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Healthy Beats

State: CA Type: Promising Practice Year: 2018

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The City of San Antonio Metropolitan Health District
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Healthy Beats
The San Antonio Metropolitan Health District (Metro Health) is the public health agency charged by State law, City code, and County resolution with the responsibility for providing public health programs in San Antonio and unincorporated areas of Bexar County. Although Metro Health is a City/County organization, administrative control is under the City of San Antonio and Metro Health is operated as a City department. Services include: health code enforcement, food inspections, immunizations, clinical services, environmental monitoring, disease control, health education, dental health and emergency preparedness. According to the US Census Bureau, Bexar County has approximately 1.9 million residents (approximately 30% white, non-Hispanics, 60% Hispanics, and 8% African Americans). As a public health department, Metro Health provides services to 1.9 million residents and has a particular focus on underserved populations and those experiencing health disparities which often include a higher representation of Medicaid funded individuals. The STD/HIV Branch serves individuals through STD surveillance, contact investigation and clinic services. Each year over 16,000 STD reports are submitted, over 8,000 contact investigations are conducted and approximately 11,000 patient visits occur in the clinic. In the past decade, Bexar County has consistently had higher rates of syphilis compared to the state and the nation. Bexar County's primary and secondary syphilis rate in 2016 was 11.5 per 100,000 population compared to 8.7 for the state and 7.1 for the US. With 18 cases in 2012, the congenital syphilis rate in Bexar County was 75.3 per 100,000 live births, a rate far surpassing any recent year. From 2008-2011 the average congenital syphilis rate for Bexar County was 40.9 per 100,000 live births, which is 30% higher than the average rate for Texas for that same period (at 28.6 per 100,000 live births) and five times the national average (8.5 per 100,000). The overall goal for Healthy Beats is to decrease the number of congenital syphilis cases in Bexar County. The objective measures for the program include: 1. Conducting clinical case management by enrolling 120 high risk pregnant women to assure appropriate prenatal care and third trimester syphilis screening to prevent congenital syphilis cases and other STD transmission; 2. Improve the percentage of women who have undergone treatment for primary and secondary syphilis and complete clinical and/or serologic testing at 6 months by 5%. Two Public Health Nurses and one Public Health Aide enrolled pregnant patients visiting the STD/HIV clinic and completed follow up calls to ensure patient continued with prenatal care and obtained 3rd trimester syphilis tests. Home visits were also conducted if patient did not return follow up calls and to perform 6 month follow up for patient diagnosed with primary or secondary syphilis. Since the inception of the program, the objectives of the program have been met. The target of enrolling 120 women each year has been surpassed with 167 enrolled between October 2013-September 2014- 167; 132 between October 2014-September 2015; 244 between October 2015-September 2016; and 161 between October 2016-September 2017. In addition, the percentage of women who were diagnosed and treated for primary and secondary syphilis and completed serologic testing at 6 months was met each year with a range of 15% in 2014 to 35% in 2016. The success of the program relies heavily on having adequately trained and dedicated staff that provides patients with quality care and close patient follow up. Another factor that has assisted in the success for the program is community collaboration and staff attending community events to reach women who otherwise not seek our services at the STD clinic. Collaborating with internal public health programs, provided networking amongst maternal child health and outreach staff which provides an opportunity to educate these program about the importance of third trimester testing. Healthy Beats has made an impact on these pregnant women enrolled in the program to ensure that they are receiving syphilis testing and preventing congenital syphilis cases among the women enrolled in the program. In addition, the program is also working to refer these women for needed services, such as prenatal care, Medicaid, food, clothing and housing. The website for the health department is http://www.sanantonio.gov/Health .
In 2012, there was an increase in primary and secondary syphilis cases and 5 stillbirths directly related to congenital syphilis. In addition, it was learned that women were being tested early in pregnancy and were negative for syphilis and then were later tested at delivery and were positive and did not receive treatment prior to the 30 days of delivery. The infants born to these women were classified as congenital syphilis cases. This issue prompted the health department to encourage the state to make a change in the legislation to require third trimester testing. This is in addition to the testing during the first trimester and at delivery. Congenital syphilis cases have been reported since the 15th century and are known to cause early fetal loss, stillbirth, prematurity, low birth weight and neonatal and infant death if left untreated. Untreated maternal syphilis is known to be caused as a direct result of not having health insurance or access to preventive screening and treatment and late or no prenatal care. Other maternal risk factors include age, education, residency, employment, use of substance abuse, marital status and sexual health behavior. Paternal risk factors include age, residency, education, substance abuse usage, diagnosis of other STDs and unconfirmed syphilis status due to refusing screening. A congenital syphilis case is defined as one not following CDC guidelines of having received adequate treatment per stage of infection 30 or more days before delivery. From 2008-2011, Bexar County's congenital syphilis annual rate was 40.9% per 100, 000 live births, 30% higher than Texas' average rate and five times than that of the national average, for the same period. In 2012, Bexar County had eighteen cases, surpassing any recent year. Owusu-Edusei, et al. article stated the estimated unadjusted average hospitalization cost was $1689 for uncomplicated healthy newborns and $25,659 for admissions with congenital syphilis diagnosis, with an average length of stay of 2.0 days. Research has also shown, expanding syphilis screening and treatment in existing antenatal care programs, yields a cost saving of $12,261,250. In a study conducted by Kahn, et al. the cost of testing was $1.83 – $2.30 per woman and the cost of treatment with a three-dose course of penicillin was $3.72 – $3.79, proving screening is inexpensive. The target population is Bexar County pregnant females of all ages, race/ethnicity, socioeconomic and educational level and their unborn infant are at the forefront of being affected. The target population for this project is women that are pregnant and are at high risk receiving late or no prenatal care. In 2015, there were 28,182 live births in Bexar County and 15% received late or no prenatal care (4,446). In addition our target focuses on pregnant women that receive services in our STD clinic and those that attend our outreach events, which are approximately 400 women. Healthy Beats has enrolled a total of 704 pregnant women from October 2013 through September 2017, 176 pregnant women enrolled each year which represents 44% of the target population each year. Traditional STD public health follow-up was conducted on each positive lab report received for syphilis. This entails a Disease Intervention Specialist (DIS) contacting the patient by phone or in person to determine pregnancy status, as this is frequently not noted on the laboratory report. In addition, the DIS ensured that appropriate treatment was received. Education was provided to the individual on sexual health safe practice and importance of prenatal care. However, there was no intensive case management to ensure that the individual continued to receive testing and treatment throughout the pregnancy, nor follow-up to ensure that the individual was seeking prenatal care. The Healthy Beats model is better because it is focused on prevention of the congenital syphilis case by offering case management of the pregnant women. The program ensures that they are receiving prenatal care services, receiving syphilis testing early in their pregnancy and early during their third trimester, and ensure that the woman is appropriately treated prior to delivery thereby protecting their baby and preventing congenital syphilis from occurring. To conduct the case management services, the program employs two full time public health nurses that are dedicated to provide this case management and education to these women on how to protect their children. The two PHN have years of experience with maternal child health, case management and care coordination. Having designated staff provides continuity of care and helps build rapport with patient to help alleviate some of the fears and worries that a pregnancy may bring. To our knowledge, Metro Health is the only health department that utilizes this practice. Providing nurse case management as part of the STD/HIV clinic for pregnant women who are at high-risk for delivering a congenital syphilis infant is an innovative practice. There have been other case management programs in the state that focus on other pregnancy related issues such as infant mortality, low birth weight and prematurity. One such program is the Nurse-Family Partnership in Texas, which works by having specially trained nurses regularly visit young, first-time moms-to-be, starting early in the pregnancy, and continuing through the child's second birthday. Healthy Beats is based on this evidence-based, community health program that serves low-income women pregnant with their first child.
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The overall goal of the project is to reduce the number of congenital syphilis cases. There are 3 objectives associated with the project: 1. Conduct clinical case management by enrolling 120 high risk pregnant women to assure appropriate prenatal care and third trimester syphilis screening to prevent congenital syphilis cases and other STD transmission. 2. Improve the percentage of women who have undergone treatment for primary and secondary syphilis and complete clinical and/or serologic testing at 6 months by 5%. 3. Conduct education and outreach to local medical providers to encourage the adoption of third trimester syphilis testing among all pregnant women in Bexar County. In order to administer the project, two public health nurses and a public health aide were hired to conduct clinical case management to ensure third trimester syphilis screening is completed to prevent congenital syphilis cases. Pregnant women are recruited into the program by either seeking services at the health department's STD clinic or by attending one of the Department's community outreach events. Upon enrollment, the individual is educated about syphilis, congenital syphilis, healthy sexual encounters, and the importance of prenatal care. The individual is also educated on Texas laws for syphilis testing during pregnancy (first, third and at delivery). In addition, consent forms are obtained to share information with the obstetrician (OB), if they have one. If they do not have an OB, then referrals are made to assure that they will receive prenatal care. All patient documentation is completed within electronic medical record. Incentives are provided at enrollment, when the woman completes her third trimester testing, completion of treatment, if needed, and upon delivery. After enrollment, Healthy Beast conducts a thorough need assessment questionnaire to identify any barriers that may greatly influence patient's ability to remain in prenatal care. Once needs are identified, appropriate community based organization services are discussed with patient and appropriate referrals are made. Referrals can be made to organizations such as federally qualified health centers for obstetrical care, community organizations which provide maternity or baby clothing, assistance with rent or applying for Medicaid, Woman, Infant and Children (WIC) program or Supplemental Nutrition Assistance Program (SNAP). Healthy Beats staff conduct follow up call one week after initial enrollment to assess if other needs are identified, including questions about syphilis testing and treatment. After the initial call, a monthly call is completed until delivery. If staff are unable to reach patient after three phone call attempts, the staff will contact OB on record to verify demographics and find alternative contact phone number. Home visits are conducted when the patient is no longer responsive to phone calls. If patient not found at home, a confidential envelope with letter stating to call office is left. In order to assure the pregnant women who have undergone treatment for primary and secondary syphilis complete follow-up serologic testing at 6 months all women a tracking system was developed that was utilized by the Healthy Beats staff. The staff contacted the individuals by phone to remind them of the 6 month follow-up test and arranged for testing if needed. If the individual could not be contacted via phone, then a home visit was conducted and offered 6 month test in their home. Targeted outreach and education is done with medical providers of pregnant women enrolled in Healthy Beats. Once patient enrolled, Healthy Beats staff fax patient's consent form to share information along with a provider letter with a description of the program and addressing syphilis testing and treatment during pregnancy. In addition, program staff participate in various community events, baby showers, health and resource fairs to educate the community about syphilis testing, treatment, and to reinforce sexual health screenings. During these community events, Healthy Beats staff have the opportunity to offer, on the spot 3rd trimester syphilis testing and HIV. Likewise, Healthy Beats staff provide prenatal care education related to fetal development, kick counts, fish consumption, stages of labor, how to prevent sudden infant death syndrome and what to do when infant cries. Healthy Beats was initiated in October of 2014 and is entering its fifth year of existence. The program was developed utilizing funds from 1115 Waiver Transformation Project to address the congenital syphilis issue in Bexar County. Stakeholder input was incorporated into the planning and implementation of the project and evaluation of the project. Beat AIDS, the Center for Healthcare Services, and UTHealth provided input. Healthy Beats continues to foster collaboration with community stakeholders that are involved in the Community Health Improvement Plan. The Program works closely with internal and external stakeholders to assure coordination of services. Internal stakeholders include the Healthy Start Program, Immunization Program, Neighborhoods Program and WIC. External stakeholder partners include University Health System, Bexar County Jail, Center for Healthcare Services Mommies Program, Planned Parenthood, Federally Qualified Health Centers. The staff also participate in the Healthy Families Network, which have multiple internal and external stakeholders that meet on a monthly basis to discuss maternal and child health issues. Prior to receiving the funds through the 1115 waiver mechanism, Metro Health was utilizing general fund staff in the STD/HIV Branch to conduct the services of the program.
It is essential to have designated staff who have experience in maternal health and case management. Case management is time consuming, yet rewarding to ensure that pregnant women receive appropriate testing and treatment for syphilis to protect their unborn infant. It is vital to provide testing and treatment in various settings. Even with our efforts, there remains a small portion of pregnant women that are not utilizing any services for prenatal care. This has been a hard to reach population. The overall goal of the project is to reduce the number of congenital syphilis cases in Bexar County. There are 3 objectives associated with the project: 1. Conduct clinical case management by enrolling 120 high risk pregnant women to assure appropriate prenatal care and third trimester syphilis screening to prevent congenital syphilis cases and other STD transmission. 2. Improve the percentage of women who have undergone treatment for primary and secondary syphilis and complete clinical and/or serologic testing at 6 months by 5%. 3. Conduct education and outreach to local medical providers to encourage the adoption of third trimester syphilis testing among all pregnant women in Bexar County. Since the inception of the program, the objectives of the program have been met. The target of enrolling 120 women each year has been surpassed with 167 enrolled between October 2013-September 2014- 167; 132 between October 2014-September 2015; 244 between October 2015-September 2016; and 161 between October 2016-September 2017. In addition, the percentage of women who were diagnosed and treated for primary and secondary syphilis and completed serologic testing at 6 months was met each year with a range of 15% in 2014, 24% in second year and 35% in 2016. Healthy Beats also captured the following information on individuals being served: patient's reason for clinic visit, primary language, race/ethnicity, marital status, education level, risk assessment, number of persons in household, monthly family income, health insurance, current results for sexual transmitted infection, past medical history, maternal health history, alternate emergency contact. In addition, a needs assessment questionnaire was completed by Healthy Beats staff during initial visit with patient and collected information on housing, health insurance, income/ support services needed, domestic violence and substance abuse/usage. Needs identified were listed in needs assessment plan handout, which laid out, action, person responsible, target date and outcome. No secondary data were used. Data was analyzed using Excel. One adjustment that has been made to the program was collaborating with the Bexar County Jail to enroll incarcerated women that were pregnant. Another issue identified is the homeless population and those addicted to drugs. There is a lot of difficulty with tracking these individuals, meaning they have higher needs and are mobile, which increases difficulties to have their needs met. This is still a challenge that we are attempting to work on with our partners to identify the best solution for this population. Throughout the implementation, when staff called OB's office to inquire if patient had 3rd trimester syphilis test, Obstetrician's staff stated, doctor does not order syphilis test, until 32 or 36 wks. If this occurred, Healthy Beats staff informed health department medical director, who contacted OB to educate them on the new testing law in Texas. Project standard operating procedure was evaluated on a six-month basis to ensure processes were being followed. Any deficiencies or practices that needed to be changed to improve performance were modified and staff were educated on the changes.
The Healthy Beats Projects has partnered with dozens of organizations, such as the San Antonio Housing Authority (SAHA), that aim to serve our target population. Fortunately we are able to use tangible reinforcements to incentivize patients to be engaged regarding their sexual health. Most importantly, partnering with our mobile STD/HIV outreach team has been tremendously successful thanks to the mobile health unit that allows for syphilis testing and treatment in alternative settings and removes the barrier of having to schedule a clinic appointment. This has been critical for the project for reaching specific high risk populations. The sustainability plan includes increasing the clinic's revenue by ensuring billable services are billed properly to private insurances and Medicaid. We are investigating alternate funding opportunities and we continue to develop and cultivate existing relationships with our community partners to increase the effectiveness of services. Collaboration is of key importance; having buy-in from our stakeholders has been vital to the success of the program.
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