Communicating With Medical Partners for Better Health Outcomes

State: NY Type: Neither Year: 2016

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Nassau County (Long Island) is a suburban county located immediately east of New York City and has a population slightly over 1.3 million residents.  Nassau county has historically had above average STD/HIV rates compared to other New York State counties. This is because the county is located adjacent to New York City and often encounters residents that migrate, work and socialize throughout the tri state area. Residents of the county have an overall high standard of living with median household income of 97,047 and a  ranking of 13 in the nation. Nonetheless significant inequalities exist between communities and rates of STDs and HIV are significant throughout the county.   In 2014, Nassau County received over 4600 cases of reportable STDs including Syphilis, Gonorrhea, Chlamydia, and newly diagnosed HIV. As mandated by the New York State Department of Health, providers must report all positive tests and any treatment given to individuals residing in the county to the county health department.    STD and HIV disease intervention is an important public health service conducted nationally. The purpose of these programs is to ensure proper treatment of infected individuals and notification of exposed to interrupt the spread of disease. With growing rates of these infections, threats of antibiotic resistance, and serious long term consequences, it is essential that patients understand their diagnosis and learn effective prevention strategies.  Unfortunately, providers often times have very busy schedules and provide many services related to HIV and STDs.  With the increasing rates of these infections and the overall uncomfortable nature of sexually transmitted disease, many providers may not take the time to discuss with their patients individual risk, exposure to others, or alternative treatment options.  Sometimes it is easier to write a prescription and send the patient on their way. The goal of this practice is to engage providers in best practices for STD/HIV care for patients.  The following objectives of the practice is to ensure optimal health outcomes by improving quality of communication between the local health department and medical providers: 1.      Provide up to date and latest Centers for Disease Control and Prevention (CDC) recommended guidelines for testing and treatment.      2.       Provide appropriate  resources for easy access and reference 3.       Build  personal communication and relationship between providers/DOH staff to foster communication and collaboration 4.       Focus efforts on at risk patients and promptly and effectively address issues with specific provider alerts 5.       Collect feedback from providers to adapt services to better serve.  The practice began in early 2014 by conducting several provider in-service meetings at four community health centers.  Each meeting consisted of up to 15 medical professionals who currently provide STD/HIV services. Each provider was given a comprehensive materials/ information packet consisting of up to date CDC treatment guidelines, medical provider reporting forms, communicable disease reporting requirements, easy to read CDC brochures about current programs including but not limited to Expedited Partner Therapy and PEP/ PREP resources for providers, and local STD/HIV staff contact information.  The providers were also given a brief survey to evaluate the packet and give feedback for improvement and additions.  56 surveys were evaluated and 42 providers (75%) expressed the need for better communication from the local health department including added personal communication. Subsequently, a more comprehensive packet was developed.  In addition to the packet, three components were added.  (1) a brief provider  survey , available as a hard copy and electronically, requesting feed back and specific needs; (2) specific medical alert letters  to be sent to provider when special attention regarding an individual patient is warranted and (3) a dedicated email address for convenient electronic correspondence between providers and DOH staff. In addition to these activities, we have developed and continue to maintain a comprehensive provider directory for contact and referrals.  An initial 95 packets were mailed to appropriate providers thus meeting the listed objectives.  In the first 60 days, 19 (20%) surveys were completed by providers. 4 providers requested a personal in-service, and 1 provider called with specific questions regarding an individual case. At 90 days, 20 more packets were mailed,  3 additional providers called with specific questions  and requested guidance and 1 email was received from dedicated email.  Continued engagement through these activities will foster relationships between Nassau County providers and the health department. Feedback from surveys can be used to adapt services and approaches to treatment verification and partner services. Ultimately the program can expect to be more effective and efficient through these projects  
Nassau County (Long Island) is a suburban county located immediately east of New York City and has a population slightly over 1.3 million residents. Nassau county has historically had above average STD/HIV rates compared to other New York State counties. This is because the county is located adjacent to New York City and often encounters residents that migrate, work and socialize throughout the tri state area.    In 2014, Nassau County Department of Health received over 4600 cases of reportable STDs including Syphilis, Gonorrhea, Chlamydia, and newly diagnosed HIV, from approximately 150 different providers and laboratories. As mandated by the New York State Department of Health, providers must report all positive tests and any treatment given to individuals residing in the county to the county health department.   The goals of measuring health care quality are to determine the effects of health care on desired outcomes and to assess the degree to which health care adheres to processes based on scientific evidence or agreed to by professional consensus and is consistent with patient preferences.  Because errors are caused by system or process failures, it is important to adopt various process-improvement techniques to identify inefficiencies, ineffective care, and preventable errors to then influence changes associated with systems.  The rationale for measuring quality improvement is the belief that good performance reflects good-quality practice, and that enhancing performance among providers and organizations will encourage better performance. The goal of this practice is to create a new enhanced, comprehensive, and cost-effective way of communicating to 150 + existing STD/HIV providers as well as any newly identified providers using existing tools.   This practice will ultimately improve quality by personally engaging reporting providers and providing a number of ways to communicate best practices for STD/HIV care for patients to ensure optimal health outcomes. In the past, providers who were identified as needing acute DOH guidance or intervention was sent a host of already existing materials. The division noticed more and more providers were being sent materials and therefore a decision was made to develop a single comprehensive packet to send to all providers as well as the creation of additional components deemed as a way to improve communication and quality of services.     By improving quality of communication  between the local health department and medical providers will be able to : Follow current HIV/STD testing and treatment from MMWR Sexually Transmitted Diseases Treatment Guidelines 2015   Integrate Evidence-based practice by incorporating the best available research evidence in decision making.  The commination and resources from DOH allow for effective asking answerable questions, accessing the best information, appraising the information for validity and relevance, applying the information to care of patients and populations, and evaluating the impact for evidence of change and expected outcomes.  Reduction of barriers to implementing appropriate training and resource constraints.  
HIV in the U.S.
The goal and objectives of the practice is to improve quality as determined by the effects of health care on desired outcomes and to assess the degree to which health care adheres to processes based on scientific evidence or agreed to by professional consensus.   The intent of this practice is to engage providers in best practices for STD/HIV care for patients.  The objectives of the practice is to ensure optimal health outcomes by improving quality of communication between the local health department and medical providers.  The practice was implemented in 2014 by conducting several stakeholder in-service meetings to determine existing practices and identified needed improvements.  Using a survey,  42 providers (75%) expressed the need for better communication from the local health department including added personal communication. Subsequently, a more comprehensive packet was developed.  In addition to the packet, three components were added.  (1) a brief provider  survey , available as a hard copy and electronically, requesting feed back and specific needs; (2) specific medical alert letters  to be sent to provider when special attention regarding an individual patient is warranted and (3) a dedicated email address for convenient electronic correspondence between providers and DOH staff.  The criteria for selected practice were the  150 + existing STD/HIV providers as well as any newly identified providers using existing tools.   The timeframe for the practice is an ongoing effort to continue to improve quality of services through collaboration of efforts among the LHD and medical providers.  An initial in-kind minimal cost to create,  print materials and mail 105 packets was incurred.  The use of a volunteer intern to make packets, monitor survey responses, and set up future correspondence also made for in-kind minimal cost.  Ongoing practice has been incorporated into current staff routine.     
Evaluation is crucial to quality improvement. It is important to understand what impact your improvement work is having, or if it is having an impact at all! Evaluation helps to highlight the good as well as the bad, helping you to work out what to do and what not to do. Evaluation provides the sort of information that will be important when it comes to making a decision about what happens to the improvement work in the future.  The following objectives of the practice were designed to ensure optimal health outcomes by improving quality of communication between the local health department and medical providers: 1. Provide up to date and latest Centers for Disease Control and Prevention (CDC) recommended guidelines for testing and treatment. 2. Provide appropriate resources for easy access and reference 3. Build personal communication and relationship between providers/DOH staff to foster communication and collaboration 4. Focus efforts on at risk patients and promptly and effectively address issues with specific provider alerts 5. Collect feedback from providers to adapt services to better serve. Evaluation means using information you collect to make informed decisions about changes and improvements.   The first evaluation was conducted after the initial in-service meetings to determine what stakeholders think about what we're currently doing and what we need to do additionally to meet their needs.  We used information from the 40+ completed in-service surveys to plan and develop future work.   Next, we added to the preliminary provider packet and created an enhanced communication tool, based on recommendations, which provided a broader based tool for sharing good practice with others.  Additionally, another provider survey was added to the packet in order to continue to receive feedback from providers.  Finally, to evaluate if the new enhanced packet was effective, follow-up calls were made to 90 providers who were mailed the packet for verbal feedback.  Presently, the program has had success in engaging specific providers. Designating time to address providers individually has made a difference in the responsiveness to the program. Blanket messages and materials can be effective. However, tailored activities have proven to be ideal in engaging providers in best practices. In time, as we  receive more feedback and identify other medical and non- medical providers, it will be evident that the goals and objectives of the practice will address STD/HIV issues in Nassau County. 
There are many lessons learned from the program implementation and evaluation. The program has allowed for “new ways of working” within the health department. This means that, due to an intervention of some sort, a targeted group of individuals have begun to work in new ways. It is important in the agency, as in public health,  to adapt to changes and be innovative in our work to better address the needs of patients. Work can become routine and make for difficulty in developing new strategies. It is evident that these projects are effective and must be adopted as part of STD/HIV work. As part of this program we will maintain the algorithm for provider engagement activities which consists of the following: 1.When patient is identified as having been treated with a non-cdc recommended treatment, provider contact letter is initiated for corrective action 2. When a patient is identified as infected two or more times within a 6 month period, provider contact letter will be initiated for education and assistance with keeping the patient infection free.  In addition to these activities, we will maintain a comprehensive and organized directory of Nassau County providers for future contact and reference. As new providers are identified, they will be added to the directory which is accessible to all staff. Annually, the division will send out a mass mailing to providers including all updated information and reports from the department of health. Partner collaboration has been the key to success in this program. Providers and the Department of Health has been in contact with each other for many years and we have found that it take very little effort and explanation to employ efforts of providers in better practices for STD/HIV.  Even non-specialist providers have expressed interest in making STD/HIV prevention and treatment a priority for their own practice. Being a tangible resource for providers has proven helpful in several situations and we are confident that this will continue.  As mentioned previously, there are some barriers with regards to of time commitment towards the project by DOH staff. However, it is clear that that the time put in so far has been well received and has created a better system for the future. With continued efforts integrated into daily work routines, and support from administration in quality improvement, the program will be sustainable and  have a desirable impact on STD/HIV services.   
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