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Program Collaboration and Service Integration (PCSI) at NCHHSTP

PCSI Webcast Slides

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Program Collaboration and Service Integration. Enhancing the Prevention and Control of HIV/AIDS, viral hepatitis, STDs, and TB Slide 1
Program Collaboration and Service Integration
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Gustavo Aquino, Associate Director Program Integration. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), CDC Slide 2
Gustavo Aquino, Associate Director Program Integration
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), CDC
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Webcast Agenda. Presentations. Dr. Kevin Fenton, director, CDC, NCHHSTP. Julie Scofield, executive director, National Alliance of State and Territorial AIDS Directors. Phil Griffin, director, TB Control and Prevention, Kansas Department of Health and Environment Dr. Shannon Hader, senior deputy director, HIV/AIDS, Hepatitis, STD, and TB Administration, Washington, D.C. Department of Health Question and Answer period Slide 3
Webcast Agenda
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Kevin Fenton, MD, PhD, FFPH.  Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Slide 4
Kevin Fenton, MD, PhD, FFPH
Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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Heterogeneity in National Epidemics of HIV/AIDS, Hepatitis B, TB, and Selected STDs
Six line charts showing the heterogeneity within the United States for HIV/AIDS, Hepatitis B, TB and Chlamydia,  Gonorrhea, and Syphilis, with Chlamydia showing increasing rates spiking to 35,000,000. Slide 5
Heterogeneity in National Epidemics of HIV/AIDS, Viral Hepatitis, and STDs
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Syndemics (overlapping epidemics). Similar or overlapping at-risk populations. Disease interactions. Common transmission for HIV, hepatitis, and STDs. STDs increase risk of HIV infection. HIV is the greatest risk factor for progression to TB disease. HIV accelerates liver disease associated with viral hepatitis, making hepatitis the leading cause of death among persons living with HIV/AIDS. Clinical course and outcomes influenced by concurrent disease.Social determinants, Poor access to, and quality of, health care Stigma, discrimination, homophobia. Socioeconomic factors, such as poverty. Prevention and control Slide 6
Syndemics (overlapping epidemics)
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Modernizing Prevention Responses. Traditional Public Health responses. Vertical programs, Focused on the infection, Highly specialized, Limited connectivity, Targeted approach, Clinical intervention.  Syndemic approach. Recognizes interactions, Focuses on the client, Connects specialities.  Networked approach, Adopts holistic approach. Structural intervention Slide 7
Modernizing Prevention Responses
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What Is PCSI?  A mechanism for organizing and blending interrelated health issues, activities, and prevention strategies to facilitate comprehensive delivery  of services that is based on five principles: Appropriateness, Effectiveness, Flexibility, Accountability, Acceptability Slide 8
What Is PCSI?
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Benefits of PCSI. To maximize the health benefits. Increase service efficiency by combining, streamlining, and enhancing prevention services. Maximize opportunities to screen, treat, or vaccinate, Improve the health among populations negatively affected by multiple diseases, Enable service providers to adapt to and keep pace with changes in disease epidemiology and new technologies Slide 9
Benefits of PCSI
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Barriers to PCSI. Lack of national guidelines on where and when best used. Administrative requirements. Data collection systems. Slide 10
Barriers to PCSI
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Implementing PCSI. High quality prevention services. Performance indicators. Ongoing local evaluation of impact. Documentation of best practices. Training and technical assistance Slide 11
Implementing PCSI
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Key Steps for PCSI. Integrated Surveillance to enhance quality and sharing of data across programs. Integrated Training to ensure more holistic approach to health is practiced in community-based organizations, state and local health departments, health clinics and other venues. Integrated Services to provide a multi-level approach to prevention services and interventions for the individual and the community Slide 12
Key Steps for PCSI
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What Is Program Collaboration? A mutually beneficial and well-defined relationship between two programs, organizations or organizational units to achieve common goals. Slide 13
What Is Program Collaboration?
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What Is Service Integration? Provides persons with seamless comprehensive services from multiple programs without repeated registration procedures, waiting periods, or other administrative barriers. Slide 14
What Is Service Integration?
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Moving Forward. CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Open, active, and coordinated communication. Internal, External, Cross collaboration among Branches, Divisions, and the Office of the Director. Consistent, clear messages Slide 15
Moving Forward
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Julie Scofield, Executive Director, National Alliance of State and Territorial AIDS Directors Slide 16
Julie Scofield, Executive Director, National Alliance of State and Territorial AIDS Directors
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Public Health and PCSI. Public health role of assuring services, Importance of local health departments and community based organizations, Important to implement in low, medium and high incidence jurisdictions, Funders can encourage PCSI, Increase flexibility of funding, Reduce contractual barriers, Era of shrinking resources Slide 17
Public Health and PCSI 
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State Health Department Action. PCSI implementation at the state level – many models exist: Integrated partner services, HIV, hepatitis, STD, and TB screening; hepatitis A and B and other vaccination. Client services, Epidemiology and surveillance activities, Training and workforce development, Integrated health communication. Harm reduction Slide 18
State Health Department Action
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Service Integration. CDC recommendations and new diagnostic technologies. Routine HIV testing. Partner services. Noninvasive urine-based testing for chlamydia and gonorrhea. Multiple venues. STD, family planning, and TB clinics. Community health centers, Correctional and juvenile detention facilities, Prenatal clinics, Drug treatment centers, Hospital emergency departments Slide 19
Service Integration
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A Framework for integration? Three levels of Service Integration Level 1:  Nonintegrated services, Prevention services are completely separate or not integrated at the point of client care. Level 2:  Core integrated services, Basic package of services that integrates two or more CDC-recommended HIV/AIDS, viral hepatitis, STDs, and TB prevention, screening, testing or treatment services into clinical care. Level 3:  Expanded integrated services. Comprehensive package of best and promising evidence-based practices of prevention, screening, testing, or treatment services integrated into general and social services Slide 20
A Framework for integration?
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Where we are now? Collaboration and Integration 
Bar chart showing the combined programs of HIV Prevention and Select Categories (n=52) for TB Services, STD Services, Viral Hepatitis Services, HIV/AIDS Surveillance, HIV/AIDS care and treatment, and HIV prevention. TB Services was the lowest with 10 (19%) and HIV prevention was the highest with 52 (100%). Slide 21
Where we are now?
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Where we are now? Collaboration and Integration
Graph showing Program Collaboration and Service Integration between HIV Prevention and Other Programs (n=57) for STD Program, Viral Hepatitis Program, and TB Program and listing Inter-program Meetings Held, Programs Collaborate on Projects (content and/or funding), and Services that are Integrated at the Client-level. STD program had the highest levels at 83% for Inter-program meetings that are held, 88% for Programs Collaborate on Projects (content and/or funding), and 67% for Services that are integrated at the client-level. Slide 22
Where we are now?
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Reality Check! Fiscal Challenges Impacting PCSI. In FY2009. More than $170 million lost in state revenue for HIV and hepatitis programs. Nearly 200 open or unfilled positions in HIV and hepatitis programs. 1-36 day mandatory staff furloughs. There are still opportunities to collaborate and integrate services! Slide 23
Reality Check! Fiscal Challenges Impacting PCSI
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Identifying PCSI Opportunities. CDC Funding Opportunity Announcements. Expanded HIV Testing Initiative. Exemplary FOA with PCSI language incorporated. More FOAs from NCHHSTP now include PCSI language, NCHHSTP encourages – but not mandatory, Jurisdictions must take advantage of these funding opportunities to fund their cutting edge programs Slide 24
Identifying PCSI Opportunities
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Opt-Out HIV Testing in Health Care Settings by Health Departments after the ETI (as of February 2008)
Graph showing the number of health care settings consisting of Corrections, TB Clinics, Hospital Outpatient, Hospital Inpatient, Urgent Care, ED, Family Planning, Primary Care, L&D, Prenatal/OB, Sub Abuse TX, Community Health Clinics, and STD Clinics that are maintained, expanded, and initiated, with an overall  figure of ≥ 80% increase. Slide 25
Opt-Out HIV Testing in Health Care Settings by Health Departments after the ETI (as of February 2008)
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Steps for Local Implementation. Assess and articulate how/where PCSI can improve local service delivery. Adopt PCSI as a strategic imperative where appropriate. Obtain clear political commitment. Identify an appropriate “PCSI champion” and create a PCSI committee . Support evidence-based practices in the adoption of PCSI and evaluate PCSI’s impact on behavioral and health outcomes. Slide 26
Steps for Local Implementation
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What do we gain? Can be applied in various settings. Increased flexibility in how we respond to community needs. Quality vs. quantity of services offered. Greater client satisfaction. Greater return on prevention investment. Fewer missed opportunities Slide 27
What do we gain?
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Phil Griffin, BBA, Director, TB Control and Prevention, Kansas Department of Health and Environment Slide 28
Phil Griffin, BBA, Director, TB Control and Prevention, Kansas Department of Health and Environment
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Know Your Epidemic In 2008, the State of Kansas... eported 2,107 AIDS cases to CDC, cumulatively from the beginning of the epidemic through December 2008 
Reported
Primary and secondary syphilis: 1.1 per 100,00 
- Cases co-infected with HIV: 35%

Chlamydia: 375  per 100,000 persons 
- Among women: 582 per 100,000
- Among men: 165 per 100,000

Gonorrhea: 82 per 100,000 persons

Since 1992, the overall rate of TB has declined slightly and even less among Black/African American and foreign born persons:
64.9% of TB cases occurred in foreign born
19.3% of TB cases occurred in African Americans
11% of TB cases occurred in White Non Hispanics
4% TB cases co-infected with HIV in 2008 Slide 29
Know Your Epidemic In 2008, the State of Kansas
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Understanding Kansas. Population – 2,818,747. White – 88.7%. White not Hispanic – 80.3%. Hispanic or Latin, All races – 9.1%. Black – 6.2%. Asian – 2.2%. Multi Racial – 1.8%. American Indian and Alaska native – 1.0%. Native Hawaiian/other Pacific Islander - 0.1% Slide 30
Understanding Kansas
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Understanding Kansas (2). Land area – 81,814.88 square miles. 9 hour drive from NE KS to SW KS (580 miles). Persons per square miles – 32.9. 105 Counties. 71 counties have less than 15,000 population. 52% of total population in 5 counties. 100 Autonomous Health Departments. State health department has no direct authority over local health departments Slide 31
Understanding Kansas (2)
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Understanding Kansas (3). TB Clinics – 6 health departments have full time nurses assigned to TB, no full time physicians or other primary providers. STD Clinics – 5 health departments have STD clinics – 85 trained to provide Family Planning Services including STD services. HIV Services – 2 full time HIV clinics with 3 satellites where direct care is provided approximately every 6 weeks, 92 HIV counseling and testing sites. Adult Viral Hepatitis Services – 31 contracted sites providing high risk Hepatitis A/B vaccinations Slide 32
Understanding Kansas (3)
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PCSI Priorities - Kansas. Assess the level of integrated services currently available within the state. Identify barriers to further integration of services. Develop opportunities for eliminating the barriers. Identify services needing further integration within NCHHSTP supported programs as well as those otherwise supported. Implement new opportunities to optimize service integration at the state and local levels Slide 33
PCSI Priorities - Kansas
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Implementation in Kansas. HIV, adult viral hepatitis, STD, and tuberculosis prevention programs joined with Immunization Program, Bureau of Disease Control and Prevention (BDCP). PCSI objectives included in most NCHHSTP cooperative agreement applications in current agreement cycles. All BDCP programs will participate in a PCSI tour in the summer and fall of 2010, reaching six areas of the state. Plan and conduct a formal evaluation of the current status of integrated services Slide 34
Implementation in Kansas
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Benefits of State Implementation. Increased opportunities to achieve cooperation from clients. Increased opportunities to better meet client needs. Earlier detection of disease, preventing potential exposure to others. Increased training opportunities using integrated training between programs. More efficient use of resources at state and local level. Increased trust among local partners and the public at large Slide 35
Benefits of State Implementation
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Shannon Hader, M.D., MPH, Senior Deputy Director, HIV/AIDS, Hepatitis, STD, TB Administration, Washington, D.C. Department of Health Slide 36
Shannon Hader, M.D., MPH
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Know Your Epidemic. In 2008, the District of Columbia… Reported 16,513 HIV/AIDS cases to CDC, cumulatively from the beginning of the epidemic through December 2008. Reported 145 primary and secondary syphilis cases in 2008; 621 over the last 5 years with 160 cases co-infected with HIV. Reported 3,530 persons living with chronic hepatitis B (2004-2008); 9.2% co-infected with HIV. Reported 11,624 persons living with chronic hepatitis C (2004-2008); 8.5% co-infected with HIV. Reported Chlamydia infection rate at 1,166 per 100,000 persons in 2008. Although the overall rate of TB in DC has declined substantially since 1992 (54 cases in 2008; 321 TB cases 2004-2008), the rate decreased among Black/African American and foreign born has been smaller. 38.9% of TB cases occurred in U.S. born blacks, 51.9% of TB cases occurred in foreign born, 16.7% of TB cases co-infected with HIV in 2008 Slide 37
Know Your Epidemic
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PCSI Priorities. District of Columbia. PCSI when applicable… Impact, efficiencies. Redundancy, missed opportunities. Consistency… messages, standards, quality. Resiliency, back-up, surge capacity. Strategies. Organizational Accountability. Data-driven decision-making. Standards of Care, Data Quality, Data Use. Innovation in Programs for Expanded Impact Slide 38
PCSI Priorities
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Syndemics (synergistically interacting epidemics)
Eight slides showing how HIV/AIDS rates, HEP B numbers, Chlamydia rates, P&S Syphilis rates, HIV/AIDS numbers, Hepatitis C numbers, Gonorrhea rates, and TB numbers are synergistically interacting epidemics. Slide 39
Syndemics (synergistically interacting epidemics)
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Routine HIV Testing Scale-up. 2)  Focus on Medical Settings: Ask for the Test. Offer the Test. 1) June 2006, Testing Campaign >50 Partners, Rapid Test Expansion. DC Jail. Images: Come Together DC Get Screened for HIV Poster, ASK for the TEST Poster, New Indication the Test Poster, Test Results sample. Slide 40
Routine HIV Testing Scale-up
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HIV Testing Expansion: More Tests, Earlier Diagnosis, Higher CD4+ Counts
One slide with two graphs, with the first graph showing the number of publicly funded HIV tests from 2009: ~93,000 tests PEMS data with the start of routine testing expansion in 2006 just under 40,000 and rising to 72,866 in 2008. The second graph shows the median CD4+ count at time of Dx for HARS HIV Surveillance Data as 216 in 2004 and rising to 343 in 2008. Slide 41
HIV Testing Expansion: More Tests, Earlier Diagnosis, Higher CD4+ Counts
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Partner Services:  Expanded & integrated. STD Syphilis DIS. Service to be offered to all newly diagnosed. Need partners to offer, help with partner solicitation. DC outreach to partners (confidential) offering testing and support services. Image: Partner Services Save Lives brochure. Slide 42
Partner Services: Expanded & integrated
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Youth STD Outreach Testing, Condom Distribution, Master of Condoms (MC) 
A graph showing the numbers of youth tested for GC/Chlamydia in 2-20 schools, the number of tests conducted with positivity rates, and the projected number of tests for FY08, FY09, and FY10; slide also reviews the District Condom Program with 3.2 million distributed in FY09, expanded school availability, and the Wrap MC Web Training. Slide 43
Youth STD Outreach Testing, Condom Distribution, Master of Condoms (MC)
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Implementation in D.C. HIV/AIDS, Hepatitis, STD and TB  Administration

Office of the Senior Deputy Director
Bureau of Administrative Services
Bureau of Partnerships, Capacity Building & Community Outreach
Bureau of Care Housing and Support Services
Bureau of Grants Management/Fiscal Control
Bureau of Prevention and Intervention Services
Bureau of Strategic Information
Bureau of STD Control
Bureau of TB Control Slide 44
Implementation in D.C. HIV/AIDS, Hepatitis, STD and TB Administration
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Data Sharing Partners Puzzle Graphic: - Disease Surveillance Programs
- Medicaid Claims Data
- Prevention Programs CTR
- Vital Statistics Deaths Births
- Cancer Registries
- Pharmacy Claims Data ADAP
- Hospital Discharge Summary
- Electronic Laboratory Reports
- RW Care Information System Slide 45
Data Sharing Partners
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Benefits of Local Implementation. Innovation, Improvement, Impact. Image: Annual Report 2009 Update cover. Slide 46
Benefits of Local Implementation
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Summary. Evolving syndemics of HIV, STD, viral hepatitis and TB epidemics in the United States. Small changes in the way services are delivered have the potential to maximize prevention opportunities. Modernizing our public health response based on best practices of what and how services are delivered. Facilitating ongoing effectiveness and efficiency of services. Implementing best and promising practices, and a commitment to evaluation, based on core PCSI principles Slide 47
Summary
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“Given the complexity of the problems and the need for innovation, it is not possible to achieve goals without collaboration.” - PResident Barack Obama Slide 48
“Given the complexity of the problems and the need for innovation, it is not possible to achieve goals without collaboration.”
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Program Collaboration and Service Integration
http://blogs.cdc.gov/healthprotectionperspectives/ Slide 49
Program Collaboration and Service Integration
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