Integration of Family Planning Services into an STD Clinic Setting

State: CO Type: Model Practice Year: 2010

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Strategies are needed which address the integration of pregnancy and STD prevention activities in order to improve clinical efficiency, reduce redundancy in services and avoid missed opportunities. Currently, over 50% of pregnancies are unintended, with rates higher in certain high-risk populations (e.g., adolescents, never-married women, low-income women, those not using contraception, women attending STD clinics). Additionally, a high number of people are infected with or affected by the consequences of STD. While family planning clinics provide both STD and family planning services, most of these clients are low-risk women, with few men ever seeking services in these clinics. Thus, different types of clinical venues are needed to reach clients who are at high-risk for STDs and unintended pregnancy. STD clinics offer an ideal opportunity to provide both services since many of the clients being seen do not use contraception or condoms and thus are at risk for STDs and unintended pregnancy.

The goal of this program is to offer initial family planning services to all eligible males/females presenting for STD services at least once a year. The objective of the program is to provide integrated family planning services in an STD clinic setting which compliments STD clinical services. The program intends to ensure that all eligible individuals presenting for clinical care at the Denver Metro Health Clinic (DMHC)(the Denver STD clinic) are offered family planning counseling and services at least once annually. Currently, all STD clinicians have been trained in STD prevention/treatment and family planning services and provides both services to women and men who are eligible for care.

Since the program’s inception, approximately 12,500 individual women and 13,000 individual men have received initial family planning services with their STD evaluation. In 2009, almost 80% of heterosexual/bisexual clients seen in the STD clinic received family planning services. Services provided include preconception counseling, pregnancy testing with options, contraceptive counseling, and provision of birth control methods. Contraceptive methods available include oral contraceptives, depot medroxyprogesterone acetate injections (DMPA), combined hormonal patch, combined hormonal ring, emergency contraception, condoms, intrauterine devices, progesterone implant, and spermicide. Each woman seen is provided a three month supply of contraception free of charge, with the majority of women referred to primary care for ongoing services. Teens and high-risk women are offered continuity services.

To ensure that all eligible clients are offered family planning at least once annually, we developed programming in our electronic medical record to query the STD database nightly updating the medical information of the client to be able to provide a display on the client’s electronic medical record indicating date of last enrollment for family planning services, ineligibility to receive services, or need to “check eligibility”. Additionally, changes were made to the computerized electronic medical record to combine all required family planning documentation data into the STD clinic chart and to ensure that all required documentation for both STD and family planning reporting are completed, avoiding redundancy in the completion of the clinical chart.

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Denver Public Health Department
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Integration of Family Planning Services into an STD Clinic Setting
Strategies are needed which address the integration of pregnancy and STD prevention activities in order to improve clinical efficiency, reduce redundancy in services and avoid missed opportunities. Currently, over 50% of pregnancies are unintended, with rates higher in certain high-risk populations (e.g., adolescents, never-married women, low-income women, those not using contraception, women attending STD clinics). Additionally, a high number of people are infected with or affected by the consequences of STD. While family planning clinics provide both STD and family planning services, most of these clients are low-risk women, with few men ever seeking services in these clinics. Thus, different types of clinical venues are needed to reach clients who are at high-risk for STDs and unintended pregnancy. STD clinics offer an ideal opportunity to provide both services since many of the clients being seen do not use contraception or condoms and thus are at risk for STDs and unintended pregnancy. The goal of this program is to offer initial family planning services to all eligible males/females presenting for STD services at least once a year. The objective of the program is to provide integrated family planning services in an STD clinic setting which compliments STD clinical services. The program intends to ensure that all eligible individuals presenting for clinical care at the Denver Metro Health Clinic (DMHC)(the Denver STD clinic) are offered family planning counseling and services at least once annually. Currently, all STD clinicians have been trained in STD prevention/treatment and family planning services and provides both services to women and men who are eligible for care. Since the program’s inception, approximately 12,500 individual women and 13,000 individual men have received initial family planning services with their STD evaluation. In 2009, almost 80% of heterosexual/bisexual clients seen in the STD clinic received family planning services. Services provided include preconception counseling, pregnancy testing with options, contraceptive counseling, and provision of birth control methods. Contraceptive methods available include oral contraceptives, depot medroxyprogesterone acetate injections (DMPA), combined hormonal patch, combined hormonal ring, emergency contraception, condoms, intrauterine devices, progesterone implant, and spermicide. Each woman seen is provided a three month supply of contraception free of charge, with the majority of women referred to primary care for ongoing services. Teens and high-risk women are offered continuity services. To ensure that all eligible clients are offered family planning at least once annually, we developed programming in our electronic medical record to query the STD database nightly updating the medical information of the client to be able to provide a display on the client’s electronic medical record indicating date of last enrollment for family planning services, ineligibility to receive services, or need to “check eligibility”. Additionally, changes were made to the computerized electronic medical record to combine all required family planning documentation data into the STD clinic chart and to ensure that all required documentation for both STD and family planning reporting are completed, avoiding redundancy in the completion of the clinical chart.
Strategies are needed which address the integration of pregnancy and STD prevention activities in order to improve clinical efficiency, reduce redundancy in services and avoid missed opportunities. It is estimated that almost 50% of pregnancies in the United States are unintended, and that approximately half of these result in therapeutic abortions. Almost all women are at risk for unintended pregnancy throughout their reproductive years. However, rates of unintended pregnancies are higher in certain populations such as adolescents, never-married women, women with low-incomes, those not using contraception, and women attending STD clinics. Identifying and removing obstacles to effective contraceptive use will enable women to control the timing of their child-bearing, resulting in positive consequences for the parent, child, and society as a whole. The number of people infected with or affected by the consequences of STD is a major public health problem in modern society. It is estimated that approximately 19 million people are newly infected with an STD annually in the United States, almost half of them being young people ages 15 to 24. Likewise, in the United States, while the pregnancy rate among young women under age 20 has been declining (until 2006), it is still considerably higher than other developed countries. Despite similar rates of sexual activity, one in 14 women aged 15 to 19 becomes pregnant each year in the US. It is estimated that three million pregnancies per year are unintended, including both mistimed and unwanted births, and nearly 1.22 million abortions are reported each year, figures that are most likely understated. Conditions leading to STD and unintended pregnancy resemble each other in a variety of ways. Both require sexual contact, usually intercourse, and it is women who suffer the biological consequences of both of these conditions. For STD, these are more easily transmissible in women, yet more difficult to diagnose because they are more frequently asymptomatic in women than in men, thus potentially delaying treatment and leading to serious sequale. Furthermore, the entire burden of unintended pregnancy often falls entirely on women. Moreover, the characteristics of women most affected by STD and unintended pregnancy are similar: poor, minority women younger than 25 years have the highest rates of both STD and unintended pregnancies. While the responsibility for pregnancy prevention has been mainly the woman’s responsibility, focusing on the role of men in family planning is important. In addition, more men than women seek clinical services in STD clinics but their role in family planning is often ignored. Men have reported that they want to know more about reproductive health and want to support their partner more actively. Furthermore, family planning directed at men has been shown to increase condom use and reliance on vasectomy. Programs are needed for men that integrate pregnancy prevention with STD prevention. Unintended pregnancy is an important and complex problem that has significant public health consequences. While family planning clinics have combined the treatment model to include STD screening and treatment services with contraceptive services, STD clinics, which serve a different population, often less socially organized and less interested in preventive health care have less frequently combined these services. At the DMHC, all women seen for services are interviewed regarding their reproductive and contraceptive, as well as their STD history. In the mid 1990s, prior to the initiation of the described program, women in need of contraceptive care who were <19 years of age were referred to our teen clinic, while those women >19 years were provided with condoms and offered a referral for family planning services through an outside community health clinic. During this time period, we suspected that given the generally poor preventive health care behaviors
Agency Community RolesDenver Public Health (DPH) is the local public health department for the City and County of Denver. It has a long and effective track record of meeting City, State and Federal contracts to improve the health of the residents of Denver. DPH provides contracted public health services for the City and County of Denver which includes recommendations for addressing disease control, provision of direct disease control services (e.g., tuberculosis, HIV, STD clinics and immunizations), administration of vital records/vital statistics (such as births and deaths), tobacco control, STD/HIV training programs, and health promotion/wellness programs. The Denver Metro Health Clinic (DMHC) is the largest STD clinic and HIV testing facility in the Rocky Mountain region with nearly 16,000 visits annually. DMHC offers free confidential testing, counseling, and treatment for a comprehensive array of STDs for residents in the Denver metro region. Since 2001, the clinic has offered initial family planning services with subsequent referral of clients to primary care for ongoing services. Initially services were only provided for women, but were expanded in 2003 to provide family planning services for both men and women. To increase access to family planning services, we have partnered with a number of outside organizations to increase exposure of the services available and allow them to refer primarily women to our clinic. These groups represent community-based organizations, schools, peer educators, and teen groups throughout the Denver Metro area. Additionally, staff has provided training to groups seen through these community-based organizations. Costs and ExpendituresThis program was initially started in 2001. Based on a study conducted at the the Denver Metro Health Clinic (DMHC) which determined the effectiveness of initiation of contraception in an STD clinic setting, stable funding was procured for the provision of initial family planning services for women through Title X. (Please see the previous 2004 Model Practice award on this program for more explicit details on the initial start-up). Initially, funding covered an RN posiition who provided family planning services to clients identified as needing assistance by the STD clinicians as well as contraceptive supplies. In-kind services were provided by the STD program and included attending back-up, laboratory services, an examination room within the STD clinic to provide counseling and treatment, and all ancillary services needed to register and discharge the family planning clients. However, the original staffing model used (single RN providing family planning services) was inefficient since patients had to wait for another clinician to receive family planning services. To address this issue, gradually all staff were trained to provide integrated family planning/STD prevention services. Additional funding was provided by Title X in order to address the need for more integrated services and to provide counseling to men on their role in family planning as part of their STD clinical assessment. This program receives funds from the Colorado Department of Public Health and Environment’s (CDPHE) Women’s Health Section. Funding is provided through Title X and other state health department grants. The infrastructure of the STD clinical program also supports this program. Currently, family planning funding provides approximately 25% of the total funding for our STD clinical program. ImplementationWhen a client presents to the DMHC, the following processes are used to ensure that the client receives the most appropriate type of service. First, the client is seen by an LPN who asks a series of questions in order to properly triage the client to the type of clinical service needed. Based on the responses to the questions, clients is triaged to receive either a comprehensive examination (offered to men who have sex with men, intravenous drug users, persons who exchange money or drugs for sex, and partners of these individuals, regardless of having symptoms or contact status; symptomatic clients are all triaged to receive a comprehensive examination), an express visit (offered to asymptomatic, low-risk individuals), confidential HIV testing services (offered to persons only wanting anonymous or confidential HIV testing), or teen/continuity clinical services (for high-risk women/teens receiving ongoing family planning services). Female clients requesting emergency contraception or family planning are triaged to see a registered nurse. For the express visits and comprehensive examinations, the clinician completes a detailed medical history. Questions focus on the chief complaint, symptoms, gynecological history (women), past medical history, contraceptive history, sexual history, past STDs, other risks, and STD prevention activities. The clinical examination is dictated by the type of visit being done. For express visits no clinical examination is performed. Comprehensive visits have a standardized STD-related physical examination performed as part of the visit. All documentation of the clinical encounter is done electronically. Men are eligible for enrollment into the family planning program unless they are men who have sex with men or they have had a vasectomy. All enrolled men receive information and counseling on their role in family planning. Counseling available to men include contraceptive counseling and preconception counseling. Any woman is eligible for family planning services unless she has had a tubal ligation, hysterectomy, or is menopausal. Family planning services provided to women include preconception counseling, pregnancy testing with options, and contraceptive counseling with provision of a contraceptive method, as indicated. Women seen in the STD clinic who are currently using an effective contraceptive method are not offered contraceptive services if they are satisfied with their current method. After provision of family planning services most clients, with the exception of those eligible for referral to our teen or continuity clinic, (see below for inclusion criteria) are referred to a PCP for ongoing reproductive services. Contraceptive methods available include oral contraceptives, DMPA, combined hormonal patch, combined hormonal ring, intrauterine devices, progesterone-only implant, emergency contraception, and condoms. Women requesting a tubal ligation are referred to a PCP or a Title X clinic which offers these services. Each woman is provided a three month supply of contraception free of charge. Title X rules indicate that all women at or below 100% of the federal poverty level (federal poverty level is calculated using the Federal Registry and is based on a person’s weekly income and family size) are eligible for free family planning services, with women with higher income levels eligible for family planning services based on a sliding scale fee structure. DMHC elects to waive all fees for family planning services irrespective of the woman’s income level. This follows the clinic’s practice of not charging for clinical services since requiring fees was concluded to be a major barrier to receiving STD clinical services. As part of their initial evaluation women who receive family planning services are classified as being low-risk or high-risk for subsequent pregnancy. This classification is based on certain demographic and clinical characteristics
The overall goal of the program is to offer family planning services to all eligible males and females (i.e., heterosexual/bisexual males or females who are not sterilized) presenting for STD services at least once a year. To provide integrated family planning services in an STD clinic setting which compliments STD clinical services. The performance measure is measuring the total number of persons who received family planning services at least once in a calendar year compared to the total number of eligible persons seen during the same time period.All data is obtained through the DMHC electronic medical record system. Information collected includes all demographic, behavioral, and clinical parameters collected during a clinical encounter. The data is collected with the completion of the electronic medical record at the time of service. All family planning and STD clinical information including demographic, behavioral, and clinical information is documented electronically. Aggregate information is available to allow an examination of the extent integration of services is provided.Prior to the development of the integrated electronic medical record and the reminder system indicating whether the client is eligible for family planning services at the time of the STD clinic visit, feedback on the extent that integrated family planning/STD prevention services were provided was done by chart review. Now, with the electronic reminders and the integrated charting system, the majority of clients are provided both servic Each year the proportion of eligible patients receiving family planning services has increased from 36.8% in 2006, to 44.4% in 2007, to 50.8% in 2008, to 79% in 2009 (p<0.01). The electronic reminder system and integrated charting was initiated January 1, 2010. Preliminary data from the first quarter indicates that approximately 95% of clients are receiving integrated services.
Over the years DPH has seen the value in providing integrated family planning and STD prevention services together. The family planning brings in necessary resources that augment STD clinical services funding allowing our health department to provide these two complementary services in a seamless fashion. Over the past year, the STD clinic developed the processes needed to safely offer intrauterine devices and progesterone-only implants to clients seen in the clinic. While clients seen in these clinics are at higher risk for having STDs, careful screening and utilization of standardized protocols has allowed our clinic to be able to offer long-acting contraceptives to women at high-risk for unintended pregnancy. Furthermore, in 2008 we obtained a three year grant from the Office of Population Affairs to evaluate feasibility, acceptability, replicability, and cost effectiveness of these integrated services. As part of this grant we are in the process of conducting an extensive evaluation of our program. To date, a baseline assessment of the processes being utilized in the clinic has been done. Staff and clients have been interviewed to access the strengths and challenges of the current program. From these baseline assessments, clinical processes have been revised included integrating all charting for family planning and STD services into one electronic clinical record. Additionally, an electronic reminder system has been developed to prompt staff that a client is eligible for family planning services. Clients have indicated that they value the program. Our final evaluation after the development of an integrated charting system and an electronic reminder system will be conducted in 2011. Findings from this grant will be used to determine if integrating family planning and STD services in an STD clinic are beneficial. All of the systems developed and the processes being utilized have been established to provide these integrated services over the long-haul. We will continue to be a Title X clinical site which offers financial resources to our program to provide the family planning services. The main challenge for our program is leveraging the grant support that we have to be able to continue to offer the services we currently have. In the future, we plan to explore the possibility of billing Medicaid for family planning services provided as part of Medicaid waiver program being developed in Colorado. The feasibility of billing for services will need to be examined carefully.
 
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