Program Collaboration & Service Integration (PCSI):Expanding collaboration to enhance

integrated services and improve public health outcomes for San Franciscans

Tomás Aragón, MD, DrPH Health Officer, City & County of San Francisco

Director, Population Health & Prevention

Israel Nieves-Rivera, PCSI ManagerPriscilla Lee Chu, DrPH, PCSI Analyst

San Francisco Health CommissionTuesday, June 19, 2012

• Federal imperatives: Expand collaboration within and outside of health departments to implement targeted integrated services and programs that promote positive health outcomes for affected communities

• Purpose of award: The purpose of the PCSI grant is to plan, scale-up, and support the implementation of a syndemics approach to the prevention and control of viral hepatitis, TB, STDs, and HIV transmission and disease.

• System level intervention: The goal of the grant is to develop system level changes that can be sustained over time

Communication, Coordination, Collaboration, and Integration

A syndemic is “two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.” Related concepts include: linked epidemics, interacting epidemics, connected epidemics, co-occurring epidemics, co-morbidities, and clusters of health-related crises.

Pathogen-Pathogen Interaction (PPI) * Mobility support (e.g., hepatitis B and D) * Enhance infectiousness (e.g., syphilis and HIV) * Alterations of physical body (e.g., HSV and HIV) * Gene reassortment (e.g., swine influenza)

A syndemics orientation is “a way of thinking about public health work that focuses on connections among health-related problems, considers those connections when developing health policies, and aligns with other avenues of social change to assure the conditions in which all people can be healthy.”

* Connections (e.g., social networks) * Influence (e.g., systems thinking & dynamics) * Direction (e.g., social navigation: directing change & charting progress)

Syndemics Approach & Orientation

MissionTo collaboratively develop a sustainable system of primary prevention and clinical care in San Francisco that comprehensively addressing HIV, other STDs, viral hepatitis, and TB to prevent transmission, disease, disability, and death; to reduce co-infections; and to increase health equity.

VisionThe DPH PCSI project envisions a system of primary prevention and clinical care which effectively prevents, screens, treats, and monitors HIV, other STDs, viral hepatitis, and TB in a coordinated and efficient manner that maximizes health outcomes. DPH will build on existing best practices and find new ways to foster collaborative work, coordinate disease control and surveillance efforts, expand programmatic flexibility, and facilitate the appropriate integration of service delivery at the client level.

Principles•Client’s first, systems second•We must create a Win-Win-Win-Win•Maximizing collective resources across sections•We must lead, so that others may follow

Developing Foundation of the Planning Process

• Develop SFDPH screening and vaccination recommendations for viral hepatitis, TB, STDs and HIV, May 2012

• Identify an estimate of the prevalence of HCV among MSM, May 2012

• Develop SFDPH report on recommendations to increase screening and vaccination for population and clinical sites, July 2012

• Develop SFDPH Action Plan to increase screening and vaccination for population and clinical sites, August 2012

• Develop educational materials and dissemination plan, August 2012

• Develop Technical Assistance (TA) plan for integrated HIV/AIDS, viral hepatitis, STD, and TB prevention services, August 2012

• Develop status evaluation plan, September 2012

• Develop report on methods to increase vaccination and screening opportunities through contractual services, September 2012

Objectives for Scope of Works for Preventative Services Guidelines

Working Group

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Overview of each specific disease

and data from the Surveillance

Baseline Assessment of Syndemics for each disease

Discrepancy between current

recommendations / guidelines and

the data

New guidelines for preventive

services for Viral Hepatitis , STDs,

TB, and HIV for SF

Data on current level of integrated

services to new screening

recommendations

Discrepancy between current

level of integrated services to new

screening recommendations

Educational materials, TA plan, indicators and evaluation plan for measuring the impact of the new recommendations on the level of integrated services

Review Compare Identify Develop

Federal / state guidelines and/or recommendations

(e.g., USPSTF), recommendations

from local planning groups (e.g. HPPC) , and

current DPH Guidelines for each disease

Developing Integrated Guidelines for Preventative Services

New guidelines for preventive

services for Viral Hepatitis , STDs,

TB, and HIV for SF

Surveillance Baseline Assessment

(Presented at the 2011 HIV Prevention Conference abstract submitted)

• Overall, 3% (N=4,296) of

people affected by one disease had one or more co-infections

• Highest syndemics within-disease rates: Syphilis, Gonorrhea, and Chlamydia

• Highest syndemics within-population rates for San Francisco: HIV, Hepatitis B, Hepatitis C, and Latent TB

• Demographic categories correlated with having co-infection: Male, African-American, Latino/a, Age 20-60

By syndemics: When used as a noun, a syndemic is defined as two or more afflictions (diseases), interacting synergistically, contributing to increased transmission and/or worsened outcomes of either or all diseases in a population.

By population group: Develop reviewing epidemiological data to identify populations with disproportionate burdern of disease.

Screening vs diagnostic testing:* Screening means testing regardless of risk-factor or symptoms, please note that this does not preclude testing based on clinical symptoms * Diagnostic testing based on signs or systems, exposure to a specific disease, and or prior infection and retesting after treatment to assess for possible re-infection

Revised Preventative Services Guidelines

Overall the process validated the work each Sections to promote Preventive Guidelines.

New recommendations:

• All persons 13 and older should have a documented HIV test in their Electronic Medical Record (EMR) at least once in their lifetime.

• All persons 40-69 should documented have a HCV test in their EMR at least once in their lifetime.

• For pregnant women: Test surface antigen for HBV (required by law) and test for antibody, if both HBsAg and antibody to HBsAg results are negative, provide first vaccination before discharge of hospital and follow-up on additional vaccination post hospital release.

Changes in Preventative Guidelines for Health Commission Consideration

• Work in partnership with CDC to identify Section-specific needs and how they can be maintained in a integrated data system, May 2012

• Develop Integrated Security and Confidentiality Policies and Procedures for Communicable Diseases (including viral hepatitis), TB, STDs, and HIV, September 2012

• Choose an integrated data system to use based on identified options, December 2012

• Identify improvements to lab and billing systems to maximize reimbursement for integrated screening and treatment efforts, Ongoing

Objectives for Departmental Data Working Group

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CURRENT IT/DATA PROCESS FOR COMMUNICABLE DISEASES IN SF

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Developing an Integrated Communicable Disease IT Solution

• The resources will complement the current process begun by the CDC Program Collaboration and Service Integration (PCSI) grant. The findings from the Informatics Report produced by the CDC consultants will be used to identify and purchase an integrated data solution. • Funds will also support existing health department staff to participate in the process• Resources will support new staff, including a Health Informatics Project Manager, a

Project Coordinator, and IT staff, to implement the project

The health department has secured a grant from CDC for $1,869,977 per year for 2 years, with the possibility of applying for an additional 2 years of funding

The goal is to have a system that is client/community centered, where you enter the person into the system once, but can be tied to several diseases over time with each one resulting in a different event.

Benefits:

• Report information to state and national partners

• Electronic data exchange and sharing among different groups working on public health disease management

• Security settings allows users to only see data they are authorized to see

• Reduce paper based reporting

• Case management, contact-tracing, and outbreak management

• Secure access point for providers to view reported cases and run reports

Project Goals:

• Web-based submission and access to electronic case-reports

• Ability to manage all reportable diseases, as well as needed follow-up information for each disease

• Ability to monitor, analyze an report disease cases data

Benefits and Project Goal of an Integrated Data Solution

Integrating Our Work with Broader Efforts to Improve and Protect Health

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Integrating Our Work with Broader Efforts to Improve and Protect Health

• Israel Nieves-Rivera, PCSI Manager • Priscilla Lee Chu, PCSI Analyst

• Tomás Aragón, Erin Bachus, Kyle Bernstein, Bill Blum, Deb Borne, Noah Carraher, Grant Colfax, Moupali Das, Susan Fernyak, Maureen Flaherty, Barbara Garcia, Dara Geckeler, Jennifer Grinsdale, Barbara Haller, Sandra Huang, Emalie Huriaux, Ling Hsu, Lisa Johnson, Masae Kawamura, Bob Kohn, Julia Marcus, Maria X Martinez, Taylor Maturo, Kate Monico-Klein, Nicholas Moss, Kathy Murphy, Tracey Packer, Mark Pandori, Susan Phillip, Amy Pine, Nick Reid, Susan Scheer, Ameera Snell, Arfana Sogal, Fred Strauss, and Frank Strona, and Janet Zola

Acknowledgements