1. Effect of Clinical Program Integration on Eliminating Disparities in Access to Care P. Tambe, M. Allen, R. Lewis-Hardy, T. Dupree-Bright, E. Benning, S. Katkowsky March 13, 2008 2008 National STD Prevention Conference Chicago, Illinois

2. Introduction To increase program efficiency To increase program efficiency To maximize staff capability through cross training To maximize staff capability through cross training To provide cost effective patient care To provide cost effective patient care In 2004, the Fulton County Department of Health & Wellness Communicable Disease Prevention Branch (CDPB) began noticing the rewards of clinical program integration. The STD, HIV, and Tuberculosis clinics were integrated:

3. Background The CDPB recognized the three separate clinics resulted in delayed access to patient care, higher costs, and duplication of services. The CDPB recognized the three separate clinics resulted in delayed access to patient care, higher costs, and duplication of services. Fulton County (Atlanta) accounts for more than 50% of the STD, HIV, & TB morbidity in the state. Fulton County (Atlanta) accounts for more than 50% of the STD, HIV, & TB morbidity in the state.

4. Fulton County Morbidity Georgia ranks 8 th in cumulative AIDS cases in the nation Georgia ranks 8 th in cumulative AIDS cases in the nation Fulton County is #1 for HIV/AIDS cases in Georgia Fulton County is #1 for HIV/AIDS cases in Georgia Over 10,000 Fulton County residents living with HIV Over 10,000 Fulton County residents living with HIV Georgia ranks 3 rd in Primary & Secondary Syphilis Georgia ranks 3 rd in Primary & Secondary Syphilis Fulton County ranks 1 st for P & S cases in Georgia Fulton County ranks 1 st for P & S cases in Georgia Georgia ranks 8 th in TB cases in the nation Georgia ranks 8 th in TB cases in the nation Fulton County is 1# for TB cases in Georgia Fulton County is 1# for TB cases in Georgia

5. Objectives Develop systems to improve infrastructure, work force training, and team work to increase efficiency in the public health system. Develop systems to improve infrastructure, work force training, and team work to increase efficiency in the public health system. List and monitor the job duties of each public health staff position to increase the individual capabilities. List and monitor the job duties of each public health staff position to increase the individual capabilities.

6. Methods Integrated Components of the Branch Sexually Transmitted Infections HIV Primary Care Tuberculosis Co-infected clients are easily referred between clinics Medical staff trained to identify infections and complications Personnel trained to expedite patient care in all three clinics

7. Results Cross training resulted in more efficient and cost effective patient care, increased patient and partner referrals, and improved communication and team work between staff related to patient care.

8. What Were the Types of Integration Efforts Used? Capacity Building Enhanced Surveillance Community Outreach

9. How Did The Communicable Disease Prevention Branch Conduct Integration Efforts?

10. Answer..… By addressing each objective with a defined integration effort By addressing each objective with a defined integration effort

11. Objective 1: To develop systems to improve infrastructure/capacity building Standardize and improve information systems Laboratory renovation and equipment Registration renovation and equipment Program monitoring and supervision Cross-training all staff (enhanced communication) Development and dissemination of guidelines Cost sharing and Cost reduction

12. Objective 1: To develop systems to improve infrastructure /capacity building Electronic medical records were implemented. Patients appointments and treatment records are accessible allowing clients to be served more efficiently and medical alerts are placed on patients files as needed. Electronic medical records were implemented. Patients appointments and treatment records are accessible allowing clients to be served more efficiently and medical alerts are placed on patients files as needed. Cross training staff eliminated stagnation of services due to staff leave or absence. Cross training enhances quality assurance and reduces duplication of services. Cross training staff eliminated stagnation of services due to staff leave or absence. Cross training enhances quality assurance and reduces duplication of services.

13. What Were the Findings When Objective 1 Was Integrated?  Shorter time to service clients i.e., TB client with STD signs/symptoms can be referred and seen the same day  Efficiency increased without increasing cost of care  Increased training enhanced staff credentials

14. Objective 2: To Enhanced Surveillance and Community Outreach  Enhanced Surveillance-includes complete, accurate, and timely reporting of positive tests; effective, timely and regular data analysis; development of a framework for implementation of disease surveillance; and ongoing evaluation of the amount of disease in a community by monitoring positive tests.  Data Analysis showed the need for program integration

15. Fulton County Active TB Cases % HIV Infected (2004 -2006)

16. Fulton County TB Cases w/ known HIV Status

17. Main Objectives: Meet National 2010 HHS Target InfectionGeorgiaFulton 2010 Target Tuberculosis Per 100,000 6.1 14.4 in 2004 9.7 in 2005 7.5 in 2006 1.0 Syphilis Per 100,000 6.426.40.2 LIVING WITH AIDS per 100,000 152657 Universal access to treatment

18. Objective 2: To Enhanced Surveillance and Community Outreach  Community Outreach – Utilized the mobile unit, in high morbidity areas, to conduct STD/HIV and TB screenings and education; pilot tested a needs assessment; and held focus groups to assist in the development of a media campaign

19. Methods The Mobile Unit was used in areas of high STD/HIV/TB incidence to provide education and intervention through screening and early detection. The van is parked in an agreed upon location by the community. The mobile van is used in a comprehensive screening site…

20. Objective 2: To Enhanced Surveillance and Community Outreach  Disease Intervention Specialists were certified in venipuncture and PPD skin testing  TB clients on Directly Observed Therapy were also offered HIV and Syphilis screening in the field  All health fairs and training included STD/HIV/TB information

21. What Were the Findings When Objective 2 Was Integrated?  Clients in TB clients should be routinely screened for HIV and STDs  Co-infections among the clinics  Data analysis showed the same zip codes were disproportionately impacted by STD/HIV/TB  African-Americans were disproportionately impacted by STD/HIV/TB

22. What Were the Results of the Integrated Efforts? Lessons Learned Results

23.  Cross training staff was cost effective for program services by providing more services with the same amount of staff  Program integration improved client services  When screening in HMAs, you should offer STD/HIV & TB

24. Results Success was demonstrated by stabilizing new infections. The TB rate declined from 14 in 2004 to 7.6 in 2006. Syphilis rates also declined from 36.0 in 2005 to 26.4 in 2006. Success was demonstrated by stabilizing new infections. The TB rate declined from 14 in 2004 to 7.6 in 2006. Syphilis rates also declined from 36.0 in 2005 to 26.4 in 2006. Client compliance improved with decrease waiting time. Client compliance improved with decrease waiting time.

25. Conclusions

26. Integration of clinical services should be promoted to improve access for disadvantaged clients.