Assessment of Sexual
Healthcare in Maryland Safety
Net Providers Sites:
Creation of the Sexual Health
Integration Network
Katherine Jochim, RN
Karen Silver, MPP
Office of Population Health Improvement
Maryland Department of Health and Mental Hygiene
May 2013
Overview
 Introduction:
 The Frontier of Sexual Health in Maryland
 Methods:
 Creation of SHINE
 Development of Assessment Survey
 Findings
 Limitations and Challenges
 Lessons Learned
 Policy and Practice Implications
Sexual Health in Maryland
The Burden of HIV in Maryland
 Ranked 3rd in
States/Territories in
estimated HIV diagnoses
in 2011
 Ranked 4th in
States/Territories in
estimated number of
persons living with
diagnosed HIV
 Total lifetime treatment
cost for all new HIV
diagnoses is $514 million
(in 2009).
Trends in Living HIV Cases
MD HIV/AIDS Epidemiological Profile, Bureau of Infectious Diseases, DHMH. 2011
Continuum of HIV Care
MD HIV/AIDS Epidemiological Profile, Bureau of Infectious Diseases, DHMH. 2011
The Burden of STIs in Maryland
MD Ranking in
US
States/Territori
es
2011 MD Rate
2011 US Rate
Gonorrhea
16
111.9
104.2
Chlamydia
15
670.9
648.9
Syphilis
3
7.8
4.5
Congenital
Syphilis
2
31.1**
8.5
*per 100,000 people
**per 100,000 live births
CDC Sexually Transmitted Diseases Surveillance Data, 2011
The Affordable Care Act
• Increased Medicaid eligibility to
individuals at or below 133%
the federal poverty level
• Provides insurance exchanges
for those at or below the 400%
federal poverty level (who are
not eligible for Medicaid or
Medicare)
• Children <26 years can remain
on parents’ insurance plan
• 30 million people are
expected to have new
insurance coverage
• This will affect sexual
healthcare in unanticipated
ways.
The Creation of SHINE
(Sexual Health Integration Network)
Initial Goals:
 Holistic sexual health
 Do not silo HIV, STIs and viral hepatitis
 Create standard protocols for all federally funded safety
net providers.






Federally-qualified health centers (FQHCs) and look-alike
Local health departments (LHDs)
Community Health Centers (CHCs)
School-based Health Centers (SBHCs)
Hospital clinics
Title X Clinics
 Use other states, such as Oregon, as a model for
integration and protocols.
Identification of Stakeholders
 DHMH




Center for HIV Surveillance
Office of Family Planning
Office of Primary Care Access
Other members from the Infectious Diseases Bureau and
the Office of Population Health
 Baltimore City Health Department
 As well as other LHDs around the state
 FQHC Representatives
 Johns Hopkins University
Revised Goals
 Perform assessment of current sexual health
practices in the state of Maryland.
 Holistic sexual health
 Do not silo HIV, STIs and viral hepatitis
 Develop standard protocols for all federally
funded safety net providers.
Development of Assessment
Survey
Clinical Guidelines
Recommendations:
Recommending Body:
Treatment of HIV/STIs
ACOG, ACP, USPSTF, CDC
Disease Screening
USPSTF, CDC, HRSA, HEDIS
Counseling
ACOG, CDC, USPSTF
 American College for Obstetricians and Gynecologists (ACOG)
 American College of Physicians (ACP)
 United States Preventive Services Task Force (USPSTF)
 Centers for Disease Control and Prevention (CDC)
 Health Resources and Services Administration (HRSA)
 Health Effectiveness Data and Information Set (HEDIS)
The Holistic Assessment
 HIV/STI treatment
 HIV/STI screening
 HPV and Hepatitis Vaccinations
 Condom availability
 Social Services
 Partner Services
 Mental Health
 Substance Abuse
 Behavioral Counseling
 Referral Process
Pilot Survey
www.education.randmcnally.com
Pilot County Characteristics
Prince George’s
County
Dorchester
County
Allegany
County
Elevated rates;
higher pop.
density
Average rates of
STI/HIV
Lower rates;
rural area
Geographic
location
Middle-south
Eastern Shore
Western
HIV/AIDS
prevalence
799
403
118
Chlamydia rate
698
506
234
Syphilis rate
11
6
3
Gonorrhea rate
184
235
41
Representative
characteristic
*HIV/AIDS information based on 2011 statistics. Data from the Maryland HIV/AIDS Epidemiological Profile,
Third Quarter, 2012 by the Center of HIV Surveillance, Epidemiology and Evaluation, DHMH.
**STI information based on 2011 statistics. Data from the Center for Sexually Transmitted Infection
Prevention, DHMH.
Pilot Survey Implementation
 Survey built using Survey Monkey
 BETA version can be taken at:
https://www.surveymonkey.com/s/SHINEAssetMappingSurveyTEST
 Notified providers of impending survey via telephone on
April 8, 2013
 Emailed survey to providers April 8, 2013
 Surveys were due April 22, 2013
Findings
Results Pending
 23/28 surveys have been returned
 Current Result Summary:
 All providers offer HIV testing
 Following CDC guidelines
 All providers offer STI testing
 Treat patients in house with oral or injectable treatment
 Primarily follow CDC guidelines
 Majority provide hepatitis and HPV vaccines
 Very few offer partner services
Demographics
Please select the county (or counties) that your facility primarily serves.
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Please specify type of facility. (Check all that apply)
Other
Hospitalbased
Clinic
Hospital
Emergen
cy
Departme
nt
Communi
ty Health
Center
Schoolbased
Health
Center
Local
Health
Departme
nt
FQHC
look-alike
Federally
Qualified
Health
Center
(FQHC)
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
40.00
40.0%
35.00
30.0%
30.00
20.0%
25.00
10.0%
20.00
0.0%
15.00
10.00
5.00
.00
Other (please specify)
50.0%
When symptoms are present
45.00
When diagnosed with an STI
60.0%
Prenatal visit
50.00
When patient identified risk
OR requested by patient
Please quantify (by percentage) the patient
population by payer type in the past 12 months.
Routine - (every patient
entering the provider's care is
offered an HIV test)
Other
N/A
% Unknown
% Self-pay
% Uninsured
% Private
% Public
Payer Type and HIV Testing
Under what circumstances do you provide HIV
testing?
70.0%
Linkage to Care
Steps Taken to Ensure Patients Remain Linked
to HIV Treatment
50%
40%
30%
20%
10%
0%
Referral
In House Treatment Follow Up in Schools
Social Services
0
Social Support
Services
Intensive
behavioral
counseling
(counseling to…
Mental Health
and/or
Substance
Abuse Support
Partner Services
(patient is
interviewed to
identify…
HIV Specialty
Care
HIV Treatment
Treatment Services
If the patient tests positive for HIV, does your facility provide the following
services?
35
30
25
In House
20
15
Willing to receive referrals for
this service
10
Refer Out
5
N/A
STI Vaccines
STI vaccinations:
30
25
We provide this service on-site.
20
We accept patients referred to
us for this service.
15
We do not provide this service.
10
We would like to refer out this
service.
5
0
Hepatitis A Vaccine
Hepatitis B Vaccine
HPV Vaccine
Social Support
Services
Intensive behavioral
counseling** for adults
at increased risk for
STIs
Intensive behavioral
counseling** to
sexually active
adolescents
Mental Health and/or
Substance Abuse
Support
Partner services* for
gonorrhea
Partner services* for
chlamydia
Partner services* for
syphilis
STI Treatment Services
If the patient tests positive for an STI
30
25
We provide this service on-site.
20
We accept patients referred to
us for this service.
15
We refer out for this service.
10
5
We would like to refer out for
this service.
0
Limitations and Challenges
 Fluctuating timeline
 Contact information for providers
 Poor response rate
Lessons Learned
•
•
•
•
•
Be flexible.
Be patient.
Utilize your resources.
Be positive.
The DHMH is not
glamorous.
• But, it is dedicated,
hard-working, and
thorough.
Google Image, 2013
Policy and Practice Implications
 Official implications are pending.
 My recommendations:
 Invite a representative from each LHD to SHINE for a voice in
the network.
 Follow CDC guidelines only when implementing standard
protocol.
 Provide increased incentives for clinics to report HIV/STIs and
fines if they do not.
 Before receiving federal funds, clinics must identify from
where they receive referrals or to whom they refer, ensuring
that effective linkages exist between providers.
 Increase funding for partner services and disease intervention
specialists.
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Questions?