit necessary. FDT in SHIP is a quick, efficient and effective method of treatment for the asymptomatic STD client (and contact).
HIV in the U.S.
Florida has one of the highest HIV rates in the country and the STD rates continue to rise, even with strenuous public health efforts. The goal of the DOH-Sarasota Sexually Transmitted Disease-HIV Intervention Program (SHIP) and its supplementary Field Delivered Therapy (FDT) program is to provide quick, convenient and confidential STD and HIV testing, along with ease of treatment for non-symptomatic positive clients and their contacts, to break the cycle of these diseases in the Sarasota community. The objectives were to provide this service at minimal cost, minimal interruption to existing agency services and have the program be approved by and recommended by the local community.
The Department of Health (DOH)-Sarasota operates three primary care sites in the county providing medical care to approximately 30,000 unduplicated clients in the county. The clinics are busy and bustling and, at times, difficult to navigate. The SHIP and FDT clinic allows for clients to circumvent the crowded clinical setting for testing and select treatment. SHIP is well-known in the community, often referred, has a well-respected reputation and is growing its client base every month.
DOH-Sarasota has a long-standing history of staff working as one teamâ€ and of collaboration with community members, foundations, other agencies and healthcare facilities. . Developing SHIP and the FDT programs within the agency took the teamwork of multiple departments. Upon being championed by the agency's front-line Disease Intervention Specialists (DIS), other areas of the agency were brought into the work-group meetings for buy-in, input, and expertise regarding how to handle the increased walk-in traffic, how to market the program, how to acquire the medications, etc. Health Promotions department assisted with marketing, Reception was made aware of the possibility of increased phone calls and foot traffic. The agency's Lab, Pharmacy, Facilities and Clinical Health departments were all at the table. Meetings were held and the program explained to all internal stakeholders with input and compromise allowing for a process that worked for all areas. The process took several months and included all the legal and administrative vetting. Once the program was ready to be introduced, information was released to local community-based organizations, health-care providers and local ERs. School Health nurses, college health clinics and community centers in high risk areas were notified of the testing and treatment opportunities available at SHIP. Getting the information out to the community was beneficial, however it was client word-of-mouth that made the program successful.
The expense of this program is minimal. Other than printing card and flyers (approximately $200 annually), there were no actual start-upâ€ costs. No additional staff or overtime was required for start-up or sustaining the program, supervision was absorbed by the existing leadership and the program was housed in existing space. The only realâ€ costs were phlebotomy and lab supplies, laboratory fees and medication for the increase in the number of clients (about $15 per person), all of which were anticipated public health expenses.
Evaluating the effectiveness of a sexually-transmitted disease program can be double-edged. There is data on the number of tests done and the number of persons counselled or referred to treatment. The anticipated outcome for such a program, however, should truly be attaining is a decrease in the community's STD rate. Regrettably, two factors are working against reaching that result: STDs are on the increase throughout all of FL, including Sarasota County, andâ€”the more one looks for and tests for a disease, the more one normally finds it. That certainly holds true here: the more clients are encouraged to be tested, the more time spent is locating their contacts, then the more STDs are diagnosed in the community. So, the STD rate goes up instead of down. Good for public health however counterproductive to any balanced scorecard.
The evaluation process then changes, becoming less indefinable and more concrete by counting clients served and budgets met. The stated goals of the program were to meet the demand for testing that was mindful of the client's time by being convenient, confidential and quick and additionally to provide timely treatment services, outside of the main primary care clinic, for non-symptomatic, non-HIV STD positive clients and their contacts. The objectives were to meet or exceed the FL DOH requirement of 90% for timely treatment of non-symptomatic positive clients and to encourage 75% of their contacts to be treated prophylactically.
From 2011-2016, SHIP has provided services to over 6800 clients, indicating that the community demand was real and that a definite need existed for a walk-in testing clinic. The program continues to grow, with increase in clients resulting in the possibility of increased service hours. The second part of the program, Field Delivered Therapy (FDT) also showed an immediate success. Since its inception in January, 2016 through this November, 231 clients or 76.2% of non-symptomatic chlamydia or gonorrhea positive clients and their contacts, have been treated in SHIP, saving them a trip to the primary care clinic and ensuring a break in the spread of an STD. By providing this treatment in the SHIP, it eliminates the lag in treatment due to lack of available clinical appointments and the subsequent client no showâ€ factor, therefore decreasing the actual time from testing to treatment. The agency is now exceeding FL-DOH expectations of 90% with 93% of all STD clients receiving treatment within 14 days of testing. All data is entered into and retrieved from the FL-DOH client information systems of HMS and PRISM. Data is entered daily and tabulated and analyzed monthly. Monthly reports are provided to supervisors and staff for monitoring with numbers compared to the monthly administrative snap shotâ€ reports provided by FL-DOH.
An important secondary gain for this program is a significant monetary savings to the agency's primary care clinic. Most STD clients qualify for zero-pay status and receive no-cost treatment in the clinics. Additionally, when an STD client is seen in the primary care clinic, s/he occupies an appointment slot which could be utilized by an adult health client. A simple measure of 231 clinical appointment times opened up and made available to non-STD clients (due to these clients being treated in SHIP) x the average fee per clinical new client encounter ($146) results in a potential savings of $33,726 for the agency's primary care clinic.
The Sexually Transmitted Infection Cost Savings matrix (STIC), found on the Centers for Disease Control's website, is a more complex measurement of cost-savings to the community with each treated STD infection. The matrix indicates the direct medical costs and indirect costs (lost productivity) saved by sexually transmitted disease prevention programsâ€. By utilizing this matrix for the treatment of 231 STD clients since January, 2016, preventing them from spreading these communicable diseases, $140,000 is the potential savings to direct and indirect costs of the impact of these diseases.
The third leg of the evaluation process is the budget. What does the program cost and what is the cost to benefit ratio of these services. SHIP and its FDT component excel in being able to provide maximum services for minimal expenditure. During the same time period that SHIP was introduced, the agency's ability to use technology and an electronic health record system for charting, receiving lab results and contacting clients via text with STD results saved inordinate amount of staff time. The result of this technological time-saving is that staff are able to put more hours into direct client contact than administrative paperwork, with a benefit to the agency of running a newly implemented program with no additional staff or resource monies. SHIP is housed in the original STD counselling area, existing Epidemiology nurses are called to administer the injectable medication, the addition of two appointees from the CDC Public Health Associate Program (PHAP) to the department and an overwhelming desire of all staff to implement these programs have enabled it to be initiated and continue with no additional expense, other than minimal printing costs, lab shipping and supplies, and medication, to the agency.
The program was slightly modified several times since inception. Total number of walk-in hours and number of days was increased based on demand. Actual days and times of SHIP was changed to coordinate with the laboratory specimen-shipping schedule. The process was tweakedâ€ based on actual client need for better contact and counselling and reporting forms were adjusted to better provide the data needed to analyze the program. Each of these changes were the result of the original workgroup reconvening and reviewing the program on a monthly basis. Those meetings continue and the program will continue to evolve to best meet the needs of the client.
Taking all three of these evaluation pieces into consideration: meeting the initial program goals and objectives of convenient, confidential and quick testing coupled with timely treatment services; off-loading non-symptomatic clients and contacts from the primary care clinic resulting in a significant monetary savings to the agency; and introducing a valuable program for the community and public health with minimal expenditure substantiates this initiative's worth to the community and public health. The program, currently at one site, is being evaluated for expansion to the agency's second largest site.
When front-line staff first began to consider a walk-in testing program, the issue of sustainability due to in the inability to hire additional staff was a serious consideration. The unknown of whether or not a minimal marketing effort (flyers) would be enough to entice clients to the agency, how many clients would actually utilize the program, and how much time would be taken away from other important public health tasks to man the SHIP clinic hours were issues given much thought. The concern that a program would be started and then have to be discontinued was real. These budgetary constraints and the inability to discontinue other aspects of the departmental responsibilities to make time for SHIP were major issues that got much attention in the planning meetings.
Those concerns were unfounded, however, as the work and responsibilities of SHIP were able to be incorporated into the daily work schedules of the Disease Intervention Services staff. The addition of CDC Public Health Associates to the team provided additional manpower and the introduction of technology to charting and contacting clients freed up time in the workday that was routed to SHIP.
One of lessons learned was that the client base most likely to utilize SHIP paid scant attention to the details of the program times. Although they noted from the marketing flyers that there was a walk-in testing clinic at the DOH-Sarasota, they did not pay particular attention to the days and times. There were moments of frustration when a client would arrive at the agency for a HIV or STD test and find the staff were all out in the community, doing educational presentations or field investigation visits. Flyers were revamped to emphasize the hours, posters on stands were displayed in the agency's lobby, information was resent to community partners and receptionists were coached in stressing days and times to those clients who called the agency for information. After a few months, all of these interventions appeared to work and the situation was corrected. When it was necessary to alter SHIP days and times to coincide with lab shipping dates, the planned changes were advertised for 60 days prior to implementation. The change went smoothly.
Due to the program's success at identifying cases, providing treatment and reducing the burden clinic staff, the agency plans to expand the program to our site in the southern part of the County. The city of North Port is the largest municipality in Sarasota County and continues to grow. It is expected that the addition of SHIP testing and FDT treatment at the DOH-Sarasota North Port location will increase access to testing and treatment for residents in this area. Offering testing at a more convenient location to residents in this area of Sarasota should reduce the travel time needed for residents seeking these services. Additionally, the addition of SHIP and FDT services in North Port should reduce the number of clinic appointments needed to provide care for these individuals. Resulting in additional cost savings to the agency, as well as opening for appointments for other clients.
At this time, SHIP has become one of the core programs of the agency and will be sustained indefinitely. It is well-liked and utilized by clients, it is referred by community partners, it requires minimal funding and the Field Delivered Therapy component is a benefit not only to public health but also to the primary care clinic by freeing up space for adult health clients with serious health issues. It is a program that will soon be expanded to a second DOH-Sarasota site and could also be replicated in other health departments.